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PRESENTED BY This is a summary of drug and health services covered by Aspire Health Plan (HMO-POS) January 1, 2026– December 31, 2026. H8764MKT.001.EOC20260825C Aspire Health ADVANTAGE (HMO) 2026 Evidence of Coverage

OMB Approval 0938-1051 (Expires: August 31, 2026) January 1 - December 31, 2026 Evidence of Coverage for 2026: Your Medicare Health Benefits and Services and Drug Coverage as a Member of Aspire Health Advantage (HMO) This document gives the details of your Medicare health and drug coverage from January 1 - December 31, 2026. This is an important legal document. Keep it in a safe place. This document explains your benefits and rights. Use this document to understand: • Our plan premium and cost sharing • Our medical and drug benefits • How to file a complaint if you're not satisfied with a service or treatment • How to contact us • Other protections required by Medicare law. For questions about this document, call Member Services at Toll Free: (855) 570-1600. (TTY users call 711.) Hours are 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays). This call is free. This plan, Aspire Health Advantage (HMO), is offered by Aspire Health (Aspire Health Plan). (When this Evidence of Coverage says “we,” “us,” or “our,” it means Aspire Health (Aspire Health Plan). When it says “plan” or “our plan,” it means Aspire Health Advantage (HMO).) This document is available for free in Spanish. This information is available in large print, braille, audio CD. Benefits, premiums, deductibles, and/or copayments/coinsurance may change on January 1,

2027. Our formulary, pharmacy network, and/or provider network may change at any time. You'll get notice about any changes that may affect you at least 30 days in advance. H8764MKT.001.EOC20260825C

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 1 Table of Contents Table of Contents CHAPTER 1: Get started as a member..........................................................................4 SECTION 1 You're a member of Aspire Health Advantage (HMO)......................................4 SECTION 2 Plan eligibility requirements.............................................................................5 SECTION 3 Important membership materials ....................................................................5 SECTION 4 Summary of Important Costs for 2026 .............................................................7 SECTION 5 More information about your monthly plan premium..................................12 SECTION 6 Keep your plan membership record up to date.............................................14 SECTION 7 How other insurance works with our plan .....................................................15 CHAPTER 2: Phone numbers and resources ...............................................................17 SECTION 1 Aspire Health Advantage (HMO) contacts ......................................................17 SECTION 2 Get help from Medicare...................................................................................22 SECTION 3 State Health Insurance Assistance Program (SHIP).......................................23 SECTION 4 Quality Improvement Organization (QIO) ......................................................24 SECTION 5 Social Security .................................................................................................25 SECTION 6 Medicaid...........................................................................................................25 SECTION 7 Programs to help people pay for prescription drugs.....................................26 SECTION 8 Railroad Retirement Board (RRB)...................................................................28 SECTION 9 If you have group insurance or other health insurance from an employer ..........................................................................................................29 CHAPTER 3: Using our plan for your medical services .................................................30 SECTION 1 How to get medical care as a member of our plan........................................30 SECTION 2 Use providers in our plan's network to get medical care..............................32 SECTION 3 How to get services in an emergency, disaster, or urgent need for care...................................................................................................................36 SECTION 4 What if you're billed directly for the full cost of covered services?...............38 SECTION 5 Medical services in a clinical research study..................................................39 SECTION 6 Rules for getting care in a religious non-medical health care institution.........................................................................................................41 SECTION 7 Rules for ownership of durable medical equipment .....................................42 CHAPTER 4: Medical Benefits Chart (what's covered and what you pay) ......................44 SECTION 1 Understanding your out-of-pocket costs for covered services.....................44

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 2 Table of Contents SECTION 2 The Medical Benefits Chart shows your medical benefits and costs............46 SECTION 3 Services that aren't covered by our plan (exclusions).................................119 CHAPTER 5: Using plan coverage for Part D drugs.....................................................122 SECTION 1 Basic rules for our plan's Part D coverage....................................................122 SECTION 2 Fill your prescription at a network pharmacy or through our plan's mail-order service..........................................................................................122 SECTION 3 Your drugs need to be on our plan's Drug List .............................................126 SECTION 4 Drugs with restrictions on coverage.............................................................128 SECTION 5 What you can do if one of your drugs isn't covered the way you'd like......129 SECTION 6 Our Drug List can change during the year....................................................132 SECTION 7 Types of drugs we don't cover ......................................................................135 SECTION 8 How to fill a prescription...............................................................................136 SECTION 9 Part D drug coverage in special situations...................................................136 SECTION 10 Programs on drug safety and managing medications ................................137 CHAPTER 6: What you pay for Part D drugs ..............................................................140 SECTION 1 What you pay for Part D drugs ......................................................................140 SECTION 2 Drug payment stages for Aspire Health Advantage (HMO) members.........142 SECTION 3 Your Part D Explanation of Benefits (EOB) explains which payment stage you're in ...............................................................................................142 SECTION 4 There is no deductible for Aspire Health Advantage (HMO)........................144 SECTION 5 The Initial Coverage Stage ............................................................................144 SECTION 6 The Catastrophic Coverage Stage ................................................................149 SECTION 7 What you pay for Part D vaccines .................................................................149 CHAPTER 7: Asking us to pay our share of a bill for covered medical services or drugs..................................................................................................152 SECTION 1 Situations when you should ask us to pay our share for covered services or drugs............................................................................................152 SECTION 2 How to ask us to pay you back or pay a bill you got....................................154 SECTION 3 We'll consider your request for payment and say yes or no .......................155 CHAPTER 8: Your rights and responsibilities ............................................................156 SECTION 1 Our plan must honor your rights and cultural sensitivities.........................156 SECTION 2 Your responsibilities as a member of our plan ............................................162

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 3 Table of Contents CHAPTER 9: If you have a problem or complaint (coverage decisions, appeals, complaints).........................................................................................164 SECTION 1 What to do if you have a problem or concern..............................................164 SECTION 2 Where to get more information and personalized help ..............................164 SECTION 3 Which process to use for your problem........................................................165 SECTION 4 A guide to coverage decisions and appeals .................................................165 SECTION 5 Medical care: How to ask for a coverage decision or make an appeal .......169 SECTION 6 Part D drugs: How to ask for a coverage decision or make an appeal .......177 SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think you're being discharged too soon ................................................................187 SECTION 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon.................................................................192 SECTION 9 Taking your appeal to Levels 3, 4, and 5 ......................................................196 SECTION 10 How to make a complaint about quality of care, waiting times, customer service, or other concerns ............................................................199 CHAPTER 10: Ending membership in our plan ..........................................................203 SECTION 1 Ending your membership in our plan...........................................................203 SECTION 2 When can you end your membership in our plan? ......................................203 SECTION 3 How to end your membership in our plan ...................................................206 SECTION 4 Until your membership ends, you must keep getting your medical items, services, and drugs through our plan................................................206 SECTION 5 Aspire Health Advantage (HMO) must end our plan membership in certain situations...........................................................................................207 CHAPTER 11: Legal notices .....................................................................................209 SECTION 1 Notice about governing law..........................................................................209 SECTION 2 Notice about nondiscrimination ..................................................................209 SECTION 3 Notice about Medicare Secondary Payer subrogation rights .....................209 CHAPTER 12: Definitions ........................................................................................211

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 4 Chapter 1 Get started as a member CHAPTER 1: Get started as a member SECTION 1 You're a member of Aspire Health Advantage (HMO) Section 1.1 You're enrolled in Aspire Health Advantage (HMO), which is a Medicare HMO You're covered by Medicare, and you chose to get your Medicare health and your drug coverage through our plan, Aspire Health Advantage (HMO). Our plan covers all Part A and Part B services. However, cost sharing and provider access in this plan are different from Original Medicare. Aspire Health Advantage (HMO) is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization) approved by Medicare and run by a private company. Section 1.2 Legal information about the Evidence of Coverage This Evidence of Coverage is part of our contract with you about how Aspire Health Advantage (HMO) covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (formulary), and any notices you get from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called riders or amendments. The contract is in effect for the months you're enrolled in Aspire Health Advantage (HMO) between January 1, 2026, and December 31, 2026. Medicare allows us to make changes to our plans we offer each calendar year. This means we can change the costs and benefits of Aspire Health Advantage (HMO) after December 31,

2026. We can also choose to stop offering our plan in your service area, or to offer it in a different service area, after December 31, 2026. Medicare (the Centers for Medicare & Medicaid Services) must approve Aspire Health Advantage (HMO) each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue offering our plan and Medicare renews approval of our plan.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 5 Chapter 1 Get started as a member SECTION 2 Plan eligibility requirements Section 2.1 Eligibility requirements You're eligible for membership in our plan as long as you meet all these conditions: • You have both Medicare Part A and Medicare Part B • You live in our geographic service area (described in Section 2.2). People who are incarcerated aren't considered to be living in the geographic service area even if they're physically located in it. • You're a United States citizen or lawfully present in the United States. Section 2.2 Plan service area for Aspire Health Advantage (HMO) Aspire Health Advantage (HMO) is only available to people who live in our plan service area. To stay a member of our plan, you must continue to live in our service area. The service area is described below. Our service area includes these counties in California: Monterey County If you move out of our plan's service area, you can't stay a member of this plan. Call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) to see if we have a plan in your new area. When you move, you'll have a Special Enrollment Period to either switch to Original Medicare or enroll in a Medicare health or drug plan in your new location. If you move or change your mailing address, it's also important to call Social Security. Call Social Security at 1-800-772-1213 (TTY users call 1-800-325-0778). Section 2.3 U.S. citizen or lawful presence You must be a U.S. citizen or lawfully present in the United States to be a member of a Medicare health plan. Medicare (the Centers for Medicare & Medicaid Services) will notify Aspire Health Advantage (HMO) if you're not eligible to stay a member of our plan on this basis. Aspire Health Advantage (HMO) must disenroll you if you don't meet this requirement. SECTION 3 Important membership materials Section 3.1 Our plan membership card Use your membership card whenever you get services covered by our plan and for prescription drugs you get at network pharmacies. You should also show the provider your Medicaid card if you have one. Sample plan membership card:

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 6 Chapter 1 Get started as a member DON'T use your red, white, and blue Medicare card for covered medical services while you're a member of this plan. If you use your Medicare card instead of your Aspire Health Advantage (HMO) membership card, you may have to pay the full cost of medical services yourself. Keep your Medicare card in a safe place. You may be asked to show it if you need hospital services, hospice services, or participate in Medicare-approved clinical research studies (also called clinical trials). If our plan membership card is damaged, lost, or stolen, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) right away and we'll send you a new card. Section 3.2 Provider/Pharmacy Directory The Provider/Pharmacy Directory lists our current network providers and durable medical equipment suppliers and pharmacies. Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost sharing as payment in full. You must use network providers to get your medical care and services. If you go elsewhere without proper authorization, you'll have to pay in full. The only exceptions are emergencies, urgently needed services when the network isn't available (that is, situations when it's unreasonable or not possible to get services in network), out-of-area dialysis services, and cases when Aspire Health Advantage (HMO) authorizes use of out-of-network providers. Network pharmacies are pharmacies that agree to fill covered prescriptions for our plan members. Use the Provider/Pharmacy Directory to find the network pharmacy you want to use. See Chapter 5, Section 2.4 for information on when you can use pharmacies that aren't in our plan's network. If you don't have a Provider/Pharmacy Directory, you can request a copy from Member Services at Toll Free: (855) 570-1600 (TTY users call 711). You can also find this information on

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 7 Chapter 1 Get started as a member our website at www.aspirehealthplan.org.or download it from this website. Both Member Services and the website can give you the most up-to-date information about changes in our network providers and pharmacies. Section 3.3 Drug List (formulary) Our plan has a List of Covered Drugs (also called the Drug List or formulary). It tells which prescription drugs are covered under the Part D benefit included in Aspire Health Advantage (HMO). The drugs on this list are selected by our plan, with the help of doctors and pharmacists. The Drug List must meet Medicare's requirements. Drugs with negotiated prices under the Medicare Drug Price Negotiation Program will be included on your Drug List unless they have been removed and replaced as described in Chapter 5, Section 6. Medicare approved the Aspire Health Advantage (HMO) Drug List. The Drug List also tells if there are any rules that restrict coverage for a drug. We'll give you a copy of the Drug List. To get the most complete and current information about which drugs are covered, visit www.aspirehealthplan.org for our drug list or call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). SECTION 4 Summary of Important Costs for 2026 Your Costs in 2026 Monthly plan premium*

• Your premium can be higher or lower than this amount. Go to Section 4.1 for details. $196.00 Maximum out-of-pocket amount This is the most you'll pay out of pocket for covered Part A and Part B services. (Go to Chapter 4 Section 1 for details.) $4,300 Primary care office visits $0 copay per visit Specialist office visits $25 copay per visit

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 8 Chapter 1 Get started as a member Your Costs in 2026 Inpatient hospital stays $600 copay per day for days 1-2; $300 copay per day for days 3-4; $0 copay per day for days 5-90 Part D drug coverage deductible (Go to Chapter 6 Section 4 for details.) $0 Part D drug coverage (Go to Chapter 6 Sections 4-6 for details, including Yearly Deductible, Initial Coverage, and Catastrophic Coverage Stages.) Copayment/Coinsurance during the Initial Coverage Stage: • Drug Tier 1: $4 copay • Drug Tier 2: $15 copay • Drug Tier 3: $47 copay • Drug Tier 4: 25% coinsurance • Drug Tier 5: 33% coinsurance • Drug Tier 6: $11 copay Catastrophic Coverage Stage: During this payment stage, you pay nothing for your covered Part D drugs. Your costs may include the following: • Plan Premium (Section 4.1) • Monthly Medicare Part B Premium (Section 4.2) • Optional Supplemental Benefit Premium (Section 4.3) • Part D Late Enrollment Penalty (Section 4.4) • Income Related Monthly Adjusted Amount (Section 4.5) • Medicare Prescription Payment Plan Amount (Section 4.6) Section 4.1 Plan premium As a member of our plan, you pay a monthly plan premium. For 2026, the monthly plan premium for Aspire Health Advantage (HMO) is $196.00.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 9 Chapter 1 Get started as a member In some situations, our plan premium could be less The Extra Help program helps people with limited resources pay for their drugs. Learn more about this program in Chapter 2, Section 7. If you qualify, enrolling in this program might lower your monthly plan premium. If you already get help from this program, the information about premiums in this Evidence of Coverage may not apply to you. We sent you a separate document, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low-Income Subsidy Rider or the LIS Rider), which tells you about your drug coverage. If you don't have this insert, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) and ask for the LIS Rider. Medicare Part B and Part D premiums differ for people with different incomes. If you have questions about these premiums, check your copy of the Medicare & You 2026 handbook in the section called 2026 Medicare Costs. Download a copy from the Medicare website (www.Medicare.gov/medicare-and-you) or order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. Section 4.2 Monthly Medicare Part B Premium Many members are required to pay other Medicare premiums In addition to paying the monthly plan premium, you must continue paying your Medicare premiums to stay a member of our plan. This includes your premium for Part B. You may also pay a premium for Part A if you aren't eligible for premium-free Part A. Section 4.3 Optional Supplemental Benefit Premium If you signed up for extra benefits, also called optional supplemental benefits, you pay an additional premium each month for these extra benefits. Go to Chapter 4, Section 2.1 for details. For 2026, the monthly Enhanced Benefits - Option C premium for Aspire Health Advantage (HMO) is $43.00. Section 4.4 Part D Late Enrollment Penalty Some members are required to pay a Part D late enrollment penalty. The Part D late enrollment penalty is an additional premium that must be paid for Part D coverage if at any time after your initial enrollment period is over, there was a period of 63 days or more in a row when you didn't have Part D or other creditable drug coverage. Creditable drug coverage is coverage that meets Medicare's minimum standards since it is expected to pay, on average,

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 10 Chapter 1 Get started as a member at least as much as Medicare's standard drug coverage. The cost of the late enrollment penalty depends on how long you went without Part D or other creditable drug coverage. You'll have to pay this penalty for as long as you have Part D coverage. The Part D late enrollment penalty is added to your monthly premium. When you first enroll in Aspire Health Advantage (HMO), we let you know the amount of the penalty. If you don't pay your Part D late enrollment penalty, you could lose your prescription drug benefits. You don't have to pay the Part D late enrollment penalty if: • You get Extra Help from Medicare to help pay your drug costs. • You went less than 63 days in a row without creditable coverage. • You had creditable drug coverage through another source (like a former employer, union, TRICARE, or Veterans Health Administration (VA)). Your insurer or human resources department will tell you each year if your drug coverage is creditable coverage. You may get this information in a letter or in a newsletter from that plan. Keep this information, because you may need it if you join a Medicare drug plan later. • Note: Any letter or notice must state that you had creditable prescription drug coverage that's expected to pay as much as Medicare's standard drug plan pays. • Note: Prescription drug discount cards, free clinics, and drug discount websites aren't creditable prescription drug coverage. Medicare determines the amount of the Part D late enrollment penalty. Here's how it works: • If you went 63 days or more without Part D or other creditable prescription drug coverage after you were first eligible to enroll in Part D, our plan will count the number of full months you didn't have coverage. The penalty is 1% for every month you didn't have creditable coverage. For example, if you go 14 months without coverage, the penalty percentage will be 14%. • Then Medicare determines the amount of the average monthly plan premium for Medicare drug plans in the nation from the previous year(national base beneficiary premium). For 2026, this average premium amount is $38.99. • To calculate your monthly penalty, multiply the penalty percentage by the national base beneficiary premium and round it to the nearest 10 cents. In the example here, it would be 14% times $38.99, which equals $5.4586. This rounds to $5.50. This amount would be added to the monthly plan premium for someone with a Part D late enrollment penalty.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 11 Chapter 1 Get started as a member Three important things to know about the monthly Part D late enrollment penalty: • The penalty may change each year because the national base beneficiary premium can change each year. • You'll continue to pay a penalty every month for as long as you are enrolled in a plan that has Medicare Part D drug benefits, even if you change plans. • If you're under 65 and enrolled in Medicare, the Part D late enrollment penalty will reset when you turn 65. After age 65, your Part D late enrollment penalty will be based only on the months you don't have coverage after your initial enrollment period for aging into Medicare. If you disagree about your Part D late enrollment penalty, you or your representative can ask for a review. Generally, you must ask for this review within 60 days from the date on the first letter you get stating you have to pay a late enrollment penalty. However, if you were paying a penalty before you joined our plan, you may not have another chance to ask for a review of that late enrollment penalty. Important: Don't stop paying your Part D late enrollment penalty while you're waiting for a review of the decision about your late enrollment penalty. If you do, you could be disenrolled for failure to pay our plan premiums. Section 4.5 Income Related Monthly Adjustment Amount Some members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment Amount (IRMAA). The extra charge is calculated using your modified adjusted gross income as reported on your IRS tax return from 2 years ago. If this amount is above a certain amount, you'll pay the standard premium amount and the additional IRMAA. For more information on the extra amount you may have to pay based on your income, visit www.Medicare.gov/health-drug-plans/part-d/basics/costs. If you have to pay an extra IRMAA, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be. The extra amount will be withheld from your Social Security, Railroad Retirement Board, or Office of Personnel Management benefit check, no matter how you usually pay our plan premium, unless your monthly benefit isn't enough to cover the extra amount owed. If your benefit check isn't enough to cover the extra amount, you'll get a bill from Medicare. You must pay the extra IRMAA to the government. It can't be paid with your monthly plan premium. If you don't pay the extra IRMAA, you'll be disenrolled from our plan and lose prescription drug coverage. If you disagree about paying an extra IRMAA, you can ask Social Security to review the decision. To find out how to do this, call Social Security at 1-800-772-1213 (TTY users call 1- 800-325-0778).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 12 Chapter 1 Get started as a member Section 4.6 Medicare Prescription Payment Plan Amount If you're participating in the Medicare Prescription Payment Plan, each month you'll pay our plan premium (if you have one) and you'll get a bill from your health or drug plan for your prescription drugs (instead of paying the pharmacy). Your monthly bill is based on what you owe for any prescriptions you get, plus your previous month's balance, divided by the number of months left in the year. Chapter 2, Section 7 tells more about the Medicare Prescription Payment Plan. If you disagree with the amount billed as part of this payment option, you can follow the steps in Chapter 9 to make a complaint or appeal. SECTION 5 More information about your monthly plan premium Section 5.1 How to pay our plan premium There are four ways you can pay our plan premium. Option 1: Pay by check You can pay your plan premium by check or money order. You can choose whether to make the payments monthly, quarterly or annually. If you choose to pay quarterly or annually, full payment must be received at the beginning of each quarter or coverage year. Payments by check or money order should be made payable to Aspire Health Plan and be sent to: P.O. Box 511279, Los Angeles, CA 90051-7834. Payments must be made by the 1st day of the month. If your check is returned for insufficient funds, you will be charged a $25.00 fee. You can choose to have us send you a monthly invoice for your payments. The invoice will be mailed to you no later than the 10th day of the month prior to the payment due date. Please call Member Services for more information on how to arrange to receive a monthly invoice. (Phone numbers for Member Services are printed on the back cover of this document). Option 2: Pay by automatic deduction from your bank account You can have your premium automatically deducted from your checking or savings account by electronic funds transfer (EFT) on a monthly basis. If your payment is returned for insufficient funds, you will be charged a $25.00 fee.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 13 Chapter 1 Get started as a member Contact Member Services for more information on how to pay your premium by automatic electronic funds transfer. (Phone numbers for Member Services are printed on the back cover of this document.) Option 3: You can pay by debit card or credit card You can have the plan premium billed to your debit card or credit card. If your payment is returned for insufficient funds, you will be charged a $25.00 fee. Contact Member Services for more information on how to pay your premium this way. (Phone numbers for Member Services are printed on the back cover of this document.) Option 4: Having your plan premiums deducted from your monthly Social Security check You can have the plan premium taken out of your monthly Social Security check. Contact Member Services for more information on how to pay your plan premium this way. We will be happy to help you set this up. (Phone numbers for Member Services are printed on the back cover of this document.) You can elect this option if your total monthly plan premium is less than $300.00. The Social Security Administration only deducts plan premiums below $300.00. Changing the way you pay your plan premium. If you decide to change how you pay your plan premium, it can take up to 3 months for your new payment method to take effect. While we process your new payment method, you're still responsible for making sure your plan premium is paid on time. To change your payment method, contact Member Services. (Phone numbers for Member Services are printed on the back cover of this document.) If you have trouble paying your plan premium Your plan premium is due in our office by the 1st. If we don't get your payment by the 7th, we'll send you a notice letting you know your plan membership will end if we don't get your premium within 90 days. If you owe a Part D late enrollment penalty, you must pay the penalty to keep your drug coverage. If you have trouble paying your premium on time, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) to see if we can direct you to programs that will help with your costs. If we end your membership because you didn't pay your premium, you'll have health coverage under Original Medicare. You may not be able to get Part D drug coverage until the following year if you enroll in a new plan during the Open Enrollment Period. (If you go

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 14 Chapter 1 Get started as a member without creditable drug coverage for more than 63 days, you may have to pay a Part D late enrollment penalty for as long as you have Part D coverage.) At the time we end your membership, you may still owe us for unpaid premiums. We have the right to pursue collection of the amount you owe. If you want to enroll again in our plan (or another plan that we offer) in the future, you'll need to pay the amount you owe before you can enroll. If you think we wrongfully ended your membership, you can make a complaint (also called a grievance). If you had an emergency circumstance out of your control that made you unable to pay your plan premium within our grace period, you can make a complaint. For complaints, we'll review our decision again. Go to Chapter 9 to learn how to make a complaint or call us at Toll Free: (855) 570-1600 between 8 am and 8 pm PT Monday through Friday from April 1 through September 30 and between 8 am and 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays). TTY users call 711. You must make your complaint no later than 60 calendar days after the date your membership ends. Section 5. 2 Our monthly plan premium won't change during the year We're not allowed to change our plan's monthly plan premium amount during the year. If the monthly plan premium changes for next year, we'll tell you in September, and the new premium will take effect on January 1. If you become eligible for Extra Help or lose your eligibility for Extra Help during the year, the part of our plan premium you have to pay may change. If you qualify for Extra Help with your drug coverage costs, Extra Help pays part of your monthly plan premium. If you lose your eligibility for Extra Help during the year, you'll need to start paying the full monthly plan premium. Find out more about Extra Help in Chapter 2, Section 7. SECTION 6 Keep your plan membership record up to date Your membership record has information from your enrollment form, including your address and phone number. It shows your specific plan coverage including your Primary Care Provider. The doctors, hospitals, pharmacists, and other providers in our plan's network use your membership record to know what services and drugs are covered and your cost-sharing amounts. Because of this, it's very important you help to keep your information up to date. If you have any of these changes, let us know: • Changes to your name, address, or phone number

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 15 Chapter 1 Get started as a member • Changes in any other health coverage you have (such as from your employer, your spouse or domestic partner's employer, workers' compensation, or Medicaid) • Any liability claims, such as claims from an automobile accident • If you're admitted to a nursing home • If you get care in an out-of-area or out-of-network hospital or emergency room • If your designated responsible party (such as a caregiver) changes • If you participate in a clinical research study (Note: You're not required to tell our plan about clinical research studies you intend to participate in, but we encourage you to do so.) If any of this information changes, let us know by calling Member Services at Toll Free: (855) 570-1600 (TTY users call 711). It's also important to contact Social Security if you move or change your mailing address. Call Social Security at 1-800-772-1213 (TTY users call 1-800-325-0778). SECTION 7 How other insurance works with our plan Medicare requires us to collect information about any other medical or drug coverage you have so we can coordinate any other coverage with your benefits under our plan. This is called Coordination of Benefits. Once a year, we'll send you a letter that lists any other medical or drug coverage we know about. Read over this information carefully. If it's correct, you don't need to do anything. If the information isn't correct, or if you have other coverage that's not listed, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). You may need to give our plan member ID number to your other insurers (once you confirm their identity) so your bills are paid correctly and on time. When you have other insurance (like employer group health coverage), Medicare rules decide whether our plan or your other insurance pays first. The insurance that pays first (the “primary payer”) pays up to the limits of its coverage. The insurance that pays second (“secondary payer”) only pays if there are costs left uncovered by the primary coverage. The secondary payer may not pay the uncovered costs. If you have other insurance, tell your doctor, hospital, and pharmacy.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 16 Chapter 1 Get started as a member These rules apply for employer or union group health plan coverage: • If you have retiree coverage, Medicare pays first. • If your group health plan coverage is based on your or a family member's current employment, who pays first depends on your age, the number of people employed by your employer, and whether you have Medicare based on age, disability, or End-Stage Renal Disease (ESRD): • If you're under 65 and disabled and you (or your family member) are still working, your group health plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan has more than 100 employees. • If you're over 65 and you (or your spouse or domestic partner) are still working, your group health plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan has more than 20 employees. • If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you become eligible for Medicare. These types of coverage usually pay first for services related to each type: • No-fault insurance (including automobile insurance) • Liability (including automobile insurance) • Black lung benefits • Workers' compensation Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare, employer group health plans, and/or Medigap have paid.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 17 Chapter 2 Phone numbers and resources CHAPTER 2: Phone numbers and resources SECTION 1 Aspire Health Advantage (HMO) contacts For help with claims, billing, or member card questions, call or write to Aspire Health Advantage (HMO) Member Services at Toll Free: (855) 570-1600 (TTY users call 711). We will be happy to help you. Member Services - Contact Information Call Toll Free: (855) 570-1600 Calls to this number are free. 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Member Services Toll Free: (855) 570-1600 (TTY users call 711) also has free language interpreter services for non-English speakers. TTY 711 Calls to this number are free. 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Fax Local: (831) 574-4939 Toll Free: (855) 519-5769 Write Aspire Health 10 Ragsdale Drive, Suite 101 Monterey, CA 93940 Website www.aspirehealthplan.org

