2026 CODAC Benefit Summaries and Carrier Flyers

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services UMR: CODAC Health, Recovery, & Wellness, Inc.: 7670-00-412271 $3,400 HDHP

Coverage Period: 01/01/2026 – 12/31/2026 Coverage for: Individual + Family | Plan Type: HDHP

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit umr.com or by calling 1-844-600-0919. 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 umr.com or call 1-844-600-0919 to request a copy. Important Questions Answers Why this Matters:

$3,400 person / $6,800 family In-network $8,000 person / $16,000 family Out-of-network $3,400 In-network / $8,000 Out-of-network Maximum amount that any one person will satisfy towards the annual family deductible

Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You don’t have to meet deductibles for specific services.

What is the overall deductible?

Are there services covered before you meet your deductible? Are there other deductibles for specific services?

Yes. Preventive care services are covered before you meet your deductible.

No.

$5,000 person / $10,000 family In-network Unlimited Out-of-network $5,000 In-network Maximum amount that any one person will satisfy towards the annual family out-of-pocket Penalties, premiums, balance billing charges, and health care this plan doesn’t cover.

What is the out–of–pocket limit for this plan?

What is not included in the out–of–pocket limit?

Yes. See umr.com or call 1-844-600-0919 for a list of network providers.

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

No.

You can see the specialist you choose without a referral.

Page 1 of 8

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

In-network (You will pay the least)

Out-of-network (You will pay the most)

Primary care visit to treat an injury or illness

20% Coinsurance

50% Coinsurance

None

If you visit a health care provider’s office or clinic

Specialist visit

20% Coinsurance

50% Coinsurance

None

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Preventive care/screening/ immunization

No charge; Deductible Waived

50% Coinsurance

50% Coinsurance Office setting; Not covered Outpatient setting

Diagnostic test (x-ray, blood work)

20% Coinsurance

None

If you have a test

50% Coinsurance Office setting; Not covered Outpatient setting

Imaging (CT/PET scans, MRIs)

None

20% Coinsurance

Page 2 of 8

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

In-network (You will pay the least)

Out-of-network (You will pay the most)

Retail: Up to a 31 day supply Mail-Order: Up to a 90 day supply 90 day supply at CVS retail pharmacy subject to Mail-Order copay. Specialty drugs 30 day supply regardless of retail or mail order. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by CVS/Caremark. For eligible specialty medications, after deductible, $0 copay if filled through the PrudentRx program. If you opt out you will pay 30% of the cost after deductible. Certain drugs may have a prior authorization requirement. Not all drugs are covered. If you use a non-network pharmacy, you are responsible for any amount over the allowed amount. Certain preventive medications are covered at No Charge.

Retail: $10 copay after deductible Mail-Order: $25 copay after deductible Retail: $30 copay after deductible Mail-Order: $75 copay after deductible Retail: $50 copay after deductible Mail-Order: $125 copay after deductible Retail: $50 copay after deductible Mail-Order: $50 copay after deductible

Retail: $10 copay + amount over allowed amount after deductible

Generic drugs (Tier 1)

If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at caremark.com & prudentrx.com

Retail: $30 copay + amount over allowed amount after deductible

Preferred brand drugs (Tier 2)

Retail: $50 copay + amount over allowed amount after deductible

Non-preferred brand drugs (Tier 3)

Retail: $50 copay + amount over allowed amount after deductible

Specialty drugs (Tier 4)

Facility fee (e.g., ambulatory surgery center)

20% Coinsurance

Not covered

If you have outpatient surgery

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Physician/surgeon fees

20% Coinsurance

Not covered

Page 3 of 8

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-network (You will pay the most)

In-network (You will pay the least)

In-network deductible applies to Out-of-network benefits

Emergency room care

20% Coinsurance

20% Coinsurance

In-network deductible applies to Out-of-network benefits; Preauthorization is required for Non-emergent transports. If you don’t get preauthorization, a penalty of $250 may be applied.

