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SBC CPM ALL

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Message Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2025 – 12/31/2025Charter CharE1500i100LX21B UnitedHealthcare Level Funded Coverage For: Family | Plan Type: EPOThe 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 is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-877-797-8812 or visit myuhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined termssee the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-877-797-8812 to request a copy. Important Questions Answers Why This Matters:What is the overall deductible?Network: $1,500 Individual / $3,000 Familyper year.Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the plan, eachfamily 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 servicescovered before you meetyour deductible?Yes. Preventive Care Services are covered before youmeet your deductible.This plan covers some items and services even if you haven’t yet met the annual deductible amount. But a copayment or coinsurance may apply.For example, this plan covers certain preventive services without cost-sharing andbefore you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specificservices?No. You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan? Network: $4,000 Individual / $8,000 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. Ifyou 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 inthe out-of-pocket limit?Premiums, balance-billing charges, health care this plan doesn’t cover.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Will you pay less if youuse a network provider?Yes. See myuhc.com or call 1-877-797-8812 for a listof 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 youmight receive a bill from a provider for the difference between the provider’s chargeand what your plan pays (balance billing). Be aware, your network provider mightuse an out-of-network provider for some services (such as lab work). Check withyour provider before you get services.Do you need a referral tosee a specialist?Yes. This plan will pay some or all of the costs to see a specialist for covered services butonly if you have a referral before you see the specialist.Page 1 of 8

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other ImportantInformationNetwork Provider withReferral (You will pay theleast)Network Provider withoutReferral (You may paymore)Out-of-NetworkProvider (Youwill pay the most)If you visit ahealth care provider’soffice orclinicPrimary carevisit to treat aninjury or illness$25 copay per visit, deductible does not applyNot Covered Not Covered Primary Care Physician must be assigned tomember. Primary Care includes network OB/GYNs – no referral required.Under age 19 - Network visits are covered at NoCharge.Virtual Visits - No Charge by a DesignatedVirtual Network Provider. No referral required.If you receive services in addition to office visit,additional copays, deductibles or coinsurancemay apply e.g. surgery. Specialist visit $75 copay per visit, deductible does not applyNot Covered Not Covered We only accept electronic referrals from theassigned PCP. If you receive services in addition to office visit,additional copays, deductibles or coinsurancemay apply e.g. surgery. Preventive care/screening/immunizationNo Charge Not Covered Not Covered You may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what your plan will pay for.If you have atestDiagnostic test(x-ray, bloodwork)0% coinsurance 0% coinsurance Not Covered None Imaging (CT/PET scans,MRIs)0% coinsurance 0% coinsurance Not Covered None* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 2 of 8

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CommonMedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other ImportantInformationNetwork Provider withReferral (You will pay theleast)Network Provider withoutReferral (You may paymore)Out-of-NetworkProvider (Youwill pay the most)If you needdrugs to treatyour illnessor conditionMoreinformationabout prescriptiondrug coverageis available at myuhc.comTier 1 - YourLowest CostOptionRetail: $10 copay, deductible does not apply. Mail-Order: $25 copay, deductible does not apply. Specialty Drugs: $10 copay,deductible does not apply.Retail: $10 copay, deductible does not apply. Mail-Order: $25 copay, deductible does not apply. Specialty Drugs: $10 copay,deductible does not apply.Not Covered Provider means pharmacy for purposes of thissection.Retail: Up to a 90 day supply.Mail-Order: Up to a 90 day supply.Specialty: Up to a 31 day supply.Specialty drugs are not covered through mailorder.One retail copay applies per 31-day retailprescription.You may need to obtain certain drugs, includingcertain specialty drugs, from a pharmacydesignated by us. Certain drugs may have a preauthorization requirement or may result in ahigher cost.Certain preventive medications (including certaincontraceptives) and the List of Zero Cost ShareMedications are covered at No Charge.See the website listed for information on drugscovered by your plan. Not all drugs are covered.You may be required to use a lower-cost drug(s)prior to benefits under your plan being availablefor certain prescribed drugs.If a dispensed drug has a chemically equivalentdrug at a lower tier, the cost difference betweendrugs in addition to any applicable copay and/or coinsurance may be applied.Tier 2 - YourMid-Range CostOptionRetail: $35 copay, deductible does not apply. Mail-Order: $87.50 copay, deductible does not apply. Specialty Drugs: $150 copay, deductible does notapply.Retail: $35 copay, deductible does not apply. Mail-Order: $87.50 copay, deductible does not apply. Specialty Drugs: $150 copay, deductible does notapply.Not CoveredTier 3 - YourMid-Range CostOptionRetail: $75 copay, deductible does not apply. Mail-Order: $187.50 copay, deductible does not apply. Specialty Drugs: $350 copay, deductible does notapply.Retail: $75 copay, deductible does not apply. Mail-Order: $187.50 copay, deductible does not apply. Specialty Drugs: $350 copay, deductible does notapply.Not CoveredTier 4 - YourHighest CostOptionRetail: $250 copay, deductible does not apply. Mail-Order: $625 copay, deductible does not apply. Specialty Drugs: $500 copay, deductible does notapply.Retail: $250 copay, deductible does not apply. Mail-Order: $625 copay, deductible does not apply. Specialty Drugs: $500 copay, deductible does notapply.Not CoveredIf you haveoutpatientsurgery Facility fee (e.g., ambulatorysurgery center) 0% coinsurance Not Covered Not Covered None* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 3 of 8

