City of Round Rock Medical

Choice Plan

Effective: January 1, 2025

Group Number: 925175 i

Table of Contents Summary Plan Description

What Is the Summary Plan Description?

Can This SPD Change?

Other Information You Should Have

Introduction to Your SPD What Are Defined Terms?

How Do You Use This Document?

How Do You Contact the Claims Administrator?

Your Responsibilities Enrollment and Required Contributions Be Aware the Plan Does Not Pay for All Health Care Services Decide What Services You Should Receive Choose Your Physician Obtain Prior Authorization Pay Your Share Pay the Cost of Excluded Services Show Your ID Card File Claims with Complete and Accurate Information Use Your Prior Health Care Coverage

Claims Administrator and Plan Sponsor Responsibilities Determine Benefits Process Payment for the Plan's Portion of the Cost of Covered Health Care Services Process Plan Payment to Network Providers Process Plan Payment for Covered Health Care Services Provided by Out-of-Network Providers Review and Determine Benefits in Accordance with the Claims Administrator's Reimbursement Policies Offer Health Education Services to You

United Healthcare Services, Inc Schedule of Benefits

How Do You Access Benefits?

Does Prior Authorization Apply?

What Will You Pay for Covered Health Care Services?

Payment Term and Description Table Schedule of Benefits Table Allowed Amounts Provider Network Designated Providers Health Care Services from Out-of-Network Providers Limitations on Selection of Providers

Section 1: Covered Health Care Services When Are Benefits Available for Covered Health Care Services?

Acupuncture Services Ambulance Services Cellular and Gene Therapy Clinical Trials Congenital Heart Disease (CHD) Surgeries Convenience Care Clinics Dental Services - Accident Only Diabetes Services ii

Durable Medical Equipment (DME), Orthotics and Supplies Emergency Health Care Services - Outpatient Enteral Nutrition Fertility Preservation for Iatrogenic Infertility Gender Dysphoria Habilitative Services Hearing Aids Home Health Care Hospice Care Hospital - Inpatient Stay Lab, X-Ray and Diagnostic - Outpatient Major Diagnostic and Imaging - Outpatient Mental Health Care and Substance-Related and Addictive Disorders Services Obesity - Weight Loss Surgery Ostomy Supplies Pharmaceutical Products - Outpatient Physician Fees for Surgical and Medical Services Physician's Office Services - Sickness and Injury Pregnancy - Maternity Services Preimplantation Genetic Testing (PGT-M and PGT-SR) and Related Services Preventive Care Services Private Duty Nursing - Outpatient Prosthetic Devices Radial Keratotomy Lasik Procedure Reconstructive Procedures Rehabilitation Services - Outpatient Therapy and Manipulative Treatment Scopic Procedures - Outpatient Diagnostic and Therapeutic Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Surgery - Outpatient Temporomandibular Joint (TMJ) Services Therapeutic Treatments - Outpatient Transplantation Services Urgent Care Center Services Urinary Catheters Virtual Care Services Wigs

Section 2: Exclusions and Limitations How Are Headings Used in this Section?

Plan Does Not Pay Benefits for Exclusions Where Are Benefit Limitations Shown?

Alternative Treatments Dental Devices, Appliances and Prosthetics Drugs Experimental or Investigational or Unproven Services Foot Care Gender Dysphoria Medical Supplies and Equipment Mental Health Care and Substance-Related and Addictive Disorders Nutrition Personal Care, Comfort or Convenience Physical Appearance Procedures and Treatments Providers iii

Reproduction Services Provided under another Plan Transplants Travel Types of Care Vision and Hearing All Other Exclusions

Section 3: When Coverage Begins How Do You Enroll?

Cost of Coverage What If You Are Hospitalized When Your Coverage Begins?

What If You Are Eligible for Medicare?

Who Is Eligible for Coverage?

Eligible Person Dependent When Do You Enroll and When Does Coverage Begin?

Initial Enrollment Period Open Enrollment Period New Eligible Persons Adding New Dependents Special Enrollment Period

Section 4: When Coverage Ends General Information about When Coverage Ends What Events End Your Coverage?