If you need immediate medical attention

Emergency medical transportation

20% Coinsurance

20% Coinsurance

Urgent care

20% Coinsurance

50% Coinsurance

None

Facility fee (e.g., hospital room)

20% Coinsurance

50% Coinsurance

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

If you have a hospital stay

20% Coinsurance

Physician/surgeon fees

50% Coinsurance

Preauthorization is required for Partial hospitalization. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

50% Coinsurance Office visits; Not covered other outpatient services

If you have mental health,

Outpatient services

20% Coinsurance

behavioral health, or substance abuse services

Inpatient services

20% Coinsurance

50% Coinsurance

Page 4 of 8

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

In-network (You will pay the least)

Out-of-network (You will pay the most)

No charge; Deductible Waived

Office visits

50% Coinsurance

Cost sharing does not apply for preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services

If you are pregnant

20% Coinsurance

50% Coinsurance

Childbirth/delivery facility services

20% Coinsurance

50% Coinsurance

60 Maximum visits per calendar year; Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. 20 Maximum visits per calendar year OT; 20 Maximum visits per calendar year PT; 20 Maximum visits per calendar year ST. 20 Maximum visits per calendar year. Habilitation services for Learning Disabilities are not covered. 60 Maximum days per calendar year; Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Home health care

50% Coinsurance

20% Coinsurance

50% Coinsurance office therapy; Not covered outpatient hospital 50% Coinsurance office therapy; Not covered outpatient hospital

If you need help recovering or have other special health needs

20% Coinsurance

Rehabilitation services

20% Coinsurance

Habilitation services

Skilled nursing care

20% Coinsurance

50% Coinsurance

Page 5 of 8

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information Preauthorization is required for DME in excess of $500 for rentals and $1,500 for purchases. If you don’t get preauthorization, a penalty of $250 may be applied.

Services You May Need

In-network (You will pay the least)

Out-of-network (You will pay the most)

Durable medical equipment

20% Coinsurance

50% Coinsurance

Hospice service

20% Coinsurance

50% Coinsurance

None

Children’s eye exam

20% Coinsurance

50% Coinsurance

1 Maximum exam every 2 years

If your child needs dental or eye care

Children’s glasses

Not covered

Not covered

None

Children’s dental check-up

Not covered

Not covered

None

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Bariatric surgery • Infertility treatment • Private-duty nursing • Cosmetic surgery • Long-term care • Routine foot care • Dental care (Adult) • Non-emergency care when traveling outside the U.S. • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture – 20 visits per calendar year • Hearing aids – 1 every 3 years • Chiropractic care – 20 visits per calendar year Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. • Routine eye care (Adult) – 1 exam every 2 years

Page 6 of 8

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.HealthCare.gov and http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. Does this plan Provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-844-600-0919. Traditional Chinese ( 中文 ): 如果需要中文的幫助 , 請撥打這個號碼 1-844-600-0919. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-844-600-0919. Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf die do Nummer uff 1-844-600-0919. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-844-600-0919.

Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-844-600-0919. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-844-600-0919. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-844-600-0919.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2026 – 12/31/2026 HealthSCOPE: CODAC Health, Recovery & Wellness, Inc.: 7670-00-4 1 5125 Value Based Payments Plan Coverage for: Individual + Family | Plan Type: VBP

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit healthscopebenefits.com or by calling 1-888-453-1096. 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 healthscopebenefits.com or call 1-888-453-1096 to request a copy.

Important Questions

Answers

Why this Matters:

Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet

Tier 1 - $2,500 person / $5,000 family Facility + PHCS Professional & Ancillary Tier 2 - $5,000 person / $10,000 family

What is the overall deductible?

Are there services covered before you meet your deductible?

Yes. Preventive care services are covered before you meet your deductible.

your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/

Are there other deductibles for specific services?

You don’t have to meet deductibles for specific services.

No.

Tier 1 - $5,000 person / $10,000 family Facility + PHCS Professional & Ancillary Tier 2 - $10,000 person / $20,000 family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is the out – of – pocket limit for this plan?

