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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 sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This isonly a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsok.com/member/policy-forms/2022 or by calling 1-800-942-5837. 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 1-855-756-4448to request a copy.Why This Matters:AnswersImportant QuestionsGenerally, you must pay all of the costs from providers up to the deductible amount beforethis plan begins to pay. If you have other family members on the plan, each family member$1,000 Individual/$3,000 Family.What is the overalldeductible?must meet their own individual deductible until the total amount of deductible expenses paidby all family members meets the overall family 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 preventiveYes. Doesn't apply to servicesthat charge a copay, certainAre there services coveredbefore you meet yourdeductible? services without cost-sharing and before you meet your deductible. See a list of coveredpreventive services at www.healthcare.gov/coverage/preventive-care-benefits/.preventive care, prescriptiondrugs, or ambulance. Copayscopay don't count toward theoverall deductible.You don’t have to meet deductibles for specific services.No.Are there otherdeductibles for specificservices?The out-of-pocket limit is the most you could pay in a year for covered services.Yes. Per Individual - Network:$2,000 Blue Preferred, $3,000What is the out-of-pocketlimit for this plan?Blue Choice, $4,000 BlueTraditional.Out-of-Network: $5,000.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Deductibles, copays, prescriptiondrug copays, Premiums,What is not included in theout-of-pocket limit?balance-billed charges,Preauthorization penalties, andhealth care this Plan doesn'tcover.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 fromYes. For a list of NetworkProviders please callWill you pay less if you usea network provider?a provider for the difference between the provider’s charge and what your plan pays (balance1-800-942-5837 or see www.bcbsok.com. billing). Be aware, your network provider might use an out-of-network provider for someservices (such as lab work). Check with your provider before you get services.Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Crossand Blue Shield AssociationPage 1 of 6Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 12/01/2022-11/30/2023Blue OptionsSMRYBM505T Coverage for: Individual/Family Plan Type: PPO

Why This Matters:AnswersImportant QuestionsYou can see the specialist you choose without a referral.No.Do you need a referral tosee a specialist?All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Limitations, Exceptions, & Other ImportantInformationWhat You Will PayServices You May NeedCommonMedical EventOut-of-Network Provider(You will pay the most)Network Provider (Youwill pay the least)Deductible and coinsurance apply after firstsix office visits for ages 19+. Acupuncture isnot covered.$30 copay/visit$30 copay/visitPrimary care visit to treat aninjury or illnessIf you visit a health careprovider’s office orclinic$30 copay/visit$30 copay/visitSpecialist visitAdditional $30 copay/visit. Annualmammography Screening and childhood30% coinsuranceNo ChargePreventive care/screening/immunizationimmunizations are covered at 100% of theAllowed Amount Out-of-Network. You mayhave to pay for services that aren't preventive.Ask your provider if the services you need arepreventive. Then check what your plan willpay for.No charge if billed with office visit.50% coinsurance20%/30%/40%coinsuranceDiagnostic test (x-ray, bloodwork)If you have a testnone50% coinsurance20%/30%/40%coinsuranceImaging (CT/PET scans, MRIs)Subject to separate $5,000 prescription drugOut-of-Pocket Limit. Up to 30 day supply retail.50% coinsurance50% coinsuranceGeneric drugsIf you need drugs totreat your illness orcondition50% coinsurance50% coinsurancePreferred brand drugsUp to 90 day supply of maintenance drugs50% coinsurance50% coinsuranceNon-preferred brand drugsmail, Network only. Specialty Drugs limited toMore information aboutprescription drugcoverage is available atwww.bcbsok.com/member/prescriptiondrugs.html50% coinsurance50% coinsuranceSpecialty drugs30 day supply. Prior authorization may berequired. Your cost for a covered insulin drugwill not exceed $30 per 30-day supply or $90per 90-day supply.Additional $200 copay.50% coinsurance20%/30%/40%coinsuranceFacility fee (e.g., ambulatorysurgery center)If you have outpatientsurgery50% coinsurance20%/30%/40%coinsurancePhysician/surgeon feesPage 2 of 6