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CommonMedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other ImportantInformationNetwork Provider withReferral (You will pay theleast)Network Provider withoutReferral (You may paymore)Out-of-NetworkProvider (Youwill pay the most) Physician/surgeon fees0% coinsurance Not Covered Not Covered NoneIf you needimmediatemedicalattention Emergencyroom care0% coinsurance 0% coinsurance 0% coinsurance $300 per occurrence copay applies prior to theoverall deductible. Emergencymedicaltransportation0% coinsurance 0% coinsurance 0% coinsurance None Urgent Care $50 copay per visit, deductible does not apply$50 copay per visit, deductible does not applyNot Covered Virtual Visits - No Charge by a DesignatedVirtual Network Provider. No referral required.If you receive services in addition to Urgent carevisit, additional copays, deductibles or coinsurance may apply e.g. surgery.If you have ahospital stayFacility fee (e.g., hospitalroom)0% coinsurance Not Covered Not Covered None Physician/surgeon fees0% coinsurance Not Covered Not Covered NoneIf you needmentalhealth,behavioralhealth, orsubstanceabuseservicesOutpatientservices$75 copay per visit, deductible does not apply$75 copay per visit, deductible does not applyNot Covered Network Partial hospitalization/intensiveoutpatient treatment: 0% coinsurance* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 4 of 8

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CommonMedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other ImportantInformationNetwork Provider withReferral (You will pay theleast)Network Provider withoutReferral (You may paymore)Out-of-NetworkProvider (Youwill pay the most) Inpatientservices0% coinsurance 0% coinsurance Not Covered NoneIf you arepregnantOffice Visits Primary Care Visit: $25 copay per visit, deductibledoes not apply Specialist Visit: $75 copay per visit, deductible does not applyPrimary Care Visit: $25 copay per visit, deductibledoes not apply Specialist Visit: $75 copay per visit, deductible does not applyNot Covered Cost sharing does not apply for preventiveservices. Depending on the type of services, a copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound). Childbirth/deliveryprofessionalservices0% coinsurance 0% coinsurance Not Covered Childbirth/delivery facilityservices0% coinsurance 0% coinsurance Not Covered NoneIf you needhelprecovering orhave otherspecialhealth needsHome healthcare0% coinsurance 0% coinsurance Not Covered Limited to 30 visits per year.Rehabilitationservices0% coinsurance 0% coinsurance Not Covered 30 combined visits per year for rehabilitation and habilitation services. Includes physicaltherapy, speech therapy, occupational therapy,cardiac rehabilitation therapy, pulmonaryrehabilitation therapy.Habilitationservices0% coinsurance 0% coinsurance Not Covered* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 5 of 8

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CommonMedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other ImportantInformationNetwork Provider withReferral (You will pay theleast)Network Provider withoutReferral (You may paymore)Out-of-NetworkProvider (Youwill pay the most)Skilled nursingcare0% coinsurance 0% coinsurance Not Covered Limited to 60 days per year, combined withinpatient rehabilitation and residential treatment.Durable medicalequipment0% coinsurance 0% coinsurance Not Covered NoneHospiceservices0% coinsurance 0% coinsurance Not Covered NoneIf your childneeds dentalor eye careChildren’s eyeexamNot Covered Not Covered Not Covered No coverage for Children’s eye exams. Children’sglassesNot Covered Not Covered Not Covered No coverage for Children’s glasses. Children’sdental check-upNot Covered Not Covered Not Covered No coverage for Children’s dental check-up.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 6 of 8

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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• Glasses• Infertility Treatment• Long Term Care• Non-emergency care when traveling outside -the US• Private duty nursing• Routine Eye Care• Routine foot care - Except as covered for Diabetes• Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture Services - 10 visits per year • Chiropractic (manipulative care) - 20 visits per year• Hearing aids - Limited to $5,000 every 36 MonthsYour 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:U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the HealthInsurance 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 providecomplete 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: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Health Options at 800-252-3439 or visit www.texashealthoptions.com. 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 the premium 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 1-877-797-8812. 1-877-797-8812.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-797-8812.Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf 1-877-797-8812 uff. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-797-8812. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-877-797-8812. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-877-797-8812. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-877-797-8812. To see examples of how this plan might cover costs for a sample medical situation, see the next section.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 7 of 8

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2025 – 12/31/2025Choice Plus P3500i100LX21B UnitedHealthcare Level Funded Coverage For: Family | Plan Type: POSThe 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 is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-877-797-8812 or visit myuhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined termssee the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-877-797-8812 to request a copy. Important Questions Answers Why This Matters:What is the overall deductible?Network: $3,500 Individual / $7,000 FamilyOut-of-Network: $7,000 Individual / $14,000 Familyper year.Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the plan, eachfamily 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 servicescovered before you meetyour deductible?Yes. Preventive Care Services are covered before youmeet your deductible.This plan covers some items and services even if you haven’t yet met the annual deductible amount. But a copayment or coinsurance may apply.For example, this plan covers certain preventive services without cost-sharing andbefore you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specificservices?No. You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan? Network: $6,000 Individual / $12,000 FamilyOut-of-Network: $12,000 Individual / $24,000 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. Ifyou 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 inthe out-of-pocket limit?Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure to obtain preauthorization for services.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Will you pay less if youuse a network provider?Yes. See myuhc.com or call 1-877-797-8812 for a listof 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 youmight receive a bill from a provider for the difference between the provider’s chargeand what your plan pays (balance billing). Be aware, your network provider mightuse an out-of-network provider for some services (such as lab work). Check withyour provider before you get services.Do you need a referral tosee a specialist?No. You can see the specialist you choose without a referral.Page 1 of 8

