City of Sun Prairie 2026 Renewal Folder.pdf

January 1, 2026 Renewal for:

Presented by: Al Jaeger

Usi Insurance Services Llc

Large Group Renewal

CITY OF SUN PRAIRIE

Group Health Cooperative of South Central Wisconsin

Michele Vollmer

City Of Sun Prairie

300 E Main St

Sun Prairie, WI 53590

Dear Michele Vollmer, CC: Al Jaeger

Usi Insurance Services Llc

August 2025

Thank you for selecting Group Health Cooperative of South Central Wisconsin (GHC-SCW) as a health care provider for your employees and their families.

The following pages outline your January 1, 2026 renewal, an overall increase of 5.67%.

The Notice of Changes and Clarifications describing universal benefit changes, certificate clarifications, and cost-sharing changes to GHC-SCW's Large Group plans is provided. In addition, the Cost-Sharing Change Summary, highlighting the cost-sharing changes that affect your plan(s), is included. Please review these documents.

We look forward to continuing to provide impeccable service to you and your group.

Sincerely, GHC-SCW Sales Team

2026 Underwriting Renewal Exhibit

Group Name: CITY OF SUN PRAIRIE

Corp ID: 447

Renewal Date: January 1, 2026

Plan Type: Blended

Claims Rx Claims Total Claims

Average

Members

3,334,253 441,097 3,775,350 651

Prior Recent

Risk Margin

Rating 2025 2026

1.50%

$0

Premium with ACA fees $4,972,877 $5,399,958

Blended Claims Projection 4,799,439

Calculated Overall Rate Increase 8.59%

ACA Fees $0

Final Overall Premium

Final Overall Rate Increase 5.67%

$4,972,877

Pooling Costs 32,544

$5,254,839

Recent Members 678

Premium

Admin Costs 567,974

Claims Projection Plus Admin 5,399,958

$4,972,877 $5,399,958

Claims Trended to Renewal Rating Period 0 4,370,519

Total Expected Claims 0 4,545,340

Benefit and Size Adjustment - -

Underwriting Adjustment 1.000

Weighted Prior and Recent 0% 100%

Experience Credibility 82%

Manual Claims Projection 5,562,961

Employer Claims Projection 4,545,340

Claims Reporting Period

Pooled Claims 0 0

3,775,350

0 3,775,350

1/1/2024 - 12/31/2024

Claims 0

Adjusted Incurred Claims

Blended - 8/18/2025

Corp ID: 447

Renewal Date:

Plan Type: Blended

Final Overall Rate Increase

HMO Rates PPO Rates

Premium Breakdown 2025 2026 Premium Breakdown 2025 2026 Premium Breakdown 2025 2026 Premium Breakdown 2025 2026

Employee $753.93 $796.68 0 $0.00 $0.00 Employee $1,018.28 $1,076.02 0 $0.00 $0.00

Family $1,941.39 $2,051.47 0 $0.00 $0.00 Family $2,621.29 $2,769.92 0 $0.00 $0.00

Employee $640.84 $677.18 0 $0.00 $0.00 Employee $865.53 $914.61 0 $0.00 $0.00

Employee +1 (1on) $1,394.76 $1,473.84 0 $0.00 $0.00 Employee +1 (1on) $1,883.81 $1,990.62 0 $0.00 $0.00

Employee +1 (2on) $1,281.67 $1,354.34 0 $0.00 $0.00 Employee +1 (2on) $1,731.07 $1,829.22 0 $0.00 $0.00

Family $1,828.30 $1,931.96 0 $0.00 $0.00 Family $2,468.55 $2,608.52 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 #REF! $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

Better Together - PCP $500 Ded/$1,000 MOOP - Medicare PPO - PCP $500 Ded/$1,000 MOOP - Medicare