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 18 Chapter 2 Phone numbers and resources How to ask for a coverage decision or appeal about your medical care or Part D prescription drugs A coverage decision is a decision we make about your benefits and coverage or about the amount we'll pay for your medical services or Part D drugs. An appeal is a formal way of asking us to review and change a coverage decision. For more information on how to ask for coverage decisions or appeals about your medical care or Part D drugs, go to Chapter 9. Coverage Decisions and Appeals for Medical Care or Part D drugs - Contact Information Call Medical: Toll Free: (855) 570-1600 Part D: Toll Free: (888) 495-3160 Calls to these numbers are free. Medical: 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Part D: 24 hours a day/7 days a week TTY Medical: 711 Part D: 711 Calls to this number are free. Medical: 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Part D: 24 hours a day/7 days a week

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 19 Chapter 2 Phone numbers and resources Coverage Decisions and Appeals for Medical Care or Part D drugs - Contact Information Fax Medical: Local: (831) 657-2669 Toll Free: (855) 519-5769 (coverage decisions) Local: (831) 920-5903 Toll Free: (855) 519-5769 (appeals) Part D: (858) 790-7100 (coverage decisions) (858) 790-6060 (appeals) Write Medical: Aspire Health 10 Ragsdale Drive, Suite 101 Monterey, CA 93940 Part D: Coverage decisions: MedImpact Healthcare Systems Attn: Prior Authorization 10181 Scripps Gateway Court San Diego, CA 92131 Appeals: MedImpact Healthcare Systems Attn: Appeals and Grievances 10181 Scripps Gateway Court San Diego, CA 92131 Website Medical: www.aspirehealthplan.org Part D: www.aspirehealthplan.org

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 20 Chapter 2 Phone numbers and resources How to make a complaint about your medical care or Part D drugs You can make a complaint about us or one of our network providers or pharmacies, including a complaint about the quality of your care. This type of complaint doesn't involve coverage or payment disputes. For more information on how to make a complaint about your medical care or Part D drugs, go to Chapter 9. Complaints about Medical Care or Part D drugs - Contact Information Call Medical: Toll Free: (855) 570-1600 Calls to these numbers are free. 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) TTY Medical: 711 Calls to this number are free. 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Fax Local: (831) 920-5903 Toll Free: (855) 519-5769 Write Aspire Health Attn: Appeals & Grievances Department 10 Ragsdale Drive, Suite 101 Monterey, CA 93940 Medicare website To submit a complaint about Aspire Health Advantage (HMO) directly to Medicare, go to www.Medicare.gov/my/medicare-complaint.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 21 Chapter 2 Phone numbers and resources How to ask us to pay our share of the cost for medical care or a drug you got If you got a bill or paid for services (like a provider bill) you think we should pay for, you may need to ask us for reimbursement or to pay the provider bill. Go to Chapter 7 for more information. If you send us a payment request and we deny any part of your request, you can appeal our decision. Go to Chapter 9 for more information. Payment Requests - Contact Information Call Medical: Toll Free: (855) 570-1600 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Part D: 888-495-3160 24 Hours a day/7 day a week Calls to these numbers are free. TTY Medical: 711. Part D:711. Calls to this number are free. Medical: 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Part D: 24 hours a day/7 days a week Fax Medical: Local: (831) 574-4939 Toll Free: (855) 519-5769 Part D: (858) 549-1569 Write Medical: Aspire Health P.O. Box 5490 Salem, OR 97304 Part D: ATTN: Claims Department MedImpact HealthCare Systems, Inc P.O. Box 509098 San Diego, CA 92150-9098 Website Medical: www.aspirehealthplan.org Part D: www.aspirehealthplan.org/drug-coverage/

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 22 Chapter 2 Phone numbers and resources SECTION 2 Get help from Medicare Medicare is the federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (CMS). This agency contracts with Medicare Advantage organizations including our plan. Medicare - Contact Information Call 1-800-MEDICARE (1-800-633-4227) Calls to this number are free. 24 hours a day, 7 days a week. TTY 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties hearing or speaking. Calls to this number are free. Chat Live Chat live at www.Medicare.gov/talk-to-someone Write Write to Medicare at PO Box 1270, Lawrence, KS 66044 Website www.Medicare.gov • Get information about the Medicare health and drug plans in your area, including what they cost and what services they provide. • Find Medicare-participating doctors or other health care providers and suppliers. • Find out what Medicare covers, including preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits). • Get Medicare appeals information and forms. • Get information about the quality of care provided by plans, nursing homes, hospitals, doctors, home health agencies, dialysis facilities, hospice centers, inpatient rehabilitation facilities, and long-term care hospitals. • Look up helpful websites and phone numbers.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 23 Chapter 2 Phone numbers and resources Medicare - Contact Information Website (continued) You can also visit www.Medicare.gov to tell Medicare about any complaints you have about Aspire Health Advantage (HMO). To submit a complaint to Medicare, go to www.Medicare.gov/my/medicare-complaint. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. SECTION 3 State Health Insurance Assistance Program (SHIP) The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state that offers free help, information, and answers to your Medicare questions. In California, the SHIP is called California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP). California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP) is an independent state program (not connected with any insurance company or health plan) that gets money from the federal government to give free local health insurance counseling to people with Medicare. California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP) counselors can help you understand your Medicare rights, help you make complaints about your medical care or treatment, and straighten out problems with your Medicare bills. California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP) counselors can also help you with Medicare questions or problems, help you understand your Medicare plan choices, and answer questions about switching plans. California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP) - Contact Information Call Local: (831) 655-4249 Toll Free: (800) 434-0222 TTY 1-800-735-2929 This number requires special telephone equipment and is only for people who have difficulties hearing or speaking.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 24 Chapter 2 Phone numbers and resources California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP) - Contact Information Write Alliance On Aging, Inc. 247 Main Street Salinas, CA 93901 Website https://aging.ca.gov/Programs_and_Services/Medicare_Counseling SECTION 4 Quality Improvement Organization (QIO) A designated Quality Improvement Organization (QIO) serves people with Medicare in each state. For California, the Quality Improvement Organization is called Livanta. Livanta has a group of doctors and other health care professionals paid by Medicare to check on and help improve the quality of care for people with Medicare. Livanta is an independent organization. It's not connected with our plan. Contact Livanta in any of these situations: • You have a complaint about the quality of care you got. Examples of quality-of-care concerns include getting the wrong medication, unnecessary tests or procedures, or a misdiagnosis. • You think coverage for your hospital stay is ending too soon. • You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services is ending too soon. Livanta (California's Quality Improvement Organization) - Contact Information Call (877) 588-1123 TTY 711 This number requires special telephone equipment and is only for people who have difficulties hearing or speaking. Write BFCC-QIO Program Livanta LLC PO Box 2687 Virginia Beach, VA 23450 Website https://livantaqio.com/en/states/california

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 25 Chapter 2 Phone numbers and resources SECTION 5 Social Security Social Security determines Medicare eligibility and handles Medicare enrollment. Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing event, you can call Social Security to ask for reconsideration. If you move or change your mailing address, contact Social Security to let them know. Social Security - Contact Information Call 1-800-772-1213 Calls to this number are free. Available 8 am to 7 pm, Monday through Friday. Use Social Security's automated telephone services to get recorded information and conduct some business 24 hours a day. TTY 1-800-325-0778 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Available 8 am to 7 pm, Monday through Friday. Website www.SSA.gov SECTION 6 Medicaid Medicaid is a joint federal and state government program that helps with medical costs for certain people with limited incomes and resources. Some people with Medicare are also eligible for Medicaid. Medicaid offers programs to help people with Medicare pay their Medicare costs, such as their Medicare premiums. These Medicare Savings Programs include: • Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).)

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 26 Chapter 2 Phone numbers and resources • Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).) • Qualifying Individual (QI): Helps pay Part B premiums. • Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums. To find out more about Medicaid and Medicare Savings Programs, contact California Department of Health Care Services (Medi-Cal). California Department of Health Care Services (Medi-Cal) - Contact Information Call 1-916-552-9200; hours: 8 a.m. to 5 p.m. PST Write P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413 Website www.dhcs.ca.gov/services/medi-cal SECTION 7 Programs to help people pay for prescription drugs The Medicare website (www.Medicare.gov/basics/costs/help/drug-costs) has information on ways to lower your prescription drug costs. The programs below can help people with limited incomes. Extra Help from Medicare Medicare and Social Security have a program called Extra Help that can help pay drug costs for people with limited income and resources. If you qualify, you get help paying for your Medicare drug plan's monthly plan premium, yearly deductible, and copayments. Extra Help also counts toward your out-of-pocket costs. If you automatically qualify for Extra Help, Medicare will mail you a purple letter to let you know. If you don't automatically qualify, you can apply anytime. To see if you qualify for getting Extra Help: • Visit https://secure.ssa.gov/i1020/start to apply online • Call Social Security at 1-800-772-1213. TTY users call 1-800-325-0778 When you apply for Extra Help, you can also start the application process for a Medicare Savings Program (MSP). These state programs provide help with other Medicare costs. Social

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 27 Chapter 2 Phone numbers and resources Security will send information to your state to initiate an MSP application, unless you tell them not to on the Extra Help application. If you qualify for Extra Help and you think that you're paying an incorrect amount for your prescription at a pharmacy, our plan has a process to help you get evidence of the right copayment amount. If you already have evidence of the right amount, we can help you share this evidence with us. • If you think you qualify for Extra Help with your prescription drug costs, but do not have or cannot find proof, please contact Member Services at (855) 570-1600 (toll free). TTY users should call 711 for assistance. We will work with you to update your Extra Help program status based on the best available evidence. For example, you might provide us with evidence of Medicaid status, which may show that you qualify for Extra Help. For more information on acceptable forms of evidence, contact Member Services. • When we get the evidence showing the right copayment level, we'll update our system so you can pay the right amount when you get your next prescription. If you overpay your copayment, we'll pay you back, either by check or a future copayment credit. If the pharmacy didn't collect your copayment and you owe them a debt, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make the payment directly to the state. Call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) if you have questions. What if you have Extra Help and coverage from an AIDS Drug Assistance Program (ADAP)? The AIDS Drug Assistance Program (ADAP) helps people living with HIV/AIDS access life-saving HIV medications. Medicare Part D drugs that are also on the ADAP formulary qualify for prescription cost-sharing help through the Monterey County ADAP. Note: To be eligible for the ADAP in your state, people must meet certain criteria, including proof of state residence and HIV status, low income (as defined by the state), and uninsured/under-insured status. If you change plans, notify your local ADAP enrollment worker so you can continue to get help. For information on eligibility criteria, covered drugs, or how to enroll in the program, call 831-975-5016. Medicare Prescription Payment Plan The Medicare Prescription Payment Plan is a payment option that works with your current drug coverage to help you manage your out-of-pocket costs for drugs covered by our plan by spreading them across the calendar year (January - December). Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage plan with drug coverage) can use this payment option. This payment option might help you manage

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 28 Chapter 2 Phone numbers and resources your expenses, but it doesn't save you money or lower your drug costs. If you're participating in the Medicare Prescription Payment Plan and stay in the same Part D plan, your participation will be automatically renewed for 2026. To learn more about this payment option, call Member Services at Toll Free: (888)405-3160 (TTY users call 711) or visit www.Medicare.gov. Medicare Prescription Payment Plan - Contact Information Call (888)495-3160 Calls to this number are free. Hours: 24 hours a day/7 days a week Member Services Toll Free: (855) 570-1600 (TTY users call 711) also has free language interpreter services for non-English speakers. TTY 711 Calls to this number are free. Hours: 24 hours a day/7 days a week Fax Local: (831) 574-4939 Toll Free: (855) 519-5769 Write Aspire Health 10 Ragsdale Drive, Suite 101 Monterey, CA 93940 Website https://www.aspirehealthplan.org/medicare-prescription-payment- plan/ SECTION 8 Railroad Retirement Board (RRB) The Railroad Retirement Board is an independent federal agency that administers comprehensive benefit programs for the nation's railroad workers and their families. If you get Medicare through the Railroad Retirement Board, let them know if you move or change your mailing address. For questions about your benefits from the Railroad Retirement Board, contact the agency.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 29 Chapter 2 Phone numbers and resources Railroad Retirement Board (RRB) - Contact Information Call 1-877-772-5772 Calls to this number are free. Press “0” to speak with an RRB representative from 9 am to 3:30 pm, Monday, Tuesday, Thursday, and Friday, and from 9 am to 12 pm on Wednesday. Press “1” to access the automated RRB HelpLine and get recorded information 24 hours a day, including weekends and holidays. TTY 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties hearing or speaking. Calls to this number aren't free. Website https://RRB.gov SECTION 9 If you have group insurance or other health insurance from an employer If you (or your spouse or domestic partner) get benefits from your (or your spouse or domestic partner's) employer or retiree group as part of this plan, call the employer/union benefits administrator or Member Services at Toll Free: (855) 570-1600 (TTY users call 711) with any questions. You can ask about your (or your spouse or domestic partner's) employer or retiree health benefits, premiums, or the enrollment period. You can call 1-800-MEDICARE (1-800-633-4227) with questions about your Medicare coverage under this plan. TTY users call 1-877-486-2048. If you have other drug coverage through your (or your spouse or domestic partner's) employer or retiree group, contact that group's benefits administrator. The benefits administrator can help you understand how your current drug coverage will work with our plan.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 30 Chapter 3 Using our plan for your medical services CHAPTER 3: Using our plan for your medical services SECTION 1 How to get medical care as a member of our plan This chapter explains what you need to know about using our plan to get your medical care covered. For details on what medical care our plan covers and how much you pay when you get care, go to the Medical Benefits Chart in Chapter 4. Section 1.1 Network providers and covered services • Providers are doctors and other health care professionals licensed by the state to provide medical services and care. The term “providers” also includes hospitals and other health care facilities. • Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and your cost-sharing amount as payment in full. We arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for care they give you. When you see a network provider, you pay only your share of the cost for their services. • Covered services include all the medical care, health care services, supplies, equipment, and prescription drugs that are covered by our plan. Your covered services for medical care are listed in the Medical Benefits Chart in Chapter 4. Your covered services for prescription drugs are discussed in Chapter 5. Section 1.2 Basic rules for your medical care to be covered by our plan As a Medicare health plan, Aspire Health Advantage (HMO) must cover all services covered by Original Medicare and follow Original Medicare's coverage rules. Aspire Health Advantage (HMO) will generally cover your medical care as long as: • The care you get is included in our plan's Medical Benefits Chart in Chapter 4. • The care you get is considered medically necessary. Medically necessary means that the services, supplies, equipment, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 31 Chapter 3 Using our plan for your medical services • You have a network primary care provider (a PCP) providing and overseeing your care. As a member of our plan, you must choose a network PCP (go to Section 2.1 for more information). • You don't need referrals from your PCP for emergency care or urgently needed services. To learn about other kinds of care you can get without getting approval in advance from your PCP, go to Section 2.2. • You must get your care from a network provider (go to Section 2). In most cases, care you get from an out-of-network provider (a provider who's not part of our plan's network) won't be covered. This means you have to pay the provider in full for services you get. Here are 3 exceptions: • Our plan covers emergency care or urgently needed services you get from an out-of-network provider. For more information, and to see what emergency or urgently needed services are, go to Section 3. • If you need medical care that Medicare requires our plan to cover but there are no specialists in our network that provide this care, you can get this care from an out-of-network provider at the same cost sharing you normally pay in- network. Authorization should be obtained from the plan prior to seeking care. In this situation, you pay the same as you'd pay if you got the care from a network provider. For information about getting approval to see an out-of- network doctor, go to Section 2.4. • Our plan covers kidney dialysis services you get at a Medicare-certified dialysis facility when you're temporarily outside our plan's service area or when your provider for this service is temporarily unavailable or inaccessible. The cost sharing you pay our plan for dialysis can never be higher than the cost sharing in Original Medicare. If you're outside our plan's service area and get dialysis from a provider that's outside our plan's network, your cost sharing can't be higher than the cost sharing you pay in-network. However, if your usual in- network provider for dialysis is temporarily unavailable and you choose to get services inside our service area from a provider outside our plan's network, your cost sharing for the dialysis may be higher.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 32 Chapter 3 Using our plan for your medical services SECTION 2 Use providers in our plan's network to get medical care Section 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee your medical care What is a PCP and what does the PCP do for you? What is a PCP? Your Primary Care Provider (PCP) is a physician who meets state requirements and is trained to give you basic medical care. As we explain below, you will get your routine or basic care from your PCP. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our plan. This includes: • X-rays • Laboratory tests • Therapies • Care from doctors who are specialists • Hospital admissions • Follow-up care “Coordinating” your services includes checking or consulting with other plan providers about your care and how it is going. In some cases, your PCP will need to get prior authorization (prior approval) from us. Since your PCP will provide and coordinate your medical care, you should have all of your past medical records sent to your PCP's office. Chapter 8 Section 1.3 tells you how we will protect the privacy of your medical records and personal health information. What types of providers may act as a PCP? Many types of providers can be PCPs, including: • Family practice doctors • General practice doctors • Internal Medicine doctors or internists, who treat people over the age of 18 What is the role of the PCP in making decisions about or getting prior authorization (PA), if applicable? Your PCP will determine whether prior authorization is required for the recommended treatment/service, and will request authorization by submitting an authorization request form and supporting documentation on your behalf.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 33 Chapter 3 Using our plan for your medical services How to choose a PCP When you become a member of our plan, you must choose a PCP. You can find available PCPs in the Provider/Pharmacy Directory or call Member Services to discuss available PCPs. How to change your PCP You can change your PCP for any reason, at any time. It's also possible that your PCP might leave our plan's network of providers, and you'd need to choose a new PCP. Call Member Services for assistance with changing your PCP (phone numbers are printed on the back cover of this document). When you call, Member Services will check to be sure the PCP you want to switch to is in the plan's network and accepting new patients. Member Services will change your membership record to show the name of your new PCP, and tell you when the change to your new PCP will take effect (usually, the first of the following month). You will also be sent a new membership card that shows the name and phone number of your new PCP. Section 2.2 Medical care you can get without a PCP referral You can get the services listed below without getting approval in advance from your PCP. • Routine women's health care, including breast exams, screening mammograms (x- rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. • Flu shots , COVID-19 vaccines, Hepatitis B vaccines, and pneumonia vaccines as long as you get them from a network provider. • Emergency services from network providers or from out-of-network providers. • Urgently needed plan-covered services are services that require immediate medical attention (but not an emergency) if you're either temporarily outside our plan's service area, or if it's unreasonable given your time, place, and circumstances to get this service from network providers. Examples of urgently needed services are unforeseen medical illnesses and injuries or unexpected flare-ups of existing conditions. Medically necessary routine provider visits (like annual checkups) aren't considered urgently needed even if you're outside our plan's service area or our plan network is temporarily unavailable. • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you're temporarily outside our plan's service area. If possible, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) before you leave the service area so we can help arrange for you to have maintenance dialysis while you're away.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 34 Chapter 3 Using our plan for your medical services Section 2.3 How to get care from specialists and other network providers A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. For example: • Oncologists care for patients with cancer • Cardiologists care for patients with heart conditions • Orthopedists care for patients with certain bone, joint, or muscle conditions How to access specialists and other network providers Our plan does not require you to get a referral to see a specialist; however some specialists will require a referral from your PCP prior to your specialist visit. You should always check with your PCP before seeing a specialist so s/he can help coordinate your care. Medical services requested by the PCP or specialist may require prior authorization from the plan. Generally, your PCP or specialist will request any necessary prior authorization from the plan. However, it is your responsibility to ensure that prior authorization has been granted before having any medical service or procedure. To determine which services require prior authorization, please see Chapter 4, section 2.1. When a specialist or another network provider leaves our plan We may make changes to the hospitals, doctors, and specialists (providers) in our plan's network during the year. If your doctor or specialist leaves our plan, you have these rights and protections: • Even though our network of providers may change during the year, Medicare requires that you have uninterrupted access to qualified doctors and specialists. • We'll notify you that your provider is leaving our plan so that you have time to choose a new provider. • If your primary care or behavioral health provider leaves our plan, we'll notify you if you visited that provider within the past 3 years. • If any of your other providers leave our plan, we'll notify you if you're assigned to the provider, currently get care from them, or visited them within the past 3 months. • We'll help you choose a new qualified in-network provider for continued care. • If you're undergoing medical treatment or therapies with your current provider, you have the right to ask to continue getting medically necessary treatment or therapies. We'll work with you so you can continue to get care.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 35 Chapter 3 Using our plan for your medical services • We'll give you information about available enrollment periods and options you may have for changing plans. • When an in-network provider or benefit is unavailable or inadequate to meet your medical needs, we'll arrange for any medically necessary covered benefit outside of our provider network at in-network cost sharing. Authorization should be obtained from the plan prior to seeking care. • If you find out your doctor or specialist is leaving our plan, contact us so we can help you choose a new provider to manage your care. • If you believe we haven't furnished you with a qualified provider to replace your previous provider or that your care isn't being appropriately managed, you have the right to file a quality-of-care complaint to the QIO, a quality-of-care grievance to our plan, or both (go to Chapter 9). Section 2.4 How to get care from out-of-network providers To access out-of-network providers, you must have a prior authorization from Aspire Health Plan. If you get non-emergency care from non-plan (out-of-network) providers without prior authorization, you must pay the entire cost yourself, unless the services are emergency services, are urgent and our network is not available, or the services are out-of-area dialysis services. There may be times when you require a specialized service that is not available in-network. In those circumstances you can request that we cover your services through an out-of-network provider. Please note: The out-of-network provider must be eligible to participate in Medicare. This means that the provider is not on the Office of Inspector General's (OIG) exclusion list, the Medicare preclusion list, or voluntarily opted-out of Medicare, on the date(s) you receive services. We cannot pay a provider who is not eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare. You are responsible for requesting or verifying that your care from an out-of-network provider has been authorized. Services received from out-of-network providers that are not authorized will not be paid by this plan, except for emergency care, urgently needed care, or out-of-area renal dialysis. To request or verify that services you wish to receive from an out-of-network provider have been authorized, you can call Member Services (numbers are on the back cover of this document).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 36 Chapter 3 Using our plan for your medical services If you have an emergency, call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get prior approval from Aspire Health Plan. If an out-of-network provider sends you a bill for emergency services that you think we should pay, please contact Member Services or send the bill to us for payment. See the Medical Benefits chart in Chapter 4, Section 2 for more detailed information. SECTION 3 How to get services in an emergency, disaster, or urgent need for care Section 3.1 Get care if you have a medical emergency A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life (and, if you're a pregnant woman, loss of an unborn child), loss of a limb or function of a limb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical condition that's quickly getting worse. If you have a medical emergency: • Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You don't need to get approval or a referral first from your PCP. You don't need to use a network doctor. You can get covered emergency medical care whenever you need it, anywhere in the United States or its territories, and from any provider with an appropriate state license even if they're not part of our network. • As soon as possible, make sure our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Call us at Toll Free: (855) 570- 1600 (TTY 711) from 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) so we can help. Covered services in a medical emergency Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. We also cover medical services during the emergency.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 37 Chapter 3 Using our plan for your medical services The doctors giving you emergency care will decide when your condition is stable and when the medical emergency is over. After the emergency is over, you're entitled to follow-up care to be sure your condition continues to be stable. Your doctors will continue to treat you until your doctors contact us and make plans for additional care. Your follow-up care will be covered by our plan. If your emergency care is provided by out-of-network providers, we'll try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow. What if it wasn't a medical emergency? Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care - thinking that your health is in serious danger - and the doctor may say that it wasn't a medical emergency after all. If it turns out that it wasn't an emergency, as long as you reasonably thought your health was in serious danger, we'll cover your care. However, after the doctor says it wasn't an emergency, we'll cover additional care only if you get the additional care in one of these 2 ways: • You go to a network provider to get the additional care, or • The additional care you get is considered urgently needed services and you follow the rules below for getting this urgent care. Section 3.2 Get care when you have an urgent need for services A service that requires immediate medical attention (but isn't an emergency) is an urgently needed service if you're either temporarily outside our plan's service area, or if it's unreasonable given your time, place, and circumstances to get this service from network providers. Examples of urgently needed services are unforeseen medical illnesses and injuries, or unexpected flare-ups of existing conditions. However, medically necessary routine provider visits such as annual checkups aren't considered urgently needed even if you're outside our plan's service area or our plan network is temporarily unavailable. You can contact your primary care provider for instructions and advice for urgently needed care. All network providers are listed in the Provider/Pharmacy Directory, can be found on our website www.aspirehealthplan.org and can be verified by calling Member Services at the number listed on the back cover of this document. Our plan does not cover emergency services, urgently needed services, nor any other services for care received outside of the United States and its territories.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 38 Chapter 3 Using our plan for your medical services Our plan covers medically necessary emergency and urgent care services you get on a cruise ship in these situations: • The doctor is allowed under certain laws to provide medical services on the cruise ship. • The ship is in a U.S. port or no more than 6 hours away from a U.S. port when you get the services, regardless of whether it's an emergency. Our plan doesn't cover emergency and urgent care services you get when the ship is more than 6 hours away from a U.S. port. Our plan doesn't cover emergency services, urgently needed services, or any other services you get outside of the United States and its territories. Section 3.3 Get care during a disaster If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you're still entitled to care from our plan. Visit www.aspirehealthplan.org for information on how to get needed care during a disaster. If you can't use a network provider during a disaster, our plan will allow you to get care from out-of-network providers at in-network cost sharing. If you can't use a network pharmacy during a disaster, you may be able to fill your prescriptions at an out-of-network pharmacy. Go to Chapter 5, Section 2.4. SECTION 4 What if you're billed directly for the full cost of covered services? If you paid more than our plan cost sharing for covered services, or if you get a bill for the full cost of covered medical services, you can ask us to pay our share of the cost of covered services. Go to Chapter 7 for information about what to do. Section 4.1 If services aren't covered by our plan, you must pay the full cost Aspire Health Advantage (HMO) covers all medically necessary services as listed in the Medical Benefits Chart in Chapter 4. If you get services that aren't covered by our plan or you get services out-of-network without authorization, you're responsible for paying the full cost of services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 39 Chapter 3 Using our plan for your medical services For covered services that have a benefit limitation, you also pay the full cost of any services you get after you use up your benefit for that type of covered service. After you reach your benefit limit, any costs you pay for that benefit will not count toward your out-of-pocket maximum. SECTION 5 Medical services in a clinical research study Section 5.1 What is a clinical research study A clinical research study (also called a clinical trial) is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. Certain clinical research studies are approved by Medicare. Clinical research studies approved by Medicare typically ask for volunteers to participate in the study. When you're in a clinical research study, you can stay enrolled in our plan and continue to get the rest of your care (care that's not related to the study) through our plan. If you participate in a Medicare-approved study, Original Medicare pays most of the costs for covered services you get as part of the study. If you tell us you're in a qualified clinical trial, you're only responsible for the in-network cost sharing for the services in that trial. If you paid more—for example, if you already paid the Original Medicare cost-sharing amount—we'll reimburse the difference between what you paid and the in-network cost sharing. You'll need to provide documentation to show us how much you paid. If you want to participate in any Medicare-approved clinical research study, you don't need to tell us or get approval from us or your PCP. The providers that deliver your care as part of the clinical research study don't need to be part of our plan's network. (This doesn't apply to covered benefits that require a clinical trial or registry to assess the benefit, including certain benefits requiring coverage with evidence development (NCDs-CED) and investigational device exemption (IDE) studies. These benefits may also be subject to prior authorization and other plan rules.) While you don't need our plan's permission to be in a clinical research study, we encourage you to notify us in advance when you choose to participate in Medicare-qualified clinical trials. If you participate in a study not approved by Medicare, you'll be responsible for paying all costs for your participation in the study.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 40 Chapter 3 Using our plan for your medical services Section 5.2 Who pays for services in a clinical research study Once you join a Medicare-approved clinical research study, Original Medicare covers the routine items and services you get as part of the study, including: • Room and board for a hospital stay that Medicare would pay for even if you weren't in a study. • An operation or other medical procedure if it's part of the research study. • Treatment of side effects and complications of the new care. After Medicare pays its share of the cost for these services, our plan will pay the difference between the cost sharing in Original Medicare and your in-network cost sharing as a member of our plan. This means you'll pay the same amount for services you get as part of the study as you would if you got these services from our plan. However, you must submit documentation showing how much cost sharing you paid. Go to Chapter 7 for more information on submitting requests for payments. Example of cost sharing in a clinical trial: Let's say you have a lab test that costs $100 as part of the research study. Your share of the costs for this test is $20 under Original Medicare, but the test would be $10 under our plan. In this case, Original Medicare would pay $80 for the test, and you would pay the $20 copay required under Original Medicare. You would notify our plan that you got a qualified clinical trial service and submit documentation, (like a provider bill) to our plan. Our plan would then directly pay you $10. This makes your net payment for the test $10, the same amount you'd pay under our plan's benefits. When you're in a clinical research study, neither Medicare nor our plan will pay for any of the following: • Generally, Medicare won't pay for the new item or service the study is testing unless Medicare would cover the item or service even if you weren't in a study. • Items or services provided only to collect data and not used in your direct health care. For example, Medicare won't pay for monthly CT scans done as part of a study if your medical condition would normally require only one CT scan. • Items and services provided by the research sponsors free of charge for people in the trial.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 41 Chapter 3 Using our plan for your medical services Get more information about joining a clinical research study Get more information about joining a clinical research study in the Medicare publication Medicare and Clinical Research Studies, available at www.Medicare.gov/sites/default/files/2019-09/02226-medicare-and-clinical-research- studies.pdf. You can also call 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-