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If you visit ahealth care provider’s officeor clinicPrimary care visitto treat an injuryor illness$25 copay per visit, deductible does not apply50% coinsurance Under age 19 - Network visits are covered at No Charge.Virtual Visits - No Charge by a Designated Virtual Network Provider. No virtual coverage out-of-network.If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.Specialist visit $75 copay per visit, deductible does not apply50% coinsurance If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.Preventive care/screening/immunizationNo Charge 50% coinsurance You may have to pay for services that aren’t preventive. Askyour provider if the services needed are preventive. Thencheck what your plan will pay for.If you have a test Diagnostic test (x-ray, blood work)0% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount. Imaging (CT/PETscans, MRIs)0% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 2 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If you need drugsto treat yourillness orconditionMore informationabout prescriptiondrug coverage isavailable at myuhc.comTier 1 - YourLowest CostOptionRetail: $10 copay, deductibledoes not apply. Mail-Order: $25 copay, deductible does not apply. Specialty Drugs: $10 copay, deductible does not apply.Retail: $10 copay, deductibledoes not apply. Specialty Drugs: $10 copay, deductible does not apply.Provider means pharmacy for purposes of this section.Retail: Up to a 90 day supply.Mail-Order: Up to a 90 day supply.Specialty: Up to a 31 day supply.Specialty drugs are not covered through mail order.One retail copay applies per 31-day retail prescription.You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certaindrugs may have a preauthorization requirement or may resultin a higher cost. If you use an out of network pharmacy, youmay need to pay the cost up front, submit for reimbursement,and may be responsible for any amount over the allowedamount.Certain preventive medications (including certaincontraceptives) and the List of Zero Cost Share Medicationsare covered at No Charge.See the website listed for information on drugs covered byyour plan. Not all drugs are covered. You may be required touse a lower-cost drug(s) prior to benefits under your planbeing available for certain prescribed drugs.If a dispensed drug has a chemically equivalent drug at alower tier, the cost difference between drugs in addition toany applicable copay and/or coinsurance may be applied.Tier 2 - Your Mid-Range CostOptionRetail: $35 copay, deductibledoes not apply. Mail-Order: $87.50 copay, deductible does not apply. Specialty Drugs: $150 copay, deductible does not apply.Retail: $35 copay, deductibledoes not apply. Specialty Drugs: $150 copay, deductible does not apply.Tier 3 - Your Mid-Range CostOptionRetail: $75 copay, deductibledoes not apply. Mail-Order: $187.50 copay, deductible does not apply. Specialty Drugs: $350 copay, deductible does not apply.Retail: $75 copay, deductibledoes not apply. Specialty Drugs: $350 copay, deductible does not apply.Tier 4 - YourHighest CostOptionRetail: $250 copay, deductibledoes not apply. Mail-Order: $625 copay, deductible does not apply. Specialty Drugs: $500 copay, deductible does not apply.Retail: $250 copay, deductibledoes not apply. Specialty Drugs: $500 copay, deductible does not apply.If you haveoutpatient surgeryFacility fee (e.g.,ambulatorysurgery center) 0% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 3 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most) Physician/surgeon fees0% coinsurance 50% coinsurance NoneIf you needimmediatemedical attention Emergency roomcare0% coinsurance *0% coinsurance $300 per occurrence copay applies prior to the overall deductible. *Network deductible applies.Emergencymedicaltransportation0% coinsurance *0% coinsurance *Network deductible applies.Urgent Care $50 copay per visit, deductible does not apply50% coinsurance Virtual Visits - No Charge by a Designated Virtual Network Provider. No virtual coverage out-of-network.If you receive services in addition to Urgent care visit,additional copays, deductibles or coinsurance may apply e.g.surgery.If you have ahospital stayFacility fee (e.g.,hospital room)0% coinsurance 50% coinsurance None Physician/surgeon fees0% coinsurance 50% coinsurance NoneIf you need mentalhealth, behavioralhealth, orsubstance abuseservicesOutpatientservices$75 copay per visit, deductible does not apply50% coinsurance Network Partial hospitalization/intensive outpatient treatment:0% coinsuranceInpatient services 0% coinsurance 50% coinsurance NoneIf you arepregnantOffice Visits Primary Care Visit: $25 copayper visit, deductible does notapply Specialist Visit: $75 copay pervisit, deductible does notapply50% coinsurance Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care mayinclude tests and services described elsewhere in the SBC (i.e. ultrasound).* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 4 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most) Childbirth/deliveryprofessionalservices0% coinsurance 50% coinsurance Childbirth/deliveryfacility services0% coinsurance 50% coinsurance NoneIf you need helprecovering orhave other specialhealth needsHome health care 0% coinsurance 50% coinsurance Limited to 30 visits per year. Preauthorization is required out-of-network or benefitreduces to 50% of allowed amount.Rehabilitationservices0% coinsurance 50% coinsurance 30 combined visits per year for rehabilitation and habilitationservices. Includes physical therapy, speech therapy,occupational therapy, cardiac rehabilitation therapy,pulmonary rehabilitation therapy.Habilitationservices0% coinsurance 50% coinsuranceSkilled nursingcare0% coinsurance 50% coinsurance Limited to 60 days per year, combined with inpatientrehabilitation and residential treatment. Preauthorization is required out-of-network or benefitreduces to 50% of allowed amount.Durable medicalequipment0% coinsurance 50% coinsurance Preauthorization is required out-of-network for DME over$1,000 or benefit reduces to 50% of allowed amount.Hospice services 0% coinsurance 50% coinsurance Preauthorization is required out-of-network before admissionfor an Inpatient Stay in a hospice facility or benefit reduces to50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 5 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If your child needsdental or eye careChildren’s eyeexamNot Covered Not Covered No coverage for Children’s eye exams.Children’sglassesNot Covered Not Covered No coverage for Children’s glasses.Children’s dentalcheck-upNot Covered Not Covered No coverage for Children’s dental check-up.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 6 of 8

