2026 CODAC Benefit Summaries and Carrier Flyers

If a Provider refuses to accept an Assignment of Benefits under the conditions and limitations as set forth herein, any Covered Expenses payable under the terms of the Plan will be payable directly to the Covered Person, and the Plan will be deemed to have fulfilled its obligations with respect to such Covered Expense.

PATIENT ADVOCACY CENTER

It is the Plan’s position that the Provider should not balance bill the Covered Person for amounts in excess of the Reasonable and Allowed Amount. It is the Plan’s position that these Excess Charges are clearly excessive and exorbitant. However, balance billing for such amounts can occur for non-Network claims and the Plan has no control over the actions of the Providers or their desire to pursue the Covered Person for such amounts. In the event you receive a balance-bill for an amount in excess of the Reasonable and Allowable Amount payable, please immediately email pac@hstechnology.com or call the Patient Advocacy Center toll free at (888) 837-2237. Please Note: The Patient Advocacy Center provides assistance to Covered Persons with the understanding that (i) the Patient Advocacy Center is not acting in a fiduciary capacity under this Plan, (ii) that the Covered Person must make his or her own independent decision with respect to any course of action in connection with any balance-bill, including whether such course of action is appropriate or proper based on the Covered Person’s specific circumstances and objectives, and (iii) the Patient Advocacy Center does not provide legal or tax advice. Benefits will be payable to a Plan participant, or to a Provider that has accepted an assignment of benefits as consideration in full for services rendered. Most Providers will accept assignment and coordinate payment directly with the Plan on the Covered Person’s behalf. If the Provider will not accept assignment or coordinate payment directly with the Plan, the Covered Person will need to send the claim to the Plan within the timelines outlined below in order to receive reimbursement. The address for submitting medical claims is on the back of the group health identification card. A Covered Person who receives services in a country other than the United States is responsible for ensuring the Provider is paid. If the Provider will not coordinate payment directly with the Plan, the Covered Person will need to pay the claim up front and then submit the claim to the Plan for reimbursement. The Plan will reimburse the Covered Person for any covered amount in U.S. currency. The reimbursed amount will be based on the U.S. equivalency rate that is in effect on the date the Covered Person paid the claim, or on the date of service if the paid date is not known. • Covered Person ’s /patient ’s ID number, name, sex, date of birth, address, and relationship to Employee • Authorized signature from the Covered Person • Diagnosis • Date of service • Place of service • Procedures, services, or supplies (narrative description) • Charges for each listed service • Number of days or units • Patient ’s account number (if applicable) • Total billed charges • Provider ’s billing name, address, and telephone number • Provider ’s Taxpayer Identification Number (TIN) • Signature of Provider • Billing Provider A Clean Claim must be submitted in writing and should include the following information: PROCEDURES FOR SUBMITTING CLAIMS

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