Fraud or Intentional Misrepresentation of a Material Fact Coverage for a Disabled Dependent Child Continuation of Coverage

Section 5: How to File a Claim Claims Procedures How Are Covered Health Care Services from Network Providers Paid?

How Are Covered Health Care Services from an Out-of-Network Provider Paid?

How Are Outpatient Prescription Drug Benefits Paid?

Required Information Payment of Benefits

Section 6: Questions, Complaints and Appeals What if You Have a Question?

What if You Have a Complaint?

How Do You Appeal a Claim Decision?

Post-service Claims Pre-service Requests for Benefits How to Request an Appeal Appeal Process Appeals Determinations Pre-service Requests for Benefits and Post-service Claim Appeals Urgent Appeals that Require Immediate Action External Review Program Standard External Review Expedited External Review Urgent Care Request for Benefits* Type of Request for Benefits or Appeal Timing Pre-Service Request for Benefits* Type of Request for Benefits or Appeal iv

Timing Post-Service Claims Type of Claim or Appeal Timing

Section 7: Coordination of Benefits Benefits When You Have Coverage under More than One Plan When Does Coordination of Benefits Apply?

What Are the Rules for Determining the Order of Benefit Payments?

How Are Benefits Paid When This Plan is Secondary?

How is the Allowable Expense Determined when this Plan is Secondary?

What is Different When You Qualify for Medicare?

Medicare Crossover Program Right to Receive and Release Needed Information?

Does This Plan Have the Right of Recovery?

Section 8: General Legal Provisions What Is Your Relationship with the Claims Administrator and Plan Sponsor?

What Is the Claims Administrator's Relationship with Providers and Plan Sponsors?

What Is Your Relationship with Providers and Plan Sponsors?

Notice Statements by the Plan Sponsor or Participants Does the Claims Administrator Pay Incentives to Providers?

Are Incentives Available to You?

Does the Claims Administrator Receive Rebates and Other Payments?

Who Interprets Benefits and Other Provisions under the Plan?

Who Provides Administrative Services?

What is the Future of the Plan?

Amendments to the Plan How Does the Claims Administrator Use Information and Records?

Does the Plan Require Examination of Covered Persons?

Is Workers' Compensation Affected?

How Are Benefits Paid When You Are Medicare Eligible?

Subrogation and Reimbursement When Does the Plan Receive Refunds of Overpayments?

Is There a Limitation of Action?

What Is the Entire Plan?

Section 9: Defined Terms Clinical Programs and Resources

Care Management Solutions Personal Health Support Complex Medical Conditions, Programs and Services Bariatric Resource Services (BRS) Cancer Resource Services (CRS) Program Congenital Heart Disease (CHD) Resource Services Kidney Disease Programs Transplant Resource Services (TRS) Program Complex Medical Conditions Travel and Lodging Assistance Program for the Covered Health Services Described Below Decision Support Disease Management Reminder Programs Women's Health/Reproductive Maternity Support Program Consumer Solutions and Self-Service Tools v www.myuhc.com Health Survey UnitedHealth Premium® Designation Program

Outpatient Prescription Drug Plan Schedule of Benefits When Are Benefits Available for Prescription Drug Products?

What Happens When a Brand-name Drug Becomes Available as a Generic?

What Happens When a Biosimilar Product Becomes Available for a Reference Product?

How Do Supply Limits Apply?

Do Prior Authorization Requirements Apply?

What Do You Pay?

Payment Information

Outpatient Prescription Drug Plan Coverage Policies and Guidelines Identification Card (ID Card) - Network Pharmacy Designated Pharmacies When Does the Claims Administrator Limit Selection of Pharmacies?

Rebates and Other Payments Coupons, Incentives and Other Communications Special Programs Maintenance Medication Program Prescription Drug Products Prescribed by a Specialist

Benefits for Prescription Drug Products Outpatient Prescription Drug Plan Exclusions Outpatient Prescription Drug Defined Terms Your Right to Request an Exception for Contraceptives

Amendments, Riders and Notices (As Applicable) Amendment: Wellness Federal Notice

City of Round Rock Medical and Outpatient Prescription Drugs Plan

1 Summary Plan Description

Summary Plan Description

United Healthcare Services, Inc.