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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• Glasses• Infertility Treatment• Long Term Care• Non-emergency care when traveling outside -the US• Private duty nursing• Routine Eye Care• Routine foot care - Except as covered for Diabetes• Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture Services - 10 visits per year • Chiropractic (manipulative care) - 20 visits per year• Hearing aids - Limited to $5,000 every 36 MonthsYour 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:U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the HealthInsurance 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 providecomplete 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: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Health Options at 800-252-3439 or visit www.texashealthoptions.com. 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 the premium 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 1-877-797-8812. 1-877-797-8812.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-797-8812.Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf 1-877-797-8812 uff. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-797-8812. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-877-797-8812. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-877-797-8812. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-877-797-8812. To see examples of how this plan might cover costs for a sample medical situation, see the next section.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 7 of 8

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$ERXWWKHVH&RYHUDJH([DPSOHV7KLVLVQRWDFRVWHVWLPDWRU7UHDWPHQWVVKRZQDUHMXVWH[DPSOHVRIKRZWKLVSODQPLJKWFRYHUPHGLFDOFDUH<RXUDFWXDOFRVWVZLOOEHGLIIHUHQWGHSHQGLQJRQWKHDFWXDOFDUH\RXUHFHLYHWKHSULFHV\RXUSURYLGHUVFKDUJHDQGPDQ\RWKHUIDFWRUV)RFXVRQWKHFRVWVKDULQJDPRXQWVGHGXFWLEOHVFRSD\PHQWVDQGFRLQVXUDQFHDQGH[FOXGHGVHUYLFHVXQGHUWKHSODQ8VHWKLVLQIRUPDWLRQWRFRPSDUHWKHSRUWLRQRIFRVWV\RXPLJKWSD\XQGHUGLIIHUHQWKHDOWKSODQV3OHDVHQRWHWKHVHFRYHUDJHH[DPSOHVDUHEDVHGRQVHOIRQO\FRYHUDJH3HJLV+DYLQJD%DE\PRQWKVRILQQHWZRUNSUHQDWDOFDUHDQGDKRVSLWDOGHOLYHU\0DQDJLQJ-RH·VW\SH'LDEHWHVD\HDURIURXWLQHLQQHWZRUNFDUHRIDZHOOFRQWUROOHGFRQGLWLRQ0LD·V6LPSOH)UDFWXUHLQQHWZRUNHPHUJHQF\URRPYLVLWDQGIROORZXSFDUH7KHSODQ·VRYHUDOOGHGXFWLEOH SUHQDW  7KHSODQ·VRYHUDOOGHGXFWLEOH SUHQDW  7KHSODQ·VRYHUDOOGHGXFWLEOH SUHQDW 6SHFLDOLVWFRSD\PHQW SUHQDW  6SHFLDOLVWFRSD\PHQW SUHQDW  6SHFLDOLVWFRSD\PHQW SUHQDW +RVSLWDOIDFLOLW\FRLQVXUDQFH SUHQDW  +RVSLWDOIDFLOLW\FRLQVXUDQFH SUHQDW  +RVSLWDOIDFLOLW\FRLQVXUDQFH SUHQDW 2WKHUFRLQVXUDQFH SUHQDW  2WKHUFRLQVXUDQFH SUHQDW  2WKHUFRLQVXUDQFH SUHQDW 7KLV(;$03/(HYHQWLQFOXGHVVHUYLFHVOLNH6SHFLDOLVWRIILFHYLVLWVSUHQDWDOFDUH&KLOGELUWK'HOLYHU\3URIHVVLRQDO6HUYLFHV&KLOGELUWK'HOLYHU\)DFLOLW\6HUYLFHV'LDJQRVWLFWHVWVXOWUDVRXQGVDQGEORRGZRUN6SHFLDOLVWYLVLWDQHVWKHVLD7KLV(;$03/(HYHQWLQFOXGHVVHUYLFHVOLNH3ULPDU\FDUHSK\VLFLDQRIILFHYLVLWVLQFOXGLQJGLVHDVHHGXFDWLRQ'LDJQRVWLFWHVWVEORRGZRUN3UHVFULSWLRQGUXJV'XUDEOHPHGLFDOHTXLSPHQWJOXFRVHPHWHU7KLV(;$03/(HYHQWLQFOXGHVVHUYLFHVOLNH(PHUJHQF\URRPFDUHLQFOXGLQJPHGLFDOVXSSOLHV'LDJQRVWLFWHVW[UD\'XUDEOHPHGLFDOHTXLSPHQWFUXWFKHV5HKDELOLWDWLRQVHUYLFHVSK\VLFDOWKHUDS\7RWDO([DPSOH&RVW SUHQDW  7RWDO([DPSOH&RVW SUHQDW  7RWDO([DPSOH&RVW SUHQDW ,QWKLVH[DPSOH3HJZRXOGSD\ ,QWKLVH[DPSOH-RHZRXOGSD\ ,QWKLVH[DPSOH0LDZRXOGSD\&RVW6KDULQJ  &RVW6KDULQJ  &RVW6KDULQJ 'HGXFWLEOHV SUHQDW  'HGXFWLEOHV SUHQDW  'HGXFWLEOHV SUHQDW &RSD\PHQWV SUHQDW  &RSD\PHQWV SUHQDW  &RSD\PHQWV SUHQDW &RLQVXUDQFH SUHQDW  &RLQVXUDQFH SUHQDW  &RLQVXUDQFH SUHQDW :KDWLVQªWFRYHUHG  :KDWLVQªWFRYHUHG  :KDWLVQªWFRYHUHG /LPLWVRUH[FOXVLRQV SUHQDW  /LPLWVRUH[FOXVLRQV SUHQDW  /LPLWVRUH[FOXVLRQV SUHQDW 7KHWRWDO3HJZRXOGSD\LV SUHQDW  7KHWRWDO-RHZRXOGSD\LV SUHQDW  7KHWRWDO0LDZRXOGSD\LV SUHQDW The plan would be responsible for the other costs of these EXAMPLE covered services. Page 8 of 8

