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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 11/01/2024-10/31/2025 Your Silver Health Plan with Benemax Wrap®: SEEM Collaborative Coverage for: Individual & Family | Plan Type: HMO 1 of 6 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, call 1-800-528-1530. 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.mybenemax.com or call 1-800-528-1530 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $3,000 Individual Contract/ $6,000 family Contract See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? Yes: preventive care, , routine eye exams, are covered before you meet your deductibles. 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 preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $8,000 / person or $16,000 / family. 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 out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balanced-billed 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 you use a network provider? Yes. See www.harvardpilgrim.org/public/find-a-provider or call 1-888-333-4742 for a list of Network providers. 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 a provider for the difference between the provider’s charge and what your plan pays (balance billing). 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. Do you need a referral to see a specialist? Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

2 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.mybenemax.com All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information 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 clinic Primary care visit to treat an injury or illness 35% Co-insurance / visit Not covered No copay for the first 2 office visits/Member Specialist visit 35% Co-insurance / visit; Not covered Deductible applies first; Preventive care/screening/ immunization No charge Not covered You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 35% Co-insurance Not covered Deductible applies first; Imaging (CT/PET scans, MRIs) 35% Co-insurance Not covered Deductible applies first; Cost sharing may vary for certain imaging services If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http://www.harvardpilgrim.org/2024Premium3T Generic drugs $0 copay / prescription (retail); $0 copay / prescription (mail order) Not covered Deductible applies first; You pay retail price for Out of Network pharmacy drugs and are reimbursed minus applicable cost sharing. Covered only outside of service area. Preferred brand drugs $0 copay / prescription (retail); $0 copay / prescription (mail order) Not covered Non-preferred brand drugs $0 copay / prescription (retail); $0 copay / prescription (mail order) Not covered Specialty drugs All drugs are covered in Retail Pharmacy and Mail Order Pharmacy Tiers 1 - 3 Not covered Some drugs must be obtained through a Specialty Pharmacy. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 35% Co-insurance/ surgery Not covered Deductible applies first. Physician/surgeon fees No charge Not covered None If you need immediate medical attention Emergency room care 35% Co-insurance 35% Co-insurance Deductible applies first; Emergency medical transportation No charge No charge None Urgent care 35% Co-insurance /visit Urgent care center: Not covered Services with non-participating providers are only covered outside of the service area. Cost sharing may vary based on location.

3 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.mybenemax.com Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) you have a hospital stay Facility fee (e.g., hospital room) 35% Co-insurance/ admission Not covered Deductible applies first; Physician/surgeon fees No charge Not covered None If you need mental health, behavioral health, or substance abuse services Outpatient services 35% Co-insurance / visit Not covered Deductible applies first; Inpatient services 35% Co-insurance / visit Not covered Deductible applies first; If you are pregnant Office visits 35% Co-insurance / visit Not covered Deductible applies first; Cost sharing does not apply for preventive services (such as routine prenatal visits) . Childbirth/delivery professional services No charge Not covered Childbirth/delivery facility services 35% Co-insurance/ admission Not covered If you need help recovering or have other special health needs Home health care 35% Co-insurance / visit Not covered None Rehabilitation services 35% Co-insurance / visit Not covered Occupational & physical therapy – 60 combined visits /Plan Year Habilitation services 35% Co-insurance / visit Not covered Occupational & physical therapy – 60 combined visits /Plan Year Skilled nursing care 35% Co-insurance/ admission Not covered Deductible applies first; 100 days/Plan Year. Durable medical equipment 30% coinsurance Not covered Deductible applies first; Wigs – $350/Plan Year Hospice services 35% Co-insurance Not covered For inpatient see “If you have a hospital stay”. If your child needs dental or eye care Children’s eye exam $25 copay/visit; deductible does not apply Not covered 1 exam/Plan Year Children’s glasses Not covered Not covered None Children’s dental check-up – Up to age of 13 No charge Not covered 2 exams/Plan Year

4 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.mybenemax.com 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.) • Children’s glasses • Cosmetic Surgery • Dental care (adult) • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine Foot Care (except for diabetes or systemic circulatory diseases) • Services that are not Medically Necessary • Weight Loss Programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture • Bariatric surgery • Chiropractic care – 12 visits / Plan Year • Hearing aids -$2,000/aid every 36 months, for each impaired ear up to age 22 • Infertility treatment • Routine eye care (Adult)-1 exam/plan year

5 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.mybenemax.com 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: the Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , or the Department of Health and Human Services, Centers for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov , or for more information on your rights to continue coverage, you can contact the Member Service number listed on your ID card or call 1-888-333-4742. 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: HPHC Member Appeals-Member Services Department Harvard Pilgrim Health Care, Inc. 1 Wellness Way Canton, MA 02021-1166 Department of Labor’s Employee Benefits Security Administration 1-866-444-3272 www.dol.gov/ebsa/healthreform Health Care for All 30 Winter Street, Suite 1004 Boston, MA 02108 1-800-272-4232 http://www.hcfama.org/helpline Massachusetts Division of Insurance 1000 Washington Street, Suite 810 Boston, MA 02118–6200 1-617-521-7794 Telephone: 1-888-333-4742 Fax: 1-617-509-3085 Does this plan meet the 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. 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. Language Access Services: Para obtener asistencia en Español, llame al 1–888–333–4742. 如果需要中文的帮助, 请拨打这个号码1–888–333–4742. De assistência em Português, por favor ligue 1–888–333–4742. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

6 of 6 The plan would be responsible for the other costs of these EXAMPLE covered services. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-controlled condition) ◼ The plan’s overall deductible $3,000 ◼ PCP fee copay 35% ◼ Specialist fee copay 35% ◼ Hospital Stay copay 35% This 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 $12,700 In this example, Peg would pay: Cost Sharing Deductibles $3,000 Copayments $560 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Peg would pay is $3,560 ◼ The plan’s overall deductible $3,000 ◼ Primary care visit copay 35% ◼Specialist visit copay 35% ◼ Durable Medical Equipment 30% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $3,000 Copayments $750 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Joe would pay is $3,750 ◼ The plan’s overall deductible $3,000 ◼ Primary care visit copay 35% ◼ Specialist visit copay 35% ◼ Emergency Room 35% This 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 $2,800 In this example, Mia would pay: Cost Sharing Deductibles $3,000 Copayments $730 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $3,730 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.