Renewal Rates TableJanuary 1, 2026

Better Together - PCP $500 Ded/$1,000 MOOP PPO - PCP $500 Ded/$1,000 MOOP

5.67%

Rates - 8/18/2025

Corp ID: 447

Renewal Date: January 1, 2026

Plan Type: HMO

Claims Rx Claims Total Claims

Average

Members

2,874,990 400,325 3,275,315 583

Prior Recent

Risk Margin

Rating 2025 2026

Recent Members

Manual Claims Projection

1.04

ACA Fees $0$0

100%

Total Expected Claims

Benefit and Size Adjustment 1.00

0%

3,921,804

Employer Claims Projection

Admin Costs

Weighted Prior and Recent

1/1/2024 - 12/31/2024

Claims

Pooled Claims

3,275,315

Claims Reporting Period

3,921,804

Pooling Costs 29,136

Underwriting Adjustment 1.000

1.50%

Premium $4,681,510$4,358,236

Calculated Overall Rate Increase

Premium with ACA fees $4,681,510$4,358,236

7.42%

Adjusted Incurred Claims

0 3,770,965

3,275,3150

Claims Trended to Renewal Rating Period

4,681,510

508,496

82%

4,815,331

Claims Projection Plus Admin

Experience Credibility

4,143,878Blended Claims Projection

HMO - 8/18/2025

Corp ID: 447

Renewal Date: January 1, 2026

Plan Type: PPO

Claims Rx Claims Total Claims

Average

Members

459,263 40,772 500,035 68

Prior Recent

Risk Margin

Rating 2025 2026

Claims Projection Plus Admin

655,561

59,478

718,447

16.89%

ACA Fees

Recent Members

Premium

Calculated Overall Rate Increase

Premium with ACA fees $614,641 $718,447

$0

Manual Claims Projection

Experience Credibility

Blended Claims Projection

Admin Costs

Pooling Costs

Underwriting Adjustment

623,536

0% 100%

0 599,554

Claims Reporting Period

0 500,035

0 0

Adjusted Incurred Claims

Claims Trended to Renewal Rating Period

1/1/2024 - 12/31/2024

Claims

Pooled Claims

Employer Claims Projection 623,536

1.00 1.04

0 500,035

Benefit and Size Adjustment

Total Expected Claims

Weighted Prior and Recent

$614,641 $718,447

747,630

82%

$0

3,408

1.000

1.50%

PPO - 8/18/2025

Current Subscriber/Member Count Employer Name: CITY OF SUN PRAIRIE

Employer ID: 447 Coverage Date: 2025 July

Single Family(A) TOTALS

ALL PLAN GROUPS COMBINED Subs Members Subs Members Subs Members

COMBINED TOTAL 86 86 174 592 260 678

OVERALL

Single Family(A) TOTALS

Network Benefit Plan ID

Plan Group ID Plan Group Name Subs Members Subs Members Subs Members

Better Together HMO 2502739 7764000 CITY OF SUN PRAIRIE 82 82 155 521 237 603

7764100 CITY OF SUN PRAIRIE-RETIREE 2 2 1 2 3 4

2502739 84 84 156 523 240 607

Better Together HMO - Total 84 84 156 523 240 607

Connections PPO 2503819 7764001 CITY OF SUN PRAIRIE-PPO 2 2 18 69 20 71

2503819 2 2 18 69 20 71

Connections PPO - Total 2 2 18 69 20 71

2026 Renewal Plan Options

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2502739* Renewal Plan: 2602739* Alternate 1: 2691864* Alternate 2: 2691865* Alternate 3: 2691866*

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Member $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit

Family $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit

Member $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit $4,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit

Family $2,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit $4,000 No Out-of-Network Benefit $8,000 No Out-of-Network Benefit $4,000 No Out-of-Network Benefit

Member

Family

20% No Out-of-Network Benefit 20% No Out-of-Network Benefit 20% No Out-of-Network Benefit 20% No Out-of-Network Benefit 20% No Out-of-Network Benefit

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit

$75 No Out-of-Network Benefit $75 No Out-of-Network Benefit $75 No Out-of-Network Benefit $75 No Out-of-Network Benefit $75 No Out-of-Network Benefit

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge

$250 $250 $250 $250 $250 $250 $250 $250 $250 $250

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Tier 1 $10 $10 $10 $10 $10

Tier 2 $30 $30 $30 $30 $30

Tier 3 $50 $50 $50 $50 $50

Tier 4 (Specialty) $100 $100 $100 $100 $100

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit

Premium Breakdown Current Subs Rates Rates Rates

Employee 84 $773.56 $753.60 $771.20

Family 156 $1,991.95 $1,940.55 $1,985.85

Monthly Total $375,723.24 $366,028.20 $374,573.40

Annual Total $4,508,678.88 $4,392,338.40 $4,494,880.80

Increase of 5.67% Increase of 2.60% Decrease of -0.04% Increase of 2.29%

Benefit Change Premium Credit/Charge Decrement Credit of 2.90% Credit of 5.41% Credit of 3.20%

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2602739* Alternate 1: 2691864* Alternate 2: 2691865* Alternate 3: 2691866*

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

Premium Adjustment to Current

Hospital Services

Inpatient Hospital Services

Outpatient Hospital Services

$4,394,243.52

$366,186.96

$1,941.39

$753.93

Renewal RatesCurrent Rates

Better Together HMO Primary Care Preferred

$1,000 Ded/$2,000 MOOP

Core Benefits

Deductible

Maximum Out-of-Pocket

Pharmacy Maximum

Out-of-Pocket

Better Together HMO Primary Care Preferred

$500 Ded/$4,000 MOOP

HMO Better Together HMO Primary Care Preferred

$500 Ded/$1,000 MOOP

Better Together HMO Primary Care Preferred

$500 Ded/$2,000 MOOP

Better Together Better Together HMO Primary Care Preferred

$500 Ded/$1,000 MOOP

August 2025

January 1, 2026

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

Clinic Services

Primary Care Office Visit

Emergency and Urgent Care

Urgent Care Visit

Outpatient Rehabilitation Therapy (PT/OT)

Policy Coinsurance

Specialist Care Office Visit

Advanced Radiology

Emergency Room Visit

X-ray, Diag Imaging, Outpatient Lab

$796.68

$4,643,405.28

$386,950.44

$2,051.47

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2502739* Renewal Plan: 2602739* Alternate 1: 2691864* Alternate 2: 2691865* Alternate 3: 2691866*