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2025 – 12/31/2025Choice Plus P500i100LX21B UnitedHealthcare Level Funded Coverage For: Family | Plan Type: POSThe 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 is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-877-797-8812 or visit myuhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined termssee the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-877-797-8812 to request a copy. Important Questions Answers Why This Matters:What is the overall deductible?Network: $500 Individual / $1,000 FamilyOut-of-Network: $1,000 Individual / $2,000 Familyper year.Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the plan, eachfamily 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 servicescovered before you meetyour deductible?Yes. Preventive Care Services are covered before youmeet your deductible.This plan covers some items and services even if you haven’t yet met the annual deductible amount. But a copayment or coinsurance may apply.For example, this plan covers certain preventive services without cost-sharing andbefore you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specificservices?No. You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan? Network: $3,000 Individual / $6,000 FamilyOut-of-Network: $6,000 Individual / $12,000 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. Ifyou 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 inthe out-of-pocket limit?Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure to obtain preauthorization for services.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Will you pay less if youuse a network provider?Yes. See myuhc.com or call 1-877-797-8812 for a listof 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 youmight receive a bill from a provider for the difference between the provider’s chargeand what your plan pays (balance billing). Be aware, your network provider mightuse an out-of-network provider for some services (such as lab work). Check withyour provider before you get services.Do you need a referral tosee a specialist?No. You can see the specialist you choose without a referral.Page 1 of 8

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If you visit ahealth care provider’s officeor clinicPrimary care visitto treat an injuryor illness$25 copay per visit, deductible does not apply50% coinsurance Under age 19 - Network visits are covered at No Charge.Virtual Visits - No Charge by a Designated Virtual Network Provider. No virtual coverage out-of-network.If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.Specialist visit $75 copay per visit, deductible does not apply50% coinsurance If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.Preventive care/screening/immunizationNo Charge 50% coinsurance You may have to pay for services that aren’t preventive. Askyour provider if the services needed are preventive. Thencheck what your plan will pay for.If you have a test Diagnostic test (x-ray, blood work)0% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount. Imaging (CT/PETscans, MRIs)0% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 2 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If you need drugsto treat yourillness orconditionMore informationabout prescriptiondrug coverage isavailable at myuhc.comTier 1 - YourLowest CostOptionRetail: $5 copay, deductibledoes not apply. Mail-Order: $12.50 copay, deductible does not apply. Specialty Drugs: $5 copay, deductible does not apply.Retail: $5 copay, deductibledoes not apply. Specialty Drugs: $5 copay, deductible does not apply.Provider means pharmacy for purposes of this section.Retail: Up to a 90 day supply.Mail-Order: Up to a 90 day supply.Specialty: Up to a 31 day supply.Specialty drugs are not covered through mail order.One retail copay applies per 31-day retail prescription.You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certaindrugs may have a preauthorization requirement or may resultin a higher cost. If you use an out of network pharmacy, youmay need to pay the cost up front, submit for reimbursement,and may be responsible for any amount over the allowedamount.Certain preventive medications (including certaincontraceptives) and the List of Zero Cost Share Medicationsare covered at No Charge.See the website listed for information on drugs covered byyour plan. Not all drugs are covered. You may be required touse a lower-cost drug(s) prior to benefits under your planbeing available for certain prescribed drugs.If a dispensed drug has a chemically equivalent drug at alower tier, the cost difference between drugs in addition toany applicable copay and/or coinsurance may be applied.Tier 2 - Your Mid-Range CostOptionRetail: $30 copay, deductibledoes not apply. Mail-Order: $75 copay, deductible does not apply. Specialty Drugs: $150 copay, deductible does not apply.Retail: $30 copay, deductibledoes not apply. Specialty Drugs: $150 copay, deductible does not apply.Tier 3 - Your Mid-Range CostOptionRetail: $65 copay, deductibledoes not apply. Mail-Order: $162.50 copay, deductible does not apply. Specialty Drugs: $350 copay, deductible does not apply.Retail: $65 copay, deductibledoes not apply. Specialty Drugs: $350 copay, deductible does not apply.Tier 4 - YourHighest CostOptionRetail: $150 copay, deductibledoes not apply. Mail-Order: $375 copay, deductible does not apply. Specialty Drugs: $500 copay, deductible does not apply.Retail: $150 copay, deductibledoes not apply. Specialty Drugs: $500 copay, deductible does not apply.If you haveoutpatient surgeryFacility fee (e.g.,ambulatorysurgery center) 0% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 3 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most) Physician/surgeon fees0% coinsurance 50% coinsurance NoneIf you needimmediatemedical attention Emergency roomcare0% coinsurance *0% coinsurance $300 per occurrence copay applies prior to the overall deductible. *Network deductible applies.Emergencymedicaltransportation0% coinsurance *0% coinsurance *Network deductible applies.Urgent Care $50 copay per visit, deductible does not apply50% coinsurance Virtual Visits - No Charge by a Designated Virtual Network Provider. No virtual coverage out-of-network.If you receive services in addition to Urgent care visit,additional copays, deductibles or coinsurance may apply e.g.surgery.If you have ahospital stayFacility fee (e.g.,hospital room)0% coinsurance 50% coinsurance None Physician/surgeon fees0% coinsurance 50% coinsurance NoneIf you need mentalhealth, behavioralhealth, orsubstance abuseservicesOutpatientservices$75 copay per visit, deductible does not apply50% coinsurance Network Partial hospitalization/intensive outpatient treatment:0% coinsuranceInpatient services 0% coinsurance 50% coinsurance NoneIf you arepregnantOffice Visits Primary Care Visit: $25 copayper visit, deductible does notapply Specialist Visit: $75 copay pervisit, deductible does notapply50% coinsurance Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care mayinclude tests and services described elsewhere in the SBC (i.e. ultrasound).* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 4 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most) Childbirth/deliveryprofessionalservices0% coinsurance 50% coinsurance Childbirth/deliveryfacility services0% coinsurance 50% coinsurance NoneIf you need helprecovering orhave other specialhealth needsHome health care 0% coinsurance 50% coinsurance Limited to 30 visits per year. Preauthorization is required out-of-network or benefitreduces to 50% of allowed amount.Rehabilitationservices0% coinsurance 50% coinsurance 30 combined visits per year for rehabilitation and habilitationservices. Includes physical therapy, speech therapy,occupational therapy, cardiac rehabilitation therapy,pulmonary rehabilitation therapy.Habilitationservices0% coinsurance 50% coinsuranceSkilled nursingcare0% coinsurance 50% coinsurance Limited to 60 days per year, combined with inpatientrehabilitation and residential treatment. Preauthorization is required out-of-network or benefitreduces to 50% of allowed amount.Durable medicalequipment0% coinsurance 50% coinsurance Preauthorization is required out-of-network for DME over$1,000 or benefit reduces to 50% of allowed amount.Hospice services 0% coinsurance 50% coinsurance Preauthorization is required out-of-network before admissionfor an Inpatient Stay in a hospice facility or benefit reduces to50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 5 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If your child needsdental or eye careChildren’s eyeexamNot Covered Not Covered No coverage for Children’s eye exams.Children’sglassesNot Covered Not Covered No coverage for Children’s glasses.Children’s dentalcheck-upNot Covered Not Covered No coverage for Children’s dental check-up.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 6 of 8