Limitations, Exceptions, & Other ImportantInformationWhat You Will PayServices You May NeedCommonMedical EventOut-of-Network Provider(You will pay the most)Network Provider (Youwill pay the least)Additional $100 Copay; waived if admitted.20% coinsurance20% coinsuranceEmergency room careIf you need immediatemedical attentionnoneNo ChargeNo ChargeEmergency medicaltransportationCopay may apply.50% coinsurance20%/30%/40%coinsuranceUrgent careAdditional $500 copay. $500 penalty forfailure to preauthorize. Preauthorization50% coinsurance20%/30%/40%coinsuranceFacility fee (e.g., hospitalroom)If you have a hospitalstayrequirement is waived if admitted from theemergency room.none50% coinsurance20%/30%/40%coinsurancePhysician/surgeon feesOutpatient: Preauthorization required forpsychological testing, neuropsychological$20 copay for office visitsor 50% coinsurance forother outpatient services$20 copay for office visitsor 20%/30%/40%coinsurance for otheroutpatient servicesOutpatient servicesIf you need mentalhealth, behavioralhealth, or substanceabuse servicestesting, electroconvulsive therapy, andintensive outpatient treatment; Deductible andcoinsurance apply after first six office visits50% coinsurance20%/30%/40%coinsuranceInpatient servicesfor ages 19+. Inpatient: Additional $500copay.Copay applies to first prenatal visit (perpregnancy) if one of first six office visits per50% coinsurance20%/30%/40%coinsuranceOffice visitsIf you are pregnantbenefit period. Cost sharing does not apply50% coinsurance20%/30%/40%coinsuranceChildbirth/delivery professionalservicesto certain preventive services. Depending onthe type of services, deductible may apply.50% coinsurance20%/30%/40%coinsuranceChildbirth/delivery facilityservicesMaternity care may include tests and servicesdescribed elsewhere in the SBC (i.e.ultrasound).30 visit maximum per benefit period. $500penalty for failure to preauthorize.50% coinsurance20%/30%/40%coinsuranceHome health careIf you need helprecovering or haveother special healthneedsOutpatient: Combined 25 visit limit per benefitperiod for physical and occupational50% coinsurance20%/30%/40%coinsuranceRehabilitation servicestherapies. Speech therapy not covered.50% coinsurance20%/30%/40%coinsuranceHabilitation servicesInpatient: 30 day maximum per benefit period.$500 penalty for failure to preauthorize.30 day maximum per benefit period. $500penalty for failure to preauthorize.50% coinsurance20%/30%/40%coinsuranceSkilled nursing caremedically necessary rental or purchase at thePlan's discretion.50% coinsurance20%/30%/40%coinsuranceDurable medical equipment$500 penalty for failure to preauthorize.50% coinsurance20%/30%/40%coinsuranceHospice servicesPage 3 of 6

Limitations, Exceptions, & Other ImportantInformationWhat You Will PayServices You May NeedCommonMedical EventOut-of-Network Provider(You will pay the most)Network Provider (Youwill pay the least)noneNot CoveredNot CoveredChildren’s eye examIf your child needsdental or eye careNot CoveredNot CoveredChildren’s glassesNot CoveredNot CoveredChildren’s dental check-upExcluded 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.)Routine eye care (Adult)Elective abortion (Unless the life of the mother isendangered)AcupunctureBariatric surgery (For treatment of obesity/weightreduction)Routine foot careWeight loss programsHearing aids (Limited coverage for children)Cosmetic surgery (With exception of accidentalinjury repair and some instances for physiologicalfunctioning improvement of a malformed bodymember)Infertility treatmentLong-term careDental care (Adult)Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)Private-duty nursingNon-emergency care when traveling outside theU.S. (With the exception of any services andsupplies provided to a subscriber incurred outsidethe United States if the subscriber traveled to thelocation for the purposes of receiving medicalservices, supplies, or drugs)Chiropractic careYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Oklahoma at 1-800-942-5837 or visit www.bcbsok.com. For grouphealth coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for ConsumerInformation and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuationcoverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverageunder 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.Page 4 of 6