What Is the Summary Plan Description?

This Summary Plan Description (SPD) is a summary of the Covered Health Care Services available to you under the City of Round Rock ("Plan Sponsor") Self-Funded health benefit plan. This SPD is a legal document that describes Benefits for the portion of the Plan for which United Healthcare Services, Inc.

("Claims Administrator") administers claims payment, either directly or in conjunction with one of the Claims Administrator's affiliates.

For the purposes of this provision "Self-Funded" means that the Plan Sponsor, on behalf of the Plan, has the sole responsibility to pay, and provide funds, to pay for all Plan benefits. The Claims Administrator has no liability or responsibility to provide these funds. The Claims Administrator is a private healthcare claims administrator. The Claims Administrator is not the Plan Administrator for the Plan. Although the Claims Administrator will assist you in many ways, it does not guarantee any Benefits. The Plan Sponsor is solely responsible for the benefit plan design and funding payment of Benefits.

In addition to this SPD, the Plan includes:

• The Schedule of Benefits.

• Amendments.

• Addendums.

• Summary Material Modifications (SMM).

If there should be an inconsistency between the contents of this summary and the Plan, your rights shall be determined under the Plan and not under this summary. A copy of the plan document is available for your inspection during regular business hours in the office of the Plan Administrator. You (or your personal representative) may obtain a copy of the official plan document by written request to the Plan Administrator, for a nominal charge.

Can This SPD Change?

The Plan Sponsor may, from time to time, change this SPD by attaching legal documents called SMMs and/or Amendments that may change certain provisions of this SPD. When this happens the Plan Sponsor will send you a new SPD, Amendment, Addendums or SMMs.

Other Information You Should Have The Plan Sponsor intends to continue this Plan, but reserves the right, in its sole discretion, to change, interpret, withdraw or add Benefits, or to end the Plan, as permitted by law, without your approval subject to any collective bargaining agreements, if applicable.

On its effective date, this SPD replaces and overrules any SPD that the Plan Sponsor may have previously issued to you. This SPD will in turn be overruled by any SPD issued to you in the future.

The Plan is not subject to ERISA. To the extent other federal law (e.g. PHSA, IRC) does not apply, TX- Texas law governs the Plan.

2 Introduction to Your SPD

Introduction to Your SPD This SPD and the other Plan documents describe your Benefits, as well as your rights and responsibilities, under the Plan.

What Are Defined Terms?

Certain capitalized words have special meanings. The Plan Sponsor has defined these words in Section 9: Defined Terms.

When the Plan Sponsor uses the words "you" and "your," the Plan Sponsor is referring to people who are Covered Persons, as that term is defined in Section 9: Defined Terms.

How Do You Use This Document?

Read your entire SPD and any attached Amendments, Addendums or SMMs. You may not have all of the information you need by reading just one section. Keep your SPD and Schedule of Benefits and any attachments in a safe place for your future reference. You can also get this SPD at www.myuhc.com.

Review the Benefit limitations of this SPD by reading the attached Schedule of Benefits along with Section 1: Covered Health Care Services and Section 2: Exclusions and Limitations. Read Section 8:

General Legal Provisions to understand how this SPD and your Benefits work. Call the Claims Administrator if you have questions about the limits of the coverage available to you.

If there is a conflict between this SPD and any summaries provided to you by the Plan Sponsor, this SPD controls.

Please be aware that your Physician is not responsible for knowing or communicating your Benefits.

How Do You Contact the Claims Administrator?

Call the telephone number listed on your identification (ID) card. Throughout the document you will find statements that encourage you to contact the Claims Administrator for more information.

3 Your Responsibilities

Your Responsibilities Enrollment and Required Contributions Benefits are available to you if you are enrolled for coverage under the Plan. Your enrollment options, and the corresponding dates that coverage begins, are listed in Section 3: When Coverage Begins. To be enrolled and receive Benefits, both of the following apply:

• Your enrollment must be in accordance with the requirements of the Plan issued to your Plan Sponsor, including the eligibility requirements.

• You must qualify as a Participant or a Dependent as those terms are defined in Section 9: Defined Terms.