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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• Glasses• Infertility Treatment• Long Term Care• Non-emergency care when traveling outside -the US• Private duty nursing• Routine Eye Care• Routine foot care - Except as covered for Diabetes• Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture Services - 10 visits per year • Chiropractic (manipulative care) - 20 visits per year• Hearing aids - Limited to $5,000 every 36 MonthsYour 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:U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the HealthInsurance 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 providecomplete 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: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Health Options at 800-252-3439 or visit www.texashealthoptions.com. 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 the premium 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 1-877-797-8812. 1-877-797-8812.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-797-8812.Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf 1-877-797-8812 uff. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-797-8812. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-877-797-8812. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-877-797-8812. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-877-797-8812. To see examples of how this plan might cover costs for a sample medical situation, see the next section.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 7 of 8

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$ERXWWKHVH&RYHUDJH([DPSOHV7KLVLVQRWDFRVWHVWLPDWRU7UHDWPHQWVVKRZQDUHMXVWH[DPSOHVRIKRZWKLVSODQPLJKWFRYHUPHGLFDOFDUH<RXUDFWXDOFRVWVZLOOEHGLIIHUHQWGHSHQGLQJRQWKHDFWXDOFDUH\RXUHFHLYHWKHSULFHV\RXUSURYLGHUVFKDUJHDQGPDQ\RWKHUIDFWRUV)RFXVRQWKHFRVWVKDULQJDPRXQWVGHGXFWLEOHVFRSD\PHQWVDQGFRLQVXUDQFHDQGH[FOXGHGVHUYLFHVXQGHUWKHSODQ8VHWKLVLQIRUPDWLRQWRFRPSDUHWKHSRUWLRQRIFRVWV\RXPLJKWSD\XQGHUGLIIHUHQWKHDOWKSODQV3OHDVHQRWHWKHVHFRYHUDJHH[DPSOHVDUHEDVHGRQVHOIRQO\FRYHUDJH3HJLV+DYLQJD%DE\PRQWKVRILQQHWZRUNSUHQDWDOFDUHDQGDKRVSLWDOGHOLYHU\0DQDJLQJ-RH·VW\SH'LDEHWHVD\HDURIURXWLQHLQQHWZRUNFDUHRIDZHOOFRQWUROOHGFRQGLWLRQ0LD·V6LPSOH)UDFWXUHLQQHWZRUNHPHUJHQF\URRPYLVLWDQGIROORZXSFDUH7KHSODQ·VRYHUDOOGHGXFWLEOH SUHQDW  7KHSODQ·VRYHUDOOGHGXFWLEOH SUHQDW  7KHSODQ·VRYHUDOOGHGXFWLEOH SUHQDW 6SHFLDOLVWFRSD\PHQW SUHQDW  6SHFLDOLVWFRSD\PHQW SUHQDW  6SHFLDOLVWFRSD\PHQW SUHQDW +RVSLWDOIDFLOLW\FRLQVXUDQFH SUHQDW  +RVSLWDOIDFLOLW\FRLQVXUDQFH SUHQDW  +RVSLWDOIDFLOLW\FRLQVXUDQFH SUHQDW 2WKHUFRLQVXUDQFH SUHQDW  2WKHUFRLQVXUDQFH SUHQDW  2WKHUFRLQVXUDQFH SUHQDW 7KLV(;$03/(HYHQWLQFOXGHVVHUYLFHVOLNH6SHFLDOLVWRIILFHYLVLWVSUHQDWDOFDUH&KLOGELUWK'HOLYHU\3URIHVVLRQDO6HUYLFHV&KLOGELUWK'HOLYHU\)DFLOLW\6HUYLFHV'LDJQRVWLFWHVWVXOWUDVRXQGVDQGEORRGZRUN6SHFLDOLVWYLVLWDQHVWKHVLD7KLV(;$03/(HYHQWLQFOXGHVVHUYLFHVOLNH3ULPDU\FDUHSK\VLFLDQRIILFHYLVLWVLQFOXGLQJGLVHDVHHGXFDWLRQ'LDJQRVWLFWHVWVEORRGZRUN3UHVFULSWLRQGUXJV'XUDEOHPHGLFDOHTXLSPHQWJOXFRVHPHWHU7KLV(;$03/(HYHQWLQFOXGHVVHUYLFHVOLNH(PHUJHQF\URRPFDUHLQFOXGLQJPHGLFDOVXSSOLHV'LDJQRVWLFWHVW[UD\'XUDEOHPHGLFDOHTXLSPHQWFUXWFKHV5HKDELOLWDWLRQVHUYLFHVSK\VLFDOWKHUDS\7RWDO([DPSOH&RVW