2048. SECTION 6 Rules for getting care in a religious non-medical health care institution Section 6.1 A religious non-medical health care institution A religious non-medical health care institution is a facility that provides care for a condition that would ordinarily be treated in a hospital or skilled nursing facility. If getting care in a hospital or a skilled nursing facility is against a member's religious beliefs, we'll instead cover care in a religious non-medical health care institution. This benefit is provided only for Part A inpatient services (non-medical health care services). Section 6.2 How to get care from a religious non-medical health care institution To get care from a religious non-medical health care institution, you must sign a legal document that says you're conscientiously opposed to getting medical treatment that is non- excepted. • Non-excepted medical care or treatment is any medical care or treatment that's voluntary and not required by any federal, state, or local law. • Excepted medical treatment is medical care or treatment you get that's not voluntary or is required under federal, state, or local law. To be covered by our plan, the care you get from a religious non-medical health care institution must meet the following conditions: • The facility providing the care must be certified by Medicare. • Our plan only covers non-religious aspects of care. • If you get services from this institution provided to you in a facility, the following conditions apply: • You must have a medical condition that would allow you to get covered services for inpatient hospital care or skilled nursing facility care.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 42 Chapter 3 Using our plan for your medical services • – and – you must get approval in advance from our plan before you’re admitted to the facility, or your stay won’t be covered. Medicare Inpatient Hospital coverage limits apply. (See the Medical Benefits chart in Chapter 4.) SECTION 7 Rules for ownership of durable medical equipment Section 7.1 You won't own some durable medical equipment after making a certain number of payments under our plan Durable medical equipment (DME) includes items like oxygen equipment and supplies, wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating devices, IV infusion pumps, nebulizers, and hospital beds ordered by a provider for members to use in the home. The member always owns some DME items, like prosthetics. Other types of DME you must rent. In Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the item for 13 months. As a member of Aspire Health Advantage (HMO), you usually won't get ownership of rented DME items no matter how many copayments you make for the item while a member of our plan. You won't get ownership even if you made up to 12 consecutive payments for the DME item under Original Medicare before you joined our plan. Under some limited circumstances, we'll transfer ownership of the DME item to you. Call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) for more information. What happens to payments you made for durable medical equipment if you switch to Original Medicare? If you didn't get ownership of the DME item while in our plan, you'll have to make 13 new consecutive payments after you switch to Original Medicare to own the DME item. The payments you made while enrolled in our plan don't count towards these 13 payments. Example 1: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. The payments you made in Original Medicare don't count. You'll have to make 13 payments to our plan before owning the item. Example 2: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. You didn't get ownership of the item while in our plan. You then go back to Original Medicare. You'll have to make 13 consecutive new payments to own the item once you rejoin Original Medicare. Any payments you already made (whether to our plan or to Original Medicare) don't count.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 43 Chapter 3 Using our plan for your medical services Section 7.2 Rules for oxygen equipment, supplies, and maintenance If you qualify for Medicare oxygen equipment coverage Aspire Health Advantage (HMO) will cover: • Rental of oxygen equipment • Delivery of oxygen and oxygen contents • Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents • Maintenance and repairs of oxygen equipment If you leave Aspire Health Advantage (HMO) or no longer medically require oxygen equipment, then the oxygen equipment must be returned. What happens if you leave our plan and return to Original Medicare? Original Medicare requires an oxygen supplier to provide you services for 5 years. During the first 36 months, you rent the equipment. For the remaining 24 months, the supplier provides the equipment and maintenance (you're still responsible for the copayment for oxygen). After 5 years, you can choose to stay with the same company or go to another company. At this point, the 5-year cycle starts over again, even if you stay with the same company, and you're again required to pay copayments for the first 36 months. If you join or leave our plan, the 5- year cycle starts over.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 44 Chapter 4 Medical Benefits Chart (what's covered and what you pay) CHAPTER 4: Medical Benefits Chart (what's covered and what you pay) SECTION 1 Understanding your out-of-pocket costs for covered services The Medical Benefits Chart lists your covered services and shows how much you pay for each covered service as a member of Aspire Health Advantage (HMO). This section also gives information about medical services that aren't covered and explains limits on certain services. Section 1.1 Out-of-pocket costs you may pay for covered services Types of out-of-pocket costs you may pay for covered services include: • Copayment: the fixed amount you pay each time you get certain medical services. You pay a copayment at the time you get the medical service. (The Medical Benefits Chart tells you more about your copayments.) • Coinsurance: the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service. (The Medical Benefits Chart tells you more about your coinsurance.) Most people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB) program don't pay deductibles, copayments, or coinsurance. If you're in one of these programs, be sure to show your proof of Medicaid or QMB eligibility to your provider. Section 1.2 What's the most you'll pay for Medicare Part A and Part B covered medical services? Medicare Advantage Plans have limits on the total amount you have to pay out of pocket each year for in-network medical services covered under Medicare Part A and Part B. This limit is called the maximum out-of-pocket (MOOP) amount for medical services. For calendar year 2026 the MOOP amount is $4,300. The amounts you pay for copayments and coinsurance for in-network covered services count toward this maximum out-of-pocket amount. The amounts you pay for plan premiums and Part D drugs don't count toward your maximum out-of-pocket amount. In addition, amounts you pay for some services don't count toward your maximum out-of-pocket amount. These services are marked with an asterisk in the Medical Benefits Chart. If you reach the maximum

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 45 Chapter 4 Medical Benefits Chart (what's covered and what you pay) out-of-pocket amount of $4,300, you won't have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. However, you must continue to pay our plan premium and the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). Section 1.3 Providers aren't allowed to balance bill you As a member of Aspire Health Advantage (HMO), you have an important protection because you only have to pay your cost-sharing amount when you get services covered by our plan. Providers can't bill you for additional separate charges, called balance billing. This protection applies even if we pay the provider less than the provider charges for a service and even if there's a dispute and we don't pay certain provider charges. Here's how protection from balance billing works: • If your cost sharing is a copayment (a set amount of dollars, for example, $15.00), you pay only that amount for any covered services from a network provider. • If your cost sharing is a coinsurance (a percentage of the total charges), you never pay more than that percentage. However, your cost depends on which type of provider you see: • If you get covered services from a network provider, you pay the coinsurance percentage multiplied by our plan's reimbursement rate (this is set in the contract between the provider and our plan). • If you get covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. (Our plan covers services from out-of- network providers only in certain situations, such as when you get a referral or for emergencies or urgently needed services.) • If you get covered services from an out-of-network provider who doesn't participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers. (Our plan covers services from out-of-network providers only in certain situations, such as when you get a referral, or for emergencies or for urgently needed services outside the service area.) • If you think a provider has balance billed you, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 46 Chapter 4 Medical Benefits Chart (what's covered and what you pay) SECTION 2 The Medical Benefits Chart shows your medical benefits and costs The Medical Benefits Chart on the next pages lists the services Aspire Health Advantage (HMO) covers and what you pay out of pocket for each service (Part D drug coverage is in Chapter 5). The services listed in the Medical Benefits Chart are covered only when these are met: • Your Medicare-covered services must be provided according to the Medicare coverage guidelines. • Your services (including medical care, services, supplies, equipment, and Part B drugs) must be medically necessary. Medically necessary means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. • For new enrollees, your MA coordinated care plan must provide a minimum 90-day transition period, during which time the new MA plan can't require prior authorization for any active course of treatment, even if the course of treatment was for a service that commenced with an out-of-network provider. • You get your care from a network provider. In most cases, care you get from an out-of- network provider won't be covered unless it's emergency or urgent care, or unless our plan or a network provider gave you a referral. This means you pay the provider in full for out-of-network services you get. • You have a primary care provider (a PCP) providing and overseeing your care. • Some services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval from us in advance (sometimes called prior authorization). Other important things to know about our coverage: • Like all Medicare health plans, we cover everything that Original Medicare covers. For some of these benefits, you pay more in our plan than you would in Original Medicare. For others, you pay less. (To learn more about the coverage and costs of Original Medicare, go to your Medicare & You 2026 handbook. View it online at www.Medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048.) • For preventive services covered at no cost under Original Medicare, we also cover those services at no cost to you. However, if you're also treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care you got for the existing medical condition.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 47 Chapter 4 Medical Benefits Chart (what's covered and what you pay) • If Medicare adds coverage for any new services during 2026, either Medicare or our plan will cover those services. This apple shows preventive services in the Medical Benefits Chart. Medical Benefits Chart Covered Service What you pay Abdominal aortic aneurysm screening A one-time screening ultrasound for people at risk. Our plan only covers this screening if you have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist. There is no coinsurance, copayment, or deductible for members eligible for this preventive screening. Acupuncture for chronic low back pain Covered services include: Up to 12 visits in 90 days are covered under the following circumstances: For the purpose of this benefit, chronic low back pain is defined as: • Lasting 12 weeks or longer; • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious disease, etc.); • not associated with surgery; and • not associated with pregnancy. An additional 8 sessions will be covered for patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing. $0 copay for each Medicare-covered visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 48 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Acupuncture for chronic low back pain (continued) Provider Requirements: Physicians (as defined in 1861(r)(1) of the Social Security Act (the Act)) may furnish acupuncture in accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa) (5) of the Act), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have: • a master's or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and, • a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e., Puerto Rico) of the United States, or District of Columbia. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS required by our regulations at 42 CFR §§ 410.26 and 410.27. Acupuncture (routine benefit) Benefit includes: • 6 visits every year $10 copay for each routine visit. Ambulance services Covered ambulance services, whether for an emergency or non-emergency situation, include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care if they're furnished to a member whose medical condition is such that other means of transportation could endanger the person's health or if authorized by our plan. If the covered ambulance services aren't for an emergency situation, it should be documented that the member's condition is such that other means of transportation could endanger the person's health and that transportation by ambulance is medically required. Prior authorization rules may apply $325 copay for each Medicare-covered ground ambulance service. 20% coinsurance for each Medicare-covered air ambulance service. Cost sharing applies to each one-way trip.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 49 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Annual wellness visit If you've had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months. Note: Your first annual wellness visit can't take place within 12 months of your Welcome to Medicare preventive visit. However, you don't need to have had a Welcome to Medicare visit to be covered for annual wellness visits after you've had Part B for 12 months. There is no coinsurance, copayment, or deductible for the annual wellness visit. Bone mass measurement For qualified people (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician's interpretation of the results. There is no coinsurance, copayment, or deductible for Medicare-covered bone mass measurement. Breast cancer screening (mammograms) Covered services include: • One baseline mammogram between the ages of 35 and 39 • One screening mammogram every 12 months for women aged 40 and older • Clinical breast exams once every 24 months There is no coinsurance, copayment, or deductible for covered screening mammograms. If your doctor orders a breast ultrasound due to dense breast tissue, the ultrasound is subject to a copayment. Please refer to the "Outpatient diagnostic tests and therapeutic services and supplies" section for more information.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 50 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Cardiac rehabilitation services Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor's order. Our plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. Prior authorization rules may apply $15 copay for each Medicare-covered cardiac rehabilitation services visit. $15 copay for each Medicare-covered intensive cardiac rehabilitation services visit. Cardiovascular disease risk reduction visit (therapy for cardiovascular disease) We cover one visit per year with your primary care doctor to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you're eating healthy. There is no coinsurance, copayment, or deductible for the intensive behavioral therapy cardiovascular disease preventive benefit. Cardiovascular disease screening tests Blood tests for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every 5 years (60 months). There is no coinsurance, copayment, or deductible for cardiovascular disease testing that is covered once every 5 years. Cervical and vaginal cancer screening Covered services include: • For all women: Pap tests and pelvic exams are covered once every 24 months • If you're at high risk of cervical or vaginal cancer or you're of childbearing age and have had an abnormal Pap test within the past 3 years: one Pap test every 12 months There is no coinsurance, copayment, or deductible for Medicare-covered preventive Pap and pelvic exams.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 51 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Chiropractic services Covered services include: • Manual manipulation of the spine to correct subluxation • Routine chiropractic services: 6 visits every year limited to manual manipulation of the spine that is supportive, not corrective. This is sometimes called maintenance therapy or maintenance care. Routine chiropractic services are limited to the following codes: 98940, 98941 or 98942. Note: We do not cover CT, PET or MRI Scans, ultrasound, hot/cold packs, blood pressure checks, durable medical equipment, prescriptions, acupuncture, dietary supplements, office visits / exam, physical therapies, supportive braces, counseling or education, laboratory or other diagnostic tests, massage, supportive pillows, or x-rays when provided or ordered by a chiropractor. $10 copay for each Medicare-covered chiropractic visit. $10 copay for each routine chiropractic services visit. Chronic pain management and treatment services Covered monthly services for people living with chronic pain (persistent or recurring pain lasting longer than 3 months). Services may include pain assessment, medication management, and care coordination and planning. Cost sharing for this service will vary depending on individual services provided under the course of treatment.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 52 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Colorectal cancer screening The following screening tests are covered: • Colonoscopy has no minimum or maximum age limitation and is covered once every 120 months (10 years) for patients not at high risk, or 48 months after a previous flexible sigmoidoscopy for patients who aren't at high risk for colorectal cancer, and once every 24 months for high- risk patients after a previous screening colonoscopy. • Computed tomography colonography for patients 45 years and older who are not at high risk of colorectal cancer and is covered when at least 59 months have passed following the month in which the last screening computed tomography colonography was performed or 47 months have passed following the month in which the last screening flexible sigmoidoscopy or screening colonoscopy was performed. For patients at high risk for colorectal cancer, payment may be made for a screening computed tomography colonography performed after at least 23 months have passed following the month in which the last screening computed tomography colonography or the last screening colonoscopy was performed. • Flexible sigmoidoscopy for patients 45 years and older. Once every 120 months for patients not at high risk after the patient received a screening colonoscopy. Once every 48 months for high-risk patients from the last flexible sigmoidoscopy or computed tomography colonography. • Screening fecal-occult blood tests for patients 45 years and older. Once every 12 months. • Multitarget stool DNA for patients 45 to 85 years of age and not meeting high risk criteria. Once every 3 years. • Blood-based Biomarker Tests for patients 45 to 85 years of age and not meeting high risk criteria. Once every 3 years. • Colorectal cancer screening tests include a follow-on screening colonoscopy after a Medicare-covered non- invasive stool-based colorectal cancer screening test returns a positive result. • Colorectal cancer screening tests include a planned screening flexible sigmoidoscopy or screening There is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. If your doctor finds and removes a polyp or other tissue during the colonoscopy or flexible sigmoidoscopy, the screening exam becomes a diagnostic exam and is subject to a $60 copay.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 53 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay colonoscopy that involves the removal of tissue or other matter, or other procedure furnished in connection with, as a result of, and in the same clinical encounter as the screening test. Dental services In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) aren't covered by Original Medicare. However, Medicare pays for dental services in a limited number of circumstances, specifically when that service is an integral part of specific treatment of a person's primary medical condition. Examples include reconstruction of the jaw after a fracture or injury, tooth extractions done in preparation for radiation treatment for cancer involving the jaw, or oral exams prior to organ transplantation. Prior authorization rules may apply $25 copay for Medicare- covered dental services. In addition, we cover: Preventive dental services: • 2 oral exams every year, limited to the following codes: D0120, D0140, D0150, D0160 or D0180 • 2 cleanings every year, limited to the following codes: D1110 • 1 X-ray every year, limited to the following codes: D0270 or D0272 $0 copay for each preventive dental exam. $0 copay for each cleaning. $0 copay for X-rays. Depression screening We cover one screening for depression per year. The screening must be done in a primary care setting that can provide follow-up treatment and/or referrals. There is no coinsurance, copayment, or deductible for an annual depression screening visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 54 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Diabetes screening We cover this screening (includes fasting glucose tests) if you have any of these risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes. You may be eligible for up to 2 diabetes screenings every 12 months following the date of your most recent diabetes screening test. There is no coinsurance, copayment, or deductible for the Medicare-covered diabetes screening tests. Diabetes self-management training, diabetic services, and supplies For all people who have diabetes (insulin and non-insulin users). Covered services include: • Supplies to monitor your blood glucose: blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors. • For people with diabetes who have severe diabetic foot disease: one pair per calendar year of therapeutic custom- molded shoes (including inserts provided with such shoes) and 2 additional pairs of inserts, or one pair of depth shoes and 3 pairs of inserts (not including the non-customized removable inserts provided with such shoes). Coverage includes fitting. • Diabetes self-management training is covered under certain conditions. Note: Continuous Glucose Monitor (CGM) devices and supplies are covered under our Durable Medical Equipment benefit. Please refer to the “Durable medical equipment (DME) and related supplies” benefit for additional information. Prior authorization rules may be required for select diabetes supplies. 0% to 20% coinsurance for Medicare-covered diabetic monitoring supplies. $0 copay for Medicare- covered diabetic therapeutic shoes or inserts. $0 copay for Medicare- covered diabetes self- management training services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 55 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Durable medical equipment (DME) and related supplies (For a definition of durable medical equipment, go to Chapter 12 and Chapter 3) Covered items include, but aren't limited to, wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. We cover all medically necessary DME covered by Original Medicare. If our supplier in your area doesn't carry a particular brand or manufacturer, you can ask them if they can special order it for you. The most recent list of suppliers is available on our website at www.aspirehealthplan.org. Prior authorization required for Durable Medical Equipment that costs over $500. 20% coinsurance for Medicare-covered durable medical equipment. Your cost sharing for Medicare oxygen equipment coverage is 20% coinsurance, every date of service. Your cost sharing won't change after you're enrolled for 36 months. If you made 36 months of rental payment for oxygen equipment coverage before you enrolled in Aspire Health Advantage (HMO), your cost sharing in Aspire Health Advantage (HMO) is 20% coinsurance. EKG following the “Welcome to Medicare” visit Medicare covers a routine EKG or ECG screening if you get an order from your doctor or other health care provider during your one-time “Welcome to Medicare” preventive visit. $0 copay for an EKG following the “Welcome to Medicare” visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 56 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Emergency care Emergency care refers to services that are: • Furnished by a provider qualified to furnish emergency services, and • Needed to evaluate or stabilize an emergency medical condition. A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life (and, if you're a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that's quickly getting worse. Cost sharing for necessary emergency services you get out-of- network is the same as when you get these services in- network. Not covered outside the U.S. and its territories. Our plan may cover medically necessary emergency care you get on a cruise ship in these situations: • The doctor is allowed under certain laws to provide medical services on the cruise ship. • The ship is in a U.S. port or no more than 6 hours away from a U.S. port when you get the services, regardless of whether it's an emergency. Our plan doesn't cover emergency care services you get when the ship is more than 6 hours away from a U.S. port. $115 copay for each Medicare-covered emergency room visit. ER cost sharing is waived if you are admitted to the hospital within 24 hours for the same condition. If you get emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must return to a network hospital for your care to continue to be covered.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 57 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Health and wellness education programs Benefits include: • Health and wellness education program services • Fitness benefit is available only at Montage Wellness Centers. You must use a Montage Wellness Center location to access and receive this benefit. Benefit includes: • Facility orientation and introduction to programs and policies • One-on-one health & fitness assessment with a certified trainer • One personal training session to create a fitness plan • Unlimited instructor-led group exercise classes • Full access to strength and cardio equipment, lap and therapy pools at both locations $0 copay for health and wellness education program services. $0 copay for the fitness benefit. Hearing services Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when you get them from a physician, audiologist, or other qualified provider. $25 copay for each Medicare-covered exam to diagnose and treat hearing and balance issues. HIV screening For people who ask for an HIV screening test or are at increased risk for HIV infection, we cover: • One screening exam every 12 months. If you are pregnant, we cover: • Up to 3 screening exams during a pregnancy. There's no coinsurance, copayment, or deductible for members eligible for Medicare-covered preventive HIV screening.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 58 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Home health agency care Before you get home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort. Covered services include, but aren't limited to: • Part-time or intermittent skilled nursing and home health aide services (to be covered under the home health care benefit, your skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week) • Physical therapy, occupational therapy, and speech therapy • Medical and social services • Medical equipment and supplies Prior authorization rules may apply $0 copay for Medicare- covered home health services. Home infusion bundled services Part D home infusion drugs are part of a bundled service as a supplemental benefit under Part C. These specific drugs are included in our formulary. $0 copay for the bundled home infusion drugs.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 59 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Home infusion therapy Home infusion therapy involves the intravenous or subcutaneous administration of drugs or biologicals to a person at home. The components needed to perform home infusion include the drug (for example, antivirals, immune globulin), equipment (for example, a pump), and supplies (for example, tubing and catheters). Covered services include, but aren't limited to: • Professional services, including nursing services, furnished in accordance with the plan of care • Patient training and education not otherwise covered under the durable medical equipment benefit • Remote monitoring • Monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier Prior authorization and step therapy rules may apply 20% coinsurance for Medicare-covered home infusion therapy services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 60 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Hospice care You're eligible for the hospice benefit when your doctor and the hospice medical director have given you a terminal prognosis certifying that you're terminally ill and have 6 months or less to live if your illness runs its normal course. You can get care from any Medicare-certified hospice program. Our plan is obligated to help you find Medicare- certified hospice programs in our plan's service area, including programs we own, control, or have a financial interest in. Your hospice doctor can be a network provider or an out-of-network provider. Covered services include: • Drugs for symptom control and pain relief • Short-term respite care • Home care When you're admitted to a hospice, you have the right to stay in our plan; if you stay in our plan you must continue to pay plan premiums. For hospice services and services covered by Medicare Part A or B that are related to your terminal prognosis: Original Medicare (rather than our plan) will pay your hospice provider for your hospice services and any Part A and Part B services related to your terminal prognosis. While you're in the hospice program, your hospice provider will bill Original Medicare for the services Original Medicare pays for. You'll be billed Original Medicare cost sharing. For services covered by Medicare Part A or B not related to your terminal prognosis: If you need non-emergency, non- urgently needed services covered under Medicare Part A or B that aren't related to your terminal prognosis, your cost for these services depends on whether you use a provider in our plan's network and follow plan rules (like if there's a requirement to get prior authorization). • If you get the covered services from a network provider and follow plan rules for getting service, you pay only our plan cost-sharing amount for in-network services When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not Aspire Health Advantage (HMO).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 61 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Hospice care (continued) • If you get the covered services from an out-of-network provider, you pay the cost sharing under Original Medicare For services covered by Aspire Health Advantage (HMO) but not covered by Medicare Part A or B: Aspire Health Advantage (HMO) will continue to cover plan-covered services that aren't covered under Part A or B whether or not they're related to your terminal prognosis. You pay our plan cost- sharing amount for these services. For drugs that may be covered by our plan's Part D benefit: If these drugs are unrelated to your terminal hospice condition, you pay cost sharing. If they're related to your terminal hospice condition, you pay Original Medicare cost sharing. Drugs are never covered by both hospice and our plan at the same time. For more information, go to Chapter 5, Section 9.4. Note: If you need non-hospice care (care that's not related to your terminal prognosis), contact us to arrange the services. Immunizations Covered Medicare Part B services include: • Pneumonia vaccines • Flu/influenza shots (or vaccines), once each flu/influenza season in the fall and winter, with additional flu/influenza shots (or vaccines) if medically necessary • Hepatitis B vaccines if you're at high or intermediate risk of getting Hepatitis B • COVID-19 vaccines • Other vaccines if you're at risk and they meet Medicare Part B coverage rules We also cover most other adult vaccines under our Part D drug benefit. Go to Chapter 6, Section 7 for more information. There is no coinsurance, copayment, or deductible for the pneumonia, flu/influenza, Hepatitis B, and COVID-19 vaccines.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 62 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Inpatient hospital care Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you're formally admitted to the hospital with a doctor's order. The day before you're discharged is your last inpatient day. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Covered services include but aren't limited to: • Semi-private room (or a private room if medically necessary) • Meals including special diets • Regular nursing services • Costs of special care units (such as intensive care or coronary care units) • Drugs and medications • Lab tests • X-rays and other radiology services • Necessary surgical and medical supplies • Use of appliances, such as wheelchairs • Operating and recovery room costs • Physical, occupational, and speech language therapy • Inpatient substance use disorder services Prior authorization rules may apply For Medicare-covered inpatient hospital stays, you pay: $600 copay per day for days 1-2; $300 copay per day for days 3-4; $0 copay per day for days 5-90

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 63 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Inpatient hospital care (continued) • Under certain conditions, the following types of transplants are covered: corneal, kidney, kidney- pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and intestinal/multivisceral. If you need a transplant, we'll arrange to have your case reviewed by a Medicare-approved transplant center that will decide whether you're a candidate for a transplant. Transplant providers may be local or outside of the service area. If our in-network transplant services are outside the community pattern of care, you may choose to go locally as long as the local transplant providers are willing to accept the Original Medicare rate. If Aspire Health Advantage (HMO) provides transplant services at a location outside the pattern of care for transplants in your community and you choose to get transplants at this distant location, we'll arrange or pay for appropriate lodging and transportation costs for you and a companion. • Blood - including storage and administration. Coverage of whole blood and packed red cells starts only with the fourth pint of blood you need. You must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered starting with the first pint. • Physician services Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you're not sure if you're an inpatient or an outpatient, ask the hospital staff. Get more information in the Medicare fact sheet, Medicare Hospital Benefits. This fact sheet is available at www.Medicare.gov/publications/11435-Medicare-Hospital- Benefits.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. If you get inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the cost sharing you'd pay at a network hospital.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 64 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Inpatient services in a psychiatric hospital Covered services include mental health care services that require a hospital stay. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental health services provided in a general hospital. The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Prior authorization rules may apply For Medicare-covered inpatient mental health care stays, you pay: $275 copay per day for days 1-6; $0 copay per day for days 7-90

