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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2025 – 06/30/2026 Coverage for: Single & Family I Plan Type: PPO Dallas County PPO 05/15/2025;07/01/2025;PL001997;RL004248;189199-77;189199-78;00055829;N;NGF Page 1 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.wellmark.com or call 1-[PHONE REDACTED]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-[PHONE REDACTED] to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? $200 person/$400 family per calendar year. Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Well-child care, preventive care, in- network independent labs for mental health/substance abuse, in-network prosthetic limbs, mammograms, laboratory services performed at Dallas County Hospital and services subject to health and drug card copayments are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive- care-benefits/. Are there other deductibles for specific services? No. There are no other deductibles. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? Health: $1,500 person/$3,000 family per calendar year. Drug Card: $1,500 person/$3,000 family per calendar year. The In-Network health and drug card out-of-pocket maximum amounts accumulate together. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. 10 ---PAGE BREAK--- 05/15/2025;07/01/2025;PL001997;RL004248;189199-77;189199-78;00055829;N;NGF Page 2 For more information about limitations and exceptions, see your plan document or call Wellmark at 1-[PHONE REDACTED]. Important Questions Answers Why this Matters: Will you pay less if you use a network provider? Yes. See www.wellmark.com or call 1- [PHONE REDACTED] for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay In-Network (IN) Provider (You will pay the least) What You Will Pay Out-of-Network (OON) Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $15 copay per date of service 30% coinsurance Waive copay and apply deductible and coinsurance to office surgery. Specialist visit $15 copay per date of service 30% coinsurance Waive copay and apply deductible and coinsurance to office surgery. Hearing exams are covered according to ACA guidelines. Preventive care/screening/ immunization No charge 0% coinsurance One preventive exam and one Pap smear per calendar year. Well-child care is covered to age 7. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 30% coinsurance For a test in a provider's office or clinic, your cost is included in the cost-share listed above. Waive cost-share for mammograms. Waive cost-share on in-network independent lab services for mental health/substance abuse. Waive cost-share for lab services performed at Dallas County Hospital when labs are the only services billed. Imaging (CT/PET scans, MRIs) 20% coinsurance 30% coinsurance For a test in a provider's office or clinic, your cost is included in the cost-share listed above. 11 ---PAGE BREAK--- 05/15/2025;07/01/2025;PL001997;RL004248;189199-77;189199-78;00055829;N;NGF Page 3 For more information about limitations and exceptions, see your plan document or call Wellmark at 1-[PHONE REDACTED]. Common Medical Event Services You May Need What You Will Pay In-Network (IN) Provider (You will pay the least) What You Will Pay Out-of-Network (OON) Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.wellmark.com/ prescriptions. Tier 1 $10 copay per prescription $10 copay per prescription Refer to your Blue Rx Complete Drug List to determine the tier that applies to a covered drug. For out-of-network prescription drugs, you may be balance billed. 1 copay for 30-day supply. 1 copay for 90-day supply (retail and mail order). Waive cost-share for oral chemotherapy medications. Waive cost-share for over-the-counter (OTC) medications when prescribed by a physician. Waive cost-share for immunizations and flu vaccines obtained at a participating pharmacy under your drug card plan. Weight loss drugs are covered subject to pre- authorization. Specialty drugs are covered only when obtained through the CVS Specialty Pharmacy Program. See wellmark.com/prescriptions for information about drugs and drug quantities that require prior authorization by Wellmark to be covered by your plan. Tier 2 $40 copay per prescription $40 copay per prescription Tier 3 $60 copay per prescription $60 copay per prescription Tier 4 $100 copay per prescription $100 copay per prescription Specialty drugs Same as cost-share above depending on drug category. Not Covered If you have outpatient surgery Facility fee ambulatory surgery center) 20% coinsurance 30% coinsurance Physician/surgeon fees 20% coinsurance 30% coinsurance 12 ---PAGE BREAK--- 05/15/2025;07/01/2025;PL001997;RL004248;189199-77;189199-78;00055829;N;NGF Page 4 For more information about limitations and exceptions, see your plan document or call Wellmark at 1-[PHONE REDACTED]. Common Medical Event Services You May Need What You Will Pay In-Network (IN) Provider (You will pay the least) What You Will Pay Out-of-Network (OON) Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you need immediate medical attention Emergency room care 20% coinsurance 20% coinsurance For emergency medical conditions treated out-of-network, it is likely you may not be balance billed pursuant to the federal rules developed for implementation of the No Surprises Act. Emergency medical transportation 20% coinsurance 20% coinsurance For covered non-emergent situations, out-of-network ground ambulance services are NOT reimbursed at the in- network level. You may be balance