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Member $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit

Family $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit

Member $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit $4,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit

Family $2,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit $4,000 No Out-of-Network Benefit $8,000 No Out-of-Network Benefit $4,000 No Out-of-Network Benefit

Member

Family

20% No Out-of-Network Benefit 20% No Out-of-Network Benefit 20% No Out-of-Network Benefit 20% No Out-of-Network Benefit 20% No Out-of-Network Benefit

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit

$75 No Out-of-Network Benefit $75 No Out-of-Network Benefit $75 No Out-of-Network Benefit $75 No Out-of-Network Benefit $75 No Out-of-Network Benefit

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge

$250 $250 $250 $250 $250 $250 $250 $250 $250 $250

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Tier 1 $10 $10 $10 $10 $10

Tier 2 $30 $30 $30 $30 $30

Tier 3 $50 $50 $50 $50 $50

Tier 4 (Specialty) $100 $100 $100 $100 $100

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit

Premium Breakdown Current Subs Rates Rates Rates

Employee $657.53 $640.56 $655.52

Employee +1 (1on) $1,431.08 $1,394.15 $1,426.69

Employee +1 (2on) $1,315.04 $1,281.11 $1,311.02

Family $1,875.90 $1,827.50 $1,870.16

Monthly Total $0.00 $0.00 $0.00

Annual Total $0.00 $0.00 $0.00

Increase of 5.67% -- -- -- -- -- --

Benefit Change Premium Credit/Charge Decrement Credit of 2.90% Credit of 5.41% Credit of 3.20%

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2602739* Alternate 1: 2691864* Alternate 2: 2691865* Alternate 3: 2691866*

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

0 $0.00 $0.00

$0.00 $0.00

Premium Adjustment to Current

$1,394.76 $1,473.84

$1,281.67 $1,354.34

$1,828.30 $1,931.96

Urgent Care Visit

Emergency Room Visit

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

Hospital Services

Inpatient Hospital Services

Outpatient Hospital Services

Current Rates Renewal Rates

$640.84 $677.18

Emergency and Urgent Care

Better Together HMO Primary Care Preferred

$500 Ded/$4,000 MOOP

Better Together HMO Primary Care Preferred

$1,000 Ded/$2,000 MOOP

Core Benefits

Deductible

Maximum Out-of-Pocket

Pharmacy Maximum

Out-of-Pocket

Policy Coinsurance

Clinic Services

Primary Care Office Visit

Specialist Care Office Visit

Advanced Radiology

X-ray, Diag Imaging, Outpatient Lab

Outpatient Rehabilitation Therapy (PT/OT)

January 1, 2026

August 2025

Medicare HMO Better Together HMO Primary Care Preferred

$500 Ded/$1,000 MOOP

Better Together HMO Primary Care Preferred

$500 Ded/$1,000 MOOP

Better Together HMO Primary Care Preferred

$500 Ded/$2,000 MOOP

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2503819* Renewal Plan: 2603819* Alternate 1: 2693864* Alternate 2: 2693865* Alternate 3: 2693866*

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Member $500 $1,000 $500 $1,000 $500 $1,000 $500 $1,000 $1,000 $2,000

Family $1,000 $2,000 $1,000 $2,000 $1,000 $2,000 $1,000 $2,000 $2,000 $4,000

Member $1,000 $2,000 $1,000 $2,000 $2,000 $4,000 $4,000 $8,000 $2,000 $4,000

Family $2,000 $4,000 $2,000 $4,000 $4,000 $8,000 $8,000 $16,000 $4,000 $8,000

Member

Family

20% 40% 20% 40% 20% 40% 20% 40% 20% 40%

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible

$75 40% after Deductible $75 40% after Deductible $75 40% after Deductible $75 40% after Deductible $75 40% after Deductible

No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible

No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible

No Charge 40% after Deductible No Charge 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge

$250 $250 $250 $250 $250 $250 $250 $250 $250 $250

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Tier 1 $10 $10 $10 $10 $10

Tier 2 $30 $30 $30 $30 $30

Tier 3 $50 $50 $50 $50 $50

Tier 4 (Specialty) $100 $100 $100 $100 $100

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible

Premium Breakdown Current Subs Rates Rates Rates

Employee 2 $1,044.80 $1,017.84 $1,041.60

Family 18 $2,689.55 $2,620.15 $2,681.32

Monthly Total $50,501.50 $49,198.38 $50,346.96

Annual Total $606,018.00 $590,380.56 $604,163.52

Increase of 5.67% Increase of 2.60% Decrease of -0.04% Increase of 2.29%

Benefit Change Premium Credit/Charge Decrement Credit of 2.90% Credit of 5.41% Credit of 3.20%

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2603819* Alternate 1: 2693864* Alternate 2: 2693865* Alternate 3: 2693866*

