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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesCoverage Period: 09/01/2023 - 08/31/2024 : AFA OAAS 100% $25 $1000D CY V23Coverage for: Employee + Family | Plan Type: EPO 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, www.HealthReformPlanSBC.com or by calling 1-888-982-3862. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-888-982-3862 to request a copy.Important Questions Answers Why This Matters:What is the overall deductible?$0.See the Common Medical Events chart below for your costs for services this plancovers.Are there servicescovered before you meetyour deductible?No.You will have to meet the deductible before the planpays for any services.Are there otherdeductibles for specificservices?No.You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan?In-Network: Individual $6,500 / Family $13,000.The out-of-pocket limitis 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 limitsuntil the overall family out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Premiums, balance-billing 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.Will you pay less if youuse a network provider?Yes. See http://www.aetna.com/docfind or call 1-888-982-3862 for a list of in-network providers. This planuses aprovider network. You will pay less if you use a providerin theplan’snetwork. 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'scharge and what your plan pays (balance billing). Be aware, your network providermight use anout-of-network provider for some services (such as lab work). Check with your providerbefore you get services.Do you need a referral tosee a specialist?No.You can see the specialist you choose without a referral.080600-040020-042318 Page 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 NeedWhat You Will PayLimitations, Exceptions, & Other Important InformationIn-Network Provider (You will pay the least)Out–of–Network Provider (You will pay the most)If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness$25 copay/visit Not coveredNo charge for in-network virtual primary care telemedicine provider visits for certain services.Specialist visit $100 copay/visit Not coveredNonePreventive care /screening /immunizationNo charge Not coveredYou 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)Lab: $25 copay/visit; X-ray: $75 copay/visitNot coveredNoneImaging (CT/PET scans, MRIs) $500 copay/visit Not covered NoneIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.aetnapharmacy.com/advancedcontrolaetnaPreferred generic drugsTier 1A: $3 copay/ prescription (retail), $6 copay/ prescription (mail order); Tier 1: $10 copay/ prescription (retail), $20 copay/ prescription (mail order)Not coveredCovers up to a 30 day supply (retail prescription), 31-90 day supply (mail order prescription). Your cost will be higher for choosing Brand over Generics unless prescribed Dispense as Written; cost difference penalty doesn’t apply to out-of-pocket limit. No charge for preferred generic FDA-approved women's contraceptives in-network. Maintenance drugs- after two retail fills, you are required to fill a 90-day supply at CVS Caremark Mail Service Pharmacy or CVS Pharmacy.Preferred brand drugs$50 copay/ prescription (retail), $100 copay/ prescription (mail order)Not coveredNon-preferred generic/brand drugs$80 copay/ prescription (retail), $160 copay/ prescription (mail order)Not coveredSpecialty drugsPreferred: 20% coinsurance up to a $250 maximum/ prescription for up to a 30 day supply; Non-preferred: 40% coinsurance up to a $500 maximum/ prescription for up to a 30 day supplyNot coveredFirst prescription fill at any retail or specialty pharmacy. Subsequent fills must be through our preferred specialty pharmacy network.080600-040020-042318 Page 2 of 6

CommonMedical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & Other Important InformationIn-Network Provider (You will pay the least)Out–of–Network Provider (You will pay the most)If you have outpatient surgeryFacility fee (e.g., ambulatory surgery center)$500 copay/visit Not coveredNonePhysician/surgeon fees No charge Not covered NoneIf you need immediate medical attentionEmergency room care $500 copay/visit $500 copay/visitCopay waived if admitted. Out-of-network emergency room care cost-share same as in-network. No coverage for non-emergency care.Emergency medical transportation $500 copay/trip $500 copay/tripOut-of-network cost-share same as in-network.Urgent care $75 copay/visit Not covered No coverage for non-urgent use.If you have a hospital stayFacility fee (e.g., hospital room) $1,000 copay/day, days 1-3 Not coveredNonePhysician/surgeon fees No charge Not covered NoneIf you need mental health, behavioral health, or substance abuse servicesOutpatient servicesOffice visits and all other outpatient services: No chargeNot covered NoneInpatient services $1,000 copay/day, days 1-3 Not coveredNoneIf you are pregnantOffice visitsNo charge Not coveredCost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).Childbirth/delivery professional servicesNo charge Not coveredChildbirth/delivery facility services $1,000 copay/day, days 1-3 Not covered080600-040020-042318 Page 3 of 6