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 65 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Inpatient stay: Covered services you get in a hospital or SNF during a non-covered inpatient stay If you've used up your inpatient benefits or if the inpatient stay isn't reasonable and necessary, we won't cover your inpatient stay. In some cases, we'll cover certain services you get while you're in the hospital or the skilled nursing facility (SNF). Covered services include, but aren't limited to: • Physician services • Diagnostic tests (like lab tests) • X-ray, radium, and isotope therapy including technician materials and services • Surgical dressings • Splints, casts, and other devices used to reduce fractures and dislocations • Prosthetics and orthotics devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices • Leg, arm, back, and neck braces; trusses; and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient's physical condition • Physical therapy, speech therapy, and occupational therapy Prior authorization rules may apply Physician services See Physician/Practitioner Services, Including Doctor's Office Visits row. Diagnostic and radiological services, surgical dressings, and splints See Outpatient Diagnostic Tests and Therapeutic Services and Supplies row. Prosthetics, orthotics, and outpatient medical/ therapeutic supplies See Prosthetic and Orthotic Devices and Related Supplies row. Physical, speech, and occupational therapy services See Outpatient Rehabilitation Services row.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 66 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Medical nutrition therapy This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when ordered by your doctor. We cover 3 hours of one-on-one counseling services during the first year you get medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and 2 hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to get more hours of treatment with a physician's order. A physician must prescribe these services and renew their order yearly if your treatment is needed into the next calendar year. There is no coinsurance, copayment, or deductible for members eligible for Medicare-covered medical nutrition therapy services. Medicare Diabetes Prevention Program (MDPP) MDPP services are covered for eligible people under all Medicare health plans. MDPP is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. There is no coinsurance, copayment, or deductible for the MDPP benefit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 67 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Medicare Part B drugs These drugs are covered under Part B of Original Medicare. Members of our plan get coverage for these drugs through our plan. Covered drugs include: • Drugs that usually aren't self-administered by the patient and are injected or infused while you get physician, hospital outpatient, or ambulatory surgical center services • Insulin furnished through an item of durable medical equipment (such as a medically necessary insulin pump) • Other drugs you take using durable medical equipment (such as nebulizers) that were authorized by our plan • The Alzheimer's drug, Leqembi®, (generic name lecanemab), which is administered intravenously. In addition to medication costs, you may need additional scans and tests before and/or during treatment that could add to your overall costs. Talk to your doctor about what scans and tests you may need as part of your treatment. • Clotting factors you give yourself by injection if you have hemophilia Prior authorization and step therapy rules may apply For certain Part B drugs, you may be required to try a different drug first. $35 copay for Medicare Part B insulin drugs. Cost sharing for a one-month's supply is limited to $35. Service category and plan level deductibles don't apply. 20% coinsurance for Medicare Part B chemotherapy and radiation drugs. 20% coinsurance for other Medicare Part B drugs.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 68 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Medicare Part B drugs (continued) • Transplant/immunosuppressive drugs: Medicare covers transplant drug therapy if Medicare paid for your organ transplant. You must have Part A at the time of the covered transplant, and you must have Part B at the time you get immunosuppressive drugs. Medicare Part D drug coverage covers immunosuppressive drugs if Part B doesn't cover them • Injectable osteoporosis drugs, if you're homebound, have a bone fracture that a doctor certifies was related to post- menopausal osteoporosis, and can't self-administer the drug • Some antigens: Medicare covers antigens if a doctor prepares them and a properly instructed person (who could be you, the patient) gives them under appropriate supervision • Certain oral anti-cancer drugs: Medicare covers some oral cancer drugs you take by mouth if the same drug is available in injectable form or the drug is a prodrug (an oral form of a drug that, when ingested, breaks down into the same active ingredient found in the injectable drug) of the injectable drug. As new oral cancer drugs become available, Part B may cover them. If Part B doesn't cover them, Part D does • Oral anti-nausea drugs: Medicare covers oral anti-nausea drugs you use as part of an anti-cancer chemotherapeutic regimen if they're administered before, at, or within 48 hours of chemotherapy or are used as a full therapeutic replacement for an intravenous anti-nausea drug • Certain oral End-Stage Renal Disease (ESRD) drugs covered under Medicare Part B • Calcimimetic and phosphate binder medications under the ESRD payment system, including the intravenous medication Parsabiv® and the oral medication Sensipar® • Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, and topical anesthetics

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 69 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Medicare Part B drugs (continued) • Erythropoiesis-stimulating agents: Medicare covers erythropoietin by injection if you have End-Stage Renal Disease (ESRD) or you need this drug to treat anemia related to certain other conditions (such as Epogen®, Procrit®, Retacrit®, Epoetin Alfa, Aranesp®, Darbepoetin Alfa, Mircera®, or Methoxy polyethylene glycol-epoetin beta) • Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases • Parenteral and enteral nutrition (intravenous and tube feeding) This link will take you to a list of Part B drugs that may be subject to Step Therapy: www.aspirehealthplan.org/drug- coverage/. Note: Certain Part B drugs may be subject to step therapy requirements including those in the categories and/or to treat the conditions noted below: • Alpha-1 Antitrypsin Deficiency • Anemia, Intravenous Iron Replacement Therapy • Autoimmune Infused • Infliximab and Biosimilars • Rituximab and Biosimilars • Other • Bone Density Agents (Osteoporosis; Oncology) • Botulinum Toxins • Colony Stimulating Factors, Short-acting and Long-acting • Complement Inhibitors (including Hemolytic uremic syndrome; Myasthenia gravis; Paroxysmal nocturnal hemoglobinuria; Neuromyelitis optica spectrum disorder) • Enzyme Replacement Therapy • Gemcitabine • Hematologic, Erythropoiesis Stimulating Agents (ESA) • Hematologic, Neutropenia Colony Stimulating Factors Long Acting and Short-Acting • Hematopoietic Agents, Iron • Hemophilia A and Hemophilia B • Hereditary Transthyretin Amyloidosis

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 70 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Medicare Part B drugs (continued) • Gonadotropin-Releasing Hormone Agonists / Antagonists • Immune Globulins (IVIG, SCIG) • Infliximab and Biosimilars • Leucovorin/Levoleucovorin • Lysosomal Storage Disorders (Gaucher Disease) • Mitotic Inhibitors • Multiple Sclerosis (Infused) • Nebulizer Solutions (dispensed at a pharmacy) • Oncology, including: • Anti-Nausea Products, injectable: Specifically when used as part of a chemotherapy regimen • Antimetabolite (Pemetrexed) • Bendamustine Products • Bevacizumab and Biosimilars • Breast Cancer Monoclonal Antibodies • Immune Checkpoint Inhibitors • Mitotic Inhibitors • Multiple Myeloma • Prostate Cancer: Gonadotropin Releasing Hormone Analogs; Luteinizing Hormone Releasing Hormone (LHRH) Agents • Trastuzumab (intravenous) and Biosimilars • Osteoarthritis, including • Intra-Articular Corticosteroids (Osteoarthritis) • Viscosupplements (single injections, multiple injections) • Pulmonary Arterial Hypertension • Retinal Disorders: Intravitreal Vascular Endothelial Growth Factor (VEGF) Inhibitors • Systemic Lupus Erythematosus Agents • Severe Asthma • Sickle Cell Disease • Somatostatin Analogues We also cover some vaccines under Part B and most adult vaccines under our Part D drug benefit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 71 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Chapter 5 explains our Part D drug benefit, including rules you must follow to have prescriptions covered. What you pay for Part D drugs through our plan is explained in Chapter 6. Obesity screening and therapy to promote sustained weight loss If you have a body mass index of 30 or more, we cover intensive counseling to help you lose weight. This counseling is covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention plan. Talk to your primary care doctor or practitioner to find out more. There is no coinsurance, copayment, or deductible for preventive obesity screening and therapy. Opioid treatment program services Members of our plan with opioid use disorder (OUD) can get coverage of services to treat OUD through an Opioid Treatment Program (OTP) which includes the following services: • U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications • Dispensing and administration of MAT medications (if applicable) • Substance use disorder counseling • Individual and group therapy • Toxicology testing • Intake activities • Periodic assessments Prior authorization and step therapy rules may apply Cost sharing for this service will vary depending on individual services provided under the course of treatment.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 72 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Outpatient diagnostic tests and therapeutic services and supplies Covered services include, but aren't limited to: • X-rays • Radiation (radium and isotope) therapy including technician materials and supplies • Surgical supplies, such as dressings • Splints, casts and other devices used to reduce fractures and dislocations • Laboratory tests • Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used. Prior authorization rules may apply Outpatient X-rays $10 copay for Medicare- covered services. Therapeutic radiology services 20% coinsurance for Medicare-covered services (such as radiation treatment for cancer). Medical supplies 20% coinsurance for Medicare-covered supplies. Lab services $10 copay for Medicare- covered services. Blood services 20% coinsurance for Medicare-covered services. Outpatient diagnostic tests and therapeutic services and supplies (continued) • Diagnostic non-laboratory tests such as CT scans, MRIs, EKGs, and PET scans when your doctor or other health care provider orders them to treat a medical problem. • Other outpatient diagnostic tests Diagnostic tests and procedures $10 copay for Medicare- covered services. Diagnostic radiology services $60 to $150 copay for Medicare-covered services (such as MRIs and CT scans).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 73 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Outpatient hospital observation Observation services are hospital outpatient services given to determine if you need to be admitted as an inpatient or can be discharged. For outpatient hospital observation services to be covered, they must meet Medicare criteria and be considered reasonable and necessary. Observation services are covered only when provided by the order of a physician or another person authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order outpatient tests. Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you're an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you aren't sure if you're an outpatient, ask the hospital staff. Get more information in the Medicare fact sheet, Medicare Hospital Benefits. This fact sheet is available at www.Medicare.gov/publications/11435-Medicare-Hospital- Benefits.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. $275 copay per day for Medicare-covered outpatient hospital observation services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 74 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Outpatient hospital services We cover medically necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include, but aren't limited to: • Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery • Laboratory and diagnostic tests billed by the hospital • Mental health care, including care in a partial- hospitalization program, if a doctor certifies that inpatient treatment would be required without it • X-rays and other radiology services billed by the hospital • Medical supplies such as splints and casts • Certain drugs and biologicals you can't give yourself Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you're an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you aren't sure if you're an outpatient, ask the hospital staff. Prior authorization rules may apply Emergency services See Emergency Care row. Outpatient surgery See Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers and Outpatient Hospital Observation rows. Laboratory and diagnostic tests, X-rays, radiological services, and medical supplies See Outpatient Diagnostic Tests and Therapeutic Services and Supplies row. Mental health care and partial hospitalization See Outpatient Mental Health Care and Partial Hospitalization Services and Intensive Outpatient Services rows. Drugs and biologicals that you can't give yourself See Medicare Part B Drugs row.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 75 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Outpatient mental health care Covered services include: Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, licensed professional counselor (LPC), licensed marriage and family therapist (LMFT), nurse practitioner (NP), physician assistant (PA), or other Medicare-qualified mental health care professional as allowed under applicable state laws. Prior authorization rules may apply $15 copay for each Medicare-covered individual therapy visit with a psychiatrist. $15 copay for each Medicare-covered group therapy visit with a psychiatrist. $15 copay for each Medicare-covered individual therapy visit with a mental health care professional (non- psychiatrist). $15 copay for each Medicare-covered group therapy visit with a mental health care professional (non- psychiatrist). Outpatient rehabilitation services Covered services include physical therapy, occupational therapy, and speech language therapy. Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs). Prior authorization rules may apply $15 copay for each Medicare-covered occupational therapy visit. $15 copay for each Medicare-covered physical and/or speech therapy visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 76 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Outpatient substance use disorder services Covered services may include treatment for crisis intervention, short term evaluation and substance abuse rehabilitation. Visits may include mental health consultations, medication management, and psychological testing. $15 copay for each Medicare-covered individual therapy visit. $15 copay for each Medicare-covered group therapy visit. Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers Note: If you're having surgery in a hospital facility, you should check with your provider about whether you'll be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you're an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. Prior authorization rules may apply A $60 copay applies only for Medicare-covered wound care, diagnostic colonoscopy, and endoscopy surgical procedures. A $275 copay applies to other Medicare-covered outpatient surgical procedures.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 77 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Partial hospitalization services and intensive outpatient services Partial hospitalization is a structured program of active psychiatric treatment provided as a hospital outpatient service or by a community mental health center, that's more intense than care you get in your doctor's, therapist's, licensed marriage and family therapist's (LMFT), or licensed professional counselor's office and is an alternative to inpatient hospitalization. Intensive outpatient service is a structured program of active behavioral (mental) health therapy treatment provided in a hospital outpatient department, a community mental health center, a federally qualified health center, or a rural health clinic that's more intense than care you get in your doctor's, therapist's, licensed marriage and family therapist's (LMFT), or licensed professional counselor's office but less intense than partial hospitalization. Note: Because there are no community mental health centers in our network, we cover partial hospitalization only as a hospital outpatient service. Prior authorization rules may apply $30 copay per day for Medicare-covered partial hospitalization services. $30 copay for Medicare- covered intensive outpatient program services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 78 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Physician/Practitioner services, including doctor's office visits Covered services include: • Medically necessary medical care or surgery services you get in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location • Consultation, diagnosis, and treatment by a specialist • Basic hearing and balance exams performed by your specialist, if your doctor orders it to see if you need medical treatment • Some telehealth services including consultation, diagnosis, and treatment by a physician or practitioner, for patients in certain rural areas or other places approved by Medicare Prior authorization rules may apply $0 copay for each Medicare-covered primary care visit. $25 copay for each Medicare-covered specialist visit. For each Medicare- covered visit with other health care professionals (such as nurse practitioners and physician assistants), you pay $0 to $25 copay. For additional telehealth benefits, you pay $0 copay.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 79 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Physician/Practitioner services, including doctor's office visits (continued) • Telehealth services for monthly end-stage renal disease- related visits for home dialysis members in a hospital- based or critical access hospital-based renal dialysis center, renal dialysis facility, or the member's home • Telehealth services to diagnose, evaluate, or treat symptoms of a stroke, regardless of your location • Telehealth services for members with a substance use disorder or co-occurring mental health disorder, regardless of their location • Telehealth services for diagnosis, evaluation, and treatment of mental health disorders if: • You have an in-person visit within 6 months prior to your first telehealth visit • You have an in-person visit every 12 months while getting these telehealth services • Exceptions can be made to the above for certain circumstances • Telehealth services for mental health visits provided by Rural Health Clinics and Federally Qualified Health Centers • Virtual check-ins (for example, by phone or video chat) with your doctor for 5-10 minutes if: • You're not a new patient and • The check-in isn't related to an office visit in the past 7 days and • The check-in doesn't lead to an office visit within 24 hours or the soonest available appointment • Evaluation of video and/or images you send to your doctor, and interpretation and follow-up by your doctor within 24 hours if: • You're not a new patient and • The evaluation isn't related to an office visit in the past 7 days and • The evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment • Consultation your doctor has with other doctors by phone, internet, or electronic health record

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 80 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Physician/Practitioner services, including doctor's office visits (continued) • Second opinion by another network provider prior to surgery • Remote patient monitoring through various digital devices, such as wearable sensors, to collect patient physiological metrics, such as oxygen saturation, blood pressure, blood sugar, or blood oxygen levels. Podiatry services Covered services include: • Diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs) • Routine foot care for members with certain medical conditions affecting the lower limbs $25 copay for each Medicare-covered podiatry services visit. Pre-exposure prophylaxis (PrEP) for HIV prevention If you don't have HIV, but your doctor or other health care practitioner determines you're at an increased risk for HIV, we cover pre-exposure prophylaxis (PrEP) medication and related services. If you qualify, covered services include: • FDA-approved oral or injectable PrEP medication. If you're getting an injectable drug, we also cover the fee for injecting the drug. • Up to 8 individual counseling sessions (including HIV risk assessment, HIV risk reduction, and medication adherence) every 12 months. • Up to 8 HIV screenings every 12 months. • A one-time hepatitis B virus screening. There is no coinsurance, copayment, or deductible for the PrEP benefit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 81 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Prostate cancer screening exams For men aged 50 and older, covered services include the following once every 12 months: • Digital rectal exam • Prostate Specific Antigen (PSA) test There is no coinsurance, copayment, or deductible for an annual PSA test. $0 copay for an annual Medicare-covered digital rectal exam. Prosthetic and orthotic devices and related supplies Devices (other than dental) that replace all or part of a body part or function. These include but aren't limited to testing, fitting, or training in the use of prosthetic and orthotic devices; as well as colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic and orthotic devices, and repair and/or replacement of prosthetic and orthotic devices. Also includes some coverage following cataract removal or cataract surgery - go to Vision Care later in this table for more detail. Prior authorization required for Prosthetics/Medical supplies that cost over $500. 20% coinsurance for Medicare-covered prosthetic and orthotic devices. 20% coinsurance for Medicare-covered medical supplies related to prosthetic and orthotic devices. Pulmonary rehabilitation services Comprehensive programs of pulmonary rehabilitation are covered for members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and an order for pulmonary rehabilitation from the doctor treating the chronic respiratory disease. Prior authorization rules may apply $15 copay for each Medicare-covered pulmonary rehabilitation services visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 82 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults (including pregnant women) who misuse alcohol but aren't alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face-to-face counseling sessions per year (if you're competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare-covered screening and counseling to reduce alcohol misuse preventive benefit. Screening for Hepatitis C Virus infection We cover one Hepatitis C screening if your primary care doctor or other qualified health care provider orders one and you meet one of these conditions: • You're at high risk because you use or have used illicit injection drugs. • You had a blood transfusion before 1992. • You were born between 1945-1965. If you were born between 1945-1965 and aren't considered high risk, we pay for a screening once. If you're at high risk (for example, you've continued to use illicit injection drugs since your previous negative Hepatitis C screening test), we cover yearly screenings. There is no coinsurance, copayment, or deductible for the Medicare-covered screening for the Hepatitis C Virus.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 83 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Screening for lung cancer with low dose computed tomography (LDCT) For qualified people, an LDCT is covered every 12 months. Eligible members are: people age 50 - 77 who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack-years and who currently smoke or have quit smoking within the last 15 years, who get an order for LDCT during a lung cancer screening counseling and shared decision-making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non-physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the members must get an order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non-physician practitioner. If a physician or qualified non-physician practitioner elects to provide a lung cancer screening counseling and shared decision-making visit for later lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare-covered counseling and shared decision-making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face-to-face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor's office. There is no coinsurance, copayment, or deductible for the Medicare-covered screening for STIs and counseling for STIs preventive benefit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 84 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to 6 sessions of kidney disease education services per lifetime. • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you're admitted as an inpatient to a hospital for special care) • Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under Medicare Part B. For information about coverage for Part B Drugs, go to Medicare Part B drugs in this table. Prior authorization rules may apply $0 copay for Medicare- covered kidney disease education services. 20% coinsurance for Medicare-covered dialysis services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 85 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Skilled nursing facility (SNF) care (For a definition of skilled nursing facility care, go to Chapter 12 of this document. Skilled nursing facilities are sometimes called SNFs.) You are covered for 100 days per benefit period for Medicare- covered SNF stays. Covered services include but aren't limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (this includes substances that are naturally present in the body, such as blood clotting factors.) • Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply Inpatient hospital stay is not required prior to admission. For Medicare-covered SNF stays, you pay: $0 copay per day for days 1-20; $100 copay per day for days 21-100

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 86 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Skilled nursing facility (SNF) care (continued) Generally, you get SNF care from network facilities. Under certain conditions listed below, you may be able to pay in- network cost sharing for a facility that isn't a network provider, if the facility accepts our plan's amounts for payment. • A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care) • A SNF where your spouse or domestic partner is living at the time you leave the hospital Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) Smoking and tobacco use cessation counseling is covered for outpatient and hospitalized patients who meet these criteria: • Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease • Are competent and alert during counseling • A qualified physician or other Medicare-recognized practitioner provides counseling We cover 2 cessation attempts per year (each attempt may include a maximum of 4 intermediate or intensive sessions, with the patient getting up to 8 sessions per year.) There is no coinsurance, copayment, or deductible for the Medicare-covered smoking and tobacco use cessation preventive benefits.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 87 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12-week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician's office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare-covered SET visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 88 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Transportation services (routine) Benefit includes: • 12 one-way trips every year to plan-approved health- related locations. Please note: The primary purpose of the transportation benefit is to provide non-emergency transportation to routine, medically necessary services. One companion is allowed per trip (companion must be at least 18 years old). Transportation reservations are based on driver availability and may be limited in some areas of the county. Rides must be requested at least 72 business hours in advance. Transportation Benefit Exclusions: Rides to out-of-network providers. Rides to non-medical destinations such as grocery stores, pharmacies or senior centers. Rides to the emergency department of any hospital. Drivers do not have medical training. In case of emergency, call 911. Prior authorization rules may apply $0 copay for routine transportation services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 89 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Urgently needed services A plan-covered service requiring immediate medical attention that's not an emergency is an urgently needed service if either you're temporarily outside our plan's service area, or, even if you're inside our plan's service area, it's unreasonable given your time, place, and circumstances to get this service from network providers. Our plan must cover urgently needed services and only charge you in-network cost sharing. Examples of urgently needed services are unforeseen medical illnesses and injuries, or unexpected flare-ups of existing conditions. Medically necessary routine provider visits (like annual checkups) aren't considered urgently needed even if you're outside our plan's service area or our plan network is temporarily unavailable. Not covered outside the U.S. and its territories. Our plan may cover medically necessary urgently needed services you get on a cruise ship in these situations: • The doctor is allowed under certain laws to provide medical services on the cruise ship. • The ship is in a U.S. port or no more than 6 hours away from a U.S. port when you get the services, regardless of whether it's an emergency. Our plan doesn't cover urgently needed services you get when the ship is more than 6 hours away from a U.S. port. $0 copay for each Medicare-covered visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 90 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Covered Service What you pay Vision care Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk for glaucoma, we cover one glaucoma screening each year. People at high risk of glaucoma include people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. If you have 2 separate cataract operations, you can't reserve the benefit after the first surgery and purchase 2 eyeglasses after the second surgery. Prior authorization rules may apply $25 copay for each eye exam to diagnose and treat diseases and conditions of the eye. $0 copay for an annual glaucoma screening. $0 copay for one pair of eyeglasses or contact lenses after cataract surgery. Welcome to Medicare preventive visit Our plan covers the one-time Welcome to Medicare preventive visit. The visit includes a review of your health, as well as education and counseling about preventive services you need (including certain screenings and shots (or vaccines)), and referrals for other care if needed. Important: We cover the Welcome to Medicare preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor's office know you want to schedule your Welcome to Medicare preventive visit. There is no coinsurance, copayment, or deductible for the Welcome to Medicare preventive visit.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 91 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Section 2.1 Extra optional supplemental benefits you can buy Our plan offers some extra benefits that aren't covered by Original Medicare and not included in your benefits package. These extra benefits are called Optional Supplemental Benefits. If you want these optional supplemental benefits, you must sign up for them and you may have to pay an additional premium for them. The optional supplemental benefits described in this section are subject to the same appeals process as any other benefits.

