Anthem Blue Cross: Summary of Benefits

CA/LG/Anthem Virtual Access Plus Prudent Buyer PPO 3000/30/60/8000/9LMT/01-01-2026 Page 1 of 10 Your summary of benefits Anthem® Blue Cross Your Plan: Anthem Virtual Access Plus Prudent Buyer PPO 3000/30/60/8000 Your Network: Prudent Buyer PPO 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 $60 copay per visit medical deductible does not apply Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Overall Deductible $3,000 person / $6,000 family $9,000 person / $18,000 family Overall Out-of-Pocket Limit $8,000 person / $16,000 family $24,000 person / $48,000 family 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 person 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 person out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Out-of-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder Services virtual and office virtual-No charge medical deductible does not apply office-$30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Specialist Provider virtual and office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Practitioner Visits Maternity services Prenatal and Postpartum care $30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met

Page 2 of 10 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Delivery $750 copay per pregnancy after medical deductible is met 50% coinsurance after medical deductible is met Retail Health Clinic for routine care and treatment of common illnesses; usually found in major pharmacies or retail stores. $30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Manipulation Therapy Coverage is limited to 30 visits per benefit period. $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Acupuncture Coverage is limited to 20 visits per benefit period. $30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Services in an Office Allergy Testing $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. $250 copay per day medical deductible does not apply 50% coinsurance after medical deductible is met Surgery $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Preventive care / screenings / immunizations No charge 50% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge Cost share is based on the setting services are received. Diagnostic Services Lab Office $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Freestanding Lab No charge 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services X-Ray Office $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met

Page 3 of 10 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Freestanding Radiology Center $60 copay per visit medical deductible does not apply‡ 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office $200 copay per day medical deductible does not apply 50% coinsurance after medical deductible is met Freestanding Radiology Center $200 copay per day after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital $200 copay per day after medical deductible is met 50% coinsurance after medical deductible is met Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply depending on the care provided. $30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Emergency Room Facility Services Your copay will be waived if admitted. $250 copay per visit after medical deductible is met Covered as In-Network Emergency Room Doctor and Other Services No charge after medical deductible is met Covered as In-Network Ambulance $250 copay per trip after medical deductible is met Covered as In-Network Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees $500 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Doctor Services No charge 50% coinsurance after medical deductible is met Outpatient Surgery Facility Fees Hospital $500 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met

Page 4 of 10 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Ambulatory Surgical Center $500 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital No charge after medical deductible is met 50% coinsurance after medical deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Member is responsible for an additional $500 copay if prior authorization is not obtained from Anthem for non-emergency Inpatient admissions to Out-of-Network Providers. Anthem’s maximum payment is up to $1,000 per day for non-emergency Inpatient admissions to Out-of- Network Providers. Facility Fees $750 copay per admission after medical deductible is met 50% coinsurance after medical deductible is met Physician and other services including surgeon fees No charge after medical deductible is met 50% coinsurance after medical deductible is met Home Health Care Coverage is limited to 100 visits per benefit period. $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Therapy Services Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Pulmonary rehabilitation Office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Cardiac rehabilitation

Page 5 of 10 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital $60 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Dialysis/Hemodialysis Office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital $500 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Outpatient Hospital $500 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Skilled Nursing Care (facility) Coverage for Inpatient rehabilitation and skilled nursing services is limited to 150 days combined per benefit period. $750 copay per admission after medical deductible is met 50% coinsurance after medical deductible is met Inpatient Hospice $750 copay per admission after medical deductible is met 50% coinsurance after medical deductible is met Additional Services, Equipment and Devices Durable Medical Equipment $100 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Prosthetic Devices $100 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Wigs Coverage for wigs is limited to 1 item after cancer treatment per benefit period. $100 copay per visit after medical deductible is met 50% coinsurance after medical deductible is met Covered Prescription Drug Benefits Cost if you use an In- Network Pharmacy Cost if you use an Out-of-Network Pharmacy Pharmacy Deductible Not applicable Not applicable

Page 6 of 10 Covered Prescription Drug Benefits Cost if you use an In- Network Pharmacy Cost if you use an Out-of-Network Pharmacy Pharmacy Out-of-Pocket Limit Combined with In- Network medical out- of-pocket limit Combined with Out-of- Network medical out- of-pocket limit Prescription Drug Coverage Network: Base Network Drug List: CA Essential DMHC Drugs not included on the CA Essential DMHC drug list will not be covered. 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 prescription (retail) and $10 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 1b - Typically Generic $20 copay per prescription (retail) and $40 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 2 - Typically Preferred Brand $30 copay per prescription (retail) and $75 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 3 - Typically Non-Preferred Brand $50 copay per prescription (retail) and $125 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 4 - Typically Specialty (brand and generic) 30% coinsurance up to $250 per prescription (retail and home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery)

Page 7 of 10 Covered Vision Benefits Cost if you use an In- Network Provider Cost if you use an 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) Limited to 1 exam per benefit period. No charge $0 copayment up to plan's Maximum Allowed Amount Adult Vision exam (age 19 and older) Limited to 1 exam per benefit period. No charge Reimbursed Up to $42 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. • ‡ You will pay your PCP or Specialist office visit copay for certain services provided in their office. • Outpatient Facility tests and treatments are limited to $350 per admission for Out-of-Network Providers. Includes: Diagnostic Services; X-ray; Surgery; Rehabilitation; Habilitation; Cardiac Therapy; Surgery at Ambulatory Surgical Centers. • Advanced Diagnostic Imaging is limited to $800 per service for Out-of-Network Providers. • 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. 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 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

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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. #CA-DMHC-001# Page 9 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 alternative 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.

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. #CA-DMHC-001# Page 10 of 10 It’s important we treat you fairly We follow state and federal civil rights laws in our health programs and activities. Members can get reasonable modifications as well as free auxiliary aids and services if you have a disability. We don’t discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. For people whose primary language isn’t English (or have limited proficiency), we offer free language assistance services, in a timely manner, like interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711) or visit our website. If you think we failed in any areas or to learn more about grievance procedures, you can mail a complaint to: Compliance Coordinator, P.O. Box 27401, Richmond, VA 23279, or if you think you were discriminated against based on race, color, national origin, age, disability, or sex, you can mail a complaint directly to 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. You can also call 1-800- 368-1019 (TDD: 1-800-537-7697) or visit https://ocrportal.hhs.gov/ocr/portal/lobby.jsf