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 iscalled a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plandocuments also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about yourrights, this notice, or assistance, contact: For group health coverage subject to ERISA: the plan at or visit www.bcbsok.com, the U.S. Department of Labor'sEmployee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Oklahoma Department of Insurance,Consumer Protection at 1-405-521-2991 or www.oid.ok.gov. For non-federal governmental group health plans and church plans that are group health plans,the plan at or www.bcbsok.com or contact the Oklahoma Department of Insurance, Consumer Protection at 1-405-521-2991 or www.oid.ok.gov.Additionally, a consumer assistance program can help you file your appeal. Contact the Oklahoma Department of Insurance’s Consumer Health AssistanceProgram at 1-405-521-2991 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/ok.html.Does this plan provide Minimum Essential Coverage? YesMinimum 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 thepremium tax credit.Does this plan meet the Minimum Value Standards? YesIf 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.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al .Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa .Chinese (中文): 如果需要中文的帮助，请拨打这个号码.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' .To see examples of how this plan might cover costs for a sample medical situation, see the next section.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 differentdepending 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 youmight 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 ahospital delivery)The plan's overall deductible $1,000Specialist copayment 30Hospital (facility) coinsurance 20%Other coinsurance 20%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)$12,700Total Example CostIn this example, Peg would pay:Cost Sharing$1,000Deductibles$100Copayments$900CoinsuranceWhat isn't covered$60Limits or exclusions$2,060The total Peg would pay isManaging Joe’s Type 2 Diabetes(a year of routine in-network care of awell-controlled condition)The plan's overall deductible $1,000Specialist copayment 30Hospital (facility) coinsurance 20%Other coinsurance 20%This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)$5,600Total Example CostIn this example, Joe would pay:Cost Sharing$1,000Deductibles$800Copayments$70CoinsuranceWhat isn't covered$20Limits or exclusions$1,890The total Joe would pay isMia’s Simple Fracture(in-network emergency room visit and follow upcare)The plan's overall deductible $1,000Specialist copayment 30Hospital (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)$2,800Total Example CostIn this example, Mia would pay:Cost Sharing$1,000Deductibles$200Copayments$70CoinsuranceWhat isn't covered$0Limits or exclusions$1,270The total Mia would pay isThe plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6

bcbsok.com If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 855-710-6984. Español Spanish Si usted o alguien a quien usted está ayudando tiene preguntas, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame 6984.-710-al 855 ةيبرعلا Arabic                     .        6984-710-855. 繁體中文 Chinese 如果您, 或您正在協助的對象, 對此有疑問, 您有權利免費以您的母語獲得幫助和訊息。洽詢一位翻譯員, 請撥電話 號碼 855-710-6984。 Français French Si vous, ou quelqu'un que vous êtes en train d’aider, avez des questions, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 855-710-6984. Deutsch German Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 855-710-6984 an.  Gujarati  855-710-6984  Hindi   ,         ,  ,                      855-710-6984   . Italiano Italian Se tu o qualcuno che stai aiutando avete domande, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare il numero 855-710-6984. 한국어 Korean 만약 귀하 또는 귀하가 돕는 사람이 질문이 있다면 귀하는 무료로 그러한 도움과 정보를 귀하의 언어로 받을 수 있는 권리가 있습니다. 통역사가 필요하시면 855-710-6984 로 전화하십시오. Diné Navajo 855-710-6984.  Persian                              .         855-710-6984    . Polski Polish Jeśli Ty lub osoba, której pomagasz, macie jakiekolwiek pytania, macie prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer 855-710-6984. Русский Russian Если у вас или человека, которому вы помогаете, возникли вопросы, у вас есть право на бесплатную помощь и информацию, предоставленную на вашем языке. Чтобы связаться с переводчиком, позвоните по телефону 855-710-6984. Tagalog Tagalog Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong, may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang tagasalin-wika, tumawag sa 855-710-6984. ودرا Urdu    855-710-6984                                       Ting Vit Vietnamese Nếu quý vị, hoặc người mà quý vị giúp đỡ, có câu hỏi, thì quý vị có quyền được giúp đỡ và nhận thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, gọi 855-710-6984.

bcbsok.com Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health status or disability. To receive language or communication assistance free of charge, please call us at 855-710-6984. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html