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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning On or After 1/1/2023 Silver Full PPO 2550/70 OffEx Coverage for: Individual + Family | Plan Type: PPO 1 of 8 Blue Shield of California is an independent member of the Blue Shield Association. 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, visit bsca.com/policies/M0030324_EOC.pdf or call 1-888-319-5999. 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 healthcare.gov/sbc-glossary or call 1-866-444-3272 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $2,550 per individual / $5,100 per family for participating providers; $5,100 per individual / $10,200 per family for non-participating providers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. Preventive care and services listed in your complete terms of coverage. 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 healthcare.gov/coverage/preventive-care-benefits. Are there other deductibles for specific services? Yes. Prescription drugs -- $300 per individual / $600 per family. There are no other specific deductibles. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. What is the out-of-pocket limit for this plan? $8,750 per individual / $17,500 per family for participating providers; $17,500 per individual / $35,000 per family for non-participating providers. 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 own 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? Copayments for certain services, 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 you use a network provider? Yes. See blueshieldca.com/fad or call 1-888-319-5999 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? No. You can see the specialist you choose without a referral.

2 of 8 * For more information about limitations and exceptions, see the plan or policy document at bsca.com/policies/M0030324_EOC.pdf. Blue Shield of California is an independent member of the Blue Shield Association. 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 Participating Provider (You will pay the least) Non-Participating 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 $70/visit; deductible does not apply 50% coinsurance ----------------------None----------------------- Specialist visit $80/visit; deductible does not apply 50% coinsurance Preventive care/screening /immunization No Charge; deductible does not apply Not Covered You 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 & Path: $65/visit; deductible does not apply X-Ray & Imaging: $85/visit; deductible does not apply Other Diagnostic Examination: $85/visit; deductible does not apply Lab & Path: 50% coinsurance X-Ray & Imaging: 50% coinsurance Other Diagnostic Examination: 50% coinsurance The services listed are at a freestanding location. Imaging (CT/PET scans, MRIs) Outpatient Radiology Center: 40% coinsurance Outpatient Hospital: $150/visit + 40% coinsurance Outpatient Radiology Center: 50% coinsurance Outpatient Hospital: 50% coinsurance subject to a benefit maximum of $350/day Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at blueshieldca.com/ formulary Tier 1 Retail: $25/prescription; deductible does not apply Mail Service: $50/prescription; deductible does not apply Retail: Not Covered Mail Service: Not Covered Preauthorization is required for select drugs. Failure to obtain preauthorization may result in non-payment of benefits. Retail: Covers up to a 30-day supply; 90-days may be covered with a copayment for each 30-day supply; Mail Service: Covers up to a 90-day supply. Tier 2 Retail: $75/prescription Mail Service: $150/prescription Retail: Not Covered Mail Service: Not Covered Tier 3 Retail: $115/prescription Mail Service: $230/prescription Retail: Not Covered Mail Service: Not Covered

3 of 8 * For more information about limitations and exceptions, see the plan or policy document at bsca.com/policies/M0030324_EOC.pdf. Blue Shield of California is an independent member of the Blue Shield Association. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Tier 4 Retail and Network Specialty Pharmacies: 40% coinsurance up to $250/prescription Mail Service: 40% coinsurance up to $500/prescription Retail: Not Covered Mail Service: Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Retail and Network Specialty Pharmacies: Covers up to a 30-day supply; Specialty drugs must be obtained at a Network Specialty Pharmacy. Mail Service: Covers up to a 90-day supply. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Ambulatory Surgery Center: 40% coinsurance Outpatient Hospital: 50% coinsurance Ambulatory Surgery Center: 50% coinsurance subject to a benefit maximum of $350/day Outpatient Hospital: 50% coinsurance subject to a benefit maximum of $350/day ----------------------None----------------------- Physician/surgeon fees 40% coinsurance 50% coinsurance If you need immediate medical attention Emergency room care Facility Fee: $350/visit + 40% coinsurance Physician Fee: 40% coinsurance Facility Fee: $350/visit + 40% coinsurance Physician Fee: 40% coinsurance ----------------------None----------------------- Emergency medical transportation 40% coinsurance 40% coinsurance This payment is for emergency or authorized transport. Urgent care $70/visit; deductible does not apply 50% coinsurance ----------------------None----------------------- If you have a hospital stay Facility fee (e.g., hospital room) 40% coinsurance 50% coinsurance subject to a benefit maximum of $2,000/day Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Physician/surgeon fees 40% coinsurance 50% coinsurance ----------------------None-----------------------

4 of 8 * For more information about limitations and exceptions, see the plan or policy document at bsca.com/policies/M0030324_EOC.pdf. Blue Shield of California is an independent member of the Blue Shield Association. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit: $70/visit; deductible does not apply Other Outpatient Services: 40% coinsurance Partial Hospitalization: 40% coinsurance Psychological Testing: 40% coinsurance Office Visit: 50% coinsurance Other Outpatient Services: 50% coinsurance Partial Hospitalization: 50% coinsurance subject to a benefit maximum of $350/day Psychological Testing: 50% coinsurance Preauthorization is required except for office visits and office-based opioid treatment. Failure to obtain preauthorization may result in non-payment of benefits. Inpatient services Physician Inpatient Services: 40% coinsurance Hospital Services: 40% coinsurance Residential Care: 40% coinsurance Physician Inpatient Services: 50% coinsurance Hospital Services: 50% coinsurance subject to a benefit maximum of $2,000/day Residential Care: 50% coinsurance subject to a benefit maximum of $2,000/day Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. If you are pregnant Office visits No Charge; deductible does not apply 50% coinsurance ----------------------None----------------------- Childbirth/delivery professional services 40% coinsurance 50% coinsurance Childbirth/delivery facility services 40% coinsurance 50% coinsurance subject to a benefit maximum of $2,000/day If you need help recovering or have other special health needs Home health care 40% coinsurance Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Coverage limited to 100 visits per member per Calendar Year.