1. Application Process, Effective Date, Premiums • At the time of enrollment you have the option to add the Enhanced Benefits - Option C to the plan you are enrolling in. By selecting the Enhanced Benefits - Option C, you will be responsible for paying an additional $43.00 per month. This is in addition to your monthly Aspire Health Advantage (HMO) plan premium. • You will have a ninety (90) day grace period from your MAPD enrollment effective date to add the Enhanced Benefits. After the grace period ends, you may not elect the Enhanced Benefits until the next annual enrollment period. • After initial enrollment and grace period, you will be allowed to add the Enhanced Benefits during the next annual enrollment period.
2. Disenrollment Process • You will be allowed to drop the Enhanced Benefits at any time during the year by sending a written request to the plan requesting disenrollment from the Enhanced Benefits. The request for disenrollment from the Enhanced Benefits will be effective on the first day of the month following the month in which the request to disenroll from the optional benefits was received. • An enrollee who drops the Enhanced Benefits need not pay further monthly premiums for the Enhanced Benefits. Furthermore, if s/he paid a complete annual premium for the Enhanced Benefits, s/he is entitled to a pro-rated refund of applied premium for the remaining portion of the year.
3. Failure to pay premium • If you fail to pay your Enhanced Benefits premium for a continuous 90 days after we first notify you that your supplemental premiums are overdue, we will downgrade your coverage to the Aspire Health Advantage (HMO) plan only and you will no longer have the Enhanced Benefits included in your plan coverage.
4. Amounts you pay for Enhanced Benefit copayments • Amounts you pay for Enhanced Benefit copayments do not count toward your maximum out-of-pocket amount. These services are marked with an asterisk (*) in the chart below.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 92 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Optional Benefits (you must pay an extra premium each month for these benefits) Enhanced Benefits - Option C What you pay This optional supplemental benefit includes comprehensive dental coverage, an eyewear benefit, a routine hearing exam, a hearing aid benefit, 10 additional one-way rides to in-network appointments, and 14 meals following each inpatient hospital or skilled nursing facility stay or for certain chronic conditions for a temporary period and is available for an additional monthly premium. You pay an additional $43.00 per month. You must keep paying your Medicare Part B premium and your
monthly plan premium. This optional supplemental benefit does not have a deductible. Dental benefits^: Comprehensive dental services: • Basic restorative • Oral surgery • Simple extractions • Endodontics • Surgical periodontics • Non-surgical periodontics • Major restorative • Prosthodontics - Fixed and removal • Denture repair and relining • Implants A comprehensive listing of covered codes, standard limitations and exclusions can be found in Chapter 4, Section 2.2, following this chart. Non-listed procedures are not covered. If elected, member is responsible for all non-covered procedures. ^Dental Benefits are limited to the Delta Dental Medicare Advantage Network for Aspire Health Plan. Basic restorative, simple extractions, and denture repair and relining are covered with a 20% coinsurance when rendered by in-network participating providers. Oral surgery, endodontics, surgical periodontics, non-surgical periodontics, major restorative, prosthodontics - fixed and removable, and implants are covered with a 50% coinsurance when rendered by in-network participating providers. Plan pays up to a maximum $1,000 in dental benefits each year.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 93 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Optional Benefits (you must pay an extra premium each month for these benefits) Enhanced Benefits - Option C What you pay Eyewear benefits^: In-network routine vision services are available from Vision Services Plan (VSP) Advantage network providers. Routine Eye Exam • One non-Medicare-covered routine eye exam, including refraction, per calendar year Routine Vision Hardware • Routine vision hardware is covered as outlined below every calendar year Lenses include: • Prescription basic single vision, lined bifocal, lined trifocal, and lenticular lenses • Standard progressive lenses are covered. • Additional upgrades are not covered. Frames: • $150.00 allowance Contact lenses (in lieu of lenses & frames) include: • $150 allowance for prescription contact lens material and exam services (fitting & evaluation) Your out-of-pocket costs for routine vision services do not count toward your plan maximum out-of- pocket amount. ^Eyewear Benefits are limited to Vision Services Plan (VSP) Advantage network providers. A comprehensive listing of standard limitations and exclusions can be found in Chapter 4, Section 2.2, following this chart. Non-listed services are not covered. If elected, member is responsible for all non-covered services. You pay one $10 copay for each routine eye exam. You pay one $25 copay for eyewear materials: (frames, lenses, or contacts).* In lieu of eyeglasses (lenses and frame), visually necessary contact lenses are covered in full for certain medical conditions after the $25 copayment for eyewear materials.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 94 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Optional Benefits (you must pay an extra premium each month for these benefits) Enhanced Benefits - Option C What you pay Hearing Exam: 1 routine hearing exam per year You pay a $20 copay for exam. Hearing Aids: Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearing's Advanced ($599 copay) and Premium ($899 copay) hearing aids, which come in various styles and colors and are available in rechargeable style options. You must see a TruHearing provider to use this benefit. Call 1-844-208-2631 to schedule an appointment (for TTY, dial 711). Hearing aid purchase includes: • First year of follow-up provider visits • 60-day trial period • 3-year extended warranty • 80 batteries per aid for non-rechargeable models Benefit does not include or cover any of the following: • Ear molds • Hearing aid accessories • Additional provider visits • Additional batteries, batteries when a rechargeable hearing aid is purchased • Hearing aids that are not TruHearing-branded hearing aids • Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan. You pay a $599 copay for each Advanced hearing aid. You pay a $899 copay for each Premium hearing aid.* Routine hearing exam and hearing aid copayments are not subject to the out-of-pocket maximum.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 95 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Optional Benefits (you must pay an extra premium each month for these benefits) Enhanced Benefits - Option C What you pay Routine transportation services benefit: Up to ten (10) additional one-way trips per calendar year to plan-approved health related locations. Please note: The primary purpose of the transportation benefit is to provide non-emergency transportation to routine, medically necessary services. One companion is allowed per trip (companion must be at least 18 years old).Transportation reservations are based on driver availability and may be limited in some areas of the county. Rides must be requested at least 72 business hours in advance. Transportation Benefit Exclusions: Rides to out-of- network providers. Rides to non-medical destinations such as grocery stores, pharmacies or senior centers. Rides to the emergency department of any hospital. Drivers do not have medical training. In case of emergency, call 911. You pay a $0 copayment for routine transportation. Prior authorization rules apply Contact Member Services for more details about how to use this service.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 96 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Optional Benefits (you must pay an extra premium each month for these benefits) Enhanced Benefits - Option C What you pay Meal benefit^: Following discharge from an acute care admission, the Plan will arrange and provide 14 refrigerated meals, 2 meals per day for 7 days, customized to the member's preference. Please note: Meal benefit must be requested within 14 days of an inpatient hospital or skilled nursing facility stay. To arrange refrigerated home- delivered meals, please contact the plan. Meal benefit is also available for individuals that have a chronic condition, including but not limited to cardiovascular disorders, COPD or diabetes, for a temporary period, typically two weeks, per year, when ordered by a physician or non-physician practitioner and are part of a supervised program. You pay a $0 copayment for the meal benefit. Prior authorization rules apply Contact Member Services for more details about how to use this service. Limitations and Exclusions for Eyewear Benefits (included in Option C of the optional Enhanced Benefit package) Limitations on Eyewear Benefits

1. Contact lenses, except as specifically covered;
2. Contact lens fitting, except as specifically covered;
3. Rigid gas permeable scleral and hybrid contact lenses may be partially covered up to the maximum medically necessary contact lens allowance of $350 for patients who meet the Non-Elective Contact Lens Criteria and when other contact lens approaches have been demonstrated to be unsuccessful. Any additional costs are a patient responsibility. Ocular surface diseases and treatment of underlying ocular pathologies are generally covered under the patient's medical plan;
4. If the patient meets the medically necessary criteria through the pre-approval process and the patient opts for daily disposable lenses, multi-focal lenses, or other specialty contact lenses, the patient will be responsible for the balance of the provider's charge exceeding the benefit allowance of $350;
5. Eyewear when there is no prescription change, except when benefits are otherwise available;

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 97 Chapter 4 Medical Benefits Chart (what's covered and what you pay)

6. Charges for non-standard lenses or lens options including, but not limited to, Polycarbonate, Premium Progressive Lenses, Photochromic Lenses, polarized lenses, hi-index, occupational lenses, beveled, faceted, coated (i.e., anti-reflective, scratch, mirrored, and UV), oversized exceeding the Schedule of Allowances; or other custom lens options will only be covered to the extent there is a dollar value on the schedule and the Plan will only pay up to the amount listed. Any amount for these items above that limit shall be the responsibility of the Member;
7. Tints, except as specifically covered;
8. Two pair of glasses in lieu of bifocals;
9. Non-prescription (Plano) eyewear, except when specifically covered; and
10. Subnormal/low vision testing and low vision aids, except when specifically covered. Exclusions on Eyewear Benefits
11. Any eye examination required by the employer as a condition of employment;
12. Conditions covered by Workers' Compensation;
13. Contact lens insurance or care kits; or frame cases;
14. Covered Services which began prior to the Member's effective date or after benefits have been terminated;
15. Charges for which the Member is not legally obligated to pay;
16. Orthoptics, vision training;
17. Services that are Experimental or Investigational in nature;
18. In connection with war or any act of war, whether declared or undeclared, a condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries;
19. Services or expenses that are not included in the Schedule of Allowances;
20. Any charges billed by the Provider for placing new lenses in the patient's own frame;
21. Medical or Surgical treatment of the eyes, including treatment of any suspected pathology or injury that may be uncovered during the course of a covered vision examination and that may be payable under the medical benefits of the Member's health plan. In the event that the eye care provider determines that additional diagnostic procedures or treatment plans are indicated to confirm the suspected pathology or injury, the Member will need to obtain care under her/his medical benefit;
22. Any Covered Services provided by another vision plan; except benefits payable under Coordination of Benefits;

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 98 Chapter 4 Medical Benefits Chart (what's covered and what you pay)

13. Replacement of lenses or frames which are lost, stolen or broken, except when benefits are otherwise available; and
14. Services for treatment directly related to any totally disabling condition, illness or injury. Enhanced Benefits (Option C) - Delta Dental Benefit Overview $1,000 Calendar Year Maximum The following is a complete list of dental procedures for which benefits are payable under the optional supplemental Enhanced Benefit for the Option C package. Non-listed procedures are not covered. This plan does not allow alternate benefits. If elected, Member is responsible for all non-covered procedures. Code Description Benefit Category Member Coinsurance D2140 Amalgam - one surface, primary or permanent Basic 20% D2150 amalgam - two surfaces, primary or permanent Basic 20% D2160 amalgam - three surfaces, primary or permanent Basic 20% D2161 amalgam - four or more surfaces, primary or permanent Basic 20% D2330 resin-based composite - one surface, anterior Basic 20% D2331 resin-based composite - two surfaces, anterior Basic 20% D2332 resin-based composite - three surfaces, anterior Basic 20% D2335 resin-based composite - four or more surfaces (anterior) Basic 20% D2390 resin-based composite crown, anterior Basic 20% D2391 resin-based composite - one surface, posterior Basic 20% D2392 resin-based composite - two surfaces, posterior Basic 20% D2393 resin-based composite - three surfaces, posterior Basic 20%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 99 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D2394 resin-based composite - four or more surfaces, posterior Basic 20% D2910 recement or re-bond inlay, onlay, veneer or partial coverage restorations Basic 20% D2915 recement or re-bond indirectly fabricated or prefabricated post and core Basic 20% D2920 recement or re-bond crown Basic 20% D2921 reattachment of tooth fragment, incisal edge or cusp Basic 20% D2940 placement of interim direct restoration Basic 20% D2951 pin retention - per tooth, in addition to restoration Basic 20% D2971 additional procedures to construct new crown under existing partial denture framework Basic 20% D2976 band stabilization - per tooth Basic 20% D5511 repair broken complete denture base, mandibular Basic 20% D5512 repair broken complete denture base, maxillary Basic 20% D5520 replace missing or broken teeth - complete denture - per tooth Basic 20% D5611 repair resin partial denture base, mandibular Basic 20% D5612 repair resin partial denture base, maxillary Basic 20% D5621 repair cast partial framework, mandibular Basic 20% D5622 repair cast partial framework, maxillary Basic 20% D5630 repair or replace broken clasp - per tooth Basic 20% D5640 replace missing or broken teeth - partial denture - per tooth Basic 20% D5650 add tooth to existing partial denture - per tooth Basic 20% D5660 add clasp to existing partial denture - per tooth Basic 20% D5670 replace all teeth and acrylic on cast metal framework (maxillary) Basic 20% D5671 replace all teeth and acrylic on cast metal framework (mandibular) Basic 20% D5710 rebase complete maxillary denture Basic 20%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 100 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D5711 rebase complete mandibular denture Basic 20% D5720 rebase maxillary partial denture Basic 20% D5721 rebase mandibular partial denture Basic 20% D5730 reline complete maxillary denture (chairside) Basic 20% D5731 reline complete mandibular denture (chairside) Basic 20% D5740 reline maxillary partial denture (chairside) Basic 20% D5741 reline mandibular partial denture (chairside) Basic 20% D5750 reline complete maxillary denture (laboratory) Basic 20% D5751 reline complete mandibular denture (laboratory) Basic 20% D5760 reline maxillary partial denture (laboratory) Basic 20% D5761 reline mandibular partial denture (laboratory) Basic 20% D6081 scaling and debridement of a single implant in the presence of mucositis, including inflammation, bleeding upon probing and increased pocket depths; includes cleaning of the implant surfaces, without flap entry and closure Basic 20% D6105 removal of implant body not requiring bone removal or flap elevation Basic 20% D6197 replacement of restorative material used to close an access opening of a screw- retained implant supported prosthesis, per implant Basic 20% D7111 extraction, coronal remnants - primary tooth Basic 20% D7140 extraction, erupted tooth or exposed root (elevation and/ or forceps removal) Basic 20% D9110 palliative treatment of dental pain - per visit Basic 20% D9120 fixed partial denture sectioning Basic 20% D9222 deep sedation/general anesthesia - first 15 minutes Basic 20%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 101 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D9223 deep sedation/general anesthesia - each subsequent 15 minute increment Basic 20% D9239 intravenous moderate (conscious) sedation/analgesia - first 15 minutes Basic 20% D9243 intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment Basic 20% D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Basic 20% D9999 unspecified adjunctive procedure, by report Basic 20% D2510 inlay - metallic - one surface Major 50% D2520 inlay - metallic - two surfaces Major 50% D2530 inlay - metallic - three or more surfaces Major 50% D2542 onlay - metallic - two surfaces Major 50% D2543 onlay - metallic - three surfaces Major 50% D2544 onlay - metallic - four or more surfaces Major 50% D2610 inlay - porcelain/ceramic - one surface Major 50% D2620 inlay - porcelain/ceramic - two surfaces Major 50% D2630 inlay - porcelain/ceramic - three or more surfaces Major 50% D2642 onlay - porcelain/ceramic - two surfaces Major 50% D2643 onlay - porcelain/ceramic - three surfaces Major 50% D2644 onlay - porcelain/ceramic - four or more surfaces Major 50% D2650 inlay - resin-based composite - one surface Major 50% D2651 inlay - resin-based composite - two surfaces Major 50% D2652 inlay - resin -based composite - three or more surfaces Major 50% D2662 onlay - resin -based composite - two surfaces Major 50% D2663 onlay - resin -based composite - three surfaces Major 50% D2664 onlay - resin -based composite - four or more surfaces Major 50% D2710 crown - resin -based composite (indirect) Major 50% D2712 crown - ¾ resin-based composite (indirect) Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 102 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D2720 crown - resin with high noble metal Major 50% D2721 crown - resin with predominantly base metal Major 50% D2722 crown - resin with noble metal Major 50% D2740 crown - porcelain/ceramic Major 50% D2750 crown - porcelain fused to high noble metal Major 50% D2751 crown - porcelain fused to predominantly base metal Major 50% D2752 crown - porcelain fused to noble metal Major 50% D2780 crown - 3/4 cast high noble metal Major 50% D2781 crown - 3/4 cast predominantly base metal Major 50% D2782 crown - 3/4 cast noble metal Major 50% D2784 excisional biopsy of minor salivary glands Major 50% D2783 crown - 3/4 porcelain/ceramic Major 50% D2790 crown - full cast high noble metal Major 50% D2791 crown - full cast predominantly base metal Major 50% D2792 crown - full cast noble metal Major 50% D2794 crown - titanium Major 50% D2950 core buildup, including any pins when required Major 50% D2952 post and core in addition to crown, indirectly fabricated Major 50% D2954 prefabricated post and core in addition to crown Major 50% D2956 removal of an indirect restoration on a natural tooth Major 50% D2980 crown repair necessitated by restorative material failure Major 50% D2981 inlay repair necessitated by restorative material failure Major 50% D2982 onlay repair necessitated by restorative material failure Major 50% D2999 unspecified restorative procedure, by report Major 50% D3110 pulp cap - direct (excluding final restoration) Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 103 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp corona to the dentinocemental junction and application of medicament Major 50% D3221 pulpal debridement, primary and permanent teeth Major 50% D3222 partial pulpotomy for apexogenesis - permanent tooth with incomplete root development Major 50% D3230 pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Major 50% D3240 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Major 50% D3310 endodontic therapy, anterior tooth (excluding final restoration) Major 50% D3320 endodontic therapy, premolar tooth (excluding final restoration) Major 50% D3330 endodontic therapy, molar tooth (excluding final restoration) Major 50% D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Major 50% D3333 internal root repair of perforation defects Major 50% D3346 retreatment of previous root canal therapy

• anterior Major 50% D3347 retreatment of previous root canal therapy
• premolar Major 50% D3348 retreatment of previous root canal therapy
• molar Major 50% D3410 apicoectomy- anterior Major 50% D3421 apicoectomy - premolar (first root) Major 50% D3425 apicoectomy - molar (first root) Major 50% D3426 apicoectomy (each additional root) Major 50% D3427 periradicular surgery without apicoectomy Major 50% D3430 retrograde filling - per root Major 50% D3450 root amputation - per root Major 50% D3920 hemisection (including any root removal), not including root canal therapy Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 104 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D3999 unspecified endodontic procedure, by report Major 50% D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant Major 50% D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Major 50% D4212 gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Major 50% D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant Major 50% D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant Major 50% D4245 apically positioned flap Major 50% D4249 clinical crown lengthening - hard tissue Major 50% D4260 osseous surgery (including elevation of a full thickness flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant Major 50% D4261 osseous surgery (including elevation of a full thickness flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant Major 50% D4263 bone replacement graft - retained natural tooth - first site in quadrant Major 50% D4264 bone replacement graft - retained natural tooth - each additional site in quadrant Major 50% D4265 biologic materials to aid in soft and osseous tissue regeneration Major 50% D4266 guided tissue regeneration, natural teeth - resorbable barrier, per site Major 50% D4267 guided tissue regeneration, natural teeth - non-resorbable barrier, per site Major 50% D4268 surgical revision procedure, per tooth Major 50% D4270 pedicle soft tissue graft procedure Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 105 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D4273 autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft Major 50% D4274 mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) Major 50% D4275 non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft Major 50% D4276 combined connective tissue and double pedicle graft, per tooth Major 50% D4277 free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft Major 50% D4278 free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site Major 50% D4283 autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position in same graft site Major 50% D4285 non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) - each additional contiguous tooth, implant or edentulous tooth position in same graft site Major 50% D4286 removal of non-resorbable barrier Major 50% D4341 periodontal scaling and root planing - four or more teeth per quadrant Major 50% D4342 periodontal scaling and root planing - one to three teeth per quadrant Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 106 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D4355 full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit Major 50% D4910 periodontal maintenance Major 50% D4999 unspecified periodontal procedure, by report Major 50% D5110 complete denture - maxillary Major 50% D5120 complete denture - mandibular Major 50% D5130 immediate denture - maxillary Major 50% D5140 immediate denture - mandibular Major 50% D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) Major 50% D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) Major 50% D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Major 50% D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Major 50% D5221 immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth) Major 50% D5222 Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth) Major 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Major 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 107 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) Major 50% D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) Major 50% D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) Major 50% D5410 Adjust complete denture - maxillary Major 50% D5411 Adjust complete denture - mandibular Major 50% D5421 Adjust partial denture - maxillary Major 50% D5422 Adjust partial denture - mandibular Major 50% D5820 Interim partial denture - maxillary Major 50% D5821 Interim partial denture - mandibular Major 50% D5850 Tissue conditioning - maxillary Major 50% D5851 Tissue conditioning - mandibular Major 50% D5899 unspecified removable prosthodontic procedure, by report Major 50% D6010 surgical placement of implant body: endosteal implant Major 50% D6013 surgical placement of mini implant Major 50% D6040 surgical placement: eposteal implant Major 50% D6050 surgical placement: transosteal implant Major 50% D6055 connecting bar - implant supported or abutment supported Major 50% D6056 prefabricated abutment - includes modification and placement Major 50% D6057 custom fabricated abutment - includes placement Major 50% D6058 abutment supported porcelain/ceramic crown Major 50% D6059 Abutment supported porcelain fused to metal crown (high noble metal) Major 50% D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) Major 50% D6061 Abutment supported porcelain fused to metal crown (noble metal) Major 50% D6062 Abutment supported cast metal crown (high noble metal) Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 108 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D6063 Abutment supported cast metal crown (predominantly base metal) Major 50% D6064 Abutment supported cast metal crown (noble metal) Major 50% D6065 Implant supported porcelain / ceramic crown Major 50% D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) Major 50% D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) Major 50% D6068 abutment supported retainer for porcelain / ceramic FPD Major 50% D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) Major 50% D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) Major 50% D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) Major 50% D6072 abutment supported retainer for cast metal FPD (high noble metal) Major 50% D6073 abutment supported retainer for cast metal FPD (predominantly base metal) Major 50% D6074 abutment supported retainer for cast metal FPD (noble metal) Major 50% D6075 implant supported retainer for ceramic FPD Major 50% D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) Major 50% D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) Major 50% D6080 implant maintenance procedures when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments Major 50% D6089 accessing and retorquing loose implant screw - per screw Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 109 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D6090 repair of implant/abutment supported prosthesis Major 50% D6091 replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment Major 50% D6092 replacement or re-bond implant / abutment supported crown Major 50% D6093 re-cement or re-bond implant / abutment supported fixed partial denture Major 50% D6094 abutment supported crown - (titanium) Major 50% D6096 remove broken implant retaining screw Major 50% D6100 implant removal, by report Major 50% D6101 debridement of a peri-implant defect or defects surrounding a single implant and surface cleaning of exposed implant surfaces, including flap entry and closure Major 50% D6102 debridement and osseous contouring of a peri-implant defect; or defects surrounding a single implant and includes surface cleaning or exposed implant surfaces including flap entry and closure Major 50% D6110 Implant/abutment supported removable denture for edentulous arch - maxillary Major 50% D6111 Implant/abutment supported removable denture for edentulous arch - mandibular Major 50% D6112 Implant/abutment supported removable denture for partially edentulous arch - maxillary Major 50% D6113 Implant/abutment supported removable denture for partially edentulous arch - mandibular Major 50% D6114 implant/abutment supported fixed denture for edentulous arch - maxillary Major 50% D6115 implant/abutment supported fixed denture for edentulous arch - mandibular Major 50% D6116 implant/abutment supported fixed denture for partially edentulous arch - maxillary Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 110 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D6117 implant/abutment supported fixed denture for partially edentulous arch - mandibular Major 50% D6180 implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments Major 50% D6190 radiographic/surgical implant index, by report Major 50% D6193 replacement of an implant screw Major 50% D6194 albutment supported retainer crown for FPD - (titanium) Major 50% D6199 unspecified implant procedure, by report Major 50% D6205 pontic - indirect resin based composite Major 50% D6210 pontic - cast high noble metal Major 50% D6211 pontic - cast predominantly base metal Major 50% D6212 pontic - cast noble metal Major 50% D6214 pontic - titanium Major 50% D6240 pontic - porcelain fused to high noble metal Major 50% D6241 pontic - porcelain fused to predominantly base metal Major 50% D6242 pontic - porcelain fused to noble metal Major 50% D6245 pontic - porcelain/ceramic Major 50% D6250 pontic - resin with high noble metal Major 50% D6251 pontic - resin with predominantly base metal Major 50% D6252 pontic - resin with noble metal Major 50% D6545 retainer - cast metal for resin bonded fixed prosthesis Major 50% D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis Major 50% D6549 resin retainer - for resin bonded fixed prosthesis Major 50% D6600 retainer inlay - porcelain/ceramic, two surfaces Major 50% D6601 retainer inlay - porcelain/ceramic, three or more surfaces Major 50% D6602 retainer inlay - cast high noble metal, two surfaces Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 111 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D6603 retainer inlay - cast high noble metal, three or more surfaces Major 50% D6604 retainer inlay - cast predominantly base metal, two surfaces Major 50% D6605 retainer inlay - cast predominantly base metal, three or more surfaces Major 50% D6606 retainer inlay - cast noble metal, two surfaces Major 50% D6607 retainer inlay - cast noble metal, three or more surfaces Major 50% D6608 retainer onlay - porcelain/ceramic, two surfaces Major 50% D6609 retainer onlay - porcelain/ceramic, three or more surfaces Major 50% D6610 retainer onlay - cast high noble metal, two surfaces Major 50% D6611 retainer onlay - cast high noble metal, three or more surfaces Major 50% D6612 retainer onlay - cast predominantly base metal, two surfaces Major 50% D6613 retainer onlay - cast predominantly base metal, three or more surfaces Major 50% D6614 retainer onlay - cast noble metal, two surfaces Major 50% D6615 retainer onlay - cast noble metal, three or more surfaces Major 50% D6624 retainer inlay - titanium Major 50% D6634 retainer onlay - titanium Major 50% D6710 retainer crown - indirect resin-based composite Major 50% D6720 retainer crown - resin with high noble metal Major 50% D6721 retainer crown - resin with predominantly base metal Major 50% D6722 retainer crown - resin with noble metal Major 50% D6740 retainer crown - porcelain/ceramic Major 50% D6750 retainer crown - porcelain fused to high noble metal Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 112 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D6751 retainer crown - porcelain fused to predominantly base metal Major 50% D6752 retainer crown - porcelain fused to noble metal Major 50% D6780 retainer crown - 3/4 cast high noble metal Major 50% D6781 retainer crown - 3/4 cast predominantly base metal Major 50% D6782 retainer crown - 3/4 cast noble metal Major 50% D6783 retainer crown - 3/4 porcelain/ceramic Major 50% D6790 retainer crown - full cast high noble metal Major 50% D6791 retainer crown - full cast predominantly base metal Major 50% D6792 retainer crown - full cast noble metal Major 50% D6794 retainer crown - titanium Major 50% D6930 recement or re-bond fixed partial denture Major 50% D6940 stress breaker Major 50% D6980 fixed partial denture repair necessitated by restorative material failure Major 50% D6999 unspecified fixed prosthodontic procedure, by report Major 50% D7210 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Major 50% D7220 removal of impacted tooth - soft tissue Major 50% D7230 removal of impacted tooth - partially bony Major 50% D7240 removal of impacted tooth - completely bony Major 50% D7241 removal of impacted tooth - completely bony, with unusual surgical complications Major 50% D7250 removal of residual tooth roots (cutting procedure) Major 50% D7252 partial extraction for immediate implant placement Major 50% D7259 nerve dissection Major 50% D7260 oroantral fistula closure Major 50% D7261 primary closure of a sinus perforation Major 50% D7282 mobilization of erupted or malpositioned tooth to aid eruption Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 113 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D7284 excisional biopsy of minor salivary glands Major 50% D7285 incisional biopsy of oral tissue - hard (bone, tooth) Major 50% D7286 incisional biopsy of oral tissue - soft Major 50% D7310 alveoloplasty in conjunction with extractions - four or more teeth, or tooth spaces, per quadrant Major 50% D7311 alveoloplasty in conjunction with extractions - one to three teeth, or tooth spaces, per quadrant Major 50% D7320 alveoloplasty not in conjunction with extractions - four or more teeth, or tooth spaces, per quadrant Major 50% D7321 alveoloplasty not in conjunction with extractions - one to three teeth, or tooth spaces, per quadrant Major 50% D7340 vestibuloplasty - ridge extension (secondary epithelialization) Major 50% D7350 vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Major 50% D7471 removal of lateral exostosis (maxilla or mandible) Major 50% D7472 removal of torus palatinus Major 50% D7473 removal of torus mandibularis Major 50% D7485 reduction of osseous tuberosity Major 50% D7510 incision and drainage of abscess - intraoral soft tissue Major 50% D7520 incision and drainage of abscess - extraoral soft tissue Major 50% D7530 removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue Major 50% D7540 removal of reaction producing foreign bodies, musculoskeletal system Major 50% D7550 partial ostectomy/sequestrectomy for removal of non-vital bone Major 50%

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 114 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Code Description Benefit Category Member Coinsurance D7560 maxillary sinusotomy for removal of tooth fragment or foreign body Major 50% D7920 skin graft (identify defect covered, location and type of graft) Major 50% D7951 sinus augmentation with bone or bone substitutes via a lateral open approach Major 50% D7952 sinus augmentation via a vertical approach Major 50% D7953 bone replacement graft for ridge preservation - per site Major 50% D7955 repair of maxillofacial soft and/or hard tissue defect Major 50% D7970 excision of hyperplastic tissue - per arch Major 50% D7971 excision of pericoronal gingiva Major 50% D7972 surgical reduction of fibrous tuberosity Major 50% D7999 unspecified oral surgery procedure, by report Major 50% Limitations on Dental Benefits (included in Option C of the optional Enhanced Benefit package)

1. Exam and cleaning limitations: a. We will pay for oral examinations (except after-hours exams and exams for observation) and cleanings (including periodontal cleanings in the presence of inflamed gums or any combination thereof) no more than two times in a Calendar Year. b. A full mouth debridement is allowed once in a lifetime and counts toward the cleaning frequency in the year provided. c. Note that periodontal cleanings Procedure Codes that include periodontal cleanings and full mouth debridement are covered as a Major Benefit, and routine cleanings are covered as a Diagnostic and Preventive Benefit.
2. Bitewing x-rays are limited to once each Calendar Year for Members. Bitewings of any type are disallowed within 12 months of a full mouth series unless warranted by special circumstances.
3. Specialist Consultations are limited to once per lifetime per dentist and count toward the oral exam frequency.

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4. We will not cover replacement of an amalgam or resin-based composite restorations (fillings) within 24 months of treatment if the service is provided by the same dentist/dentist office. Replacement restorations within 24 months are included in the fee for the original restoration.
5. Protective restorations (sedative fillings) are allowed once per tooth per lifetime when definitive treatment is not performed on the same date of service.
6. Therapeutic pulpotomy is limited to once per lifetime for baby (deciduous) teeth only and is considered palliative treatment for permanent teeth.
7. Apexification is only benefited on permanent teeth with incomplete root canal development or for the repair of a perforation. Apexification visits have a lifetime limit per tooth of one (1) initial visit, one (1) interim visit and one (1) final visit.
8. Pulpal therapy (resorbable filling) is limited to once in a lifetime. Retreatment of root canal therapy by the same dentist/dentist office within 24 months is considered part of the original procedure.
9. Retreatment of apical surgery by the same dentist/dentist office within 24 months is considered part of the original procedure.
10. Palliative treatment is covered per visit, not per tooth, and the fee includes all treatment provided other than required x-rays or select Diagnostic procedures
11. Periodontal limitations: a. Benefits for periodontal scaling and root planing in the same quadrant are limited to once in every 24-month period. b. Periodontal surgery in the same quadrant is limited to once in every 36-month period and includes any surgical re-entry or scaling and root planing. c. Periodontal services, including bone replacement grafts, guided tissue regeneration, graft procedures and biological materials to aid in soft and osseous tissue regeneration are only covered for the treatment of natural teeth and are not covered when submitted in conjunction with extractions, periradicular surgery, ridge augmentation. d. Periodontal surgery is subject to a 30 day wait following periodontal scaling and root planning in the same quadrant. e. Cleanings (regular and periodontal) and full mouth debridement are subject to a 30 day wait following periodontal scaling and root planing if performed by the same dentist office.
12. Oral Surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.