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

Premium Adjustment to Current

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

$2,621.29 $2,769.92

20 $49,219.78 $52,010.60

$590,637.36 $624,127.20

Inpatient Hospital Services

Outpatient Hospital Services

Current Rates Renewal Rates

$1,018.28 $1,076.02

Hospital Services

Pharmacy Maximum

Out-of-Pocket

Policy Coinsurance

Clinic Services

Primary Care Office Visit

Specialist Care Office Visit

Advanced Radiology

Emergency and Urgent Care

Urgent Care Visit

Emergency Room Visit

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

X-ray, Diag Imaging, Outpatient Lab

Outpatient Rehabilitation Therapy (PT/OT)

Connections PPO Primary Care Preferred $500

Ded/$4,000 MOOP

Connections PPO Primary Care Preferred $1,000

Ded/$2,000 MOOP

Core Benefits

Deductible

Connections PPO Primary Care Preferred $500

Ded/$1,000 MOOP

Maximum Out-of-Pocket

January 1, 2026

August 2025

PPO Connections PPO Primary Care Preferred $500

Ded/$1,000 MOOP

Connections PPO Primary Care Preferred $500

Ded/$2,000 MOOP

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2503819* Renewal Plan: 2603819* Alternate 1: 2693864* Alternate 2: 2693865* Alternate 3: 2693866*

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Member $500 $1,000 $500 $1,000 $500 $1,000 $500 $1,000 $1,000 $2,000

Family $1,000 $2,000 $1,000 $2,000 $1,000 $2,000 $1,000 $2,000 $2,000 $4,000

Member $1,000 $2,000 $1,000 $2,000 $2,000 $4,000 $4,000 $8,000 $2,000 $4,000

Family $2,000 $4,000 $2,000 $4,000 $4,000 $8,000 $8,000 $16,000 $4,000 $8,000

Member

Family

20% 40% 20% 40% 20% 40% 20% 40% 20% 40%

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible

$75 40% after Deductible $75 40% after Deductible $75 40% after Deductible $75 40% after Deductible $75 40% after Deductible

No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible

No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible No Charge 40% after Deductible

No Charge 40% after Deductible No Charge 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge

$250 $250 $250 $250 $250 $250 $250 $250 $250 $250

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Tier 1 $10 $10 $10 $10 $10

Tier 2 $30 $30 $30 $30 $30

Tier 3 $50 $50 $50 $50 $50

Tier 4 (Specialty) $100 $100 $100 $100 $100

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible

Premium Breakdown Current Subs Rates Rates Rates

Employee $888.07 $865.16 $885.35

Employee +1 (1on) $1,932.86 $1,882.99 $1,926.94

Employee +1 (2on) $1,776.14 $1,730.31 $1,770.71

Family $2,532.83 $2,467.48 $2,525.08

Monthly Total $0.00 $0.00 $0.00

Annual Total $0.00 $0.00 $0.00

Increase of 5.67% -- -- -- -- -- --

Benefit Change Premium Credit/Charge Decrement Credit of 2.90% Credit of 5.41% Credit of 3.20%

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2603819* Alternate 1: 2693864* Alternate 2: 2693865* Alternate 3: 2693866*

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

0 $0.00 $0.00

$0.00 $0.00

Premium Adjustment to Current

$1,883.81 $1,990.62

$1,731.07 $1,829.22

$2,468.55 $2,608.52

Urgent Care Visit

Emergency Room Visit

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

Hospital Services

Inpatient Hospital Services

Outpatient Hospital Services

Current Rates Renewal Rates

$865.53 $914.61

Emergency and Urgent Care

Connections PPO Primary Care Preferred $500

Ded/$4,000 MOOP

Connections PPO Primary Care Preferred $1,000

Ded/$2,000 MOOP

Core Benefits

Deductible

Maximum Out-of-Pocket

Pharmacy Maximum

Out-of-Pocket

Policy Coinsurance

Clinic Services

Primary Care Office Visit

Specialist Care Office Visit

Advanced Radiology

X-ray, Diag Imaging, Outpatient Lab

Outpatient Rehabilitation Therapy (PT/OT)

January 1, 2026

August 2025

Medicare PPO Connections PPO Primary Care Preferred $500

Ded/$1,000 MOOP

Connections PPO Primary Care Preferred $500

Ded/$1,000 MOOP

Connections PPO Primary Care Preferred $500

Ded/$2,000 MOOP

Employer Name

Plan Type

HMO

In-Network Out-of-Network In-Network Out-of-Network

ACA Maximum Out-of-Pocket (MOOP) - Individual $1,000 $1,000

High Deductible Health Plan (HDHP)

Deductible - Individual N/A N/A

High Deductible Health Plan (HDHP)

Maximum Out-of-Pocket (MOOP) - Individual N/A N/A

Plan Specific Benefit Realignment In-Network Out-of-Network In-Network Out-of-Network

2026 GHC-SCW Cost-Sharing Change Summary

Renewal Date

1/1/2026

2025 Plan Number 2026 Plan Number

Notice Of Change Benefit Benefit Under Current Plan Benefit for 2026

2502739 2602739

Employer Name

Plan Type

PPO

In-Network Out-of-Network In-Network Out-of-Network

ACA Maximum Out-of-Pocket (MOOP) - Individual $1,000 $2,000 $1,000 $2,000

High Deductible Health Plan (HDHP)