What is not included in the out – of – pocket limit?

Penalties, premiums, balance billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Yes. See healthscopebenefits.com or call 1-888-453-1096 for a list of network providers.

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

You can see the specialist you choose without a referral.

No.

Page 1 of 8 56

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 2 All Other Providers

Tier 1 Facility+ PHCS Professional & Ancillary

Primary care visit to treat an injury or illness

$25 Copay per visit; Deductible Waived

50% Coinsurance

None

If you visit a health care provider’s office or clinic

$50 Copay per visit; Deductible Waived

Specialist visit

50% Coinsurance

None

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Preventive care/screening/ immunization

No charge; Deductible Waived

50% Coinsurance

Labs - office or outpatient setting no charge; Deductible Waived X-ray - office no charge; Deductible Waived $75 copay outpatient setting; Deductible Waived

Diagnostic test (x-ray, blood work)

50% Coinsurance

None

If you have a test

Preauthorization is required for MRI/CT/PET scans. If you don’t get preauthorization, a penalty of $250 may be applied.

Imaging (CT/PET scans, MRIs)

50% Coinsurance

30% Coinsurance

Page 2 of 8 56

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 2 All Other Providers

Tier 1 Facility+ PHCS Professional & Ancillary

Retail: Up to a 31 day supply Mail-Order: Up to a 90 day supply 90 day supply at CVS retail pharmacy subject to Mail-Order copay. Specialty drugs 30 day supply regardless of retail or mail order. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by CVS/Caremark. For eligible specialty medications, $0 copay if filled through the PrudentRx program. If you opt out you will pay 30% of the cost. Certain drugs may have a prior authorization requirement. Not all drugs are covered. If you use a non-network pharmacy, you are responsible for any amount over the allowed amount. Certain preventive medications are covered at No Charge.

Retail: $15 copay Mail-Order: $37.50 copay

Retail: $15 copay + amount over allowed amount

Generic drugs (Tier 1)

If you need drugs to treat your illness or condition.

Retail: $45 copay Mail-Order: $112.50 copay

Retail: $45 copay + amount over allowed amount

Preferred brand drugs (Tier 2)

More information about prescription

drug coverage is available at caremark.com & prudentrx.com

Retail: $85 copay Mail-Order: $212.50 copay

Non-preferred brand drugs (Tier 3)

Retail: $85 copay + amount over allowed amount

Retail: $170 copay Mail-Order: $170 copay

Retail: $170 copay + amount over allowed amount

Specialty drugs (Tier 4)

Facility fee (e.g., ambulatory surgery center)

If you have outpatient surgery

30% Coinsurance

50% Coinsurance

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Physician/surgeon fees

30% Coinsurance

50% Coinsurance

Page 3 of 8 56

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other

Services You May Need

Tier 2 All Other Providers

Tier 1 Facility+ PHCS Professional & Ancillary

Important Information

$350 Copay per visit; Deductible Waived

$350 Copay per visit; Deductible Waived

Emergency room care

Copay may be waived if admitted

If you need immediate medical attention

Tier 1 deductible applies to Tier 2 benefits; Preauthorization is required for Non-emergent air transports. If you don’t get preauthorization, a penalty of $250 may be applied.

Emergency medical transportation

30% Coinsurance

30% Coinsurance

$75 Copay per visit; Deductible Waived

Urgent care

50% Coinsurance

None

Facility fee (e.g., hospital room)

30% Coinsurance

50% Coinsurance

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

If you have a hospital stay

Physician/surgeon fees

30% Coinsurance

50% Coinsurance

$25 Copay per visit; Deductible Waived Office visits; 30% Coinsurance other outpatient services

If you have mental health,

Subject to Medical Necessity Review.

