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Summary of Silver POS 7100 Benefits Benefit In-Network Out-of-Network General Provisions Benefit Period Plan Year Provider Network WNY HMO/POS 200 Network Deductible Individual Family $2,500 $5,000 $5,000 $10,000 Coinsurance N/A 50% after deductible Out-of-Pocket Maximum Individual Family $7,000 $14,000 $10,000 $20,000 Domestic Partner and Children Includes coverage for Domestic Partner and Children Office Visits Primary Care Provider Office & Telehealth Visits $30 copay after deductible 50% after deductible Specialist Office & Telehealth Visits $50 copay after deductible 50% after deductible Telemedicine (Doctor on Demand) Covered in full after deductible Not Covered Allergy Testing & Injections $30 copay after deductible / $50 copay after deductible 50% after deductible Prenatal and Postnatal Care Cost-share applies to initial visit only $30 copay after deductible 50% after deductible Preventive Care Immunizations Covered in full 50% after deductible Colorectal cancer screening Covered in full 50% after deductible Mammograms Covered in full 50% after deductible Routine Physical exams Covered in full Not Covered Routine Gynecological exams Covered in full 50% after deductible Routine Diagnostic services Covered in full 50% after deductible Well Child Visits Covered in full Not Covered Hospital Services Inpatient Hospital $1000 copay after deductible 50% after deductible Inpatient Maternity $1000 copay after deductible 50% after deductible Outpatient Surgery Facility $250 copay after deductible 50% after deductible Skilled Nursing Facility $1000 copay after deductible Limit: None 50% after deductible Emergency & Urgent Care Services Emergency Room Waived if admitted $250 copay after deductible Covered as In-Network Ambulance $250 copay after deductible Covered as In-Network Urgent Care Center $75 copay after deductible Covered as In-Network Therapy, Rehabilitative and Habilitative Services Chiropractic Care $30 copay after deductible 50% after deductible Physical, Occupational, & Speech Therapies (Rehabilitative and Habilitative) $30 copay after deductible 50% after deductible Therapy Benefit Maximum 60 combined PT/OT/ST Visits per condition per plan year Respiratory Therapy $50 copay after deductible 50% after deductible Mental Health/Substance Abuse Inpatient Mental Health $1000 copay after deductible 50% after deductible Inpatient Substance Abuse Detoxification & Rehabilitation $1000 copay after deductible 50% after deductible Outpatient Mental Health $30 copay after deductible 50% after deductible Outpatient Substance Abuse Detoxification & Rehabilitation $30 copay after deductible 50% after deductible Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) $50 copay after deductible 50% after deductible Radiology (X-ray, Diagnostic testing) $50 copay after deductible 50% after deductible

This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available under your program. 11/16/2022 Silver POS 7100 23_H_PPO_NY Benefit In-Network Out-of-Network Laboratory Testing & Pathology $50 copay after deductible 50% after deductible Other Services Diabetic Insulin, Equipment, & Supplies Includes Test strips, Syringes, etc $30 copay after deductible 50% after deductible Diabetes Care Management Program 100% Not Covered Continuous glucose monitor sprints are limited to three (3) per benefit period Dialysis $30 copay after deductible / $50 copay after deductible 50% after deductible Outpatient Chemotherapy $30 copay after deductible / $50 copay after deductible 50% after deductible Durable Medical Equipment 50% coinsurance after deductible 50% after deductible Orthotics & Prosthetics 50% coinsurance after deductible 50% after deductible Home Health Care $30 copay after deductible / $50 copay after deductible 50% after deductible Limit: 40 aggregate visits per year; Home Infusion counts toward home health care visit limit. Hospice $250 copay after deductible 50% after deductible Limit: None Wellness Card $250 per contract Benefit allowance accessible through the use of a debit card, at participating providers for exercise centers, fitness clubs, & gyms Prescription Drugs Prescription Drug Retail Drugs (30-day Supply) $10 after deductible $40 after deductible 50% after deductible Mail Order Drugs (90-day Supply) $25 after deductible $100 after deductible 42% after deductible Pediatric Vision Services - Davis Vision National Network Exam Covered in full after deductible Not Covered Pediatric frame selection Covered in full after deductible Not Covered Standard eyeglass lenses (per pair) Covered in full after deductible Not Covered Pediatric Dental Services - United Concordia Elite Prime Network Preventive Services $25 copay $25 copay Basic Services 50% after deductible 50% after deductible Major Services 50% after deductible 50% after deductible Medically Necessary Orthodontics 50% after deductible 50% after deductible Discrimination is Against the Law The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Claims Administrator/Insurer will not deny or limit coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Claims Administrator/Insurer will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. The Claims Administrator/Insurer:  Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified sign language interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats)  Provides free language services to people whose primary language is not English, such as: - Qualified interpreters

- Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the 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, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.