Deductible - Individual N/A N/A N/A N/A

High Deductible Health Plan (HDHP)

Maximum Out-of-Pocket (MOOP) - Individual N/A N/A N/A N/A

Plan Specific Benefit Realignment In-Network Out-of-Network In-Network Out-of-Network

Outpatient Prescription Drugs Tier 1 $10 No Out-of-Network Benefit $10 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 2 $30 No Out-of-Network Benefit $30 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 3 $50 No Out-of-Network Benefit $50 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 4 $100 No Out-of-Network Benefit $100 No Out-of-Network Benefit

2026 GHC-SCW Cost-Sharing Change Summary

Renewal Date

1/1/2026

2025 Plan Number 2026 Plan Number

Notice Of Change Benefit Benefit Under Current Plan Benefit for 2026

2503819 2603819

2026 NOTICE OF COST-SHARING CHANGES

Large Group Member Certificate and Plans – Partners HMO & Better Together HMO

Notice of Cost-Sharing Changes/2026 Large Group Partners HMO & Better Together HMO Plans Group Health Cooperative of South Central Wisconsin (GHC-SCW)

Group Health Cooperative of South Central Wisconsin (GHC-SCW) continually monitors Federal and State rules and regulations to ensure our plan design and benefits are compliant. Certain changes and clarifications outlined below reflect ongoing requirements of the Patient Protection and Affordable Care Act and other changes to Federal and State rules and regulations.

This Notice of Cost-Sharing Changes provides a list of significant Cost-Sharing Changes to GHC-SCW’s 2026 Large Group Partners HMO and Better Together HMO plans with an effective date on or after January 1, 2026. A Cost-Sharing Change communicates a change to a Member’s out-of-pocket cost for a covered Benefit. A Cost-Sharing Change does not result in a change to the Benefit covered, only the cost of utilizing such Benefit. Not all communicated Cost-Sharing Changes will affect all plans.

2026 COST-SHARING CHANGES

Benefit Plan Type 2026 Cost-Sharing Change

ACA Maximum Out-of-Pocket (MOOP)

All 2025 Plans with an In- Network Individual MOOP of $9,200

The In-Network ACA Maximum Out-of-Pocket (MOOP) for an Individual is increasing from $9,200 to $10,600. Based on plan benefit design, plans with an In-Network Individual MOOP of $9,200 will be increasing to $10,600. Family MOOPs will also reflect an increase. Please see Your Benefit Summary for Your plan’s Family MOOP.

2025 Individual ACA MOOP: $9,200 2026 Individual ACA MOOP: $10,600

High Deductible Health Plan (HDHP) Deductible

All 2025 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual Deductible of $1,650 or In-Network Family Deductible of $3,300

The High Deductible Health Plan (HDHP) (HSA-eligible) Deductible for an Individual is increasing from $1,650 to $1,700 and for a Family is increasing from $3,300 to $3,400.

Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual Deductible of $1,650 will be increasing to $1,700 and those with an In-Network Family Deductible of $3,300 will be increasing to $3,400.

2025 Individual HDHP Deductible: $1,650 2026 Individual HDHP Deductible: $1,700 2025 Family HDHP Deductible: $3,300 2026 Family HDHP Deductible: $3,400

High Deductible Health Plan (HDHP) Maximum Out-of- Pocket (MOOP)

All 2025 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual MOOP of $8,300

The High Deductible Health Plan (HDHP) (HSA-eligible) Maximum Out-of-Pocket (MOOP) for an Individual is increasing from $8,300 to $8,500. Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual MOOP of $8,300 will be increasing to $8,500. Family MOOPs will also reflect an increase. Please see Your Benefit Summary for Your plan’s Family MOOP.

2025 Individual HDHP MOOP: $8,300 2026 Individual HDHP MOOP: $8,500

For a complete description of services and coverage, please refer to your 2026 Large Group Member Certificate, Benefit Summary, Summary of Benefit and Coverage (“SBC”), Formulary, and any applicable Amendments. Your plan documents are available at http://planfinder.ghcscw.com/.

http://planfinder.ghcscw.com/

2026 NOTICE OF COST-SHARING CHANGES

Large Group Member Certificate and Plans – Connections PPO

Notice of Cost-Sharing Changes/2026 Large Group Connections PPO Plans Group Health Cooperative of South Central Wisconsin (GHC-SCW)

Group Health Cooperative of South Central Wisconsin (GHC-SCW) continually monitors Federal and State rules and regulations to ensure our plan design and benefits are compliant. Certain changes and clarifications outlined below reflect ongoing requirements of the Patient Protection and Affordable Care Act and other changes to Federal and State rules and regulations.

This Notice of Cost-Sharing Changes provides a list of significant Cost-Sharing Changes to GHC-SCW’s 2026 Large Group Connections PPO plans with an effective date on or after January 1, 2026. A Cost-Sharing Change communicates a change to a Member’s out-of-pocket cost for a covered Benefit. A Cost-Sharing Change does not result in a change to the Benefit covered, only the cost of utilizing such Benefit. Not all communicated Cost-Sharing Changes will affect all plans.