50% Coinsurance

Outpatient services

behavioral health, or substance abuse services

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Inpatient services

30% Coinsurance

50% Coinsurance

Page 4 of 8 56

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 2 All Other Providers

Tier 1 Facility+ PHCS Professional & Ancillary

No charge; Deductible Waived

50% Coinsurance

Office visits

Cost sharing does not apply for preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services

If you are pregnant

50% Coinsurance

30% Coinsurance

Childbirth/delivery facility services

50% Coinsurance

30% Coinsurance

60 Maximum visits per calendar year. Subject to Medical Necessity Review.

50% Coinsurance

Home health care

30% Coinsurance

20 Maximum visits per calendar year OT; 20 Maximum visits per calendar year PT; 20 Maximum visits per calendar year ST. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. 20 Maximum visits per calendar year. Habilitation services for Learning Disabilities are not covered

50% Coinsurance office therapy; Not covered outpatient hospital

$25 Copay per visit; Deductible Waived

If you need help recovering or have other special health needs

Rehabilitation services

50% Coinsurance office therapy; Not covered outpatient hospital

$25 Copay per visit; Deductible Waived

Habilitation services

60 Maximum days per calendar year. Subject to Medical Necessity Review.

50% Coinsurance

Skilled nursing care

30% Coinsurance

Page 5 of 8 56

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 2 All Other Providers

Tier 1 Facility+ PHCS Professional & Ancillary

Durable Medical Equipment over $2,500 (excluding CPAPs) subject to Medical Necessity Review.

Durable medical equipment

30% Coinsurance

50% Coinsurance

Hospice service

30% Coinsurance

50% Coinsurance

Subject to Medical Necessity Review.

$25 Copay per visit; Deductible Waived

Children’s eye exam

50% Coinsurance

1 Maximum exam every 2 years

If your child needs dental or eye care

Children’s glasses

Not covered

Not covered

None

Children’s dental check-up

Not covered

Not covered

None

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Bariatric surgery Cosmetic surgery Dental care (Adult)

Infertility treatment

Private-duty nursing Routine foot care Weight loss programs

• •

• •

• •

Long-term care

• Non-emergency care when traveling outside the U.S.

•

•

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Acupuncture – 20 visits per calendar year • Chiropractic care – 20 visits per calendar year

Hearing aids – 1 every 3 years

• Routine eye care (Adult) – 1 exam every 2 years

•

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Page 6 of 8 56

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at: www.HealthCare.gov and http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/.

Does this plan Provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-888-453-1096.

Traditional Chinese ( 中文 ): 如果需要中文的幫助 , 請撥打這個號碼 1-888-453-1096.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-453-1096.

Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf die do Nummer uff 1-888-453-1096.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-453-1096.

Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-888-453-1096.

Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-888-453-1096.

Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang 1-888-453-1096.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8 56

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Mia’s Simple Fracture (in-network emergency room visit and follow up care)

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)

◼ The plan's overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance

◼ The plan's overall deductible

◼ The plan's overall deductible

$2,500

$2,500

$2,500 $50

◼ Specialist copayment

◼ Specialist copayment

$50

$50

◼ Hospital (facility) coinsurance

◼ Hospital (facility) coinsurance

30% 30%

30% 30%

30% 30%

◼ Other coinsurance

◼ Other coinsurance

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray)

This EXAMPLE event includes services like: Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

$12,700

Total Example Cost

$2,800

Total Example Cost

$5,600

In this example, Peg would pay:

In this example, Mia would pay:

In this example, Joe would pay:

Cost Sharing

Cost Sharing

Cost Sharing

Deductibles Copayments Coinsurance

$2,500

Deductibles Copayments Coinsurance

$200 $200

Deductibles Copayments Coinsurance

$1,200

$0

$500

$2,200

$0

$0

What isn’t covered

What isn’t covered

What isn’t covered

Limits or exclusions

$70

Limits or exclusions

$4,300 $4,700

Limits or exclusions

$10

The total Peg would pay is

$4,770

The total Joe would pay is

The total Mia would pay is

$1,710

*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”" row above.

The plan would be responsible for the other costs of these EXAMPLE covered services.

