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Yes. Preventive care and primary care services are covered before you meet your deductible. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit us at www.alliedbenefit.com or call 1-888-292-0272. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlinedterms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-888-292-0272 to request a copy.Coverage Period:ANDREA KATZ MD FAAP PA: Plan Option Plan 2Important QuestionsAnswersWhy this Matters:For participating providers $6,600 individual/$13,200 family; For non-participating providers $13,200 individual/$26,400 family.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.What is the overall deductible?No.You don't have to meet deductibles for specific services.Are there other deductiblesfor specific services?No.You can see the specialist you choose without a referral.Do you need a referral to see a specialist?Yes. See www.aetna.com/asa 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.For participating providers $8,550 individual/ $17,100 family; for non-participating providers $25,650 individual / $51,300 family.The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is the out-of-pocket limit for this plan?Premiums, balance-billed charges, penalty for not obtaining Preauthorization and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.What is not included in the out-of-pocket limit?Summary of Benefits and Coverage:Coverage for: Plan Type:What this Plan Covers & What You Pay For Covered Services 09/01/2023-08/31/2024Individual/Family PPOThe 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.Are there services covered before you meet your deductible?This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/Will you pay less if you usea network provider?Page 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Participating Provider(You will pay the least)Preventive care/screening/immunizationIf you visit a health care provider's office or clinicIf you have a testPrimary care visit to treat an injury or illnessIf you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myCigna.comSpecialist visit$50 copay/visit, then covered at 100%50% coinsuranceCopayment is not subject to any Deductible. Copay applies to exam charge only. Does not include office surgery.$75 copay/visit, then covered at 100%50% coinsuranceNo charge. Deductible does not apply.50% coinsuranceDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)30% coinsurance30% coinsurance50% coinsuranceGeneric drugs$20 copay retail/$60 copaymail orderNot coveredWhen the retail store offers a lower price for generic, pay only the lower price. Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription).50% coinsuranceInpatient services are subject to deductible and coinsurance. Deductible and coinsurance are waived for covered charges for outpatient services.Cost sharing does not apply to preventive services. 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.Copay applies to exam charge only. See Plan Document for other services.What You Will PayCommon Medical EventServices You MayNeedNon-Participating Provider(You will pay the most)Limitations, Exceptions & Other Important InformationPreferred brand drugs$50 copay retail/$150 copaymail orderNot coveredWhen a generic is available, pay the difference between the Brand and Generic contracted rate. Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription).Preauthorization is required. If not received, a penalty will be applied.Page 2 of 7

If you have outpatient surgeryFacility fee (e.g., ambulatory surgery center)If you need immediate medical attention30% coinsurance50% coinsurancePreauthorization is required. If not received, a penalty will be applied.Emergency room careEmergency medical transportation$500 copay/visit, then covered at 100%30% coinsurance30% coinsuranceTo the nearest Acute Medical Facility that can treat the sickness or injury.Urgent care$100 copay/visit, then covered at 100%50% coinsuranceNone$500 copay/visit, then covered at 100%Non-emergency use will result in a reduction of charges up to the preauthorization penalty amount. The penalty is not covered.30% coinsurance50% coinsurancePhysician/surgeon fees30% coinsuranceSpecialty drugsNot coveredTo receive the network provider benefit, you must obtain specialty drugs from a specialty pharmacy provider as designated by us. Call 1-800-MyCigna for further information. Specialty drugs obtained from a non-designated specialty pharmacy provider will not be covered. Authorization is required. Benefits will not be paid for any specialty drugs that are not authorized by the Medical Review Manager.Preauthorization is required. If not received, a penalty will be applied.Facility fee (e.g., hospital room)If you have a hospital stay30% coinsurance50% coinsurancePreauthorization is required. If not received, a penalty will be applied.Non-preferred brand drugs$75 copay retail/$225 copaymail orderNot coveredWhen a generic is available, pay the difference between the Brand and Generic contracted rate. Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription).Participating Provider(You will pay the least)What You Will PayCommon Medical EventServices You MayNeedNon-Participating Provider(You will pay the most)Limitations, Exceptions & Other Important InformationPage 3 of 7