2026 COST-SHARING CHANGES

Benefit Plan Type 2026 Cost-Sharing Change

ACA Maximum Out-of-Pocket (MOOP)

All 2025 Plans with an In- Network Individual MOOP of $9,200

The In-Network ACA Maximum Out-of-Pocket (MOOP) for an Individual is increasing from $9,200 to $10,600. Based on plan benefit design, plans with an In-Network Individual MOOP of $9,200 will be increasing to $10,600. Family and Out-Of-Network MOOPs will also reflect an increase. Please see Your Benefit Summary for Your plan’s Family and Out-of-Network MOOPs.

2025 Individual ACA MOOP: $9,200 2026 Individual ACA MOOP: $10,600

High Deductible Health Plan (HDHP) Deductible

All 2025 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual Deductible of $1,650 or In-Network Family Deductible of $3,300

The High Deductible Health Plan (HDHP) (HSA-eligible) Deductible for an Individual is increasing from $1,650 to $1,700 and for a Family is increasing from $3,300 to $3,400.

Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual Deductible of $1,650 will be increasing to $1,700 and those with an In-Network Family Deductible of $3,300 will be increasing to $3,400. Out-of-Network MOOPs will also reflect an increase. Please see Your Benefit Summary for Your plan’s Out-of-Network MOOPs.

2025 Individual HDHP Deductible: $1,650 2026 Individual HDHP Deductible: $1,700 2025 Family HDHP Deductible: $3,300 2026 Family HDHP Deductible: $3,400

High Deductible Health Plan (HDHP) Maximum Out-of- Pocket (MOOP)

All 2025 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual MOOP of $8,300

The High Deductible Health Plan (HDHP) (HSA-eligible) Maximum Out-of-Pocket (MOOP) for an Individual is increasing from $8,300 to $8,500. Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual MOOP of $8,300 will be increasing to $8,500. Family and Out-of-Network MOOPs will also reflect an increase.

Please see Your Benefit Summary for Your plan’s Family and Out-of-Network MOOPs.

2025 Individual HDHP MOOP: $8,300 2026 Individual HDHP MOOP: $8,500

For a complete description of services and coverage, please refer to your 2026 Large Group Member Certificate, Benefit Summary, Summary of Benefit and Coverage (“SBC”), Formulary, and any applicable Amendments. Your plan documents are available at http://planfinder.ghcscw.com/.

http://planfinder.ghcscw.com/

Clinic Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Primary Care Office Visits No No Charge Not Covered Example: Office visits with Your Primary Care

Provider (PCP) Chiropractic Office Visits No No Charge Not Covered Preventive Health Examinations No No Charge Not Covered Coverage is limited to preventive services as defined by the Affordable Care Act.

Specialist Care Office Visits Yes $75 Not Covered Examples: Specialist Hearing Exams, Autism Spectrum

Specialist Office Visit; Most Specialists do not require Prior Authorization

Preventive Immunizations No No Charge Not Covered Coverage is limited to preventive services as defined by the Affordable Care Act.

Prenatal and Postnatal Maternity Care

No No Charge Not Covered In-Network cost-sharing value is limited to preventive services. Cost-sharing described elsewhere in this Benefit Summary may apply depending on the maternity-related test or service.

Diagnostic X-Ray and Laboratory Tests

Yes No Charge Not Covered X-rays and routine lab tests ordered by Your Provider do not require Prior Authorization.

Advanced Radiology Yes No Charge Not Covered Examples: CT, PET Scans, MRIs

Emergency and Urgent Care Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Urgent Care Visits No No Charge No Charge Emergency Ambulance Service (air/ground)

No 20% after Deductible 20% after Deductible Coverage is limited to emergency care

Emergency Room Visits No $250 $250 Coverage is limited to emergency care; Copayment waived if admitted as a hospital inpatient

Prescription Drugs Tier You Pay In-Network You Pay Out-of-Network Benefit Notes Outpatient Prescription Drugs on GHC-SCW Formulary

Prior Authorizations, quantity limits, step therapy, age restrictions and other limits may apply

Tier 1 $10 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Some brand names and many generics;

Drugs in Tier 1 are the greatest value

Tier 2 $30 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Many brand names and some generics

Tier 3 $50 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; There are often similar or equivalent drugs in either Tier 1 or Tier 2

Tier 4 (Specialty)

$100 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; May require the use of a specialty-designated pharmacy

The Prescription Drugs Benefit is administered by GHC-SCW Clinic pharmacies and Navitus. Prescription Drugs are NOT COVERED outside of the GHC-SCW network of providers. For a list of formulary drugs, tier ($) placement, prior authorization requirements and other limitations that may apply, see https://www.ghcscw.com.

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Diabetic Disposable Supplies No 20% up to maximum Not Covered Member pays Coinsurance up to $500 maximum Durable Medical Equipment Yes 20% Not Covered

Better Together HMO Primary Care Preferred $500 Ded/$1,000 MOOP

Plan Number: 2502739 Benefits Accumulate on a Plan Year.