Your Plan Sponsor may require you to make certain payments to them, in order for you to remain enrolled under the Plan. If you have questions about this, contact your Plan Sponsor.

Be Aware the Plan Does Not Pay for All Health Care Services The Plan does not pay for all health care services. Benefits are limited to Covered Health Care Services.

The Schedule of Benefits will tell you the portion you must pay for Covered Health Care Services.

Decide What Services You Should Receive Care decisions are between you and your Physician. The Claims Administrator and the Plan Sponsor do not make decisions about the kind of care you should or should not receive.

Choose Your Physician It is your responsibility to select the health care professionals who will deliver your care. The Claims Administrator arranges for Physicians and other health care professionals and facilities to participate in a Network. The Claims Administrator's credentialing process confirms public information about the professionals' and facilities' licenses and other credentials, but does not assure the quality of their services. These professionals and facilities are independent practitioners and entities that are solely responsible for the care they deliver.

Obtain Prior Authorization Some Covered Health Care Services require prior authorization. Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization. For detailed information on the Covered Health Care Services that require prior authorization, please refer to the Schedule of Benefits.

Pay Your Share You must meet any applicable deductible and pay a Copayment and/or Coinsurance for most Covered Health Care Services. These payments are due at the time of service or when billed by the Physician, provider or facility. Any applicable deductible, Copayment and Coinsurance amounts are listed in the Schedule of Benefits.

Pay the Cost of Excluded Services You must pay the cost of all excluded services and items. Review Section 2: Exclusions and Limitations to become familiar with the Plan's exclusions.

4 Your Responsibilities

Show Your ID Card You should show your ID card every time you request health care services. If you do not show your ID card, the provider may fail to bill the correct entity for the services delivered.

File Claims with Complete and Accurate Information When you receive Covered Health Care Services from an out-of-Network provider, you are responsible for requesting payment from the Plan. You must file the claim in a format that contains all of the information the Claims Administrator requires to process the claim, as described in Section 5: How to File a Claim.

Use Your Prior Health Care Coverage If you have prior coverage that, as required by state law, extends benefits for a particular condition or a disability, the Plan will not pay Benefits for health care services for that condition or disability until the prior coverage ends. The Plan will pay Benefits as of the day your coverage begins under the Plan for all other Covered Health Care Services that are not related to the condition or disability for which you have other coverage.

5 Claims Administrator and Plan Sponsor Responsibilities

Claims Administrator and Plan Sponsor Responsibilities

Determine Benefits Plan Sponsor and the Claims Administrator make administrative decisions regarding whether the Plan will pay for any portion of the cost of a health care service you intend to receive or have received. Plan Sponsor's and the Claims Administrator's decisions are for payment purposes only. Plan Sponsor and the Claims Administrator do not make decisions about the kind of care you should or should not receive. You and your providers must make those treatment decisions.

Plan Sponsor and the Claims Administrator have the discretion to do the following:

• Interpret Benefits and the other terms, limitations and exclusions set out in this SPD, the Schedule of Benefits and any SMMs and/or Amendments.

• Make factual determinations relating to Benefits.

Plan Sponsor and the Claims Administrator may assign this discretionary authority to other persons or entities including Claims Administrator's affiliates that may provide administrative services for the Plan, such as claims processing. The identity of the service providers and the nature of their services may be changed from time to time in Plan Sponsor's and the Claims Administrator's discretion. In order to receive Benefits, you must cooperate with those service providers.

Process Payment for the Plan's Portion of the Cost of Covered Health Care Services The Claims Administrator processes the Plan's payment of Benefits for Covered Health Care Services as described in Section 1: Covered Health Care Services and in the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations. This means the Claims Administrator processes only the payment of the Plan's portion of the cost of Covered Health Care Services. It also means that not all of the health care services you receive may be paid for (in full or in part) by the Plan.

Process Plan Payment to Network Providers It is the responsibility of Network Physicians and facilities to file for payment from the Plan. When you receive Covered Health Care Services from Network providers, you do not have to submit a claim to the Plan.

Process Plan Payment for Covered Health Care Services Provided by Out-of-Network Providers The Claims Administrator processes the Plan's payment of Benefits after receiving your request for payment that includes all required information. See Section 5: How to File a Claim.