SUHQDW  7RWDO([DPSOH&RVW SUHQDW  7RWDO([DPSOH&RVW SUHQDW ,QWKLVH[DPSOH3HJZRXOGSD\ ,QWKLVH[DPSOH-RHZRXOGSD\ ,QWKLVH[DPSOH0LDZRXOGSD\&RVW6KDULQJ  &RVW6KDULQJ  &RVW6KDULQJ 'HGXFWLEOHV SUHQDW  'HGXFWLEOHV SUHQDW  'HGXFWLEOHV SUHQDW &RSD\PHQWV SUHQDW  &RSD\PHQWV SUHQDW  &RSD\PHQWV SUHQDW &RLQVXUDQFH SUHQDW  &RLQVXUDQFH SUHQDW  &RLQVXUDQFH SUHQDW :KDWLVQªWFRYHUHG  :KDWLVQªWFRYHUHG  :KDWLVQªWFRYHUHG /LPLWVRUH[FOXVLRQV SUHQDW  /LPLWVRUH[FOXVLRQV SUHQDW  /LPLWVRUH[FOXVLRQV SUHQDW 7KHWRWDO3HJZRXOGSD\LV SUHQDW  7KHWRWDO-RHZRXOGSD\LV SUHQDW  7KHWRWDO0LDZRXOGSD\LV SUHQDW The plan would be responsible for the other costs of these EXAMPLE covered services. Page 8 of 8

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2025 – 12/31/2025Choice Plus P6000i80LX21B UnitedHealthcare Level Funded Coverage For: Family | Plan Type: POSThe 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 is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-877-797-8812 or visit myuhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined termssee the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-877-797-8812 to request a copy. Important Questions Answers Why This Matters:What is the overall deductible?Network: $6,000 Individual / $12,000 FamilyOut-of-Network: $12,000 Individual / $24,000 Familyper year.Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the plan, eachfamily 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 servicescovered before you meetyour deductible?Yes. Preventive Care Services are covered before youmeet your deductible.This plan covers some items and services even if you haven’t yet met the annual deductible amount. But a copayment or coinsurance may apply.For example, this plan covers certain preventive services without cost-sharing andbefore you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specificservices?No. You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan? Network: $8,150 Individual / $16,300 FamilyOut-of-Network: $16,300 Individual / $32,600 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. Ifyou 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 inthe out-of-pocket limit?Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure to obtain preauthorization for services.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Will you pay less if youuse a network provider?Yes. See myuhc.com or call 1-877-797-8812 for a listof 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 youmight receive a bill from a provider for the difference between the provider’s chargeand what your plan pays (balance billing). Be aware, your network provider mightuse an out-of-network provider for some services (such as lab work). Check withyour provider before you get services.Do you need a referral tosee a specialist?No. You can see the specialist you choose without a referral.Page 1 of 8