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13. Crowns and Inlays/Onlays are covered not more often than once in any 60 month period except when We determine the existing Crown or Inlay/Onlay is not satisfactory and cannot be made satisfactory because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues.
14. Core buildup, including any pins, is covered not more than once in any 60 month period.
15. Post and core services are covered not more than once in any 60 month year period.
16. Crown repairs are covered not more than twice in any 60 month period.
17. Denture Repairs are covered not more than once in any six (6) month period except for fixed Denture Repairs which are covered not more than twice in any 60 month period.
18. Prosthodontic appliances, implants and/or implant supported prosthetics that were provided under any Delta Dental program will be replaced only after 60 months have passed, except when We determine that there is such extensive loss of remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made satisfactory. Fixed prosthodontic appliances are limited to Enrollees age 16 and older. Replacement of a prosthodontic appliance and/or implant supported prosthesis not provided under a Delta Dental program will be made if We determine it is unsatisfactory and cannot be made satisfactory. Diagnostic and treatment facilitating aids for implants are considered a part of, and included in, the fees for the definitive treatment. Our payment for implant removal is limited to one (1) for each implant during the Enrollee's lifetime whether provided under Delta Dental or any other dental care plan.
19. When a posterior fixed bridge and a removable partial denture are placed in the same arch in the same treatment episode, only the partial denture will be a Benefit
20. Re-cementation of Crowns, Inlays/Onlays or bridges is included in the fee for the Crown, Inlay/Onlay or bridge when performed by the same dentist/dentist office within six (6) months of the initial placement. After six (6) months, payment will be limited to one (1) re-cementation in a lifetime by the same dentist/dentist office.
21. We limit payment for dentures to a standard partial or complete denture (Member Coinsurances apply). A standard denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable materials by conventional means and includes routine post-delivery care including any adjustments and relines for the first six (6) months after placement. a. Denture rebase is limited to one (1) per arch in a 24-month period and includes any relining and adjustments for six (6) months following placement.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 117 Chapter 4 Medical Benefits Chart (what's covered and what you pay) b. Dentures, removable partial dentures and relines include adjustments for six (6) months following installation. After the initial six (6) months of an adjustment or reline, adjustments are limited to two (2) per arch in a Calendar Year and relining is limited to one (1) per arch in a six (6) month period. c. Tissue conditioning is limited to two (2) per arch in a 12-month period. However, tissue conditioning is not allowed as a separate Benefit when performed on the same day as a denture, reline or rebase service. d. Re-cementation of fixed partial dentures is limited to once in a lifetime. Exclusions on Dental Benefits (included in Option C of the optional Enhanced Benefit package) The plan does not pay benefits for:

1. Treatment of injuries or illness covered by workers' compensation or employers' liability laws; services received without cost from any federal, state or local agency, unless this exclusion is prohibited by law.
2. Cosmetic surgery or procedures for purely cosmetic reasons.
3. Maxilla facial prosthetics.
4. Provisional and/or temporary restorations. Provisional and/or temporary restorations are not separately payable procedures and are included in the fee for completed service.
5. Services for congenital (hereditary) or developmental (following birth) malformations, including but not limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth).
6. Treatment to stabilize teeth, treatment to restore tooth structure lost from wear, erosion, or abrasion or treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion. Examples include but are not limited to: equilibration, periodontal splinting, complete occlusal adjustments or Night Guards/Occlusal guards and abfraction.
7. Any Single Procedure provided prior to the date the Member became eligible for services under this plan.
8. Prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/ investigational procedures.
9. Charges for anesthesia, other than General Anesthesia and IV Sedation administered by a dentist in connection with covered Oral Surgery or selected Endodontic and Periodontal surgical procedures. Local anesthesia and regional/or trigeminal bloc anesthesia are not separately payable procedures.

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10. Extraoral grafts (grafting of tissues from outside the mouth to oral tissues).
11. Interim implants and endodontic endosseous implant.
12. Indirectly fabricated resin-based lnlays/Onlays.
13. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility.
14. Treatment by someone other than a dentist or a person who by law may work under a dentist's direct supervision.
15. Charges incurred for oral hygiene instruction, a plaque control program, preventive control programs including home care times, dietary instruction, x-ray duplications, cancer screening, tobacco counseling.
16. Dental practice administrative services including, but not limited to: preparation of claims, any non-treatment phase of dentistry such as provision of an antiseptic environment, sterilization of equipment or infection control, or any ancillary materials used during the routine course of providing treatment such as cotton swabs, gauze, bibs, masks or relaxation techniques such as music.
17. Procedures having a questionable prognosis based on a dental consultant's professional review of the submitted documentation.
18. Any tax imposed (or incurred) by a government, state or other entity, in connection with any fees charged for Benefits provided under the Plan, will be the responsibility of the Member and not a covered Benefit
19. Deductibles, amounts over Plan maximums and/or any service not covered under the dental Plan.
20. Services covered under the dental Plan but exceed Benefit limitations or are not in accordance with processing policies in effect at the time the claim is processed.
21. Services for Orthodontic treatment (treatment of malocclusion of teeth and/or jaws) except as provided under the Orthodontic Services section, if applicable.
22. Services for any disturbance of the Temporomandibular (jaw) Joints (TMJ) or associated musculature, nerves and other tissues) except as provided under the TMJ Benefit section, if applicable.
23. Services and supplies for alternate benefits (optional services) that include the use of specialized techniques instead of standard procedures.
24. Services and supplies for pulp vitality tests and complete intraoral series & panoramic film.
25. Missed and/or cancelled appointments.
26. Services not included on the Dental Procedures Codes and Descriptions.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 119 Chapter 4 Medical Benefits Chart (what's covered and what you pay) SECTION 3 Services that aren't covered by our plan (exclusions) This section tells you what services are excluded from Medicare coverage and therefore, aren't covered by this plan. The chart below lists services and items that either aren't covered under any condition or are covered only under specific conditions. If you get services that are excluded (not covered), you must pay for them yourself except under the specific conditions listed below. Even if you get the excluded services at an emergency facility, the excluded services are still not covered, and our plan won't pay for them. The only exception is if the service is appealed and decided upon appeal to be a medical service that we should have paid for or covered because of your specific situation. (For information about appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 5.3.) Services not covered by Medicare Covered only under specific conditions Cosmetic surgery or procedures Covered in cases of an accidental injury or for improvement of the functioning of a malformed body member Covered for all stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance Custodial care Custodial care is personal care that doesn't require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing Not covered under any condition Experimental medical and surgical procedures, equipment, and medications Experimental procedures and items are those items and procedures determined by Original Medicare to not be generally accepted by the medical community May be covered by Original Medicare under a Medicare-approved clinical research study or by our plan (Go to Chapter 3, Section 5 for more information on clinical research studies)

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 120 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Services not covered by Medicare Covered only under specific conditions Fees charged for care by your immediate relatives or members of your household Not covered under any condition Full-time nursing care in your home Not covered under any condition Home-delivered meals Not covered under any condition Homemaker services include basic household help, including light housekeeping or light meal preparation Not covered under any condition Medical or Recreational Marijuana Not covered under any condition Naturopath services (uses natural or alternative treatments) Not covered under any condition Non-routine dental care Dental care required to treat illness or injury may be covered as inpatient or outpatient care Orthopedic shoes or supportive devices for the feet Shoes that are part of a leg brace and are included in the cost of the brace. Orthopedic or therapeutic shoes for people with diabetic foot disease. Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television Not covered under any condition Private room in a hospital Covered only when medically necessary Reversal of sterilization procedures and/or non-prescription contraceptive supplies Not covered under any condition Routine eye examinations, eyeglasses, radial keratotomy, LASIK surgery, and other low vision aids One pair of eyeglasses with standard frames (or one set of contact lenses) covered after each cataract surgery that implants an intraocular lens. Benefit is covered if Optional Supplemental Benefits package is purchased. See Section 2.1 for Optional Supplemental Benefits. Routine foot care Some limited coverage provided according to Medicare guidelines (e.g., if you have diabetes)

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 121 Chapter 4 Medical Benefits Chart (what's covered and what you pay) Services not covered by Medicare Covered only under specific conditions Services considered not reasonable and necessary, according to Original Medicare standards Not covered under any condition

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 122 Chapter 5 Using plan coverage for Part D drugs CHAPTER 5: Using plan coverage for Part D drugs SECTION 1 Basic rules for our plan's Part D coverage Go to the Medical Benefits Chart in Chapter 4 for Medicare Part B drug benefits and hospice drug benefits. Our plan will generally cover your drugs as long as you follow these rules: • You must have a provider (a doctor, dentist, or other prescriber) write you a prescription that's valid under applicable state law. • Your prescriber must not be on Medicare's Exclusion or Preclusion Lists. • You generally must use a network pharmacy to fill your prescription (Go to Section 2) or you can fill your prescription through our plan's mail-order service. • Your drug must be on our plan's Drug List (Go to Section 3). • Your drug must be used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the FDA or supported by certain references. (Go to Section 3 for more information about a medically accepted indication.) • Your drug may require approval from our plan based on certain criteria before we agree to cover it. (Go to Section 4 in this chapter for more information) SECTION 2 Fill your prescription at a network pharmacy or through our plan's mail-order service In most cases, your prescriptions are covered only if they're filled at our plan's network pharmacies. (Go to Section 2.4 for information about when we cover prescriptions filled at out-of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with our plan to provide your covered drugs. The term “covered drugs” means all the Part D drugs that are on our plan's Drug List.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 123 Chapter 5 Using plan coverage for Part D drugs Section 2.1 Network pharmacies Find a network pharmacy in your area To find a network pharmacy, go to your Provider/Pharmacy Directory, visit our website (www.aspirehealthplan.org), and/or call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). You may go to any of our network pharmacies. If your pharmacy leaves the network If the pharmacy you use leaves our plan's network, you'll have to find a new pharmacy in the network. To find another pharmacy in your area, get help from Member Services at Toll Free: (855) 570-1600 (TTY users call 711) or use the Provider/Pharmacy Directory. You can also find information on our website at www.aspirehealthplan.org. Specialized pharmacies Some prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include: • Pharmacies that supply drugs for home infusion therapy. • Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a LTC facility (such as a nursing home) has its own pharmacy. If you have difficulty getting Part D drugs in an LTC facility, call Member Services at Toll Free: (855) 570- 1600 (TTY users call 711). • Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these pharmacies in our network. • Pharmacies that dispense drugs restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. To locate a specialized pharmacy, go to your Provider/Pharmacy Directory www.aspirehealthplan.org or call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). Section 2.2 Our plan's mail-order service For certain kinds of drugs, you can use our plan's network mail-order service. Generally, the drugs provided through mail order are drugs you take on a regular basis, for a chronic or long-term medical condition. The drugs that aren't available through our plan's mail-order service are marked with an asterisk in our Drug List.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 124 Chapter 5 Using plan coverage for Part D drugs Our plan's mail-order service allows you to order up to a 90-day supply. To get order forms and information about filling your prescriptions by mail contact Birdi at 1- 855-873-8739. You must use our prescription mail order services. Prescription drugs that you get through any other mail-order service are not covered. If you use a mail-order pharmacy that is not in our network, your prescription will not be covered. Usually, a mail-order pharmacy order will be delivered to you in no more than 14 days. However, sometimes your mail order may be delayed. If for some reason your medication order from the mail order service becomes delayed, you may always obtain a prescription from a local network pharmacy. Please call Member Services to assist you with the process. (Phone numbers for Member Services are printed on the back cover of this document). New prescriptions the pharmacy gets directly from your doctor's office. The pharmacy will automatically fill and deliver new prescriptions it gets from health care providers, without checking with you first, if either: • You used mail-order services with this plan in the past, or • You sign up for automatic delivery of all new prescriptions received directly from health care providers. You can ask for automatic delivery of all new prescriptions at any time by contacting Birdi at 1-855-873-8739. If you get a prescription automatically by mail that you don't want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund. If you used mail order in the past and don't want the pharmacy to automatically fill and ship each new prescription, contact us by calling Birdi at 1-855-873-8739 If you never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. It's important to respond each time you're contacted by the pharmacy to let them know whether to ship, delay, or cancel the new prescription. To opt out of automatic deliveries of new prescriptions received directly from your health care provider's office, contact us by calling Birdi at 1-855-873-8739 Refills on mail-order prescriptions. For refills, contact your pharmacy 14 days before your current prescription will run out to make sure your next order is shipped to you in time.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 125 Chapter 5 Using plan coverage for Part D drugs Section 2.3 How to get a long-term supply of drugs When you get a long-term supply of drugs, your cost sharing may be lower. Our plan offers 2 ways to get a long-term supply (also called an extended supply) of maintenance drugs on our plan's Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)

1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Provider/Pharmacy Directory www.aspirehealthplan.org tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You can also call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) for more information.
2. You can also get maintenance drugs through our mail-order program. Go to Section 2.2 for more information. Section 2.4 Using a pharmacy that's not in our plan's network Generally, we cover drugs filled at an out-of-network pharmacy only when you aren't able to use a network pharmacy. We also have network pharmacies outside of our service area where you can get prescriptions filled as a member of our plan. Check first with Member Services at Toll Free: (888) 495-3160 (TTY users call 711) to see if there's a network pharmacy nearby. We cover prescriptions filled at an out-of-network pharmacy only in these circumstances: • If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service. • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high cost and unique drugs). If you must use an out-of-network pharmacy, you'll generally have to pay the full cost (rather than your normal cost share) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Go to Chapter 7, Section 2 for information on how to ask our plan to pay you back.) You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost we would cover at an in- network pharmacy.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 126 Chapter 5 Using plan coverage for Part D drugs SECTION 3 Your drugs need to be on our plan's Drug List Section 3.1 The Drug List tells which Part D drugs are covered Our plan has a List of Covered Drugs (formulary). In this Evidence of Coverage, we call it the Drug List. The drugs on this list are selected by our plan with the help of doctors and pharmacists. The list meets Medicare's requirements and has been approved by Medicare. The Drug List only shows drugs covered under Medicare Part D. We generally cover a drug on our plan's Drug List as long as you follow the other coverage rules explained in this chapter and use of the drug for a medically accepted indication. A medically accepted indication is a use of the drug that is either: • Approved by the FDA for the diagnosis or condition for which it's being prescribed, or • Supported by certain references, such as the American Hospital Formulary Service Drug Information and the Micromedex DRUGDEX Information System. The Drug List includes brand name drugs, generic drugs, and biological products (which may include biosimilars). A brand name drug is a prescription drug sold under a trademarked name owned by the drug manufacturer. Biological products are drugs that are more complex than typical drugs. On the Drug List, when we refer to drugs, this could mean a drug or a biological product. A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Biological products have alternatives called biosimilars. Generally, generics and biosimilars work just as well as the brand name drug or original biological product and usually cost less. There are generic drug substitutes available for many brand name drugs and biosimilar alternatives for some original biological products. Some biosimilars are interchangeable biosimilars and, depending on state law, may be substituted for the original biological product at the pharmacy without needing a new prescription, just like generic drugs can be substituted for brand name drugs.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 127 Chapter 5 Using plan coverage for Part D drugs Go to Chapter 12 for definitions of types of drugs that may be on the Drug List. Drugs that aren't on the Drug List Our plan doesn't cover all prescription drugs. • In some cases, the law doesn't allow any Medicare plan to cover certain types of drugs. (For more information, go to Section 7.) • In other cases, we decided not to include a particular drug on our Drug List. • In some cases, you may be able to get a drug that's not on our Drug List. (For more information, go to Chapter 9.) Section 3.2 6 cost-sharing tiers for drugs on the Drug List Every drug on our plan's Drug List is in one of 6 cost-sharing tiers. In general, the higher the tier, the higher your cost for the drug: • Tier 1 - Preferred Generic (lowest cost-sharing tier) • Tier 2 - Generic • Tier 3 - Preferred Brand • Tier 4 - Non-Preferred Drug • Tier 5 - Specialty Tier (highest cost-sharing tier) • Tier 6 - Select Care Drugs To find out which cost-sharing tier your drug is in, look it up in our plan's Drug List. The amount you pay for drugs in each cost-sharing tier is shown in Chapter 6. Section 3.3 How to find out if a specific drug is on the Drug List To find out if a drug is on our Drug List, you have these options: • Check the most recent Drug List we provided electronically. • Visit our plan's website(www.aspirehealthplan.org). The Drug List on the website is always the most current. • Call Member Services at Toll Free: (888) 495-3160 (TTY users call 711) to find out if a particular drug is on our plan's Drug List or ask for a copy of the list. • Use our plan's “Real-Time Benefit Tool” (https://www.medimpact.com to search for drugs on the Drug List to get an estimate of what you'll pay and see if there are

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 128 Chapter 5 Using plan coverage for Part D drugs alternative drugs on the Drug List that could treat the same condition. You can also call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). SECTION 4 Drugs with restrictions on coverage Section 4.1 Why some drugs have restrictions For certain prescription drugs, special rules restrict how and when our plan covers them. A team of doctors and pharmacists developed these rules to encourage you and your provider to use drugs in the most effective way. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. If a safe, lower-cost drug will work just as well medically as a higher-cost drug, our plan's rules are designed to encourage you and your provider to use that lower-cost option. Note that sometimes a drug may appear more than once on our Drug List. This is because the same drugs can differ based on the strength, amount, or form of the drug prescribed by your health care provider, and different restrictions or cost sharing may apply to the different versions of the drug (for example, 10 mg versus 100 mg; one per day versus 2 per day; tablet versus liquid). Section 4.2 Types of restrictions If there's a restriction for your drug, it usually means that you or your provider have to take extra steps for us to cover the drug. Call Member Services at Toll Free: (888) 495-3160 (TTY users call 711) to learn what you or your provider can do to get coverage for the drug. If you want us to waive the restriction for you, you need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (Go to Chapter 9.) Getting plan approval in advance For certain drugs, you or your provider need to get approval from our plan based on specific criteria before we agree to cover the drug for you. This is called prior authorization. This is put in place to ensure medication safety and help guide appropriate use of certain drugs. If you don't get this approval, your drug might not be covered by our plan. Our plan's prior authorization criteria can be obtained by calling Member Services at Toll Free: (855) 570-1600 (TTY users call 711) or on our website https://www.aspirehealthplan.org/drug-coverage/ .

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 129 Chapter 5 Using plan coverage for Part D drugs Trying a different drug first This requirement encourages you to try less costly but usually just as effective drugs before our plan covers another drug. For example, if Drug A and Drug B treat the same medical condition and Drug A is less costly, our plan may require you to try Drug A first. If Drug A doesn't work for you, our plan will then cover Drug B. This requirement to try a different drug first is called step therapy. Our plan's step therapy criteria can be obtained by calling Member Services at Toll Free: (888) 495-3160 (TTY users call 711) or on our website https://www.aspirehealthplan.org/drug-coverage/ . Quantity limits For certain drugs, we limit how much of a drug you can get each time you fill your prescription. For example, if it's normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. SECTION 5 What you can do if one of your drugs isn't covered the way you'd like There are situations where a prescription drug you take, or that you and your provider think you should take, isn't on our Drug List or has restrictions. For example: • The drug might not be covered at all. Or a generic version of the drug may be covered but the brand name version you want to take isn't covered. • The drug is covered, but there are extra rules or restrictions on coverage. • The drug is covered, but in a cost-sharing tier that makes your cost sharing more expensive than you think it should be. If your drug is in a cost-sharing tier that makes your cost more expensive than you think it should be, go to Section 5.1 to learn what you can do. If your drug isn't on the Drug List or is restricted, here are options for what you can do: • You may be able to get a temporary supply of the drug. • You can change to another drug. • You can ask for an exception and ask our plan to cover the drug or remove restrictions from the drug.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 130 Chapter 5 Using plan coverage for Part D drugs You may be able to get a temporary supply Under certain circumstances, our plan must provide a temporary supply of a drug you're already taking. This temporary supply gives you time to talk with your provider about the change. To be eligible for a temporary supply, the drug you take must no longer be on our plan's Drug List OR is now restricted in some way. • If you're a new member, we'll cover a temporary supply of your drug during the first 90 days of your membership in our plan. • If you were in our plan last year, we'll cover a temporary supply of your drug during the first 90 days of the calendar year. • This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we'll allow multiple fills to provide up to a maximum of 30 days of medication. The prescription must be filled at a network pharmacy. (Note that a long- term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) • For members who've been in our plan for more than 90 days and live in a long- term care facility and need a supply right away: We'll cover one 31-day emergency supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply. • For members who have been in our plan for more than 90 days and have a level of care change (e.g., transitioning from a SNF to a long-term care facility; going home from the hospital) and need a supply right away: We will cover one 31-day emergency supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply. Exceptions are available for members who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Members being admitted to or discharged from a LTC facility will be able to access a refill upon admission or discharge. Examples of situations in which members would be eligible for the one-time temporary fill exception when they are outside of the three-month effective date into the plan are as follows: • If you enter or leave a long-term care facility

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 131 Chapter 5 Using plan coverage for Part D drugs • If you are discharged from a hospital • If you leave a skilled nursing facility • If you cancel hospice • If you are discharged from a psychiatric hospital on a specialized medication For questions about a temporary supply, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). During the time when you're using a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You have 2 options: Option 1. You can change to another drug Talk with your provider about whether a different drug covered by our plan may work just as well for you. Call Member Services at Toll Free: (888) 495-3160 (TTY users call 711) to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. Option 2. You can ask for an exception You and your provider can ask our plan to make an exception and cover the drug in the way you'd like it covered. If your provider says you have medical reasons that justify asking us for an exception, your provider can help you ask for an exception. For example, you can ask our plan to cover a drug even though it is not on our plan's Drug List. Or you can ask our plan to make an exception and cover the drug without restrictions. If you're a current member and a drug you take will be removed from the formulary or restricted in some way for next year, we'll tell you about any change before the new year. You can ask for an exception before next year and we'll give you an answer within 72 hours after we get your request (or your prescriber's supporting statement). If we approve your request, we'll authorize coverage for the drug before the change takes effect. If you and your provider want to ask for an exception, go to Chapter 9, Section 6.4 to learn what to do. It explains the procedures and deadlines set by Medicare to make sure your request is handled promptly and fairly.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 132 Chapter 5 Using plan coverage for Part D drugs Section 5.1 What to do if your drug is in a cost-sharing tier you think is too high If your drug is in a cost-sharing tier you think is too high, here are things you can do: You can change to another drug If your drug is in a cost-sharing tier you think is too high, talk to your provider. There may be a different drug in a lower cost-sharing tier that might work just as well for you. Call Member Services at Toll Free: (888) 495-3160 (TTY users call 711) to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. You can ask for an exception You and your provider can ask our plan to make an exception in the cost-sharing tier for the drug so that you pay less for it. If your provider says you have medical reasons that justify asking us for an exception, your provider can help you ask for an exception to the rule. If you and your provider want to ask for an exception, go to Chapter 9, Section 6.4 for what to do. It explains the procedures and deadlines set by Medicare to make sure your request is handled promptly and fairly. Drugs in our Tier 5 - Specialty Tier aren't eligible for this type of exception. We don't lower the cost-sharing amount for drugs in this tier. SECTION 6 Our Drug List can change during the year Most changes in drug coverage happen at the beginning of each year (January 1). However, during the year, our plan can make some changes to the Drug List. For example, our plan might: • Add or remove drugs from the Drug List. • Move a drug to a higher or lower cost-sharing tier. • Add or remove a restriction on coverage for a drug. • Replace a brand name drug with a generic version of the drug. • Replace an original biological product with an interchangeable biosimilar version of the biological product. We must follow Medicare requirements before we change our plan's Drug List.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 133 Chapter 5 Using plan coverage for Part D drugs Information on changes to drug coverage When changes to the Drug List occur, we post information on our website about those changes. We also update our online Drug List regularly. Sometimes you'll get direct notice if changes are made to a drug that you take. Changes to drug coverage that affect you during this plan year • Adding new drugs to the Drug List and immediately removing or making changes to a like drug on the Drug List. • When adding a new version of a drug to the Drug List, we may immediately remove a like drug from the Drug List, move the like drug to a different cost- sharing tier, add new restrictions, or both. The new version of the drug will be on the same or a lower cost-sharing tier and with the same or fewer restrictions. • We'll make these immediate changes only if we add a new generic version of a brand name or add certain new biosimilar versions of an original biological product that was already on the Drug List. • We may make these changes immediately and tell you later, even if you take the drug that we remove or make changes to. If you take the like drug at the time we make the change, we'll tell you about any specific change we made. • Adding drugs to the Drug List and removing or making changes to a like drug on the Drug List. • When adding another version of a drug to the Drug List, we may remove a like drug from the Drug List, move it to a different cost-sharing tier, add new restrictions, or both. The new version of the drug will be on the same or a lower cost-sharing tier and with the same or fewer restrictions. • We'll make these changes only if we add a new generic version of a brand name drug or add certain new biosimilar versions of an original biological product that was already on the Drug List. • We'll tell you at least 30 days before we make the change or tell you about the change and cover a 30-day fill of the version of the drug you're taking. • Removing unsafe drugs and other drugs on the Drug List that are withdrawn from the market. • Sometimes a drug can be deemed unsafe or taken off the market for another reason. If this happens, we may immediately remove the drug from the Drug List. If you take that drug, we'll tell you after we make the change.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 134 Chapter 5 Using plan coverage for Part D drugs • Making other changes to drugs on the Drug List. • We may make other changes once the year has started that affect drugs you are taking. For example, we may make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. • We'll tell you at least 30 days before we make these changes, or tell you about the change and cover an additional 30-day fill of the drug you're taking. If we make changes to any of the drugs you take, talk with your prescriber about the options that would work best for you, including changing to a different drug to treat your condition, or asking for a coverage decision to satisfy any new restrictions on the drug you take. You or your prescriber can ask us for an exception to continue covering the drug or version of the drug you take. For more information on how to ask for a coverage decision, including an exception, go to Chapter 9. Changes to the Drug List that don't affect you during this plan year We may make certain changes to the Drug List that aren't described above. In these cases, the change won't apply to you if you're taking the drug when the change is made; however, these changes will likely affect you starting January 1 of the next plan year if you stay in the same plan. In general, changes that won't affect you during the current plan year are: • We move your drug into a higher cost-sharing tier. • We put a new restriction on the use of your drug. • We remove your drug from the Drug List. If any of these changes happen for a drug you take (except for market withdrawal, a generic drug replacing a brand name drug, or other change noted in the sections above), the change won't affect your use or what you pay as your share of the cost until January 1 of the next year. We won't tell you about these types of changes directly during the current plan year. You'll need to check the Drug List for the next plan year (when the list is available during the open enrollment period) to see if there are any changes to drugs you take that will impact you during the next plan year.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 135 Chapter 5 Using plan coverage for Part D drugs SECTION 7 Types of drugs we don't cover Some kinds of prescription drugs are excluded. This means Medicare doesn't pay for these drugs. If you get drugs that are excluded, you must pay for them yourself. If you appeal and the requested drug is found not to be excluded under Part D, we'll pay for or cover it. (For information about appealing a decision, go to Chapter 9.) Here are 3 general rules about drugs that Medicare drug plans won't cover under Part D: • Our plan's Part D drug coverage can't cover a drug that would be covered under Medicare Part A or Part B. • Our plan can't cover a drug purchased outside the United States or its territories. • Our plan can't cover off-label use of a drug when the use isn't supported by certain references, such as the American Hospital Formulary Service Drug Information and the Micromedex DRUGDEX Information System. Off-label use is any use of the drug other than those indicated on a drug's label as approved by the FDA. In addition, by law, the following categories of drugs aren't covered by Medicare drug plans: • Non-prescription drugs (also called over-the-counter drugs) • Drugs used to promote fertility • Drugs used for the relief of cough or cold symptoms • Drugs used for cosmetic purposes or to promote hair growth • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations • Drugs used for the treatment of sexual or erectile dysfunction • Drugs used for treatment of anorexia, weight loss, or weight gain • Outpatient drugs for which the manufacturer requires associated tests or monitoring services be purchased only from the manufacturer as a condition of sale If you get Extra Help to pay for your prescriptions, Extra Help won't pay for drugs that aren't normally covered. If you have drug coverage through Medicaid, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Contact your state Medicaid program to determine what drug coverage may be available to you. (Find phone numbers and contact information for Medicaid in Chapter 2, Section 6.)