Review and Determine Benefits in Accordance with the Claims Administrator's Reimbursement Policies The Claims Administrator adjudicates claims consistent with industry standards. The Claims Administrator develops its reimbursement policy guidelines, in its sole discretion, generally in accordance with one or more of the following methodologies:

• As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).

6 Claims Administrator and Plan Sponsor Responsibilities

• As reported by generally recognized professionals or publications.

• As used for Medicare.

• As determined by medical staff and outside medical consultants pursuant to other appropriate sources or determinations that the Claims Administrator accepts.

Following evaluation and validation of certain provider billings (e.g., error, abuse and fraud reviews), the Claims Administrator's reimbursement policies are applied to provider billings. The Claims Administrator shares its reimbursement policies with Physicians and other providers in the Claims Administrator's Network through the Claims Administrator's provider website. Network Physicians and providers may not bill you for the difference between their contract rate (as may be modified by the Claims Administrator's reimbursement policies) and the billed charge. However, out-of-Network providers may bill you for any amounts the Plan does not pay, including amounts that are denied because one of the Claims Administrator's reimbursement policies does not reimburse (in whole or in part) for the service billed. You may get copies of the Claims Administrator's reimbursement policies for yourself or to share with your out-of-Network Physician or provider by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card.

The Claims Administrator may apply a reimbursement methodology established by OptumInsight and/or a third party vendor, which is based on CMS coding principles, to determine appropriate reimbursement levels for Emergency Health Care Services. The methodology is usually based on elements reflecting the patient complexity, direct costs, and indirect costs of an Emergency Health Care Service. If the methodology(ies) currently in use become no longer available, the Claims Administrator will use comparable methodology(ies). The Claims Administrator and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to the Claims Administrator's website at www.myuhc.com for information regarding the vendor that provides the applicable methodology.

Offer Health Education Services to You The Claims Administrator may provide you with access to information about additional services that are available to you, such as disease management programs, health education and patient advocacy. It is solely your decision whether to take part in the programs, but it is recommended that you discuss them with your Physician.

7 Schedule of Benefits Set 003

UnitedHealthcare Choice

United Healthcare Services, Inc.

Schedule of Benefits How Do You Access Benefits?

Designated Network Benefits apply to Covered Health Care Services that are provided by a provider or facility that has been identified as a Designated Provider. Designated Network Benefits are available only for specific Covered Health Care Services as shown in the Schedule of Benefits table below.

Network Benefits apply to Covered Health Care Services that are provided by a Network Physician or other Network provider. You are not required to select a Primary Care Physician in order to obtain Benefits.

Emergency Health Care Services provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits.

Covered Health Care Services provided at certain Network facilities by an out-of-Network Physician, when not Emergency Health Care Services, will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. For these Covered Health Care Services, "certain Network facility" is limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

Air Ambulance transport provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits.

You must show your identification card (ID card) every time you request health care services from a Network provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under the Plan. As a result, they may bill you for the entire cost of the services you receive.

Additional information about the network of providers and how your Benefits may be affected appears at the end of this Schedule of Benefits.

If there is a conflict between this Schedule of Benefits and any summaries provided to you by the Plan Sponsor, this Schedule of Benefits will control.

Does Prior Authorization Apply?

The Claims Administrator requires prior authorization for certain Covered Health Care Services. Network providers are responsible for obtaining prior authorization before they provide these services to you.

Network facilities and Network providers cannot bill you for services they do not prior authorize as required. You can call the Claims Administrator at the telephone number on your ID card.

What Will You Pay for Covered Health Care Services?

Benefits for Covered Health Care Services are described in the tables below.

Annual Deductibles are calculated on a calendar year basis.

Out-of-Pocket Limits are calculated on a calendar year basis.

8 Schedule of Benefits Set 003

When Benefit limits apply, the limit stated includes Covered Health Care Services provided at a Designated Network Benefit level unless otherwise specifically stated.

Benefit limits are calculated on a calendar year basis unless otherwise specifically stated.