Policy Coinsurance In-Network: 20% Out-of-Network: Not Covered

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible Not Covered Not Covered In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) Not Covered Not Covered

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Hearing Aids for Members age 18 and over

Yes 20% Not Covered Limited to one hearing aid per ear per 36 months;

GHC-SCW designates specific models or other cost limitations may apply

Hearing Aids for children age 17 and under

Yes 20% Not Covered Limited to one hearing aid per ear per 36 months

Cochlear Implants and Bone Anchored Hearing Aids

Yes 20% after Deductible Not Covered

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Hospital Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Inpatient Hospital Services: Physician Services, Surgery, Facility Fees

Yes 20% after Deductible Not Covered

Outpatient Hospital Surgical/Non- Surgical Services, Facility Fees

Yes 20% after Deductible Not Covered Certain oral surgeries do not require Prior Authorization

Skilled Nursing Facility Services Yes 20% after Deductible Not Covered Limited to 30 days per inpatient stay per Member Bariatric Surgery Yes 20% after Deductible Not Covered

Vision Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Vision Examinations No No Charge Not Covered Routine Eye Examinations must be provided by an In-

Network Optometrist (OD); Limited to one eye exam per Member per year

Mental Health & Substance Use Disorder Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Mental Health/Substance Use Disorder Outpatient Services

No No Charge Not Covered Prior Authorization is required for Health Psychology, Diagnostic Testing, ECT, and TMS. All services may be subject to ongoing review for medical necessity.

Mental Health/Substance Use Disorder Inpatient Services

Yes 20% after Deductible Not Covered

Mental Health/Substance Use Disorder Transitional Services

Yes 20% after Deductible Not Covered

Dental Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Accidental Dental No 20% after Deductible Not Covered Initial repair of accidental injury to sound, natural teeth Oral Surgeries Yes 20% after Deductible Not Covered Certain oral surgeries do not require Prior

Authorization

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Hospice Yes 20% after Deductible Not Covered Example: End of Life Services Home Health Services Yes 20% after Deductible Not Covered Limited to 60 visits per Member per year Health Counseling Education No No Charge Not Covered Conception Services No 50% up to maximum Not Covered Lifetime Benefit maximum payment of $2,000 by

GHC-SCW, which is accrued by GHC-SCW paying 50% Coinsurance of the first $4,000 of Conception Services

Speech Therapy Yes No Charge Not Covered Includes Rehabilitation and Habilitation Therapy;

Limited to 20 visits per therapy per Member per year

Year.

Policy Coinsurance In-Network: 20% Out-of-Network: Not Covered

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible Not Covered Not Covered In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) Not Covered Not Covered

CSC16-25-01-1(06/16)C 2025 Benefit Summary (Page 2 of 3) GHC-2502739-BR

Outpatient Habilitation Therapy Yes No Charge Not Covered Includes Physical and Occupational Therapy; Limited to 40 combined visits per Member per year; See Certificate for additional information

Cardiac Rehabilitation Therapy Yes No Charge Not Covered Limited to 36 visits per Member per year Outpatient Rehabilitation Therapy Yes No Charge Not Covered Includes Physical and Occupational Therapy; Limited to 40 combined visits per Member per year; See Certificate for additional information

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Benefit Summary Notes Prior Authorizations

Prior Authorization is required when services are not provided in a primary care setting by an In-Network Provider. Prior Authorization does not guarantee that services will be fully covered. Coverage is determined by the terms and conditions of the Certificate. Please refer to your Member Certificate for Benefits that require Prior Authorization. In addition, services and items requiring Prior Authorization are listed on GHC-SCW’s website at https://www.ghcscw.com.

It is the Member’s responsibility to ensure a Prior Authorization has been obtained when required. Failure to obtain Prior Authorization when required may result in the Member receiving a reduction in or no Benefit. To obtain Prior Authorization, call (608) 257-5294.

Provider Information For Providers see the "Find a Provider" link at https://www.ghcscw.com or contact Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504.

In-Network Providers: For a list of In-Network Providers, see the "Find a Provider" link at https://www.ghcscw.com or contact Member Services at (608)

828-4853 or (800) 605-4327, ext. 4504.

Out-of-Network Providers: Out-of-Network Providers are not covered under an HMO plan, unless Prior Authorization has been acquired for such services.

GHC-SCW Notices to Members Qualified Maximum Dependent Age: Dependents are covered until the end of the month at age 26.

This is only a summary. You are responsible for knowing the full Benefits and provisions of your policy. Please read all documents carefully including your

Member Certificate, Formulary, Benefit Summary and Summary of Benefits and Coverage (SBC). To find these documents, visit https://www.ghcscw.com or contact Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504.

Questions or Concerns?

For any questions or concerns regarding your benefits, please visit https://www.ghcscw.com, or contact Member Services at (608) 828-4853 or (800)

605-4327, ext. 4504.

Year.