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 136 Chapter 5 Using plan coverage for Part D drugs SECTION 8 How to fill a prescription To fill your prescription, provide our plan membership information (which can be found on your membership card) at the network pharmacy you choose. The network pharmacy will automatically bill our plan for our share of your drug cost. You need to pay the pharmacy your share of the cost when you pick up your prescription. If you don't have our plan membership information with you, you or the pharmacy can call our plan to get the information, or you can ask the pharmacy to look up our plan enrollment information. If the pharmacy can't get the necessary information, you may have to pay the full cost of the prescription when you pick it up. You can then ask us to reimburse you for our share. Go to Chapter 7, Section 2 for information about how to ask our plan for reimbursement. SECTION 9 Part D drug coverage in special situations Section 9.1 In a hospital or a skilled nursing facility for a stay covered by our plan If you're admitted to a hospital or to a skilled nursing facility for a stay covered by our plan, we'll generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, our plan will cover your prescription drugs as long as the drugs meet all our rules for coverage described in this chapter. Section 9.2 As a resident in a long-term care (LTC) facility Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy or uses a pharmacy that supplies drugs for all its residents. If you're a resident of an LTC facility, you may get your prescription drugs through the facility's pharmacy or the one it uses, as long as it's part of our network. Check your Pharmacy Directory www.aspirehealthplan.org to find out if your LTC facility's pharmacy or the one that it uses is part of our network. If it isn't, or if you need more information or help, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). If you're in an LTC facility, we must ensure that you're able to routinely get your Part D benefits through our network of LTC pharmacies. If you're a resident in an LTC facility and need a drug that's not on our Drug List or restricted in some way, go to Section 5 for information about getting a temporary or emergency supply.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 137 Chapter 5 Using plan coverage for Part D drugs Section 9.3 If you also have drug coverage from an employer or retiree group plan If you have other drug coverage through your (or your spouse or domestic partner's) employer or retiree group, contact that group's benefits administrator. They can help you understand how your current drug coverage will work with our plan. In general, if you have employee or retiree group coverage, the drug coverage you get from us will be secondary to your group coverage. That means your group coverage pays first. Special note about creditable coverage: Each year your employer or retiree group should send you a notice that tells you if your drug coverage for the next calendar year is creditable. If the coverage from the group plan is creditable, it means that our plan has drug coverage that is expected to pay, on average, at least as much as Medicare's standard drug coverage. Keep any notices about creditable coverage because you may need these notices later to show that you maintained creditable coverage. If you didn't get a creditable coverage notice, ask for a copy from your employer or retiree plan's benefits administrator or the employer or union. Section 9.4 If you're in a Medicare-certified hospice Hospice and our plan don't cover the same drug at the same time. If you're enrolled in Medicare hospice and require certain drugs (e.g., anti-nausea drugs, laxatives, pain medication or anti-anxiety drugs) that aren't covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must get notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover the drug. To prevent delays in getting these drugs that should be covered by our plan, ask your hospice provider or prescriber to provide notification before your prescription is filled. In the event you either revoke your hospice election or are discharged from hospice, our plan should cover your drugs as explained in this document. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, bring documentation to the pharmacy to verify your revocation or discharge. SECTION 10 Programs on drug safety and managing medications We conduct drug use reviews to help make sure our members get safe and appropriate care.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 138 Chapter 5 Using plan coverage for Part D drugs We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems like: • Possible medication errors • Drugs that may not be necessary because you take another similar drug to treat the same condition • Drugs that may not be safe or appropriate because of your age or gender • Certain combinations of drugs that could harm you if taken at the same time • Prescriptions for drugs that have ingredients you're allergic to • Possible errors in the amount (dosage) of a drug you take • Unsafe amounts of opioid pain medications If we see a possible problem in your use of medications, we'll work with your provider to correct the problem. Section 10.1 Drug Management Program (DMP) to help members safely use opioid medications We have a program that helps make sure members safely use prescription opioids and other frequently abused medications. This program is called a Drug Management Program (DMP). If you use opioid medications that you get from several prescribers or pharmacies, or if you had a recent opioid overdose, we may talk to your prescribers to make sure your use of opioid medications is appropriate and medically necessary. Working with your prescribers, if we decide your use of prescription opioid or benzodiazepine medications may not be safe, we may limit how you can get those medications. If we place you in our DMP, the limitations may be: • Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain pharmacy(ies) • Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain prescriber(s) • Limiting the amount of opioid or benzodiazepine medications we'll cover for you If we plan on limiting how you get these medications or how much you can get, we'll send you a letter in advance. The letter will tell you if we'll limit coverage of these drugs for you, or if you'll be required to get the prescriptions for these drugs only from a specific prescriber or pharmacy. You'll have an opportunity to tell us which prescribers or pharmacies you prefer to use, and about any other information you think is important for us to know. After you've had the opportunity to respond, if we decide to limit your coverage for these medications, we'll

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 139 Chapter 5 Using plan coverage for Part D drugs send you another letter confirming the limitation. If you think we made a mistake or you disagree with our decision or with the limitation, you and your prescriber have the right to appeal. If you appeal, we'll review your case and give you a new decision. If we continue to deny any part of your request about the limitations that apply to your access to medications, we'll automatically send your case to an independent reviewer outside of our plan. Go to Chapter 9 for information about how to ask for an appeal. You won't be placed in our DMP if you have certain medical conditions, such as cancer- related pain or sickle cell disease, you're getting hospice, palliative, or end-of-life care, or live in a long-term care facility. Section 10.2 Medication Therapy Management (MTM) program to help members manage medications We have a program that can help our members with complex health needs. Our program is called a Medication Therapy Management (MTM) program. This program is voluntary and free. A team of pharmacists and doctors developed the program for us to help make sure our members get the most benefit from the drugs they take. Some members who have certain chronic diseases and take medications that exceed a specific amount of drug costs or are in a DMP to help them use opioids safely, may be able to get services through an MTM program. If you qualify for the program, a pharmacist or other health professional will give you a comprehensive review of all your medications. During the review, you can talk about your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You'll get a written summary which has a recommended to-do list that includes steps you should take to get the best results from your medications. You'll also get a medication list that will include all the medications you're taking, how much you take, and when and why you take them. In addition, members in the MTM program will get information on the safe disposal of prescription medications that are controlled substances. It's a good idea to talk to your doctor about your recommended to-do list and medication list. Bring the summary with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Keep your medication list up to date and with you (for example, with your ID) in case you go to the hospital or emergency room. If we have a program that fits your needs, we'll automatically enroll you in the program and send you information. If you decide not to participate, notify us and we'll withdraw you. For questions about this program, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 140 Chapter 6 What you pay for Part D drugs CHAPTER 6: What you pay for Part D drugs SECTION 1 What you pay for Part D drugs If you're in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low-Income Subsidy Rider or the LIS Rider), which tells you about your drug coverage. If you don't have this insert, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) and ask for the LIS Rider. We use “drug” in this chapter to mean a Part D prescription drug. Not all drugs are Part D drugs. Some drugs are covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law. To understand the payment information, you need to know what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Chapter 5 explains these rules. When you use our plan's “Real-Time Benefit Tool” to look up drug coverage (https://www.medimpact.com), the cost you see shows an estimate of the out-of- pocket costs you're expected to pay. You can also get information provided by the “Real-Time Benefit Tool” by calling Member Services at Toll Free: (888) 495-3160 (TTY users call 711). Section 1.1 Types of out-of-pocket costs you may pay for covered drugs There are 3 different types of out-of-pocket costs for covered Part D drugs that you may be asked to pay: • Deductible is the amount you pay for drugs before our plan starts to pay our share. • Copayment is a fixed amount you pay each time you fill a prescription. • Coinsurance is a percentage of the total cost you pay each time you fill a prescription. Section 1.2 How Medicare calculates your out-of-pocket costs Medicare has rules about what counts and what doesn't count toward your out-of-pocket costs. Here are the rules we must follow to keep track of your out-of-pocket costs.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 141 Chapter 6 What you pay for Part D drugs These payments are included in your out-of-pocket costs Your out-of-pocket costs include the payments listed below (as long as they are for covered Part D drugs and you followed the rules for drug coverage explained in Chapter 5): • The amount you pay for drugs when you're in the following drug payment stages: • The Initial Coverage Stage • Any payments you made during this calendar year as a member of a different Medicare drug plan before you joined our plan • Any payments for your drugs made by family or friends • Any payments made for your drugs by Extra Help from Medicare, employer or union health plans, Indian Health Service, AIDS drug assistance programs, and most charities Moving to the Catastrophic Coverage Stage: When you (or those paying on your behalf) have spent a total of $2,100 in out-of-pocket costs within the calendar year, you move from the Initial Coverage Stage to the Catastrophic Coverage Stage. These payments aren't included in your out-of-pocket costs Your out-of-pocket costs don't include any of these types of payments: • Your monthly plan premium • Drugs you buy outside the United States and its territories • Drugs that aren't covered by our plan • Drugs you get at an out-of-network pharmacy that don't meet our plan's requirements for out-of-network coverage • Non-Part D drugs, including prescription drugs and vaccines covered by Part A or Part B and other drugs excluded from coverage by Medicare • Payments you make toward drugs not normally covered in a Medicare Drug Plan • Payments for your drugs made by certain insurance plans and government-funded health programs such as TRICARE and the Veterans Health Administration (VA) • Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Workers' Compensation)

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 142 Chapter 6 What you pay for Part D drugs • Payments made by drug manufacturers under the Manufacturer Discount Program. Reminder: If any other organization like the ones listed above pays part or all your out-of- pocket costs for drugs, you're required to tell our plan by calling Member Services at Toll Free: (855) 570-1600 (TTY users call 711). Tracking your out-of-pocket total costs • The Part D Explanation of Benefits (EOB) you get includes the current total of your out- of-pocket costs. When this amount reaches $2,100, the Part D EOB will tell you that you left the Initial Coverage Stage and moved to the Catastrophic Coverage Stage. • Make sure we have the information we need. Go to Section 3.1 to learn what you can do to help make sure our records of what you spent are complete and up to date. SECTION 2 Drug payment stages for Aspire Health Advantage (HMO) members There are 3 drug payment stages for your drug coverage under Aspire Health Advantage (HMO). How much you pay for each prescription depends on what stage you're in when you get a prescription filled or refilled. Details of each stage are explained in this chapter. The stages are: • Stage 1: Yearly Deductible Stage • Stage 2: Initial Coverage Stage • Stage 3: Catastrophic Coverage Stage SECTION 3 Your Part D Explanation of Benefits (EOB) explains which payment stage you're in Our plan keeps track of your prescription drug costs and the payments you make when you get prescriptions at the pharmacy. This way, we can tell you when you move from one drug payment stage to the next. We track 2 types of costs: • Out-of-Pocket Costs: this is how much you paid. This includes what you paid when you get a covered Part D drug, any payments for your drugs made by family or friends, and any payments made for your drugs by Extra Help from Medicare, employer or union health plans, Indian Health Service, AIDS drug assistance programs, charities, and most State Pharmaceutical Assistance Programs (SPAPs).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 143 Chapter 6 What you pay for Part D drugs • Total Drug Costs: this is the total of all payments made for your covered Part D drugs. It includes what our plan paid, what you paid, and what other programs or organizations paid for your covered Part D drugs. If you filled one or more prescriptions through our plan during the previous month, we'll send you a Part D EOB. The Part D EOB includes: • Information for that month. This report gives payment details about prescriptions you filled during the previous month. It shows the total drug costs, what our plan paid, and what you and others paid on your behalf. • Totals for the year since January 1. This shows the total drug costs and total payments for your drugs since the year began. • Drug price information. This displays the total drug price, and information about changes in price from first fill for each prescription claim of the same quantity. • Available lower cost alternative prescriptions. This shows information about other available drugs with lower cost sharing for each prescription claim, if applicable. Section 3.1 Help us keep our information about your drug payments up to date To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here's how you can help us keep your information correct and up to date: • Show your membership card every time you get a prescription filled. This helps make sure we know about the prescriptions you fill and what you pay. • Make sure we have the information we need. There are times you may pay for the entire cost of a prescription drug. In these cases, we won't automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, give us copies of your receipts. Examples of when you should give us copies of your drug receipts: • When you purchase a covered drug at a network pharmacy at a special price or use a discount card that's not part of our plan's benefit. • When you pay a copayment for drugs provided under a drug manufacturer patient assistance program. • Any time you buy covered drugs at out-of-network pharmacies or pay the full price for a covered drug under special circumstances. • If you're billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter 7, Section 2. • Send us information about the payments others make for you. Payments made by certain other people and organizations also count toward your out-of-pocket costs.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 144 Chapter 6 What you pay for Part D drugs For example, payments made by an AIDS drug assistance program (ADAP), the Indian Health Service, and charities count toward your out-of-pocket costs. Keep a record of these payments and send them to us so we can track your costs. • Check the written report we send you. When you get the Part D EOB, look it over to be sure the information is complete and correct. If you think something is missing or you have questions, call Member Services at Toll Free: (888) 495-3160 (TTY users call 711). Be sure to keep these reports. SECTION 4 There is no deductible for Aspire Health Advantage (HMO) There is no deductible for Aspire Health Advantage (HMO). You begin in the Initial Coverage Stage when you fill your first prescription of the year. Go to Section 5 for information about your coverage in the Initial Coverage Stage. SECTION 5 The Initial Coverage Stage Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription During the Initial Coverage Stage, our plan pays its share of the cost of your covered drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. Our plan has 6 cost-sharing tiers Every drug on our plan's Drug List is in one of 6 cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug: • Tier 1 - Preferred Generic (lowest cost-sharing tier) • Tier 2 - Generic • Tier 3 - Preferred Brand • Tier 4 - Non-Preferred Drug • Tier 5 - Specialty Tier (highest cost-sharing tier) • Tier 6 - Select Care Drugs To find out which cost-sharing tier your drug is in, look it up in our plan's Drug List.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 145 Chapter 6 What you pay for Part D drugs Your pharmacy choices How much you pay for a drug depends on whether you get the drug from: • A network retail pharmacy. • A pharmacy that isn't in our plan's network. We cover prescriptions filled at out-of- network pharmacies in only limited situations. Go to Chapter 5, Section 2.4 to find out when we'll cover a prescription filled at an out-of-network pharmacy. • Our plan's mail-order pharmacy. For more information about these pharmacy choices and filling your prescriptions, go to Chapter 5 and our plan's Provider/Pharmacy Directory www.aspirehealthplan.org. Section 5.2 Your costs for a one-month supply of a covered drug During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or coinsurance. The amount of the copayment or coinsurance depends on the cost-sharing tier. Sometimes the cost of the drug is lower than your copayment. In these cases, you pay the lower price for the drug instead of the copayment.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 146 Chapter 6 What you pay for Part D drugs Your costs for a one-month supply of a covered Part D drug Tier Standard retail cost sharing (in- network) (up to a 30- day supply) Mail-order cost sharing (up to a 30- day supply) Long-term care (LTC) cost sharing (up to a 31- day supply) Out-of-network cost sharing (Coverage is limited to certain situations; see Chapter 5 for details.) (up to a 30-day supply) Cost-Sharing Tier 1 (Preferred Generic) $4 copay Mail order is not available for 30 days supply. $4 copay $4 copay Cost-Sharing Tier 2 (Generic) $15 copay Mail order is not available for 30 days supply. $15 copay $15 copay Cost-Sharing Tier 3 (Preferred Brand) $47 copay Mail order is not available for 30 days supply. $47 copay $47 copay Cost-Sharing Tier 4 (Non-Preferred Drug) 25% coinsurance Mail order is not available for 30 days supply. 25% coinsurance 25% coinsurance Cost-Sharing Tier 5 (Specialty Tier) 33% coinsurance Mail order is not available for 30 days supply. 33% coinsurance 33% coinsurance Cost-Sharing Tier 6 (Select Care Drugs) $11 copay Mail order is not available for 30 days supply. $11 copay $11 copay You won't pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 147 Chapter 6 What you pay for Part D drugs Go to Section 7 of this chapter for more information on cost sharing for Part D vaccines. Section 5.3 If your doctor prescribes less than a full month's supply, you may not have to pay the cost of the entire month's supply Typically, the amount you pay for a drug covers a full month's supply. There may be times when you or your doctor would like you to have less than a month's supply of a drug (for example, when you're trying a medication for the first time). You can also ask your doctor to prescribe, and your pharmacist to dispense, less than a full month's supply, if this will help you better plan refill dates. If you get less than a full month's supply of certain drugs, you won't have to pay for the full month's supply. • If you're responsible for coinsurance, you pay a percentage of the total cost of the drug. Since the coinsurance is based on the total cost of the drug, your cost will be lower since the total cost for the drug will be lower. • If you're responsible for a copayment for the drug, you only pay for the number of days of the drug that you get instead of a whole month. We calculate the amount you pay per day for your drug (the daily cost-sharing rate) and multiply it by the number of days of the drug you get. Section 5.4 Your costs for a long-term (up to a 90-day) supply of a covered Part D drug For some drugs, you can get a long-term supply (also called an extended supply). A long-term supply is up to a 90-day supply. Sometimes the cost of the drug is lower than your copayment. In these cases, you pay the lower price for the drug instead of the copayment. Your costs for a long-term (up to a 90-day) supply of a covered Part D drug Tier Standard retail cost sharing (in-network) (60-day supply) Mail-order cost sharing (60-day supply) Cost-Sharing Tier 1 (Preferred Generic) $8 copay Mail order is not available for 60 days supply. Cost-Sharing Tier 2 (Generic) $30 copay Mail order is not available for 60 days supply.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 148 Chapter 6 What you pay for Part D drugs Tier Standard retail cost sharing (in-network) (60-day supply) Mail-order cost sharing (60-day supply) Cost-Sharing Tier 3 (Preferred Brand) $94 copay Mail order is not available for 60 days supply. Cost-Sharing Tier 4 (Non-Preferred Drug) A long-term supply is not available for drugs in Tier 4. Mail order is not available for 60 days supply. Cost-Sharing Tier 5 (Specialty Tier) A long-term supply is not available for drugs in Tier 5. Mail order is not available for 60 days supply. Cost-Sharing Tier 6 (Select Care Drugs) $22 copay Mail order is not available for 60 days supply. Tier Standard retail cost sharing (in-network) (90-day supply) Mail-order cost sharing (90-day supply) Cost-Sharing Tier 1 (Preferred Generic) $12 copay $8 copay Cost-Sharing Tier 2 (Generic) $45 copay $30 copay Cost-Sharing Tier 3 (Preferred Brand) $141 copay $94 copay Cost-Sharing Tier 4 (Non-Preferred Drug) A long-term supply is not available for drugs in Tier 4 Mail order is not available for drugs in Tier 4. Cost-Sharing Tier 5 (Specialty Tier) A long-term supply is not available for drugs in Tier 5. Mail order is not available for drugs in Tier 5. Cost-Sharing Tier 6 (Select Care Drugs) $33 copay $22 copay You won't pay more than $70 for up to a 2-month supply or $105 for up to a 3-month supply of each covered insulin product regardless of the cost-sharing tier.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 149 Chapter 6 What you pay for Part D drugs Section 5.5 You stay in the Initial Coverage Stage until your out-of-pocket costs for the year reach $2,100 You stay in the Initial Coverage Stage until your total out-of-pocket costs reach $2,100. You then move to the Catastrophic Coverage Stage. The Part D EOB you get will help you keep track of how much you, our plan, and any third parties have spent on your behalf during the year. Not all members will reach the $2,100 out- of-pocket limit in a year. We'll let you know if you reach this amount. Go to Section 1.3 for more information on how Medicare calculates your out-of-pocket costs. SECTION 6 The Catastrophic Coverage Stage In the Catastrophic Coverage Stage, you pay nothing for covered Part D drugs. You enter the Catastrophic Coverage Stage when your out-of-pocket costs reach the $2,100 limit for the calendar year. Once you're in the Catastrophic Coverage Stage, you'll stay in this payment stage until the end of the calendar year. • During this payment stage, you pay nothing for your covered Part D drugs. SECTION 7 What you pay for Part D vaccines Important message about what you pay for vaccines - Some vaccines are considered medical benefits and are covered under Part B. Other vaccines are considered Part D drugs. You can find these vaccines listed in our plan's Drug List. Our plan covers most adult Part D vaccines at no cost to you. Go to our plan's Drug List or call Member Services at Toll Free: (888) 495-3160 (TTY users call 711) for coverage and cost-sharing details about specific vaccines. There are 2 parts to our coverage of Part D vaccines: • The first part is the cost of the vaccine itself. • The second part is for the cost of giving you the vaccine. (This is sometimes called the administration of the vaccine.)

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 150 Chapter 6 What you pay for Part D drugs Your costs for a Part D vaccine depend on 3 things:

1. Whether the vaccine is recommended for adults by an organization called the Advisory Committee on Immunization Practices (ACIP). • Most adult Part D vaccines are recommended by ACIP and cost you nothing.
2. Where you get the vaccine. • The vaccine itself may be dispensed by a pharmacy or provided by the doctor's office.
3. Who gives you the vaccine. • A pharmacist or another provider may give the vaccine in the pharmacy. Or, a provider may give it in the doctor's office. What you pay at the time you get the Part D vaccine can vary depending on the circumstances and what drug payment stage you're in. • When you get a vaccine, you may have to pay the entire cost for both the vaccine itself and the cost for the provider to give you the vaccine. You can ask our plan to pay you back for our share of the cost. For most adult Part D vaccines, this means you'll be reimbursed the entire cost you paid. • Other times when you get a vaccine, you pay only your share of the cost under your Part D benefit. For most adult Part D vaccines, you pay nothing. Below are 3 examples of ways you might get a Part D vaccine. Situation 1: You get the Part D vaccine at the network pharmacy. (Whether you have this choice depends on where you live. Some states don't allow pharmacies to give certain vaccines.) • For most adult Part D vaccines, you pay nothing. • For other Part D vaccines, you pay the pharmacy your coinsurance or copayment for the vaccine itself which includes the cost of giving you the vaccine. • Our plan will pay the remainder of the costs. Situation 2: You get the Part D vaccine at your doctor's office. • When you get the vaccine, you may have to pay the entire cost of the vaccine itself and the cost for the provider to give it to you. • You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 7.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 151 Chapter 6 What you pay for Part D drugs • For most adult Part D vaccines, you'll be reimbursed the full amount you paid. For other Part D vaccines, you'll be reimbursed the amount you paid less any coinsurance or copayment for the vaccine (including administration). Situation 3: You buy the Part D vaccine itself at the network pharmacy and take it to your doctor's office where they give you the vaccine. • For most adult Part D vaccines, you pay nothing for the vaccine itself. • For other Part D vaccines, you pay the pharmacy your coinsurance or copayment for the vaccine itself. • When your doctor gives you the vaccine, you may have to pay the entire cost for this service. • You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 7. • For most adult Part D vaccines, you'll be reimbursed the full amount you paid. For other Part D vaccines, you'll be reimbursed the amount you paid less any coinsurance or copayment for the vaccine administration.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 152 Chapter 7 Asking us to pay our share of a bill for covered medical services or drugs CHAPTER 7: Asking us to pay our share of a bill for covered medical services or drugs SECTION 1 Situations when you should ask us to pay our share for covered services or drugs Sometimes when you get medical care or a prescription drug, you may need to pay the full cost. Other times, you may find you pay more than you expected under the coverage rules of our plan, or you may get a bill from a provider. In these cases, you can ask our plan to pay you back (reimburse you). It's your right to be paid back by our plan whenever you've paid more than your share of the cost for medical services or drugs covered by our plan. There may be deadlines that you must meet to get paid back. Go to Section 2 of this chapter. There may also be times when you get a bill from a provider for the full cost of medical care you got or for more than your share of cost sharing. First, try to resolve the bill with the provider. If that doesn't work, send the bill to us instead of paying it. We'll look at the bill and decide whether the services should be covered. If we decide they should be covered, we'll pay the provider directly. If we decide not to pay it, we'll notify the provider. You should never pay more than plan-allowed cost sharing. If this provider is contracted, you still have the right to treatment. Examples of situations in which you may need to ask our plan to pay you back or to pay a bill you got:

1. When you got emergency or urgently needed medical care from a provider who's not in our plan's network Outside the service area, you can get emergency or urgently needed services from any provider, whether or not the provider is a part of our network. In these cases, • You're only responsible for paying your share of the cost for emergency or urgently needed services. Emergency providers are legally required to provide emergency care. • If you pay the entire amount yourself at the time you get the care, ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you made.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 153 Chapter 7 Asking us to pay our share of a bill for covered medical services or drugs • You may get a bill from the provider asking for payment you think you don't owe. Send us this bill, along with documentation of any payments you already made. • If the provider is owed anything, we'll pay the provider directly. • If you already paid more than your share of the cost of the service, we'll determine how much you owed and pay you back for our share of the cost.

2. When a network provider sends you a bill you think you shouldn't pay Network providers should always bill our plan directly and ask you only for your share of the cost. But sometimes they make mistakes and ask you to pay more than your share. • You only have to pay your cost-sharing amount when you get covered services. We don't allow providers to add additional separate charges, called balance billing. This protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service and even if there's a dispute and we don't pay certain provider charges. • Whenever you get a bill from a network provider you think is more than you should pay, send us the bill. We'll contact the provider directly and resolve the billing problem. • If you already paid a bill to a network provider, but feel you paid too much, send us the bill along with documentation of any payment you made and ask us to pay you back the difference between the amount you paid and the amount you owed under our plan.
3. If you're retroactively enrolled in our plan Sometimes a person's enrollment in our plan is retroactive. (This means that the first day of their enrollment has already passed. The enrollment date may even have occurred last year.) If you were retroactively enrolled in our plan and you paid out of pocket for any of your covered services or drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You need to submit paperwork such as receipts and bills for us to handle the reimbursement.
4. When you use an out-of-network pharmacy to fill a prescription If you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When that happens, you have to pay the full cost of your prescription. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. Remember that we only cover out-of-network pharmacies in limited circumstances. Go to Chapter 5, Section 2.4 to learn about these circumstances. We may

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 154 Chapter 7 Asking us to pay our share of a bill for covered medical services or drugs not pay you back the difference between what you paid for the drug at the out-of-network pharmacy and the amount we'd pay at an in-network pharmacy.