Page 8 of 8

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Mia’s Simple Fracture (in-network emergency room visit and follow up care)

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)

 The plan's overall deductible  Specialist coinsurance  Hospital (facility) coinsurance  Other coinsurance

$3,400

 The plan's overall deductible  Specialist coinsurance  Hospital (facility) coinsurance

$3,400

 The plan's overall deductible  Specialist coinsurance  Hospital (facility) coinsurance

$3,400 20% 20% 20%

20% 20% 20%

20% 20% 20%

 Other coinsurance

 Other coinsurance

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

This EXAMPLE event includes services like: Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost

$12,700

$5,600

Total Example Cost

$2,800

In this example, Peg would pay:

In this example, Mia would pay:

In this example, Joe would pay:

Cost Sharing

Cost Sharing

Cost Sharing

Deductibles Copayments Coinsurance

$3,400

Deductibles Copayments Coinsurance

$1,100

Deductibles Copayments Coinsurance

$2,800

$0

$0 $0

$0 $0

$1,600

What isn’t covered

What isn’t covered

What isn’t covered

Limits or exclusions

$70

Limits or exclusions

$4,300 $5,400

Limits or exclusions

$10

The total Peg would pay is

$5,070

The total Joe would pay is

The total Mia would pay is

$2,810

*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”" row above.

The plan would be responsible for the other costs of these EXAMPLE covered services.

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CODAC HEALTH, RECOVERY, & WELLNESS, INC. TUCSON AZ

Health Booklet

Benefit Plan 003

HDHP 3400 Plan

Revised 01-01-2026

BENEFITS ADMINISTERED BY

Table of Contents

INTRODUCTION........................................................................................................................................... 1

PLAN INFORMATION .................................................................................................................................. 2

QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN MEDICAL SCHEDULE OF BENEFITS.......................4

TRANSPLANT SCHEDULE OF BENEFITS .............................................................................................. 12

GENERATIONYOU PROGRAM ................................................................................................................ 13

OUT-OF-POCKET EXPENSES AND MAXIMUMS.................................................................................... 14

ELIGIBILITY AND ENROLLMENT ............................................................................................................ 16

SPECIAL ENROLLMENT PROVISION ..................................................................................................... 20

TERMINATION ........................................................................................................................................... 22

COBRA CONTINUATION OF COVERAGE............................................................................................... 24

UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994..................32

PROTECTION FROM BALANCE BILLING............................................................................................... 33

PROVIDER NETWORK .............................................................................................................................. 35

COVERED MEDICAL BENEFITS .............................................................................................................. 38

TELADOC HEALTH SERVICES ................................................................................................................ 50

VIRTA.......................................................................................................................................................... 53

ENVITA ....................................................................................................................................................... 54

HINGE HEALTH ......................................................................................................................................... 55

CARRUM HEALTH..................................................................................................................................... 56

HOME HEALTH CARE BENEFITS............................................................................................................ 68

TRANSPLANT BENEFITS ......................................................................................................................... 69

VISION CARE BENEFITS .......................................................................................................................... 72

HEARING AID BENEFITS.......................................................................................................................... 73

BEHAVIORAL HEALTH BENEFITS.......................................................................................................... 74

UMR CARE: CLINICAL ADVOCACY RELATIONSHIPS TO EMPOWER .............................................. 76

CENTERS OF EXCELLENCE.................................................................................................................... 80

COORDINATION OF BENEFITS ............................................................................................................... 81

RIGHT OF SUBROGATION, REIMBURSEMENT AND OFFSET............................................................. 85

GENERAL EXCLUSIONS .......................................................................................................................... 88

CLAIMS AND APPEAL PROCEDURES ................................................................................................... 94

FRAUD ...................................................................................................................................................... 104

OTHER FEDERAL PROVISIONS ............................................................................................................ 105

HIPAA ADMINISTRATIVE SIMPLIFICATION MEDICAL PRIVACY AND SECURITY PROVISION .....107

STATEMENT OF ERISA RIGHTS ........................................................................................................... 111

PLAN AMENDMENT AND TERMINATION INFORMATION .................................................................. 113

GLOSSARY OF TERMS .......................................................................................................................... 114

Refer to the separate Prescription Drug Summary Plan Description (SPD) for the Prescription Drug benefit.

