Common use of Coverage Examples Clause in Contracts

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. ◼ The plan’s overall deductible $2,000 3,750 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% ◼ The plan’s overall deductible $3,750 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% ◼ The plan’s overall deductible $3,750 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 3,750 Copayments $0 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 3,750 Copayments $0 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 2,800 Copayments $0 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2025 – 12/31/2025 Kane County: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) Active Plan Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call ▇-▇▇▇-▇▇://▇-▇▇▇▇ or at ▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇-▇▇▇) -▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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-self- only coverage. ◼ The plan’s overall deductible $2,000 1,000 ◼ Specialist Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Specialist office Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 1,000 ◼ Specialist coinsurance 0% copayment $30 ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Primary care physician Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 1,000 ◼ Specialist coinsurance 0% copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 020% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 1,000 Copayments $0 10 Coinsurance $0 2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $2,000 900 Copayments $0 800 Coinsurance $0 Limits or exclusions $20 The total ▇▇▇ would pay is $1,720 Deductibles $2,000 1,000 Copayments $0 100 Coinsurance $0 100 Limits or exclusions $0 The plan total Mia would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. pay is $1,200 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2021 – 12/31/2021 Charter Township of Clinton Employee and Retiree Benefit Plan: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) MICHIGAN 050 Coverage for: Single + Family | Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/eocdps/aso▇▇▇▇▇.▇▇▇ or call (▇▇▇) ▇▇▇-▇▇▇▇. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, terms see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ ▇ or call Care Coordinators at (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. (9 months of in-network pre-natal care and a hospital delivery) (a year of routine in-network care of a well- controlled condition) (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,000 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 500 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why If you believe we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude peoplehave failed to provide a service, or treat them differently on the basis think we have discriminated in another way, contact us to file a grievance. Office of race, color, national origin, sex, age or disabilityCivil Rights Coordinator Phone: ▇▇▇-▇▇▇-▇▇▇▇ (voicemail) ▇▇▇ ▇. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (▇▇▇▇▇▇▇▇ St. TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race▇▇▇-▇▇▇-▇▇▇▇ 35th Floor Fax: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇▇, color, national origin, age, disability, or sex, you can ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇ You may file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at Rights, at: U.S. Dept. of Health & Human Services Phone: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇, ▇ TTY/TDD: ▇▇; ▇-▇▇▇-▇▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇; ▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇ ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at : ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. lobby.jsf ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Complaint forms are available at Forms: ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. index.html Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2022 – 12/31/2022 ▇▇▇▇ County: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) Non-Union HMOI Plan Coverage for: ALL | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call ▇-▇▇▇-▇▇://▇-▇▇▇▇ or at ▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇-▇▇▇) -▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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-self- only coverage. ◼ The plan’s overall deductible $2,000 500 ◼ Specialist Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Specialist office Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 500 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Primary care physician Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 500 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 020% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 500 Copayments $0 10 Coinsurance $0 2,400 Limits or exclusions $60 The total Peg would pay is $2,970 Deductibles $2,000 500 Copayments $0 700 Coinsurance $0 80 Limits or exclusions $20 The total ▇▇▇ would pay is $1,300 Deductibles $2,000 500 Copayments $0 70 Coinsurance $0 200 Limits or exclusions $0 The plan total Mia would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) pay is $770 Appendix "C" 29 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/eocdps/aso▇▇▇▇▇.▇▇▇ or call (▇▇▇) ▇▇▇-▇▇▇▇. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, terms see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ ▇ or call Care Coordinators at (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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-self- only coverage. ◼ The plan’s overall deductible $2,000 1,000 ◼ Specialist Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Specialist office Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 1,000 ◼ Specialist coinsurance 0% copayment $30 ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Primary care physician Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 1,000 ◼ Specialist coinsurance 0% copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 020% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 1,000 Copayments $0 10 Coinsurance $0 2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $2,000 900 Copayments $0 800 Coinsurance $0 Limits or exclusions $20 The total ▇▇▇ would pay is $1,720 Deductibles $2,000 1,000 Copayments $0 100 Coinsurance $0 100 Limits or exclusions $0 The plan total Mia would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/eocdps/aso▇▇▇▇▇.