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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesMcDonald’s Corporation Health Plan: Gold PlanCoverage Period: 01/01/2022 – 12/31/2022Coverage for: Individual Family Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-734-8254 or athttp://digital.alight.com/mcd. 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 1-855-756-4448 to request a copy.Important QuestionsWhat is the overalldeductible?Answers 1,000 Individual/ 2,000 FamilyHRA Accounts: FT Crew: 500 person / 1000 familyOther enrollees: 250 person/ 500 family - NA for preventivecare, Rx drugs, balance-billedcharges, penalties & ER copay.Are there services coveredYes. Certain preventive care is covered before youbefore you meet yourmeet your deductible.deductible?Are there other deductiblesNo.for specific services?For In-Network:What is the out-of-pocket 4,000 Individual/ 8,000 FamilyFor Out-of-Network:limit for this plan? 8,000 Individual/ 16,000 FamilyPremiums, balance-billing charges, health care thisWhat is not included in theplan doesn't cover and penalties for failure to obtainout-of-pocket limit?pre-certification.Why This Matters:Generally, you must pay all of the costs from providers up to the deductibleamount before this plan begins to pay. If you have other family members on theplan, each family member must meet their own individual deductible until the totalamount of deductible expenses paid by all family members meets the overallfamily deductible.This plan covers some items and services even if you haven’t yet met thedeductible amount. But a copayment or coinsurance may apply. For example, thisplan covers certain preventive services without cost sharing and before you meetyour deductible. See a list of covered preventive services are-benefits/.You don’t have to meet deductibles for specific services.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-ofpocket limits until the overall family out-of-pocket limit has been met.Even though you pay these expenses, they don’t count toward the out-of-pocketlimitWill you pay less if youuse a network provider?Yes. See www.bcbsil.com/mcd or call1-800-734-8254 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in theplan’s network. You will pay the most if you use an out-of-network provider, andyou might receive a bill from a provider for the difference between the provider’scharge and what your plan pays (balance billing). Be aware, your networkprovider might use an out-of-network provider for some services (such as labwork). Check with your provider before you get services.Do you need a referral tosee a specialist?No.You can see the specialist you choose without a referral.Page 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventIf you visit a healthcare provider’soffice or clinicServices You May Need20% coinsurance50% coinsuranceNoneSpecialist visit20% coinsurance50% coinsuranceNoneDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)Generic drugsIf you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable atwww.Caremark.com .Limitations, Exceptions, & OtherImportant InformationPrimary care visit to treat an injury orillnessPreventive care/screening/immunizationIf you have a testWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Preferred brand drugsNon-preferred brand drugsSpecialty drugsNo Charge; deductibledoes not applyNo Charge; deductibledoes not apply20% coinsurance20% coinsurance10% coinsurance( 10 max)/30-daysupply10% coinsurance( 25 max)/90-daysupply20% coinsurance( 30 max/30-daysupply20% coinsurance( 75 max/90-daysupply40% coinsurance( 60 max)/30-daysupply40% coinsurance( 150 max)/ 90-daysupply50% coinsurance50% coinsuranceSee limitations andexceptionsYou may have to pay for services thataren’t preventive. Ask your provider if theservices needed are preventive. Thencheck what your plan will pay for.Preauthorization may be required;see your benefit booklet* for detailsN/AN/A 25 additional copay on maintenancemedication after three/30-day fills.90-day pricing applies only to CVS MailService or CVS Retail PharmacyN/ANot Covered 0 if enrolled in the PrudentRx CopayOptimization program, otherwise, 30% coinsurance* For more information about limitations and exceptions, see the summary plan description at http://digital.alight.com/mcd. This SBC also serves as asummary of material modifications of the Plan.Page 2 of 7

CommonMedical EventIf you haveoutpatient surgeryIf you needimmediate medicalattentionIf you have ahospital stayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesIf you are pregnantServices You May NeedWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Limitations, Exceptions, & OtherImportant InformationFacility fee (e.g., ambulatory surgerycenter)20% coinsurance50% coinsuranceNonePhysician/surgeon fees20% coinsurance50% coinsuranceNoneEmergency room care 200 copay/visit;plus 20% coinsurance 200 copay/visit;plus 20% coinsuranceCopay waived if admitted.Emergency medical transportation20% coinsurance20% coinsuranceNoneUrgent care20% coinsurance50% coinsuranceNoneFacility fee (e.g., hospital room)20% coinsurance50% coinsurancePreauthorization may be required;see your benefit booklet* for details.Physician/surgeon fees20% coinsurance50% coinsuranceNoneOutpatient servicesNo Charge; deductibledoes not apply50% coinsurancePreauthorization may be required;see your benefit booklet* for details.Inpatient services20% coinsurance50% coinsurancePreauthorization required.Office visits20% coinsurance50% coinsuranceChildbirth/delivery professional services 20% coinsurance50% coinsuranceChildbirth/delivery facility services50% coinsuranceCost sharing does not apply for preventiveservices. Depending on the type ofservices, a coinsurance or deductible mayapply. Maternity care may include testsand services described elsewhere in theSBC (i.e. ultrasound.)Preauthorization required.20% coinsurance* For more information about limitations and exceptions, see the summary plan description at http://digital.alight.com/mcd. This SBC also serves as asummary of material modifications of the Plan.Page 3 of 7

CommonMedical EventIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careServices You May NeedWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Home health care20% coinsurance50% coinsuranceRehabilitation services20% coinsurance50% coinsuranceHabilitation services20% coinsurance50% coinsuranceSkilled nursing care20% coinsuranceLimitations, Exceptions, & OtherImportant InformationLimited to 80 visits per benefit period.Preauthorization may be required;see your benefit booklet* for details.Preauthorization may be required;see your benefit booklet* for details.Limited to 20 visits combined per benefitperiod for occupational therapy andspeech therapy and 20 visits for physicaltherapy. Additional visits if approved asmedically necessary.50% coinsuranceLimited to 120 days per benefit period.Preauthorization may be required;see your benefit booklet* for details.Durable medical equipment20% coinsurance50% coinsuranceBenefits are limited to items used to servea medical purpose. DME benefits areprovided for both purchase and rentalequipment (up to the purchase price).Preauthorization may be required.Hospice services20% coinsurance50% coinsurancePreauthorization may be required.Children’s eye examNot CoveredNot CoveredAvailable through voluntary vision plan.Children’s glassesNot CoveredNot CoveredAvailable through voluntary vision plan.Children’s dental check-upNot CoveredNot CoveredAvailable through voluntary dental plan* For more information about limitations and exceptions, see the summary plan description at http://digital.alight.com/mcd. This SBC also serves as asummary of material modifications of the Plan.Page 4 of 7

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.) Cosmetic surgery Long term care Routine eye care (Adult) (Available throughvoluntary plans) Dental care (Adult) (Availablethrough voluntary dental plan)Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) AcupunctureBariatric surgery (available only atBlue Distinction Plus facilities)Chiropractic care (Limited to 25visits) Hearing aidsInfertility treatmentNon-emergency care when traveling outside the U.S. Private-duty nursing (with the exception ofinpatient private duty nursing)Routine foot careWeight loss programs* For more information about limitations and exceptions, see the summary plan description at http://digital.alight.com/mcd. This SBC also serves as asummary of material modifications of the Plan.Page 5 of 7