CODAC HEALTH, RECOVERY, & WELLNESS, INC.

GROUP HEALTH BENEFIT PLAN

SUMMARY PLAN DESCRIPTION

INTRODUCTION

The purpose of this document is to provide You and Your covered Dependents, if any, with summary information in English on benefits available under this Plan as well as with information on a Covered Person's rights and obligations under the CODAC HEALTH, RECOVERY, & WELLNESS, INC. Health Benefit Plan (the "Plan"). You are a valued Employee of CODAC HEALTH, RECOVERY, & WELLNESS, INC., and Your employer is pleased to sponsor this Plan to provide benefits that can help meet Your health care needs. Please read this document carefully and contact Your Human Resources or Personnel office if You have questions or if You have difficulty translating this document. CODAC HEALTH, RECOVERY, & WELLNESS, INC. is named the Plan Administrator for this Plan. The Plan Administrator has retained the services of independent Third Party Administrators to process claims and handle other duties for this self-funded Plan. The Third Party Administrators for this Plan are UMR, Inc. (hereinafter "UMR") for medical claims, and CVS Caremark for pharmacy claims. There will be no further reference to Pharmacy in this Medical Plan as there is a separate Pharmacy Plan Document available to you. The Third Party Administrators do not assume liability for benefits payable under this Plan, since they are solely claims-paying agents for the Plan Administrator. The employer assumes the sole responsibility for funding the Plan benefits out of general assets; however, Employees help cover some of the costs of covered benefits through contributions, Deductibles, out-of-pocket amounts, and Plan Participation amounts as described in the Schedule of Benefits. All claim payments and reimbursements are paid out of the general assets of the employer and there is no separate fund that is used to pay promised benefits. The Plan is intended to comply with and be governed by the Employee Retirement Income Security Act of 1974 (ERISA) and its amendments. Some of the terms used in this document begin with capital letters, even though such terms normally would not be capitalized. These terms have special meaning under the Plan. Most capitalized terms are listed in the Glossary of Terms, but some are defined within the provisions in which they are used. Becoming familiar with the terms defined in the Glossary of Terms will help You to better understand the provisions of this Plan. Each individual covered under this Plan will be receiving an identification card that he or she may present to providers whenever he or she receives services. On the back of this card are phone numbers to call in case of questions or problems. This document contains information on the benefits and limitations of the Plan and will serve as both the Summary Plan Description (SPD) and Plan document. Therefore it will be referred to as both the SPD and the Plan document. It is being furnished to You in accordance with ERISA.

This document becomes effective on January 1, 2016.

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7670-00-412271

PLAN INFORMATION

Plan Name

CODAC HEALTH, RECOVERY, & WELLNESS, INC. GROUP BENEFIT PLAN

Name And Address Of Employer

CODAC HEALTH, RECOVERY, & WELLNESS, INC. 4585 E SPEEDWAY BLVD TUCSON AZ 85712 CODAC HEALTH, RECOVERY, & WELLNESS, INC. 4585 E SPEEDWAY BLVD TUCSON AZ 85712 520-202-1713

Name, Address, And Phone Number Of Plan Administrator

Named Fiduciary

CODAC HEALTH, RECOVERY, & WELLNESS, INC.

Claim Appeals Fiduciary For Medical Claims

UMR

Employer Identification Number Assigned By The IRS

23-7086112

Plan Number Assigned By The Plan

501

Type Of Benefit Plan Provided

Self-funded Health and Welfare Plan providing group health benefits.

Type Of Administration

The administration of the Plan is under the supervision of the Plan Administrator. The Plan is not financed by an insurance company and benefits are not guaranteed by a contract of insurance. UMR provides administrative services such as claim payments for medical claims.

