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Anthem Blue Cross and Blue ShieldYour Plan: Anthem Blue Access PPOIU GA PlanTrustees of Indiana UniversityYour Network: Blue AccessEffective: 01/01/2022Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderOverall Deductible 0 person / 0 family 500 person / 1,000 familyOut-of-Pocket Limit 2,000 person / 4,000 family 4,000 person / 8,000 familyCovered Medical BenefitsThe family deductible and out-of-pocket maximum are embedded, meaning the cost shares of one family member will beapplied to both per person deductible and per person out-of-pocket maximum; in addition, amounts for all covered familymembers apply to both the family deductible and family out-of-pocket maximum. No one member will pay more than the perperson deductible or per person out-of-pocket maximum.Your copays, coinsurance and deductible count toward your out of pocket amount(s).In-network and out-of-network deductibles and out-of-pocket maximum amounts are separate and do not accumulate towardeach other.Preventive Care / Screening / ImmunizationNo charge50% coinsurance afterdeductible is metPreventive Care for Chronic ConditionsNo charge50% coinsurance afterdeductible is metPrimary Care (PCP) 25 copay per visitdeductible does notapply50% coinsurance afterdeductible is metMental Health and Substance Abuse care 25 copay per visitdeductible does notapply50% coinsurance afterdeductible is metSpecialist 35 copay per visitdeductible does notapply50% coinsurance afterdeductible is metVirtual Care (Telehealth Visits)Virtual Visits - Online visits with Doctors who also provide services inpersonTrustees of Indiana University PPO/IU GA Plan/Custom/No RxPage 1 of 8

Covered Medical BenefitsCost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderVirtual Visits from Online Provider LiveHealth Online viawww.livehealthonline.com; our mobile app, website or Anthem-enableddevicePrimary Care (PCP) and Mental Health and Substance Abuse 25 copay per visit deductible does not applySpecialist Care 35 copay per visit deductible does not applyVisits in an OfficePrimary Care (PCP)When Allergy injections are billed separately by network providers, themember is responsible for a 5 copay. When billed as part of an officevisit, there is no additional cost to the member for the injection. 25 copay per visitdeductible does notapply50% coinsurance afterdeductible is metSpecialist CareWhen Allergy injections are billed separately by network providers, themember is responsible for a 5 copay. When billed as part of an officevisit, there is no additional cost to the member for the injection. 35 copay per visitdeductible does notapply50% coinsurance afterdeductible is metRoutine Maternity Care (Prenatal and Postnatal)20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metRetail Health Clinic 25 copay per visitdeductible does notapply50% coinsurance afterdeductible is metManipulation TherapyCoverage is limited to 12 visits per benefit period. 35 copay per visitdeductible does notapply50% coinsurance afterdeductible is metAllergy Testing20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metChemo/Radiation Therapy 25/ 35 copay per visitdeductible does notapply‡50% coinsurance afterdeductible is metDialysis/HemodialysisNo charge50% coinsurance afterdeductible is metPrescription Drugs Dispensed in the office20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metOther Practitioner VisitsOther Services in an OfficeTrustees of Indiana University PPO/IU GA Plan/Custom/No RxPage 2 of 8

Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderOfficeNo charge if billed withoffice visit copay50% coinsurance afterdeductible is metFreestanding Lab/Reference LabNo charge50% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metOfficeNo charge if billed withoffice visit copay50% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metOffice20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metFreestanding Radiology Center20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metUrgent CareWhen Allergy injections are billed separately by network providers, themember is responsible for a 5 copay. When billed as part of an officevisit, there is no additional cost to the member for the injection. 50 copay per visitdeductible does notapply50% coinsurance afterdeductible is metEmergency Room Facility ServicesCopay waived if admitted. 150 copay per visitdeductible does notapplyCovered as In-NetworkEmergency Room Doctor and Other ServicesNo chargeCovered as In-NetworkAmbulance20% coinsurance afterdeductible is metCovered as In-NetworkCovered Medical BenefitsDiagnostic ServicesLabX-RayAdvanced Diagnostic Imaging for example: MRI, PET and CAT scansEmergency and Urgent CareTrustees of Indiana University PPO/IU GA Plan/Custom/No RxPage 3 of 8

Covered Medical BenefitsCost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderOutpatient Mental Health and Substance AbuseDoctor Office Visit 25 copay per visitdeductible does notapply50% coinsurance afterdeductible is metFacility Fees20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metDoctor Services20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metHospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metFreestanding Surgical Center20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metHospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metFreestanding Surgical Center20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metFacility Fees 200 copay peradmission50% coinsurance afterdeductible is metHuman Organ and Tissue TransplantsKidney and Cornea are treated the same as any other illness and subjectto the medical benefits.No charge50% coinsurance afterdeductible is metDoctor and other services20% coinsurance afterdeductible is met50% coinsurance afterdeductible is met20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metFacility VisitOutpatient SurgeryFacility FeesDoctor and Other ServicesHospital (Including Maternity, Mental Health and Substance Abuse)Recovery & RehabilitationHome Health CareCoverage is limited to 100 visits per benefit period.Trustees of Indiana University PPO/IU GA Plan/Custom/No RxPage 4 of 8

Covered Medical BenefitsCost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderRehabilitation servicesCoverage for rehabilitative and habilitative physical therapy, occupationaltherapy and speech therapy are limited to 140 visits per benefit periodcombined.Office 35 copay per visitdeductible does notapply50% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metOffice 35 copay per visitdeductible does notapply50% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metOffice 35 copay per visitdeductible does notapply50% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metSkilled Nursing Care (facility)Coverage for Skilled Nursing is limited to 90 days per benefit period. Limitis combined In-Network and Non-Network. Benefit include coverage forOutpatient Rehabilitation program. 200 per admission50% coinsurance afterdeductible is metHospiceNo chargeCovered as In-NetworkDurable Medical Equipment20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metProsthetic Devices20% coinsurance afterdeductible is met50% coinsurance afterdeductible is metCardiac rehabilitationCoverage is unlimited visits per benefit period.Pulmonary rehabilitationCoverage is unlimited visits per benefit period.Trustees of Indiana University PPO/IU GA Plan/Custom/No RxPage 5 of 8

Notes: Dependent age: to end of the month in which the child attains age 26. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will helpthe member know if the services are considered not medically necessary. No charge means no deductible/copayment/coinsurance up to the maximum allowable amount. 0% means nocoinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member isresponsible for any balance due after the plan payment. If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital orAmbulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”. Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check yourCertificate of Coverage for details. ‡ Your cost share will be reduced when services are provided in a PCP's office.This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summarydoes not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details,important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a differencebetween this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail.Your Plan: Anthem Blue Access PPO IU GA PlanYour Network: Blue AccessThis summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule ofBenefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is aregistered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.Questions: (833) 578-4441 or visit us at www.anthem.comTrustees of Indiana University PPO/IU GA Plan/Custom/No RxPage 6 of 8