5 of 8 * For more information about limitations and exceptions, see the plan or policy document at bsca.com/policies/M0030324_EOC.pdf. Blue Shield of California is an independent member of the Blue Shield Association. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Rehabilitation services Office Visit: 40% coinsurance Outpatient Hospital: 40% coinsurance Office Visit: 50% coinsurance Outpatient Hospital: 50% coinsurance subject to a benefit maximum of $350/day ----------------------None----------------------- Habilitation services Office Visit: 40% coinsurance Outpatient Hospital: 40% coinsurance Office Visit: 50% coinsurance Outpatient Hospital: 50% coinsurance subject to a benefit maximum of $350/day Skilled nursing care Freestanding SNF: 40% coinsurance Hospital-based SNF: 40% coinsurance Freestanding SNF: 50% coinsurance Hospital-based SNF: 50% coinsurance subject to a benefit maximum of $2,000/day Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Coverage limited to 100 days per member per benefit period. Durable medical equipment 50% coinsurance Not Covered; deductible does not apply Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Hospice services No Charge Not Covered Preauthorization is required except for pre-hospice consultation. Failure to obtain preauthorization may result in non-payment of benefits. If your child needs dental or eye care Children's eye exam No Charge; deductible does not apply All charges above $30; deductible does not apply Coverage limited to one exam per member per Calendar Year. Children's glasses No Charge; deductible does not apply All charges above $25; deductible does not apply Coverage is limited to one eyeglass frame and eyeglass lenses or contact lenses instead of eyeglasses, up to the benefit per Calendar Year. The cost listed is for Single Vision. Children's dental check-up No Charge; deductible does not apply 20% coinsurance; deductible does not apply Coverage for prophylaxis services (cleaning) is limited to once in a six month period.

6 of 8 * For more information about limitations and exceptions, see the plan or policy document at bsca.com/policies/M0030324_EOC.pdf. Blue Shield of California is an independent member of the Blue Shield Association. 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 • Infertility Treatment • Private-duty nursing • Routine foot care • Dental care (Adult) • Long-term care • Routine eye care (Adult) • Weight loss programs • Hearing Aids • Non-emergency care when traveling outside the U.S. 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 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: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or cciio.cms.gov. 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 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 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: Blue Shield Customer Service at 1-888-319-5999 or the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or dol.gov/ebsa/healthreform. Additionally, you can contact the California Department of Managed Health Care Help at 1-888-466-2219 or visit helpline@dmhc.ca.gov or visit http://www.healthhelp.ca.gov. 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 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.

7 of 8 * For more information about limitations and exceptions, see the plan or policy document at bsca.com/policies/M0030324_EOC.pdf. Blue Shield of California is an independent member of the Blue Shield Association. Language Access Services: ––––––––––––––––––––––.section nextthe , see for a sample medical situation might cover costs planof how this sTo see example––––––––––––––––––––– PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

8 of 8 The plan would be responsible for the other costs of these EXAMPLE covered services. Blue Shield of California is an independent member of the Blue Shield Association. Peg is Having a Baby (9 months of participating pre-natal care and a hospital delivery) Mia’s Simple Fracture (participating emergency room visit and follow up care) Managing Joe’s Type 2 Diabetes (a year of routine participating care of a well-controlled condition) ◼ The plan’s overall deductible $2,550 ◼ Specialist copayment $80 ◼ Hospital (facility) coinsurance 40% ◼ Other copayment $65 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 $2,800 Copayments $700 Coinsurance $3,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $6,860 ◼ The plan’s overall deductible $2,550 ◼ Specialist copayment $80 ◼ Hospital (facility) coinsurance 40% ◼ Other copayment $65 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 $1,200 Copayments $1,800 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $3,020 ◼ The plan’s overall deductible $2,550 ◼ Specialist copayment $80 ◼ Hospital (facility) coinsurance 40% ◼ Other copayment $85 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 $2,600 Copayments $200 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,800 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.

Blue Shield of California Notice Informing Individuals about Nondiscrimination and Accessibility Requirements Discrimination is against the law Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Blue Shield of California does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. Blue Shield of California: • Provides aids and services at no cost to people with disabilities tocommunicate effectively with us such as:- Qualified sign language interpreters- Written information in other formats (including large print,audio, accessible electronic formats, and other formats)• Provides language services at no cost to people whose primarylanguage is not English such as:- Qualified interpreters- Information written in other languagesIf you need these services, contact the Blue Shield of California Civil Rights Coordinator. If you believe that Blue Shield of California has failed to provide these services or discriminated in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability, you can file a grievance with: Blue Shield of California Civil Rights Coordinator P.O. Box 629007 El Dorado Hills, CA 95762-9007 Phone: (844) 831-4133 (TTY: 711) Fax: (844) 696-6070 Email: BlueShieldCivilRightsCoordinator@blueshieldca.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201 (800) 368-1019; TTY: (800) 537-7697Complaint forms are available at www.hhs.gov/ocr/office/file/index.html. Blue Shield of California 601 12th Street, Oakland CA 94607 Blue Shield of California is an independent member of the Blue Shield Association A49808-DMHC-SIMPLIFIED (12/19)

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