▇▇▇ or call (▇▇▇) ▇▇▇-▇▇▇▇. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, terms see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ ▇ or call Care Coordinators at (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,000 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 500 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2025 – 12/31/2025 Kane County: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) HMOI Plan Coverage for: Individual/Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call ▇-▇▇▇-▇▇://▇-▇▇▇▇ or at ▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇-▇▇▇) -▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. (9 months of in-network pre-natal care and a hospital delivery) (a year of routine in-network care of a well- controlled condition) (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,000 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 500 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why If you believe we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude peoplehave failed to provide a service, or treat them differently on the basis think we have discriminated in another way, contact us to file a grievance. Office of race, color, national origin, sex, age or disabilityCivil Rights Coordinator Phone: ▇▇▇-▇▇▇-▇▇▇▇ (voicemail) ▇▇▇ ▇. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (▇▇▇▇▇▇▇▇ St. TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race▇▇▇-▇▇▇-▇▇▇▇ 35th Floor Fax: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇▇, color, national origin, age, disability, or sex, you can ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇ You may file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at Rights, at: U.S. Dept. of Health & Human Services Phone: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇, ▇ TTY/TDD: ▇▇; ▇-▇▇▇-▇▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇; ▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇ ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at : ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. lobby.jsf ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Complaint forms are available at Forms: ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. index.html Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2022 – 12/31/2022 ▇▇▇▇ County: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) Union HMOI Plan Coverage for: ALL | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call ▇-▇▇▇-▇▇://▇-▇▇▇▇ or at ▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇-▇▇▇) -▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,000 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 600 Coinsurance $0 Limits or exclusions $0 The plan would be responsible Health care coverage is important for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activitieseveryone. We don’t discriminate, exclude people, provide free communication aids and services for anyone with a disability or treat them differently who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, age gender identity, age,sexual orientation, health status or disability. For people with disabilitiesIf you believe we have failed to provide a service, or think we offer free aids and serviceshave discriminated in another way, contact us to file a grievance. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languagesOffice of Civil Rights Coordinator Phone: ▇▇▇-▇▇▇-▇▇▇▇ (voicemail) ▇▇▇ ▇. Interested in these services? Call the Member Services number on your ID card for help (▇▇▇▇▇▇▇▇ St. TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race▇▇▇-▇▇▇-▇▇▇▇ 35th Floor Fax: ▇▇▇-▇▇▇-▇▇▇▇ Chicago, color, national origin, age, disability, or sex, you can Illinois 60601 You may file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at Rights, at: U.S. Dept. of Health & Human Services Phone: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇ ▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TTY/TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇ Room 509F, HHH Building 1019 Complaint Portal: ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. lobby.jsf Washington, DC 20201 Complaint forms are available at Forms: ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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-self- only coverage. ◼ The plan’s overall deductible $2,000 250 ◼ Specialist Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 010% Specialist office Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 250 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 010% Primary care physician Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 250 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 250 Copayments $0 Coinsurance $0 500 Limits or exclusions $60 The total Peg would pay is $810 Deductibles $2,000 250 Copayments $0 500 Coinsurance $0 30 Limits or exclusions $20 The total ▇▇▇ would pay is $770 Deductibles $2,000 250 Copayments $0 70 Coinsurance $0 100 Limits or exclusions $0 The total Mia would pay is $420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan would exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO™ Dentist Delta Dental Premier® Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 65% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 65% 65% Brush Biopsy – to detect oral cancer 100% 65% 65% Radiographs – X-rays 100% 65% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – treatment must begin prior to age 19 and coverage will continue to the end of treatment or until the maximum has been reached Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Sealants are not a Covered Service.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Page 77 Having Delta Dental coverage makes it easy for you to Agpeptedndeinx t"aHl" care almost everywhere in the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. world! You can file now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002worldwide network of dentists and dental clinics. English-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms speaking operators are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits around the clock to answer questions and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,500 per person total per Benefit Year on all services except orthodontic services. $1,500 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, ▇▇▇▇▇://▇▇▇the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to Delta Dental. Deductible – None.