Policy Coinsurance In-Network: 20% Out-of-Network: Not Covered

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible Not Covered Not Covered In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) Not Covered Not Covered

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Clinic Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Primary Care Office Visits No No Charge 40% after Deductible Example: Office visits with Your Primary Care

Provider (PCP) Chiropractic Office Visits No No Charge 40% after Deductible Preventive Health Examinations No No Charge 40% after Deductible Coverage is limited to preventive services as defined by the Affordable Care Act.

Specialist Care Office Visits No $75 40% after Deductible Example: Specialist Hearing Exams Preventive Immunizations No No Charge 40% after Deductible Coverage is limited to preventive services as defined by the Affordable Care Act.

Prenatal and Postnatal Maternity Care

No No Charge 40% after Deductible In-Network cost-sharing value is limited to preventive services. Cost-sharing described elsewhere in this Benefit Summary may apply depending on the maternity-related test or service.

Diagnostic X-Ray and Laboratory Tests

Yes No Charge 40% after Deductible X-rays and routine lab tests ordered by Your Provider do not require Prior Authorization.

Advanced Radiology Yes No Charge 40% after Deductible Examples: CT, PET Scans, MRIs

Emergency and Urgent Care Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Urgent Care Visits No No Charge No Charge Emergency Ambulance Service (air/ground)

No 20% after Deductible 20% after Deductible Coverage is limited to emergency care

Emergency Room Visits No $250 $250 Coverage is limited to emergency care; Copayment waived if admitted as a hospital inpatient

Prescription Drugs Tier You Pay In-Network You Pay Out-of-Network Benefit Notes Outpatient Prescription Drugs on GHC-SCW Formulary

Prior Authorizations, quantity limits, step therapy, age restrictions and other limits may apply

Tier 1 $10 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Some brand names and many generics;

Drugs in Tier 1 are the greatest value

Tier 2 $30 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Many brand names and some generics

Tier 3 $50 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; There are often similar or equivalent drugs in either Tier 1 or Tier 2

Tier 4 (Specialty)

$100 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; May require the use of a specialty-designated pharmacy

The Prescription Drugs Benefit is administered by GHC-SCW Clinic pharmacies and Navitus. Prescription Drugs are NOT COVERED outside of the GHC-SCW network of providers. For a list of formulary drugs, tier ($) placement, prior authorization requirements and other limitations that may apply, see https://www.ghcscw.com.

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Diabetic Disposable Supplies No 20% up to maximum Not Covered Member pays Coinsurance up to $500 maximum Durable Medical Equipment Yes 20% 40% after Deductible Hearing Aids for Members age 18 and over

Yes 20% 40% after Deductible Limited to one hearing aid per ear per 36 months;

GHC-SCW designates specific models or other cost limitations may apply

Connections PPO Primary Care Preferred $500 Ded/$1,000

MOOP

Plan Number: 2503819

Year.

Policy Coinsurance In-Network: 20% Out-of-Network: 40%

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible $1,000 $2,000 In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) $2,000 $4,000

CSC16-25-01-1(06/16)C 2025 Benefit Summary (Page 1 of 3) PPO-2503819-BR https://ghcscw.com/SiteCollectionDocuments/GHC_SCW_4_Tier_Complete_Formulary.pdf

Hearing Aids for children age 17 and under

Yes 20% 40% after Deductible Limited to one hearing aid per ear per 36 months

Cochlear Implants and Bone Anchored Hearing Aids

Yes 20% after Deductible 40% after Deductible

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Hospital Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Inpatient Hospital Services: Physician Services, Surgery, Facility Fees

Yes 20% after Deductible 40% after Deductible

Outpatient Hospital Surgical/Non- Surgical Services, Facility Fees

Yes 20% after Deductible 40% after Deductible Certain oral surgeries do not require Prior Authorization

Skilled Nursing Facility Services Yes 20% after Deductible 40% after Deductible Limited to 30 days per inpatient stay per Member Bariatric Surgery Yes 20% after Deductible 40% after Deductible

Vision Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Vision Examinations No No Charge 40% after Deductible Routine Eye Examinations must be provided by an

Optometrist (OD); Limited to one eye exam per Member per year

Mental Health & Substance Use Disorder Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Mental Health/Substance Use Disorder Outpatient Services

No No Charge 40% after Deductible

Mental Health/Substance Use Disorder Inpatient Services

Yes 20% after Deductible 40% after Deductible

Mental Health/Substance Use Disorder Transitional Services

Yes 20% after Deductible 40% after Deductible

Dental Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Accidental Dental No 20% after Deductible 40% after Deductible Initial repair of accidental injury to sound, natural teeth Oral Surgeries Yes 20% after Deductible 40% after Deductible Certain oral surgeries do not require Prior

Authorization

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Hospice Yes 20% after Deductible 40% after Deductible Example: End of Life Services Home Health Services Yes 20% after Deductible 40% after Deductible Limited to 60 visits per Member per year Health Counseling Education No No Charge 40% after Deductible Conception Services No 50% up to maximum 50% up to maximum Lifetime Benefit maximum payment of $2,000 by

GHC-SCW, which is accrued by GHC-SCW paying 50% Coinsurance of the first $4,000 of…