If you need help recovering or have other special health needsIf you are pregnantOffice visits$75 copay/visit, then covered at 100%50% coinsuranceCopay applies to exam charge only. See Plan Document for other services.Childbirth/delivery professional services30% coinsurance50% coinsuranceNoneHome health care30% coinsurance50% coinsurancePreauthorization is required. If not received, a penalty will be applied. Limited to 60 visits per year.Rehabilitation services30% coinsurance50% coinsurancePreauthorization is required for Inpatient. If not received, a penalty will be applied. Inpatient limited to 31 days per year. Outpatient limited to 30 visits per year.Childbirth/delivery facility services30% coinsurance50% coinsuranceNone$50 copay/visit, then covered at 100%. 50% coinsurance for other services.If you need mental health, behavioral health, or substance abuse servicesInpatient servicesOutpatient services50% coinsurance70% coinsurancePreauthorization is required. If not received, a penalty will be applied. Limited to 30 days per year.70% coinsuranceLimited to 40 visits per year. Copayments apply to the office visit charge only. Any other services covered under your planare subject to deductible and coinsurance.Participating Provider(You will pay the least)What You Will PayCommon Medical EventServices You MayNeedNon-Participating Provider(You will pay the most)Limitations, Exceptions & Other Important InformationPhysician/surgeon fees30% coinsurance50% coinsurancePreauthorization is required. If not received, a penalty will be applied.Page 4 of 7

Children's eye examNot coveredIf your child needs dental or eye careChildren's glassesChildren's dental checkupNot coveredNot coveredNoneNot coveredNot coveredNoneNot coveredNoneParticipating Provider(You will pay the least)What You Will PayCommon Medical EventServices You MayNeedNon-Participating Provider(You will pay the most)Limitations, Exceptions & Other Important InformationSkilled nursing care30% coinsurance50% coinsurancePreauthorization is required. If not received, a penalty will be applied.Durable medical equipment30% coinsurance50% coinsurancePreauthorization is required for amounts greater than $1,500. If not received, a penalty will be applied.Hospice services30% coinsurance50% coinsuranceNoneHabilitation services30% coinsurance50% coinsurancePreauthorization is required for Inpatient. If not received, a penalty will be applied. Inpatient limited to 31 days per year. Outpatient limited to 30 visits per year.Page 5 of 7

866-387-0489Private-duty nursingRoutine eye care (Adult), except for treatment of diabetesRoutine foot care, except for treatment of diabetesWeight loss programsHearing aidsInfertility treatmentLong-term careNon-emergency care when traveling outside the U.S.AcupunctureBariatric surgeryCosmetic surgeryDental care (Adult)Page 6 of 7Your 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: the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA or www.dol.gov/ebsa/healthreform.Does this Plan Provide Minimum Essential Coverage?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 Standard?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.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 866-387-0489Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 866-387-0489 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: contact the plan at 1-888-292-0272 or the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)Chiropractic careYes.Yes.Excluded Services & Other Covered Services:To see examples of how this might cover costs for a sample medical situation, see the next section. planServices Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)ChineseNavajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 866-387-0489

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.Managing Joe’s type 2 Diabetes(a year of routine in-network care of a well-controlled condition)The plan's overall deductibleSpecialist copaymentHospital (facility) coinsuranceOther coinsurancePage 7 of 7About these Coverage Examples:Peg Is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Deductibles$6,600Copayments$1,500Coinsurance$500Limits or exclusions$60The total Peg would pay is$8,660The plan's overall deductibleSpecialist copaymentHospital (facility) coinsuranceOther coinsuranceIn this example, Peg would pay:The plan would be responsible for the other costs of these EXAMPLE covered services.The plan's overall deductibleEmergency room copaymentHospital (facility) coinsuranceOther coinsuranceMia’s Simple Fracture(in-network emergency room visit and follow up care)What isn't coveredCost SharingTotal Example CostTotal Example CostDeductibles$800Copayments$1,400Coinsurance$0Limits or exclusions$20The total Joe would pay is$2,220In this example, Joe would pay:What isn't coveredCost SharingDeductibles$2,000Copayments$700Coinsurance$0Limits or exclusions$0The total Mia would pay is$2,700In this example, Mia would pay:What isn't coveredCost SharingThis EXAMPLE event includes services like:This EXAMPLE event includes services like:This EXAMPLE event includes services like:$6,600$7530%30%$6,600$7530%30%$6,600$50030%30%$5,600$2,800Total Example Cost$12,700Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic Tests(ultrasounds and blood work)Specialist visit (anesthesia)Primary care physician office visits (including disease education)Diagnostic tests(blood work)Prescription drugsDurable medical equipment(glucose meter)Emergency room care(including medical supplies)Diagnostic tests(x-ray)Durable medical equipment(crutches)Rehabilitation services(physical therapy)