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. coverage ◼ The plan’s overall deductible $2,000 Specialist coinsurance 0% ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% Copayments $0 ◼ Hospital (facility) coinsurance 0% ◼ The plan’s overall deductible $2,000 $2,000 ◼ The plan’s overall deductible $2,000 ◼ Other coinsurance 0% $0 ◼ Other coinsurance 0% This EXAMPLE event includes services Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Limits or exclusions Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) Limits or exclusions $0 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $20 ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. (9 months of in-network pre-natal care and a hospital delivery) (a year of routine in-network care of a well- controlled condition) (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,000 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 600 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why If you believe we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude peoplehave failed to provide a service, or treat them differently on the basis think we have discriminated in another way, contact us to file a grievance. Office of race, color, national origin, sex, age or disabilityCivil Rights Coordinator Phone: ▇▇▇-▇▇▇-▇▇▇▇ (voicemail) ▇▇▇ ▇. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (▇▇▇▇▇▇▇▇ St. TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race▇▇▇-▇▇▇-▇▇▇▇ 35th Floor Fax: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇▇, color, national origin, age, disability, or sex, you can ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇ You may file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at Rights, at: U.S. Dept. of Health & Human Services Phone: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇, ▇ TTY/TDD: ▇▇; ▇-▇▇▇-▇▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇; ▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇ ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at : ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. lobby.jsf ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Complaint forms are available at Forms: ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. index.html Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2022 – 12/31/2022 ▇▇▇▇ County: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) Union BA HMO Plan Coverage for: ALL | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call ▇-▇▇▇-▇▇://▇-▇▇▇▇ or at ▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇-▇▇▇) -▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. (a year of routine in-network care of a well- controlled condition) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,000 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 500 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why If you believe we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude peoplehave failed to provide a service, or treat them differently on the basis think we have discriminated in another way, contact us to file a grievance. Office of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race855-661-6965 35th Floor Fax: 855-661-6960 Chicago, color, national origin, age, disability, or sex, you can Illinois 60601 You may file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇Rights, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇at: U.S. Dept. ▇▇▇▇▇ or by calling 1-of Health & Human Services Phone: 800-368- 368-1019 (200 Independence Avenue SW TTY/TDD: ▇- ▇▇▇800-▇▇▇537-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. 7697 Room 509F, HHH Building 1019 Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and CoveragePortal: What this Plan Covers & What You Pay for Covered Services Coverage Periodhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.http://www.hhs.gov/ocr/office/file/index.html

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. (9 months of in-network pre-natal care and a hospital delivery) (a year of routine in-network care of a well- controlled condition) (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $2,000 750 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% ◼ The plan’s overall deductible $750 ◼ Specialist copayment $50 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $750 ◼ Specialist copayment $50 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 750 Copayments $0 30 Coinsurance $0 2,000 Limits or exclusions $60 Deductibles $2,000 750 Copayments $0 1,000 Coinsurance $0 30 Limits or exclusions $20 Deductibles $2,000 750 Copayments $0 400 Coinsurance $0 200 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why If you believe we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude peoplehave failed to provide a service, or treat them differently on the basis think we have discriminated in another way, contact us to file a grievance. Office of race, color, national origin, sex, age or disabilityCivil Rights Coordinator Phone: ▇▇▇-▇▇▇-▇▇▇▇ (voicemail) ▇▇▇ ▇. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (▇▇▇▇▇▇▇▇ St. TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race▇▇▇-▇▇▇-▇▇▇▇ 35th Floor Fax: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇▇, color, national origin, age, disability, or sex, you can ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇ You may file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at Rights, at: U.S. Dept. of Health & Human Services Phone: ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇, ▇ TTY/TDD: ▇▇; ▇-▇▇▇-▇▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇; ▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇ ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at : ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. lobby.jsf ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Complaint forms are available at Forms: ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. index.html Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2022 – 12/31/2022 ▇▇▇▇ County: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) Non-Union BA HMO Plan Coverage for: ALL | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call ▇-▇▇▇-▇▇://▇-▇▇▇▇ or at ▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇-▇▇▇) -▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. coverage ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Deductibles Copayments Coinsurance ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Limits or exclusions Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) Limits