Your Summary of Benefits - Anthem Blue Cross

CA/LG/Anthem CaliforniaCare HMO Elements Choice 3000/9Q5K/01-01-2026 Page 1 of 9 Your summary of benefits Anthem® Blue Cross Your Plan: Anthem CaliforniaCare HMO Elements Choice 3000 Your Network: California Care HMO 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 $50 copay per visit medical deductible does not apply Covered Medical Benefits Cost if you use an In-Network Provider Overall Deductible Your plan applies a separate Pharmacy Deductible to prescription drugs obtained at a pharmacy. See the Covered Prescription Drug Benefits section. $3,000 person / $6,000 family Overall Out-of-Pocket Limit $6,400 single / $12,800 family To get benefits under this Plan, you must use In-Network Providers. Services from Out-of-Network Providers are not covered, except for Emergency or Urgent Care, Authorized Services, or when required by law. Please be sure to contact us if you are not sure if we have approved an Authorized Service. 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 single 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 single out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). A referral from your Primary Care Physician (PCP) is required for Specialist care and most other providers for select covered services. Primary Care (PCP) and Mental Health and Substance Use Disorder Services virtual and office $30 copay per visit medical deductible does not apply Specialist Provider virtual and office $50 copay per visit medical deductible does not apply Other Practitioner Visits Maternity services Prenatal and Postpartum care $30 copay per visit medical deductible does not apply Delivery 30% 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

Page 2 of 9 Covered Medical Benefits Cost if you use an In-Network Provider Manipulation Therapy Coverage is limited to 20 visits per benefit period. $30 copay per visit medical deductible does not apply Acupuncture Coverage is limited to 20 visits per benefit period. $30 copay per visit medical deductible does not apply Other Services in an Office Allergy Testing $30 copay per visit medical deductible does not apply Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. 30% coinsurance medical deductible does not apply Surgery $30 copay per surgery medical deductible does not apply Preventive care / screenings / immunizations No charge Preventive Care for Chronic Conditions per IRS guidelines No charge Diagnostic Services Lab Office No charge Freestanding Lab No charge Outpatient Hospital 30% coinsurance after medical deductible is met Diagnostic Services X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital 30% coinsurance after medical deductible is met Diagnostic Services Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office $125 copay per day medical deductible does not apply Freestanding Radiology Center $125 copay per day medical deductible does not apply Outpatient Hospital $125 copay per day medical deductible does not apply Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply depending on the care provided. In-Network and Out-of-Network Providers: $30 copay per visit medical deductible does not apply Emergency Room Facility Services Your copay will be waived if admitted. In-Network and Out-of-Network Providers: $250 copay per visit and 30% coinsurance after medical deductible is met

Page 3 of 9 Covered Medical Benefits Cost if you use an In-Network Provider Emergency Room Doctor and Other Services In-Network and Out-of-Network Providers: No charge Ambulance In-Network and Out-of-Network Providers: $150 copay per trip medical deductible does not apply Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge Doctor Services No charge Outpatient Surgery Facility Fees Hospital 30% coinsurance after medical deductible is met Ambulatory Surgical Center 30% coinsurance after medical deductible is met Physician and other services including surgeon fees Hospital No charge Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees 30% coinsurance after medical deductible is met Physician and other services including surgeon fees No charge Home Health Care Coverage is limited to 100 visits per benefit period. $30 copay per visit medical deductible does not apply Therapy Services Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical and occupational therapies is limited to 40 visits combined per benefit period. Coverage for speech therapy is limited to 20 visits per benefit period. Office $30 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Pulmonary rehabilitation Office $30 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period.

Page 4 of 9 Covered Medical Benefits Cost if you use an In-Network Provider Office $30 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Dialysis/Hemodialysis Office $50 copay per visit medical deductible does not apply Outpatient Hospital 30% coinsurance after medical deductible is met Chemo/Radiation Therapy Office $50 copay per visit medical deductible does not apply Outpatient Hospital 30% 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. 30% coinsurance after medical deductible is met Inpatient Hospice No charge Additional Services, Equipment and Devices Durable Medical Equipment 20% coinsurance medical deductible does not apply Prosthetic Devices No charge Wigs Coverage for wigs is limited to 1 item after cancer treatment per benefit period. No charge Covered Prescription Drug Benefits Cost if you use an In- Network Pharmacy Cost if you use an Out-of-Network Pharmacy Pharmacy Deductible $500 person / $1,500 family (does not apply to Tier 1a, Tier 1b drugs) Not covered Pharmacy Out-of-Pocket Limit Combined with In- Network medical out- of-pocket limit Not covered 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

Page 5 of 9 Covered Prescription Drug Benefits Cost if you use an In- Network Pharmacy Cost if you use an Out-of-Network Pharmacy 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, Pharmacy deductible does not apply (retail) and $10 copay per prescription, Pharmacy deductible does not apply (home delivery) Not covered (retail and home delivery) Tier 1b - Typically Generic $20 copay per prescription, Pharmacy deductible does not apply (retail) and $40 copay per prescription, Pharmacy deductible does not apply (home delivery) Not covered (retail and home delivery) Tier 2 - Typically Preferred Brand $50 copay per prescription after Pharmacy deductible is met (retail) and $125 copay per prescription after Pharmacy deductible is met (home delivery) Not covered (retail and home delivery) Tier 3 - Typically Non-Preferred Brand $75 copay per prescription after Pharmacy deductible is met (retail) and $188 copay per prescription after Pharmacy deductible is met (home delivery) Not covered (retail and home delivery) Tier 4 - Typically Specialty (brand and generic) 30% coinsurance up to $250 per prescription after Pharmacy deductible is met (retail and home delivery) Not covered (retail and home delivery)

Page 6 of 9 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 Not covered Adult Vision exam (age 19 and older) Limited to 1 exam per benefit period. No charge Not covered 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. • 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 HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorized by the participating medical group or independent practice association (IPA); except OB/GYN services received within the member's medical group/IPA, and services for mental health and substance use disorders. Benefits are subject to all terms, conditions, limitations, and exclusions of the EOC. 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 8 of 9 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 9 of 9 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