billed for any out-of- network service as established under the rules developed for implementation of the No Surprises Act. Urgent care $15 copay per date of service for facility and physician(s) combined 30% coinsurance If you have a hospital stay Facility fee hospital room) 20% coinsurance 30% coinsurance Physician/surgeon fees 20% coinsurance 30% coinsurance If you need mental health, behavioral health, or substance abuse services Outpatient services Office: $15 copay per date of service Facility: 20% coinsurance 30% coinsurance Inpatient services 20% coinsurance 30% coinsurance If you are pregnant Office visits 20% coinsurance 30% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Cost sharing does not apply for preventive services. For any in-network services that fall outside of routine obstetric care, the office visit benefits shown above may apply. Childbirth/delivery professional services 20% coinsurance 30% coinsurance Benefits shown reflect OB/GYN practitioner services which are typically globally billed at time of delivery for pre-natal, post-natal and delivery services. Childbirth/delivery facility services 20% coinsurance 30% coinsurance 13 ---PAGE BREAK--- 05/15/2025;07/01/2025;PL001997;RL004248;189199-77;189199-78;00055829;N;NGF Page 5 For more information about limitations and exceptions, see your plan document or call Wellmark at 1-[PHONE REDACTED]. Common Medical Event Services You May Need What You Will Pay In-Network (IN) Provider (You will pay the least) What You Will Pay Out-of-Network (OON) Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you need help recovering or have other special health needs Home health care 20% coinsurance 30% coinsurance Rehabilitation services Office: $15 copay per date of service Facility: 20% coinsurance 30% coinsurance Waive office copay and apply deductible and coinsurance to in-network inhalation/respiratory therapies and cardiac rehabilitation. Habilitation services Office: $15 copay per date of service Facility: 20% coinsurance 30% coinsurance Waive office copay and apply deductible and coinsurance to in-network inhalation/respiratory therapies and cardiac rehabilitation. Skilled nursing care 20% coinsurance 30% coinsurance Durable medical equipment 20% coinsurance 30% coinsurance Trusses are covered. Hospice services 20% coinsurance 30% coinsurance Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime. If your child needs dental or eye care Children’s eye exam Not covered Not covered Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered 14 ---PAGE BREAK--- 05/15/2025;07/01/2025;PL001997;RL004248;189199-77;189199-78;00055829;N;NGF Page 6 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic surgery • Custodial care - in home or facility • Dental care - Adult • Dental check-up • Extended home skilled nursing • Eye exam • Glasses • Hearing aids • Long-term care • Routine eye care - Adult • Routine foot care • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Applied Behavior Analysis therapy • Bariatric surgery • Chiropractic care • Infertility treatment ($15,000 LTM) • Most coverage provided outside the U.S. • Private-duty nursing - short term intermittent home skilled nursing Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-[PHONE REDACTED] x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-[PHONE REDACTED]. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, you can contact: Wellmark at 1-[PHONE REDACTED]. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next page. Wellmark Blue Cross and Blue Shield of Iowa is an independent licensee of the Blue Cross and Blue Shield Association. This contains only a partial description of the benefits, limitations, exclusions and other provisions of the health care plan. It is not a contract or policy. It is a general overview only. It does not provide all the details of coverage, including benefits, exclusions, and policy limitations. In the event there are discrepancies between this document and the Coverage Manual, Certificate, or Policy, the terms and conditions of the Coverage Manual, Certificate, or Policy will govern. 15 ---PAGE BREAK--- 05/15/2025;07/01/2025;PL001997;RL004248;189199-77;189199-78;00055829;N;NGF Page 7 About These Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) ■The plan's overall deductible $200 ■PCP copayment $15 ■Hospital(facility) coinsurance 20% ■Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $200 Copayments $80 Coinsurance $1,200 What isn’t covered What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,540 Managing Joe's type 2 Diabetes (a years of routine in-network care of a well- controlled condition) ■The plan's overall deductible $200 ■Specialist copayment $15 ■Hospital(facility) coinsurance 20% ■Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $50 Copayments $1,300 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $1,370 Mia's Simple Fracture (in-network emergency room visit and follow up care) ■The plan's overall deductible $200 ■Specialist copayment $15 ■Hospital(facility) coinsurance 20% ■Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $200 Copayments $80 Coinsurance $300 What isn’t covered Limits or exclusions $0 The total Mia would pay is $580 The amounts shown in the maternity claim example above are based on amounts using a single per person deductible. Some plans may actually apply a two-person or family deductible to maternity services for the mother and newborn baby. The plan would be responsible for the other costs of these EXAMPLE covered services. 16