CommonMedical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & Other Important InformationIn-Network Provider (You will pay the least)Out–of–Network Provider (You will pay the most)If you need help recovering or have other special health needsHome health care $100 copay/visit Not coveredCoverage is limited to 60 visits per year.Rehabilitation services$100 copay/visit Not coveredCoverage is limited to 60 visits per year for Physical Therapy, Occupational Therapy, Speech Therapy & Chiropractic care combined.Habilitation services No charge Not coveredNoneSkilled nursing care $1,000 copay/day, days 1-3 Not coveredCoverage is limited to 60 days per year.Durable medical equipment 50% coinsurance Not coveredCoverage is limited to 1 durable medical equipment for same/similar purpose. Excludes repairs for misuse/abuse.Hospice servicesInpatient: $1,000 copay/day, days 1-3; Outpatient: $100 copay/visitNot covered NoneIf your child needs dental or eye careChildren's eye exam No chargeNot coveredCoverage is limited to 1 exam every 12 months.Children's glasses Not coveredNot coveredNot covered.Children's dental check-up Not covered Not covered Not covered.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.) • Bariatric surgery• Cosmetic surgery• Dental care (Adult & Child)• Glasses (Child)• Hearing aids• Infertility treatment• Long-term care• Non-emergency care when traveling outside the U.S.• Private-duty nursing• 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 - Coverage is limited to 10 visits per year.• Chiropractic care - Coverage is limited to 60 visits per year for Physical Therapy, Occupational Therapy, Speech Therapy & Chiropractic care combined.• Routine eye care (Adult) - Coverage is limited to 1 exam every 12 months.080600-040020-042318 Page 4 of 6

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:  If your group health coverage is subject to ERISA, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For more information on your rights to continue coverage, contact the plan at 1-888-982-3862. For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law.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 1-800-318-2596.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 on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: If your group health coverage is subject to ERISA, you may contact Aetna directly by calling the toll-free number on your Medical ID Card, or by calling our general toll free number at 1-888-982-3862. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Additionally, a consumer assistance program can help you file your appeal. Contact information is at: http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html.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 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 section.080600-040020-042318 Page 5 of 6

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 $0 Specialist copayment $100 Hospital (facility) copayment $1,000 Other copayment $0This 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 $12,700In this example, Peg would pay:Cost SharingDeductibles $0Copayments $2,300Coinsurance $0What isn't coveredLimits or exclusions $60The total Peg would pay is $2,360 Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) The plan’s overall deductible $0 Specialist copayment $100 Hospital (facility) copayment $1,000 Other copayment $0This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Diabetic supplies (glucose meter)Total Example Cost $5,600In this example, Joe would pay:Cost SharingDeductibles $0Copayments $1,300Coinsurance $0What isn't coveredLimits or exclusions $20The total Joe would pay is $1,320 Mia’s Simple Fracture (in-network emergency room visit and follow up care) The plan’s overall deductible $0 Specialist copayment $100 Hospital (facility) copayment $1,000 Other copayment $0This 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 $2,800In this example, Mia would pay:Cost SharingDeductibles $0Copayments $1,500Coinsurance $0What isn't coveredLimits or exclusions $0The total Mia would pay is $1,500Note: These numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 1-888-982-3862.The plan would be responsible for the other costs of these EXAMPLE covered services.080600-040020-042318 Page 6 of 6

Assistive TechnologyPersons using assistive technology may not be able to fully access the following information. For assistance, please call 1-888-982-3862.Smartphone or TabletTo view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store.Non-DiscriminationAetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, disability, gender identity or sexual orientation.We provide free aids/services to people with disabilities and to people who need language assistance.If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: P.O. Box 24030, Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

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