Name And Address Of Agent For Service Of Legal Process

JERRY BROMIEL ONE SOUTH CHURCH AVE STE 2130 TUCSON AZ 85701

Service of legal process may also be made upon the Plan Administrator.

Funding Of The Plan

Employer and Employee Contributions

Benefits are provided by a benefit Plan maintained on a self-insured basis by Your employer.

Benefit Plan Year

Benefits begin on January 1 and end on the following December 31. For new Employees and Dependents, a Benefit Plan Year begins on the individual's Effective Date and runs through December 31 of the same Benefit Plan Year.

ERISA Plan Year

January 1 through December 31

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ERISA And Other Federal Compliance

It is intended that this Plan comply with all applicable requirements of ERISA and other federal regulations. In the event of any conflict between this Plan and ERISA or other federal regulations, the provisions of ERISA and the federal regulations will be deemed controlling, and any conflicting part of this Plan will be deemed superseded to the extent of the conflict. The Plan Administrator will perform its duties as the Plan Administrator and in its sole discretion, will determine appropriate courses of action in light of the reason and purpose for which this Plan is established and maintained. In particular, the Plan Administrator will have full and sole discretionary authority to interpret all Plan documents, including this SPD, and make all interpretive and factual determinations as to whether any individual is entitled to receive any benefit under the terms of this Plan. Any construction of the terms of any Plan document and any determination of fact adopted by the Plan Administrator will be final and legally binding on all parties, except that the Plan Administrator has delegated certain responsibilities to the Third Party Administrators for this Plan. Any interpretation, determination, or other action of the Plan Administrator or the Third Party Administrators will be subject to review only if a court of proper jurisdiction determines its action is arbitrary or capricious or otherwise a clear abuse of discretion. Any review of a final decision or action of the Plan Administrator or the Third Party Administrators will be based only on such evidence presented to or considered by the Plan Administrator or the Third Party Administrators at the time they made the decision that is the subject of review. Accepting any benefits or making any claim for benefits under this Plan constitutes agreement with and consent to any decisions that the Plan Administrator or the Third Party Administrators make, in their sole discretion, and, further, means that the Covered Person consents to the limited standard and scope of review afforded under law.

Discretionary Authority

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7670-00-412271

QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN MEDICAL SCHEDULE OF BENEFITS

Benefit Plan(s) 003 – HDHP 3400 Plan

All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses and Maximums section of this SPD for more details.

Refer to the applicable section of the Schedule of Benefits that corresponds to the place of service to determine the appropriate coverage.

Benefits are subject to all provisions of this Plan including any benefit determination based on an evaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and General Exclusions sections of this SPD for more details. Important: Prior authorization may be required before benefits will be considered for payment. Failure to obtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the UMR CARE section of this SPD for a description of these services and prior authorization procedures.

Note: Refer to the Provider Network section for clarifications and possible exceptions to the in-network or out-of-network classifications.

If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, it is a combined Maximum Benefit for services that the Covered Person receives from all in-network and out-of-network providers and facilities.

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible Per Calendar Year:

Note: Medical And Pharmacy Expenses Are Subject To The Same Deductible. • Single Coverage

$3,400 $6,800 $3,400

$8,000 $16,000 $8,000

Family Coverage

•

Individual "Embedded" Deductible

−

Plan Participation Rate, Unless Otherwise Stated Below: • Paid By Plan After Satisfaction Of Deductible

80%

50%

Annual Total Out-Of-Pocket Maximum:

Note: Medical And Pharmacy Expenses Are Subject To The Same Out-Of-Pocket Maximum. • Single Coverage

$5,000 $10,000 $5,000

Unlimited Unlimited Unlimited

Family Coverage

•

Individual "Embedded" Out-Of-Pocket Maximum

−

Acupuncture Treatment: •

20 Visits

Maximum Visits Per Calendar Year Paid By Plan After Deductible

80%

50%

•

Note: Medical Necessity Will Be Reviewed After 20 Visits.

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