15-Exhibit 5. Fort Bend ISD Kelsey UHC Charter Plan SBC 2025.pdf

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Charter Plan

Coverage Period: 01/01/2025 – 12/31/2025

Coverage for: Family | Plan Type: GIL

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 1-877-805-1970 or visit welcometouhc.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 www.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

Network: $750 Individual / $1,500 Family Per calendar year.

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. Preventive care is 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 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?

Network: $3,750 Individual / $7,500 Family Per calendar year.

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?

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 myuhc.com or call 1-877-805-1970 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will 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?

Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

http://www.welcometouhc.com/ https://www.healthcare.gov/sbc-glossary/ file://///unpiox03pn/homedirs/akonesk/BPST/BPST/2016%20projects/2017%20SBC%20Template/Final%20Templates/www.healthcare.gov/coverage/preventive-care-benefits/ http://www.myuhc.com/

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 2 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

i

Common Medical Event

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider with

Referral (You will pay the least)

Network Provider without Referral

(You may pay more)

Out-of-Network 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

$45 copay per visit, deductible does not apply.

$45 copay per visit, deductible does not apply.

Not Covered

Primary Care Physician must be assigned to member. Primary Care includes network OB/GYNs – no referral required.

Virtual visits – No Charge by a Designated Virtual Network Provider. *Cost share applies to any other Telehealth service based on provider type. No referral required.

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.

Specialist visit

$55 copay per visit, deductible does not apply.

$55 copay per visit, deductible does not apply.

Not Covered

We only accept electronic referrals from the assigned PCP.

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.

Preventive care/screening/ immunization No Charge Not Covered 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) 20% coinsurance 20% coinsurance Not Covered

None

Imaging (CT/PET scans, MRIs)

20% coinsurance 20% coinsurance Not Covered

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 3 of 6

Common Medical Event

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider with

Referral (You will pay the least)

Network Provider without Referral

(You may pay more)

Out-of-Network Provider

(You will pay the most)

If you need drugs to treat your illness or condition

Tier 1 – Your Lowest Cost Option

Not Covered Not Covered Not Covered No coverage for prescription drugs with UnitedHealthcare.

Prescription Drug Coverage is managed through CVS Caremark.

CVS Caremark Customer Service:

877-258-0105 CVS Caremark Specialty Pharmacy:

800-237-2767

Tier 2 – Your Mid- Range Cost Option

Not Covered Not Covered Not Covered

Tier 3 – Your Mid- Range Cost Option

Not Covered Not Covered Not Covered

Tier 4 – Your Highest Cost Option

Not Applicable Not Applicable Not Applicable

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

20% coinsurance 20% coinsurance Not Covered None

Physician/surgeon fees 20% coinsurance 20% coinsurance Not Covered

None

If you need immediate medical attention

Emergency room care $300 copay per visit, then

20% coinsurance $300 copay per visit, then

20% coinsurance

$300 copay per visit, then

20% coinsurance

Copay is waived if admitted to the hospital.

Emergency medical transportation 20% coinsurance 20% coinsurance 20% coinsurance

None

Urgent care $75 copay per visit, deductible does not apply.

$75 copay per visit, deductible does not apply.

Not Covered

None

If you have a hospital stay

Facility fee (e.g., hospital room)

20% coinsurance 20% coinsurance Not Covered None

Physician/surgeon fees

20% coinsurance 20% coinsurance Not Covered

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 4 of 6

Common Medical Event

Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider with

Referral (You will pay the least)

Network Provider without Referral

(You may pay more)

Out-of-Network Provider

(You will pay the most)

If you need mental health, behavioral health, or substance abuse services

Outpatient services $45 copay per visit, deductible does not apply.

$45 copay per visit, deductible does not apply.

Not Covered

Network Partial hospitalization/intensive outpatient treatment: 20% coinsurance

Inpatient services 20% coinsurance 20% coinsurance Not Covered

None

If you are pregnant

Office visits No Charge No Charge Not Covered

Cost sharing does not apply for preventive services. Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery professional services

20% coinsurance 20% coinsurance Not Covered

Childbirth/delivery facility services

20% coinsurance 20% coinsurance Not Covered None

If you need help recovering or have other special health needs

Home health care 20% coinsurance 20% coinsurance Not Covered

Limited to 60 visits per calendar year.

Rehabilitation services

$55 copay per visit, deductible does not apply.

$55 copay per visit, deductible does not apply.

Not Covered Limits per calendar year: Physical, Speech, Occupational, Pulmonary: 30 visits each;

Cardiac: 36 visits.

Habilitative services $55 copay per visit, deductible does not apply.

$55 copay per visit, deductible does not apply.

Not Covered

Services are provided under and limits are combined with Rehabilitation Services above.

Skilled nursing care 20% coinsurance 20% coinsurance Not Covered

Limited to 60 days per calendar year (combined with inpatient rehabilitation).

Durable medical equipment 20% coinsurance 20% coinsurance Not Covered

Covers 1 per type of DME (including repair/replacement) every 3 years.

Hospice services 20% coinsurance 20% coinsurance Not Covered

None

If your child needs dental or eye care

Children’s eye exam

Not Covered Not Covered Not Covered No coverage for Children’s eye exams.

Children’s glasses Not Covered Not Covered Not Covered No coverage for Children’s glasses.

Children’s dental check-up

Not Covered Not Covered Not Covered No coverage for Children’s Dental check-up.

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 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.)

• Acupuncture

• Bariatric surgery

• Cosmetic surgery

• Dental care

• Glasses

• Infertility treatment

• Long-term care

• Non-emergency care when travelling outside -the U.S.

• Prescription drugs

• Private duty nursing

• Routine eye care

• Routine foot care – Except as covered for Diabetes

• Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Chiropractic (Manipulative care) – 20 visits per calendar year

• Hearing aids - $5,000 per 3 years

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:

U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1- 877-267-2323 x61565 or www.cciio.cms.gov. 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: the Member Service number listed on the back of your ID card or myuhc.com.

Additionally, a consumer assistance program may help you file your appeal. Contact 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 1-877-805-1970.

Traditional Chinese (中文): 如果需要中文的幫助, 請撥打這個號碼 1-877-805-1970.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-805-1970.

Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf 1-877-805-1970 uff.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-805-1970.

Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-877-805-1970.

Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-877-805-1970.

Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-877-805-1970.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

http://www.dol.gov/ebsa http://www.cciio.cms.gov/ http://www.healthcare.gov/ http://www.myuhc.com/ http://www.myuhc.com/ https://www.dol.gov/ebsa/healthreform

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6

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)

◼ The plan’s overall deductible $750 ◼ Specialist copay $55 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Specialist office visits (pre-natal 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 $750

Copayments $0

Coinsurance $2,100

What isn’t covered

Limits or exclusions $70

The total Peg would pay is $2,920

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

◼ The plan’s overall deductible $750 ◼ Specialist copay $55

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:

Deductibles $250

Copayments $300

Coinsurance $0

What isn’t covered

Limits or exclusions $4,300

The total Joe would pay is $4,850

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

◼ The plan’s overall deductible $750 ◼ Specialist copay $55

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:

Deductibles $750

Copayments $600

Coinsurance $100

What isn’t covered

Limits or exclusions $10

The total Mia would pay is $1,460 https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist

We do not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil

Rights Coordinator.

Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to

8 p.m.

mailto:UHC_Civil_Rights@uhc.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html