Payment Term and Description Table Payment Term And Description Amounts The Amount You Pay Designated

Network and Network

Annual Deductible

The amount you pay for Covered Health Care Services per year before you are eligible to receive Benefits.

Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible.

Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible.

The amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table.

$500 per Covered Person, not to exceed $1,500 for all Covered Persons in a family.

Out-of-Pocket Limit

9 Schedule of Benefits Set 003

Payment Term And Description Amounts The Amount You Pay Designated

Network and Network

The maximum you pay per year for the Annual Deductible, Copayments or Coinsurance. Once you reach the Out-of- Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year. The Out-of-Pocket Limit applies to Covered Health Care Services under the Plan as indicated in this Schedule of Benefits, including Covered Health Care Services provided under the Outpatient Prescription Drug Plan.

Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table.

The Out-of-Pocket Limit does not include any of the following and, once the Out-of-Pocket Limit has been reached, you still will be required to pay the following:

• Any charges for non-Covered Health Care Services.

• Charges that exceed Allowed Amounts, or the Recognized Amount when applicable.

• Copayments or Coinsurance for any Covered Health Care Service shown in the Schedule of Benefits table that does not apply to the Out-of-Pocket Limit.

Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Out-of-Pocket Limit.

Network

$2,500 per Covered Person, not to exceed $5,000 for all Covered Persons in a family.

The Out-of-Pocket Limit includes the Annual Deductible.

Copayment

Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Copayments apply, the amount is listed on the following pages next to the description for each Covered Health Care Service.

Please note that for Covered Health Care Services, you are responsible for paying the lesser of:

• The applicable Copayment.

• The Allowed Amount, or the Recognized Amount when applicable.

Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table.

Coinsurance

Coinsurance is the amount you pay (calculated as a percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive certain Covered Health Care Services.

Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table.

10 Schedule of Benefits Set 003

Schedule of Benefits Table When Benefit limits apply, the limit stated includes Covered Health Care Services provided at a Designated Network Benefit level unless otherwise specifically stated.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in Section 9: Defined Terms. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Acupuncture Services

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

$25 per visit Benefit is only covered if provided as a form of anesthesia in connection with a covered surgical procedure.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

No

Ambulance Services

Emergency Ambulance

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

Ground Ambulance:

10%

Air Ambulance:

10%

Allowed Amounts for ground and Air Ambulance transport provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Does the Amount You Pay

Apply to the Out-of-Pocket Limit?

Ground Ambulance:

Yes

Air Ambulance:

Yes

Does the Annual Deductible Apply?

Ground Ambulance:

Yes

Air Ambulance:

Yes

Non-Emergency Ambulance

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

Ground Ambulance:

10%

Air Ambulance:

10%

Ground or Air Ambulance, as the Claims Administrator determines appropriate.

Allowed Amounts for ground and Air Ambulance transport

11 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Ground Ambulance:

Yes

Air Ambulance:

Yes provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits.

Does the Annual Deductible Apply?

Ground Ambulance:

Yes

Air Ambulance:

Yes

Cellular and Gene Therapy

Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.

Cellular or Gene Therapy services must be received from a Designated Provider.

Clinical Trials

Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.

Depending upon the Covered Health Care Service, Benefit limits are the same as those stated under the specific Benefit category in this Schedule of Benefits.

Congenital Heart Disease (CHD) Surgeries

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Benefits under this section include only the inpatient facility charges for the CHD surgery.

Depending upon where the Covered Health Care Service is provided, Benefits for diagnostic services, cardiac catheterization and non-surgical management of CHD will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Convenience Care Clinic

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Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

None

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

No

Does the Annual Deductible Apply?

No

Dental Services - Accident Only

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Diabetes Services

Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care

Depending upon where the Covered Health Care Service is provided, Benefits for diabetes self-management and training/diabetic eye exams/foot care will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.

Diabetes Self-Management Items

Depending upon where the Covered Health Care Service is provided, Benefits for diabetes self-management items will be the same as those stated under Durable Medical Equipment (DME), Orthotics and Supplies and in the Outpatient Prescription Drug Plan.

Benefits for diabetes equipment that meets the definition of DME are subject to the limit stated under Durable Medical Equipment (DME), Orthotics and Supplies.

