Summary of Benefits

CA/LG/Anthem Prudent Buyer PPO HSA/H 2000/3400/5000 10/30/9Q8W/01-01-2026 Page 1 of 9 Your summary of benefits Anthem® Blue Cross Your Plan: Anthem Prudent Buyer PPO HSA/H 2000/3400/5000 10/30 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 after deductible is met Mental Health & Substance Use Disorder Services No charge after deductible is met Specialist care 10% coinsurance after deductible is met Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Overall Deductible Subscriber Only Coverage Subscriber and Family Coverage $2,000 individual $3,400 member / $5,000 family $6,000 individual $6,000 member / $12,000 family Overall Out-of-Pocket Limit Subscriber Only Coverage Subscriber and Family Coverage $4,250 individual $4,250 member / $8,500 family $12,750 individual $12,750 member / $25,500 family The individual deductible and individual out-of-pocket limit apply to an individual enrolled under subscriber only coverage. The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the member deductible and member 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 member deductible or member 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 10% coinsurance after deductible is met 30% coinsurance after deductible is met Specialist Provider virtual and office 10% coinsurance after deductible is met 30% coinsurance after deductible is met Other Practitioner Visits Maternity Doctor services (prenatal/postpartum care and delivery) 10% coinsurance after deductible is met 30% coinsurance after deductible is met