or exclusions $0 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $20 ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $50 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 0% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,000 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 500 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for For Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town01/01/2025 – 12/31/2025 Kane County: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) HSA Plan Coverage for: Individual/Family | Plan Type: HSA The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call ▇-▇▇▇-▇▇://▇-▇▇▇▇ or at ▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇-▇▇▇) -▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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-self- only coverage. ◼ The plan’s overall deductible $2,000 500 ◼ Specialist Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Specialist office Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 500 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 020% ◼ Other coinsurance 020% Primary care physician Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 500 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 020% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 500 Copayments $0 10 Coinsurance $0 2,400 Limits or exclusions $60 The total Peg would pay is $2,970 Deductibles $2,000 500 Copayments $0 700 Coinsurance $0 80 Limits or exclusions $20 The total ▇▇▇ would pay is $1,300 Deductibles $2,000 500 Copayments $0 70 Coinsurance $0 200 Limits or exclusions $0 The plan total Mia would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) pay is $770 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/eocdps/aso▇▇▇▇▇.▇▇▇ or call (▇▇▇) ▇▇▇-▇▇▇▇. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, terms see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ ▇ or call Care Coordinators at (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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. ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $25 ◼ Hospital (facility) coinsurance 0% copayment $350 ◼ Other coinsurance 0% Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $25 ◼ Hospital (facility) coinsurance 0% copayment $350 ◼ Other coinsurance 0% Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 0 ◼ Specialist coinsurance 0% copayment $25 ◼ Hospital (facility) coinsurance 0% copayment $350 ◼ Other coinsurance 0% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 0 Copayments $0 400 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 0 Copayments $0 1,300 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 0 Copayments $0 300 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 01/01/2025 - 06/30/2026 Hamden Town12/31/2025 Coverage for: Anthem Century Preferred Individual + Family | Plan Type: PPO PS CSV HDHP (employees hired on or after July 1, 2025) + The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 ◼ Specialist coinsurance 0% ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $60 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $20 Deductibles $2,000 Copayments $0 Coinsurance $0 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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-self- only coverage. ◼ The plan’s overall deductible $2,000 250 ◼ Specialist Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 010% Specialist office Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 250 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 010% Primary care physician Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 250 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 250 Copayments $0 10 Coinsurance $0 1,200 Limits or exclusions $60 The total Peg would pay is $1,520 Deductibles $2,000 250 Copayments $0 800 Coinsurance $0 70 Limits or exclusions $20 The total ▇▇▇ would pay is $1,140 Deductibles $2,000 250 Copayments $0 70 Coinsurance $0 100 Limits or exclusions $0 The plan total Mia would be responsible for the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) pay is $420 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/eocdps/aso▇▇▇▇▇.▇▇▇ or call (▇▇▇) ▇▇▇-▇▇▇▇. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, terms see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ - glossary or call Care Coordinators at (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- 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-self- only coverage. ◼ The plan’s overall deductible $2,000 250 ◼ Specialist Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 010% Specialist office Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $2,000 250 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 010% Primary care physician Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $2,000 250 ◼ Specialist coinsurance 0% copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing Deductibles $2,000 250 Copayments $0 10 Coinsurance $0 1,200 Limits or exclusions $60 The total Peg would pay is $1,520 Deductibles $2,000 250 Copayments $0 800 Coinsurance $0 70 Limits or exclusions $20 The total ▇▇▇ would pay is $1,140 Deductibles $2,000 250 Copayments $0 70 Coinsurance $0 100 Limits or exclusions $0 The total Mia would pay is $420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan would exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the other costs of these EXAMPLE covered services That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. world! You can file now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002worldwide network of dentists and dental clinics. English-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇; ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ or by calling 1-800-368- 1019 (TDD: ▇- ▇▇▇-▇▇▇-▇▇▇▇) or online at ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ocr/portal/lobby.jsf. Complaint forms speaking operators are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. Summary of Benefits around the clock to answer questions and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2025 - 06/30/2026 Hamden Town: Anthem Century Preferred PPO PS CSV HDHP (employees hired on or after July 1, 2025) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of the complete terms of coverage, ▇▇▇▇▇://▇▇▇our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services.▇▇▇▇▇▇.▇▇▇/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇-▇▇▇▇▇▇▇▇/ or call (▇▇▇) ▇▇▇-▇▇▇▇ to request a copy.