Durable Medical Equipment (DME), Orthotics and Supplies

13 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Benefits are limited to a single purchase of a type of DME or orthotic every three years.

Repair and/or replacement of DME or orthotics would apply to this limit in the same manner as a purchase. This limit does not apply to wound vacuums.

Benefits for dedicated speech generating devices and tracheo-esophageal voice devices are limited to the purchase of one device during the entire period of time a Covered Person is enrolled under the Plan. Benefits for repair/replacement are limited to once every three years.

You must obtain the DME or orthotic from the vendor the Claims Administrator identifies or from the prescribing Network Physician.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Emergency Health Care Services - Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% after you pay $300 per visit.

Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify the Claims Administrator within one business day or on the same day of admission if reasonably

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

14 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Does the Annual Deductible Apply?

Yes possible. The Claims Administrator may elect to transfer you to a Network Hospital as soon as it is medically appropriate to do so. If you choose to stay in the out-of- Network Hospital after the date the Claims Administrator decides a transfer is medically appropriate, Benefits will not be provided.

If you are admitted as an inpatient to a Hospital directly from the Emergency room, the Benefits provided as described under Hospital - Inpatient Stay will apply. You will not have to pay the Emergency Health Care Services Copayment, Coinsurance and/or deductible.

Allowed Amounts for Emergency Health Care Services provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits.

Enteral Nutrition

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Fertility Preservation for Iatrogenic Infertility

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Limited to $20,000 per Covered Person during the entire period of time he or she is enrolled for coverage under the Plan. This Benefit limit will be the same as and combined with those stated under Preimplantation Genetic Testing (PGT) and Related

Does the Amount You Pay Apply to the Out-of-Pocket

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Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Does the Annual Deductible Apply?

Yes Services.

Gender Dysphoria

Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits and in the Outpatient Prescription Drug Plan.

Habilitative Services

Inpatient Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.

Inpatient services limited per year as follows:

Limit will be the same as, and combined with, those stated under Skilled Nursing Facility/Inpatient Rehabilitation Services.

Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

$35 per visit Outpatient therapies:

• Physical therapy.

• Occupational therapy.

• Manipulative Treatment.

• Speech therapy.

• Post-cochlear implant aural therapy.

• Cognitive therapy.

For the above outpatient therapies:

Limits will be the same as, and combined with, those stated under Rehabilitation Services - Outpatient Therapy and Manipulative Treatment.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

No

Hearing Aids

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Limited to $4,000 every year.

16 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Home Health Care

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Limited to 120 visits per year.

One visit equals up to four hours of skilled care services.

This visit limit does not include any service which is billed only for the administration of intravenous infusion

For the administration of intravenous infusion, you must receive services from a provider the Claims Administrator identifies.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Hospice Care

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Hospital - Inpatient Stay

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Lab, X-Ray and Diagnostic - Outpatient

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Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Lab Testing - Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

If performed during an office visit, it will be included in the PCP/Specialist Copay for that visit. No additional cost share should apply.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

X-Ray and Other Diagnostic Testing - Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

If performed during an office visit, it will be included in the PCP/Specialist Copay for that visit. No additional cost share should apply.

Limit?

Yes

Does the Annual Deductible Apply?

No

Major Diagnostic and Imaging - Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Mental Health Care and Substance-Related and Addictive Disorders Services

Inpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, 10%

18 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

Office Visits $35 per visit

All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Treatment:

10%

Intensive Behavioral Therapy $35 per visit

Limit?

Office Visits Yes

All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Treatment Yes

Intensive Behavioral Therapy Yes

Does the Annual Deductible Apply?

Office Visits No

All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Treatment Yes

Intensive Behavioral Therapy No

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Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Virtual Behavioral Health Therapy and Coaching

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

Designated Network

AbleTo:

None

There are no deductibles, Copayments or Coinsurance you must meet or pay for when receiving these services.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

No

Does the Annual Deductible Apply?

No

Obesity - Weight Loss Surgery

Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.