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If you visit ahealth care provider’s officeor clinicPrimary care visitto treat an injuryor illness$25 copay per visit, deductible does not apply50% coinsurance Under age 19 - Network visits are covered at No Charge.Virtual Visits - No Charge by a Designated Virtual Network Provider. No virtual coverage out-of-network.If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.Specialist visit $75 copay per visit, deductible does not apply50% coinsurance If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.Preventive care/screening/immunizationNo Charge 50% coinsurance You may have to pay for services that aren’t preventive. Askyour provider if the services needed are preventive. Thencheck what your plan will pay for.If you have a test Diagnostic test (x-ray, blood work)20% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount. Imaging (CT/PETscans, MRIs)20% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 2 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If you need drugsto treat yourillness orconditionMore informationabout prescriptiondrug coverage isavailable at myuhc.comTier 1 - YourLowest CostOptionRetail: $10 copay, deductibledoes not apply. Mail-Order: $25 copay, deductible does not apply. Specialty Drugs: $10 copay, deductible does not apply.Retail: $10 copay, deductibledoes not apply. Specialty Drugs: $10 copay, deductible does not apply.Provider means pharmacy for purposes of this section.Retail: Up to a 90 day supply.Mail-Order: Up to a 90 day supply.Specialty: Up to a 31 day supply.Specialty drugs are not covered through mail order.One retail copay applies per 31-day retail prescription.You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us. Certaindrugs may have a preauthorization requirement or may resultin a higher cost. If you use an out of network pharmacy, youmay need to pay the cost up front, submit for reimbursement,and may be responsible for any amount over the allowedamount.Certain preventive medications (including certaincontraceptives) and the List of Zero Cost Share Medicationsare covered at No Charge.See the website listed for information on drugs covered byyour plan. Not all drugs are covered. You may be required touse a lower-cost drug(s) prior to benefits under your planbeing available for certain prescribed drugs.If a dispensed drug has a chemically equivalent drug at alower tier, the cost difference between drugs in addition toany applicable copay and/or coinsurance may be applied.Tier 2 - Your Mid-Range CostOptionRetail: $35 copay, deductibledoes not apply. Mail-Order: $87.50 copay, deductible does not apply. Specialty Drugs: $150 copay, deductible does not apply.Retail: $35 copay, deductibledoes not apply. Specialty Drugs: $150 copay, deductible does not apply.Tier 3 - Your Mid-Range CostOptionRetail: $75 copay, deductibledoes not apply. Mail-Order: $187.50 copay, deductible does not apply. Specialty Drugs: $350 copay, deductible does not apply.Retail: $75 copay, deductibledoes not apply. Specialty Drugs: $350 copay, deductible does not apply.Tier 4 - YourHighest CostOptionRetail: $250 copay, deductibledoes not apply. Mail-Order: $625 copay, deductible does not apply. Specialty Drugs: $500 copay, deductible does not apply.Retail: $250 copay, deductibledoes not apply. Specialty Drugs: $500 copay, deductible does not apply.If you haveoutpatient surgeryFacility fee (e.g.,ambulatorysurgery center) 20% coinsurance 50% coinsurance Preauthorization is required out-of-network for certainservices or benefit reduces to 50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 3 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most) Physician/surgeon fees20% coinsurance 50% coinsurance NoneIf you needimmediatemedical attention Emergency roomcare20% coinsurance *20% coinsurance $300 per occurrence copay applies prior to the overall deductible. *Network deductible applies.Emergencymedicaltransportation20% coinsurance *20% coinsurance *Network deductible applies.Urgent Care $50 copay per visit, deductible does not apply50% coinsurance Virtual Visits - No Charge by a Designated Virtual Network Provider. No virtual coverage out-of-network.If you receive services in addition to Urgent care visit,additional copays, deductibles or coinsurance may apply e.g.surgery.If you have ahospital stayFacility fee (e.g.,hospital room)20% coinsurance 50% coinsurance None Physician/surgeon fees20% coinsurance 50% coinsurance NoneIf you need mentalhealth, behavioralhealth, orsubstance abuseservicesOutpatientservices$75 copay per visit, deductible does not apply50% coinsurance Network Partial hospitalization/intensive outpatient treatment:20% coinsuranceInpatient services 20% coinsurance 50% coinsurance NoneIf you arepregnantOffice Visits Primary Care Visit: $25 copayper visit, deductible does notapply Specialist Visit: $75 copay pervisit, deductible does notapply50% coinsurance Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care mayinclude tests and services described elsewhere in the SBC (i.e. ultrasound).* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 4 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most) Childbirth/deliveryprofessionalservices20% coinsurance 50% coinsurance Childbirth/deliveryfacility services20% coinsurance 50% coinsurance NoneIf you need helprecovering orhave other specialhealth needsHome health care 20% coinsurance 50% coinsurance Limited to 30 visits per year. Preauthorization is required out-of-network or benefitreduces to 50% of allowed amount.Rehabilitationservices20% coinsurance 50% coinsurance 30 combined visits per year for rehabilitation and habilitationservices. Includes physical therapy, speech therapy,occupational therapy, cardiac rehabilitation therapy,pulmonary rehabilitation therapy.Habilitationservices20% coinsurance 50% coinsuranceSkilled nursingcare20% coinsurance 50% coinsurance Limited to 60 days per year, combined with inpatientrehabilitation and residential treatment. Preauthorization is required out-of-network or benefitreduces to 50% of allowed amount.Durable medicalequipment20% coinsurance 50% coinsurance Preauthorization is required out-of-network for DME over$1,000 or benefit reduces to 50% of allowed amount.Hospice services 20% coinsurance 50% coinsurance Preauthorization is required out-of-network before admissionfor an Inpatient Stay in a hospice facility or benefit reduces to50% of allowed amount.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 5 of 8

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Common MedicalEventServices YouMay NeedWhat You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider (You willpay the least)Out-of-Network Provider(You will pay the most)If your child needsdental or eye careChildren’s eyeexamNot Covered Not Covered No coverage for Children’s eye exams.Children’sglassesNot Covered Not Covered No coverage for Children’s glasses.Children’s dentalcheck-upNot Covered Not Covered No coverage for Children’s dental check-up.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 6 of 8

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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• Glasses• Infertility Treatment• Long Term Care• Non-emergency care when traveling outside -the US• Private duty nursing• Routine Eye Care• Routine foot care - Except as covered for Diabetes• Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture Services - 10 visits per year • Chiropractic (manipulative care) - 20 visits per year• Hearing aids - Limited to $5,000 every 36 MonthsYour 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:U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the HealthInsurance 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 providecomplete 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: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Health Options at 800-252-3439 or visit www.texashealthoptions.com. 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 the premium 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 1-877-797-8812. 1-877-797-8812.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-797-8812.Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf 1-877-797-8812 uff. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-797-8812. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-877-797-8812. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-877-797-8812. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-877-797-8812. To see examples of how this plan might cover costs for a sample medical situation, see the next section.* For more information about limitations and exceptions, see the plan or policy document at myuhc.com. Page 7 of 8

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