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Anthem Consumer-Directed Health Plan-15/Health Savings AccountWhat this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2021 – 12/31/2021Coverage for: All tiers 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 would share the cost forcovered health care services. NOTE: Information about the cost of this plan (called the contribution or 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.cpg.org/mtdocs or call (800) 480-9967.For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You canview the Glossary at www.cpg.org/uniform-glossary or call (800) 480-9967 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible? 1,400/Individual or 2,800Family network 2,800 Individual or 5,600 Familyout-of-networkGenerally, you must pay all of the costs from providers up to the deductible amount before thisplan begins to pay. If you have other family members on the policy, the overall family deductiblemust be met before the plan begins to pay. The network and out-of-network deductiblesaccumulate separately.Are there servicescovered before you meetyour deductible?Yes, for example certainpreventive services and COVID19 expensesThis plan covers some items and services even if you haven’t yet met the deductible amount. But acopayment or coinsurance may apply. See a list of preventive services .**Are there otherdeductibles for specificservices?No.What is the out-of-pocketlimit for this plan?For network providers, 2,400individual / 4,800 family; for outof-network providers 4,800individual / 9,600 familyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have otherfamily members in this plan, the overall family out-of-pocket limit must be met. The network andout-of-network out-of-pocket limits accumulate separately.What is not included inthe out-of-pocket limit?Premiums (contributions), balancebilling charges, penalties, andhealthcare this plan doesn’t coverEven though you pay these expenses, they don’t count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See www.anthem.com or call(844) 812-9207 for a list ofnetwork providers.Do you need a referral tosee a specialist?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 aprovider for the difference between the provider’s charge and what your plan pays (balancebilling). 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.No.You can see the specialist you choose without a referral.Questions: Call 1-844-812-9207 or visit www.anthem.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You canview the Glossary at www.cpg.org/uniform-glossary or call 1-800-480-9967 to request a copy.** See Page 5 for important information about evaluation, testing, and treatment of COVID-19, and telehealth services.1 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedPrimary care visit to treat aninjury or illnessSpecialist visitIf you visit a healthcare provider’s officeor clinicIf you have a testIf you have outpatientsurgeryIf you need immediatemedical attentionIf you have a hospitalstayWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)15% coinsurance40% coinsuranceLimitations, Exceptions, & Other ImportantInformation**15% coinsurance40% coinsuranceNo charge.40% coinsurance15% coinsurance40% coinsurance**15% coinsurance40% coinsurance**15% coinsurance40% coinsuranceNone.Physician/surgeon fees15% coinsurance40% coinsuranceEmergency room careEmergency medicaltransportationUrgent careFacility fee (e.g., hospital room)15% coinsurance15% coinsurance**15% coinsurance15% coinsurance**15% coinsurance15% coinsurance15% coinsurance40% coinsurance**Physician/surgeon fees15% coinsurance40% coinsurancePreventive care/screening/immunizationDiagnostic test (x-ray, bloodwork)Imaging (CT/PET scans, MRIs)Facility fee (e.g., ambulatorysurgery center)**You may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for. See a list of preventiveservices at one.Prior authorization is required. *** For more information about limitations and exceptions, see the plan or policy document at www.cpg.org.** See Page 5 for important information about the evaluation, testing, and treatment of COVID-19, and telehealth services.2 of 6

CommonMedical EventIf you need mentalhealth, behavioralhealth, or substanceabuse services.If you are pregnantIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Limitations, Exceptions, & Other ImportantInformationOutpatient services15% coinsurance40% coinsuranceInpatient services15% coinsurance40% coinsurancePrior authorization required for inpatientservices.Colleague Group30% coinsurance30% coinsuranceThe plan will reimburse 70% up to a maximumreimbursable fee of 40. The member isresponsible for all costs above that amount.Office visitsChildbirth/delivery professionalservicesChildbirth/delivery facilityservices15% coinsurance40% coinsuranceNone.15% coinsurance40% coinsuranceWell-newborn care is covered. Newborn mustbe enrolled in the Plan within 30 days of birth.Home health care15% coinsurance40% coinsuranceRehabilitation services15% coinsurance40% coinsuranceHabilitation services15% coinsurance40% coinsuranceSkilled nursing care15% coinsurance40% coinsuranceDurable medical equipmentHospice servicesChildren’s eye examChildren’s glassesChildren’s dental check-up15% coinsuranceNo charge.Not covered.Not covered.Not covered.40% coinsurance40% coinsuranceNot covered.Not covered.Not covered.Services You May NeedLimited to 210 visits per plan year. Priorauthorization is required.Benefits include hearing/speech, physical, andoccupational therapy. Limited to 60 visits perplan year, combined facility and office, pereach of the three therapies.Limited to 60 days per plan year, combinedwith acute rehabilitation. Prior authorization isrequired.None.Vision benefits are available through EyeMedVision Care.* For more information about limitations and exceptions, see the plan or policy document at www.cpg.org.** See Page 5 for important information about the evaluation, testing, and treatment of COVID-19, and telehealth services.3 of 6

CommonMedical EventIf you need drugs totreat your illness orcondition. Moreinformation aboutprescription drugcoverage is available atwww.express-scripts.comServices You May NeedWhat You Will PayRetailHome DeliveryGeneric drugs15% (after deductible)Preferred brand drugs25% (after deductible)Non-preferred brand drugs50% (after deductible)Specialty drugsYour cost is based on whether the specialty drug is apreferred brand or non-preferred brand drug.Limitations, Exceptions, & Other ImportantInformationYou may get up to a 30-day supply when usinga retail pharmacy, and up to a 90-day supplywhen using home delivery. Your prescriptiondeductible and out-of-pocket limit is combinedwith your medical deductible and out-of-pocketlimit.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 Dental care (Adult) Long-term care Routine eye care (Adult) Routine foot care Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture Bariatric surgery Chiropractic careNon-emergency care when traveling outside the Hearing aids Infertility treatmentU.S. 1 Private-duty nursingCoverage for non-emergency care when traveling outside the U.S. applies only to services available through Anthem Blue Cross and Blue Shield. Non-emergencycare outside the U.S. is not available through Express Scripts.1* For more information about limitations and exceptions, see the plan or policy document at www.cpg.org.** See Page 5 for important information about the evaluation, testing, and treatment of COVID-19, and telehealth services.4 of 6