Ostomy Supplies

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Pharmaceutical Products - Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Physician Fees for Surgical and Medical Services

20 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Allowed Amounts for Covered Health Care Services provided by an out-of-Network facility based Physician in a Network Facility will be determined as described below under Allowed Amounts in this Schedule of Benefits.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Physician's Office Services - Sickness and Injury

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

For Covered Persons under the age of 19:

None per visit for a Primary Care Physician office visit or $35 per visit for a Specialist office visit

For Covered Persons age 19 and older:

$25 per visit for a Primary Care Physician office visit or $35 per visit for a Specialist office visit

Home visits and Allergy Injections:

10%

Copayment/Coinsurance and any deductible for the following services also apply when the Covered Health Care Service is performed in a Physician's office:

• Lab, radiology/X-rays and other diagnostic services described under Lab, X- Ray and Diagnostic - Outpatient.

• Major diagnostic and nuclear medicine described under Major Diagnostic and Imaging - Outpatient.

• Outpatient Pharmaceutical Products described under

Does the Amount You Pay Apply to the Out-of-Pocket

21 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Does the Annual Deductible Apply?

No

Home visits and Allergy Injections:

Yes

Pharmaceutical Products

- Outpatient.

• Diagnostic and therapeutic scopic procedures described under Scopic Procedures

- Outpatient Diagnostic and Therapeutic.

• Outpatient surgery procedures described under Surgery - Outpatient.

• Outpatient therapeutic procedures described under Therapeutic Treatments - Outpatient.

• Rehabilitation therapy procedures described under Rehabilitation Services - Outpatient Therapy and Manipulative Treatment.

• Habilitative therapy services described under Habilitative Services.

Pregnancy - Maternity Services

Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.

Preimplantation Genetic Testing (PGT) and Related Services

Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Limited to $20,000 per Covered Person during the entire period of time he or she is enrolled for coverage under the Plan. This limit does not include Preimplantation Genetic Testing (PGT) for the specific genetic disorder. This limit includes

Does the Amount You Pay Apply to the Out-of-Pocket

22 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Does the Annual Deductible Apply?

Yes Benefits for related services as described under Fertility Preservation for Iatrogenic Infertility.

This limit includes Benefits for ovarian stimulation medications provided under the Outpatient Prescription Drug Plan.

Preventive Care Services

Physician office services

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

None

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

No

Does the Annual Deductible Apply?

No

Lab, X-ray or other preventive tests

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

None

PSA Screenings:

None

Limit?

No

Does the Annual Deductible Apply?

No

Breast pumps

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

None

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

No

Does the Annual Deductible Apply?

23 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Private Duty Nursing - Outpatient

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Limited to 70 visits a year with each visit equaling up to a 8 hour visit.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Prosthetic Devices

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Benefits are limited to a single purchase of each type of prosthetic device every three years. Repair and/or replacement of a prosthetic device would apply to this limit in the same manner as a purchase.

Once this limit is reached, Benefits continue to be available for items required by the Women's Health and Cancer Rights Act of 1998.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Radial Keratotomy Lasik Procedure

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

50% Limited to $1,500 per lifetime.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Reconstructive Procedures

Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care

24 Schedule of Benefits Set 003

Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

Rehabilitation Services - Outpatient Therapy and Manipulative Treatment

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, $35 per visit

Manipulative Treatment received at Airrosti:

None

Limited per year as follows:

• 60 visits combined of physical therapy, occupational therapy, and speech therapy.

• 20 Manipulative Treatments.

• 20 visits of pulmonary rehabilitation therapy.

• 36 visits of cardiac rehabilitation therapy.

• 30 visits of post-cochlear implant aural therapy.

• 20 visits of cognitive rehabilitation therapy.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Scopic Procedures - Outpatient Diagnostic and Therapeutic

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Colonoscopies:

None

Limit?

Yes

Does the Annual Deductible Apply?

Yes

Colonoscopies:

No

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10% Limited to 100 days per year.

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Surgery - Outpatient

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Covered Health Care Service The Amount You Pay Designated Network and Network

What are the Limitations & Exceptions?

What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both.

10%

Does the Amount You Pay Apply to the Out-of-Pocket Limit?

Yes

Does the Annual Deductible Apply?

Yes

Temporomandibular Joint (TMJ) Services

Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care

Therapeutic Treatments -…