5. When you pay the full cost for a prescription because you don't have our plan membership card with you If you don't have our plan membership card with you, you can ask the pharmacy to call our plan or look up our plan enrollment information. If the pharmacy can't get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. We may not pay you back the full cost you paid if the cash price you paid is higher than our negotiated price for the prescription.
6. When you pay the full cost for a prescription in other situations You may pay the full cost of the prescription because you find the drug isn't covered for some reason. • For example, the drug may not be on our plan's “Drug List” or it could have a requirement or restriction you didn't know about or don't think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it. • Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor to pay you back for our share of the cost. We may not pay you back the full cost you paid if the cash price you paid is higher than our negotiated price for the prescription. When you send us a request for payment, we'll review your request and decide whether the service or drug should be covered. This is called making a coverage decision. If we decide it should be covered, we'll pay for our share of the cost for the service or drug. If we deny your request for payment, you can appeal our decision. Chapter 9 has information about how to make an appeal. SECTION 2 How to ask us to pay you back or pay a bill you got You can ask us to pay you back by sending us a request in writing. If you send a request in writing, send your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records. You must submit your claim to us within 365 days of the date you got the service, item, or drug.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 155 Chapter 7 Asking us to pay our share of a bill for covered medical services or drugs To make sure you're giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment. • You don't have to use the form, but it'll help us process the information faster. • Download a copy of the form from our website (www.aspirehealthplan.org) or call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) and ask for the form. Mail your request for payment together with any bills or paid receipts to us at this address: Aspire Health P.O. Box 5490 Salem, OR 97304 SECTION 3 We'll consider your request for payment and say yes or no When we get your request for payment, we'll let you know if we need any additional information from you. Otherwise, we'll consider your request and make a coverage decision. • If we decide the medical care or drug is covered and you followed all the rules, we'll pay for our share of the cost. Our share of the cost might not be the full amount you paid (for example, if you got a drug at an out-of-network pharmacy or if the cash price you paid for a drug is higher than our negotiated price). If you already paid for the service or drug, we'll mail your reimbursement of our share of the cost to you. If you haven't paid for the service or drug yet, we'll mail the payment directly to the provider. • If we decide the medical care or drug is not covered, or you did not follow all the rules, we won't pay for our share of the cost. We'll send you a letter explaining the reasons why we aren't sending the payment and your right to appeal that decision. Section 3.1 If we tell you that we won't pay for all or part of the medical care or drug, you can make an appeal If you think we made a mistake in turning down your request for payment or the amount we're paying, you can make an appeal. If you make an appeal, it means you're asking us to change the decision we made when we turned down your request for payment. The appeals process is a formal process with detailed procedures and important deadlines. For the details on how to make this appeal, go to Chapter 9.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 156 Chapter 8 Your rights and responsibilities CHAPTER 8: Your rights and responsibilities SECTION 1 Our plan must honor your rights and cultural sensitivities Section 1.1 We must provide information in a way that works for you and consistent with your cultural sensitivities (in languages other than English, braille, large print, or other alternate formats, etc.) Our plan is required to ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all enrollees, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. Examples of how our plan can meet these accessibility requirements include, but aren't limited to: provision of translator services, interpreter services, teletypewriters, or TTY (text telephone or teletypewriter phone) connection. Our plan has free interpreter services available to answer questions from non-English speaking members. We can also give you information in languages other than English including Spanish, braille, in large print, or other alternate formats at no cost if you need it. We're required to give you information about our plan's benefits in a format that's accessible and appropriate for you. To get information from us in a way that works for you, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). Our plan is required to give female enrollees the option of direct access to a women's health specialist within the network for women's routine and preventive health care services. If providers in our plan's network for a specialty aren't available, it's our plan's responsibility to locate specialty providers outside the network who will provide you with the necessary care. In this case, you'll only pay in-network cost sharing. If you find yourself in a situation where there are no specialists in our plan's network that cover a service you need, call our plan for information on where to go to get this service at in-network cost sharing. If you have any trouble getting information from our plan in a format that's accessible and appropriate for you, seeing a women's health specialist or finding a network specialist, call to file a grievance with Member Services (phone numbers are printed on the back cover of this document). You can also file a complaint with Medicare by calling 1-800-MEDICARE (1-800- 633-4227) or directly with the Office for Civil Rights 1-800-368-1019 or TTY 1-800-537-7697.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 157 Chapter 8 Your rights and responsibilities Section 1.1 Debemos proporcionarle información de una manera que sea conveniente para usted y conforme a sus sensibilidades culturales (en otros idiomas que no sean el inglés, en braille, en tamaño de letra grande, en otros formatos alternativos, etc.) Su plan tiene la obligación de garantizar que todos los servicios, tanto clínicos como no clínicos, se presten de forma culturalmente competente y sean accesibles para todos los miembros, incluidos los que tienen un dominio limitado del inglés, una capacidad limitada de lectura, una incapacidad auditiva o un origen cultural y étnico diverso. Algunos ejemplos de cómo un plan puede cumplir estos requisitos de accesibilidad incluyen, entre otros, la prestación de servicios de traducción, servicios de intérprete, teletipos o conexión TTY (teléfono de texto o teletipo). Nuestro plan cuenta con servicios de interpretación gratuitos disponibles para responder a las preguntas de los miembros que no hablan inglés. También podemos proporcionarle información en braille, en tamaño de letra grande o en otros formatos alternativos, sin costo alguno, si lo necesita. Debemos proporcionarle información sobre los beneficios del plan en un formato que sea accesible y adecuado para usted. Para obtener información sobre nosotros de una manera que sea conveniente para usted, llame a Servicios para los miembros. Nuestro plan tiene la obligación de ofrecer a las mujeres inscritas la opción de acceder directamente a un especialista en salud de las mujeres dentro de la red para servicios de atención médica preventivos y de rutina. Si los proveedores de una especialidad determinada no se encuentran disponibles en la red del plan, es responsabilidad del plan localizar proveedores de la especialidad fuera de la red que le proporcionen la atención necesaria. En este caso, solo pagará los costos compartidos dentro de la red. Si se encuentra en una situación en la que no hay especialistas en la red del plan que cubran un servicio que usted necesita, comuníquese con el plan para que le informen sobre dónde acudir para obtener este servicio con un costo compartido dentro de la red. Si tiene alguna dificultad para obtener información sobre nuestro plan en un formato que sea accesible y adecuado para usted, consultar con un especialista en salud de las mujeres o encontrar un especialista dentro de la red, llámenos para presentar un reclamo ante Servicios para los miembros (los números de teléfono están impresos en la contraportada de este documento). También puede presentar una queja ante Medicare llamando al 1-800- MEDICARE (1-800-633-4227) o directamente ante la Oficina de Derechos Civiles (Office for Civil Rights) al 1-800-368-1019 o al TTY 1-800-537-7697

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 158 Chapter 8 Your rights and responsibilities Section 1.2 We must ensure you get timely access to covered services and drugs You have the right to choose a primary care provider (PCP) in our plan's network to provide and arrange for your covered services. We don't require you to get referrals. You have the right to get appointments and covered services from our plan's network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays. If you think you aren't getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9 tells what you can do. Section 1.3 We must protect the privacy of your personal health information Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. • Your personal health information includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information. • You have rights related to your information and controlling how your health information is used. We give you a written notice, called a Notice of Privacy Practice, that tells about these rights and explains how we protect the privacy of your health information. How do we protect the privacy of your health information? • We make sure that unauthorized people don't see or change your records. • Except for the circumstances noted below, if we intend to give your health information to anyone who isn't providing your care or paying for your care, we are required to get written permission from you or someone you have given legal power to make decisions for you first. • There are certain exceptions that don't require us to get your written permission first. These exceptions are allowed or required by law. • We're required to release health information to government agencies that are checking on quality of care. • Because you're a member of our plan through Medicare, we're required to give Medicare your health information including information about your Part D drugs. If Medicare releases your information for research or other uses, this will

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 159 Chapter 8 Your rights and responsibilities be done according to federal statutes and regulations; typically, this requires that information that uniquely identifies you not be shared. You can see the information in your records and know how it's been shared with others You have the right to look at your medical records held by our plan, and to get a copy of your records. We're allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we'll work with your health care provider to decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that aren't routine. If you have questions or concerns about the privacy of your personal health information, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). Section 1.4 We must give you information about our plan, our network of providers, and your covered services As a member of Aspire Health Advantage (HMO), you have the right to get several kinds of information from us. If you want any of the following kinds of information, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711): • Information about our plan. This includes, for example, information about our plan's financial condition. • Information about our network providers and pharmacies. You have the right to get information about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network. • Information about your coverage and the rules you must follow when using your coverage. Chapters 3 and 4 provide information regarding medical services. Chapters 5 and 6 provide information about Part D drug coverage. • Information about why something is not covered and what you can do about it. Chapter 9 provides information on asking for a written explanation on why a medical service or Part D drug isn't covered or if your coverage is restricted. Chapter 9 also provides information on asking us to change a decision, also called an appeal.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 160 Chapter 8 Your rights and responsibilities Section 1.5 You have the right to know your treatment options and participate in decisions about your care You have the right to get full information from your doctors and other health care providers. Your providers must explain your medical condition and your treatment choices in a way that you can understand. You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following: • To know about all your choices. You have the right to be told about all treatment options recommended for your condition, no matter what they cost or whether they're covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely. • To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments. • The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. If you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result. You have the right to give instructions about what's to be done if you can't make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you're in this situation. This means if you want to, you can: • Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself. • Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. Legal documents you can use to give directions in advance of these situations are called advance directives. Documents like a living will and power of attorney for health care are examples of advance directives

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 161 Chapter 8 Your rights and responsibilities How to set up an advance directive to give instructions: • Get a form. You can get an advance directive form from your lawyer, a social worker, or some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) to ask for the forms. • Fill out the form and sign it. No matter where you get this form, it's a legal document. Consider having a lawyer help you prepare it. • Give copies of the form to the right people. Give a copy of the form to your doctor and to the person you name on the form who can make decisions for you if you can't. You may want to give copies to close friends or family members. Keep a copy at home. If you know ahead of time that you're going to be hospitalized, and you signed an advance directive, take a copy with you to the hospital. • The hospital will ask whether you signed an advance directive form and whether you have it with you. • If you didn't sign an advance directive form, the hospital has forms available and will ask if you want to sign one. Filling out an advance directive is your choice (including whether you want to sign one if you're in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you signed an advance directive. If your instructions aren't followed If you sign an advance directive and you believe that a doctor or hospital didn't follow the instructions in it, you can file a complaint with the California Department of Public Health at (916) 558-1784 or TDD (800) 735-2929. Section 1.6 You have the right to make complaints and ask us to reconsider decisions we made If you have any problems, concerns, or complaints and need to ask for coverage, or make an appeal, Chapter 9 of this document tells what you can do. Whatever you do - ask for a coverage decision, make an appeal, or make a complaint - we're required to treat you fairly.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 162 Chapter 8 Your rights and responsibilities Section 1.7 If you believe you're being treated unfairly, or your rights aren't being respected If you believe you've been treated unfairly or your rights haven't been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 (TTY users call 1-800-537-7697), or call your local Office for Civil Rights. If you believe you've been treated unfairly or your rights haven't been respected and it's not about discrimination, you can get help dealing with the problem you're having from these places: • Call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) • Call your local SHIP at Local: (831) 655-4249 Toll Free: (800) 434-0222. (TTY users call 1-800-735-2929) • Call Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY users call 1-877-486-2048) Section 1.8 How to get more information about your rights Get more information about your rights from these places: • Call our plan's Member Services at Toll Free: (855) 570-1600 (TTY users call 711) • Call your local SHIP at Local: (831) 655-4249 Toll Free: (800) 434-0222. (TTY users call 1-800-735-2929) • Contact Medicare • Visit www.Medicare.govto read the publication Medicare Rights & Protections. (available at: www.Medicare.gov/publications/11534-medicare-rights-and- protections.pdf) • Call 1-800-MEDICARE (1-800-633-4227) (TTY users call 1-877-486-2048) SECTION 2 Your responsibilities as a member of our plan Things you need to do as a member of our plan are listed below. For questions, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). • Get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidence of Coverage to learn what's covered and the rules you need to follow to get covered services. • Chapters 3 and 4 give details about medical services.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 163 Chapter 8 Your rights and responsibilities • Chapters 5 and 6 give details about Part D drug coverage. • If you have any other health coverage or drug coverage in addition to our plan, you're required to tell us. Chapter 1 tells you about coordinating these benefits. • Tell your doctor and other health care providers that you're enrolled in our plan. Show our plan membership card whenever you get medical care or Part D drugs. • Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. • To help get the best care, tell your doctors and other health providers about your health problems. Follow the treatment plans and instructions you and your doctors agree on. • Make sure your doctors know all the drugs you're taking, including over-the- counter drugs, vitamins, and supplements. • If you have questions, be sure to ask and get an answer you can understand. • Be considerate. We expect our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor's office, hospitals, and other offices. • Pay what you owe. As a plan member, you're responsible for these payments: • You must pay our plan premiums. • You must continue to pay a premium for your Medicare Part B to stay a member of our plan. • For most of your medical services or drugs covered by our plan, you must pay your share of the cost when you get the service or drug. • If you're required to pay a late enrollment penalty, you must pay the penalty to keep your drug coverage. • If you're required to pay the extra amount for Part D because of your yearly income, you must continue to pay the extra amount directly to the government to stay a member of our plan. • If you move within our plan service area, we need to know so we can keep your membership record up to date and know how to contact you. • If you move outside our plan service area, you can't stay a member of our plan. • If you move, tell Social Security (or the Railroad Retirement Board).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 164 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) CHAPTER 9: If you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 1 What to do if you have a problem or concern This chapter explains 2 types of processes for handling problems and concerns: • For some problems, you need to use the process for coverage decisions and appeals. • For other problems, you need to use the process for making complaints (also called grievances). Both processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that must be followed by us and by you. The information in this chapter will help you identify the right process to use and what to do. Section 1.1 Legal terms There are legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people. To make things easier, this chapter uses more familiar words in place of some legal terms. However, it's sometimes important to know the correct legal terms. To help you know which terms to use to get the right help or information, we include these legal terms when we give details for handling specific situations. SECTION 2 Where to get more information and personalized help We're always available to help you. Even if you have a complaint about our treatment of you, we're obligated to honor your right to complain. You should always call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) for help. In some situations, you may also want help or guidance from someone who isn't connected with us. Two organizations that can help you are:

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 165 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) State Health Insurance Assistance Program (SHIP) Each state has a government program with trained counselors. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you're having. They can also answer questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. Local: (831) 655-4249 Toll Free: (800) 434-0222 (TTY users call 1-800-735-2929). Medicare You can also contact Medicare for help: • Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1- 877-486-2048. • Visit www.Medicare.gov. SECTION 3 Which process to use for your problem Is your problem or concern about your benefits or coverage? This includes problems about whether medical care (medical items, services and/or Part B drugs) are covered or not, the way they are covered, and problems related to payment for medical care. Yes. Go to Section 4, A guide to coverage decisions and appeals. No. Go to Section 10, How to make a complaint about quality of care, waiting times, customer service or other concerns. Coverage decisions and appeals SECTION 4 A guide to coverage decisions and appeals Coverage decisions and appeals deal with problems about your benefits and coverage for your medical care (services, items, and Part B drugs, including payment). To keep things simple, we generally refer to medical items, services, and Medicare Part B drugs as medical

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 166 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) care. You use the coverage decision and appeals process for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions before you get services If you want to know if we'll cover medical care before you get it, you can ask us to make a coverage decision for you. A coverage decision is a decision we make about your benefits and coverage or about the amount we'll pay for your medical care. For example, if our plan network doctor refers you to a medical specialist not inside the network, this referral is considered a favorable coverage decision unless either you or your network doctor can show that you got a standard denial notice for this medical specialist, or the Evidence of Coverage makes it clear that the referred service is never covered under any condition. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we'll cover a particular medical service or refuses to provide medical care you think you need. In limited circumstances a request for a coverage decision will be dismissed, which means we won't review the request. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the request on your behalf but isn't legally authorized to do so or if you ask for your request to be withdrawn. If we dismiss a request for a coverage decision, we'll send a notice explaining why the request was dismissed and how to ask for a review of the dismissal. We make a coverage decision whenever we decide what's covered for you and how much we pay. In some cases, we might decide medical care isn't covered or is no longer covered for you. If you disagree with this coverage decision, you can make an appeal.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 167 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Making an appeal If we make a coverage decision, whether before or after you get a benefit, and you aren't satisfied, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we made. Under certain circumstances, you can ask for an expedited or fast appeal of a coverage decision. Your appeal is handled by different reviewers than those who made the original decision. When you appeal a decision for the first time, this is called a Level 1 appeal. In this appeal, we review the coverage decision we made to check to see if we properly followed the rules. When we complete the review, we give you our decision. In limited circumstances, a request for a Level 1 appeal will be dismissed, which means we won't review the request. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the request on your behalf but isn't legally authorized to do so, or if you ask for your request to be withdrawn. If we dismiss a request for a Level 1 appeal, we'll send a notice explaining why the request was dismissed and how to ask for a review of the dismissal. If we say no to all or part of your Level 1 appeal for medical care, your appeal will automatically go to a Level 2 appeal conducted by an independent review organization not connected to us. • You don't need to do anything to start a Level 2 appeal. Medicare rules require we automatically send your appeal for medical care to Level 2 if we don't fully agree with your Level 1 appeal. • Go to Section 5.4 for more information about Level 2 appeals for medical care. • Part D appeals are discussed further in Section 6. If you aren't satisfied with the decision at the Level 2 appeal, you may be able to continue through additional levels of appeal (this chapter explains the Level 3, 4, and 5 appeals processes). Section 4.1 Get help asking for a coverage decision or making an appeal Here are resources if you decide to ask for any kind of coverage decision or appeal a decision: • Call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). • Get free help from your State Health Insurance Assistance Program.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 168 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • Your doctor can make a request for you. If your doctor helps with an appeal past Level 2, they need to be appointed as your representative. Call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) and ask for the Appointment of Representative form. (The form is also available at www.CMS.gov/Medicare/CMS- Forms/CMS-Forms/downloads/cms1696.pdf or on our website at www.aspirehealthplan.org.) • For medical care or Part B drugs, your doctor can ask for a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2. • For Part D drugs, your doctor or other prescriber can ask for a coverage decision or a Level 1 appeal on your behalf. If your Level 1 appeal is denied, your doctor or prescriber can ask for a Level 2 appeal. • You can ask someone to act on your behalf. You can name another person to act for you as your representative to ask for a coverage decision or make an appeal. • If you want a friend, relative, or other person to be your representative, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) and ask for the Appointment of Representative form. (The form is also available at www.CMS.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or on our website at www.aspirehealthplan.org.) This form gives that person permission to act on your behalf. It must be signed by you and by the person you want to act on your behalf. You must give us a copy of the signed form. • We can accept an appeal request from a representative without the form, but we can't complete our review until we get it. If we don't get the form before our deadline for making a decision on your appeal, your appeal request will be dismissed. If this happens, we'll send you a written notice explaining your right to ask the independent review organization to review our decision to dismiss your appeal. • You also have the right to hire a lawyer. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are groups that will give you free legal services if you qualify. However, you aren't required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. Section 4.2 Rules and deadlines for different situations There are 4 different situations that involve coverage decisions and appeals. Each situation has different rules and deadlines. We give the details for each of these situations: • Section 5: Medical care: How to ask for a coverage decision or make an appeal • Section 6: Part D drugs: How to ask for a coverage decision or make an appeal

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 169 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • Section 7: How to ask us to cover a longer inpatient hospital stay if you think you're being discharged too soon • Section 8: How to ask us to keep covering certain medical services if you think your coverage is ending too soon (Applies only to these services: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services) If you're not sure which information applies to you, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). You can also get help or information from your SHIP. SECTION 5 Medical care: How to ask for a coverage decision or make an appeal Section 5.1 What to do if you have problems getting coverage for medical care or want us to pay you back for our share of the cost of your care Your benefits for medical care are described in Chapter 4 in the Medical Benefits Chart. In some cases, different rules apply to a request for a Part B drug. In those cases, we'll explain how the rules for Part B drugs are different from the rules for medical items and services. This section tells what you can do if you're in any of the 5 following situations:

1. You aren't getting certain medical care you want, and you believe this is covered by our plan. Ask for a coverage decision. Section 5.2.
2. Our plan won't approve the medical care your doctor or other medical provider wants to give you, and you believe this care is covered by our plan. Ask for a coverage decision. Section 5.2.
3. You got medical care that you believe should be covered by our plan, but we said we won't pay for this care. Make an appeal. Section 5.3.
4. You got and paid for medical care that you believe should be covered by our plan, and you want to ask our plan to reimburse you for this care. Send us the bill. Section 5.5.
5. You're told that coverage for certain medical care you've been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health. Make an appeal. Section 5.3. Note: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, go to Sections 7 and 8. Special rules apply to these types of care.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 170 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Section 5.2 How to ask for a coverage decision Legal Terms: A coverage decision that involves your medical care is called an organization determination. A fast coverage decision is called an expedited determination. Step 1: Decide if you need a standard coverage decision or a fast coverage decision. A standard coverage decision is usually made within 7 calendar days when the medical item or service is subject to our prior authorization rules, 14 calendar days for all other medical items and services, or 72 hours for Part B drugs. A fast coverage decision is generally made within 72 hours, for medical services, or 24 hours for Part B drugs. To get a fast coverage decision, you must meet 2 requirements: • You may only ask for coverage for medical items and/or services (not requests for payment for items and/or services you already got). • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to regain function. If your doctor tells us that your health requires a fast coverage decision, we'll automatically agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own, without your doctor's support, we'll decide whether your health requires that we give you a fast coverage decision. If we don't approve a fast coverage decision, we'll send you a letter that: • Explains that we'll use the standard deadlines • Explains if your doctor asks for the fast coverage decision, we'll automatically give you a fast coverage decision • Explains that you can file a fast complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you asked for Step 2: Ask our plan to make a coverage decision or fast coverage decision. • Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. Chapter 2 has contact information.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 171 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Step 3: We consider your request for medical care coverage and give you our answer. For standard coverage decisions we use the standard deadlines. This means we'll give you an answer within 7 calendar days after we get your request for a medical item or service that is subject to our prior authorization rules. If your requested medical item or service is not subject to our prior authorization rules, we'll give you an answer within 14 calendar days after we get your request. If your request is for a Part B drug, we'll give you an answer within 72 hours after we get your request. • However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we'll tell you in writing. We can't take extra time to make a decision if your request is for a Part B drug. • If you believe we shouldn't take extra days, you can file a fast complaint. We'll give you an answer to your complaint as soon as we make the decision. (The process for making a complaint is different from the process for coverage decisions and appeals. Go to Section 10 for information on complaints.) For fast coverage decisions we use an expedited timeframe A fast coverage decision means we'll answer within 72 hours if your request is for a medical item or service. If your request is for a Part B drug, we'll answer within 24 hours. • However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we'll tell you in writing. We can't take extra time to make a decision if your request is for a Part B drug. • If you believe we shouldn't take extra days, you can file a fast complaint. (Go to Section 10 for information on complaints.) We'll call you as soon as we make the decision. • If our answer is no to part or all of what you asked for, we'll send you a written statement that explains why we said no. Step 4: If we say no to your request for coverage for medical care, you can appeal. • If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the medical care coverage you want. If you make an appeal, it means you're going on to Level 1 of the appeals process.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 172 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Section 5.3 How to make a Level 1 appeal Legal Terms: An appeal to our plan about a medical care coverage decision is called a plan reconsideration. A fast appeal is also called an expedited reconsideration. Step 1: Decide if you need a standard appeal or a fast appeal. A standard appeal is usually made within 30 calendar days or 7 calendar days for Part B drugs. A fast appeal is generally made within 72 hours. • If you're appealing a decision we made about coverage for care, you and/or your doctor need to decide if you need a fast appeal. If your doctor tells us that your health requires a fast appeal, we'll give you a fast appeal. • The requirements for getting a fast appeal are the same as those for getting a fast coverage decision in Section 5.2. Step 2: Ask our plan for an appeal or a fast appeal • If you're asking for a standard appeal, submit your standard appeal in writing. You may also ask for an appeal by calling us. Chapter 2 has contact information. • If you're asking for a fast appeal, make your appeal in writing or call us. Chapter 2 has contact information. • You must make your appeal request within 65 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for asking for an appeal. • You can ask for a copy of the information regarding your medical decision. You and your doctor may add more information to support your appeal. We're allowed to charge a fee for copying and sending this information to you. Step 3: We consider your appeal and we give you our answer. • When our plan is reviewing your appeal, we take a careful look at all the information. We check to see if we followed all the rules when we said no to your request. • We'll gather more information if needed and may contact you or your doctor.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 173 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Deadlines for a fast appeal • For fast appeals, we must give you our answer within 72 hours after we get your appeal. We'll give you our answer sooner if your health requires us to. • If you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we'll tell you in writing. We can't take extra time if your request is for a Part B drug. • If we don't give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we're required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 5.4 explains the Level 2 appeal process. • If our answer is yes to part or all of what you asked for, we must authorize or provide the coverage we agreed to within 72 hours after we get your appeal. • If our answer is no to part or all of what you asked for, we'll automatically forward your appeal to the independent review organization for a Level 2 appeal. The independent review organization will notify you in writing when it gets your appeal. Deadlines for a standard appeal • For standard appeals, we must give you our answer within 30 calendar days after we get your appeal. If your request is for a Part B drug you didn't get yet, we'll give you our answer within 7 calendar days after we receive your appeal. We'll give you our decision sooner if your health condition requires us to. • If you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we'll tell you in writing. We can't take extra time to make a decision if your request is for a Part B drug. • If you believe we shouldn't take extra days, you can file a fast complaint. When you file a fast complaint, we'll give you an answer to your complaint within 24 hours. (Go to Section 10 of this chapter for information on complaints.) • If we don't give you an answer by the deadline (or by the end of the extended time period), we'll send your request to a Level 2 appeal where an independent review organization will review the appeal. Section 5.4 explains the Level 2 appeal process. • If our answer is yes to part or all of what you asked for, we must authorize or provide the coverage within 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your request is for a Part B drug.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 174 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • If our plan says no to part or all of your appeal, we'll automatically send your appeal to the independent review organization for a Level 2 appeal. Section 5.4 The Level 2 appeal process Legal Term: The formal name for the independent review organization is the Independent Review Entity. It's sometimes called the IRE. The independent review organization is an independent organization hired by Medicare. It isn't connected with us and isn't a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: The independent review organization reviews your appeal. • We'll send the information about your appeal to this organization. This information is called your case file. You have the right to ask us for a copy of your case file. We're allowed to charge you a fee for copying and sending this information to you. • You have a right to give the independent review organization additional information to support your appeal. • Reviewers at the independent review organization will take a careful look at all the information about your appeal. If you had a fast appeal at Level 1, you'll also have a fast appeal at Level 2. • For the fast appeal, the independent review organization must give you an answer to your Level 2 appeal within 72 hours of when it gets your appeal. • If your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The independent review organization can't take extra time to make a decision if your request is for a Part B drug. If you had a standard appeal at Level 1, you'll also have a standard appeal at Level 2. • For the standard appeal, if your request is for a medical item or service, the independent review organization must give you an answer to your Level 2 appeal within 30 calendar days of when it gets your appeal. • If your request is for a Part B drug, the independent review organization must give you an answer to your Level 2 appeal within 7 calendar days of when it gets your appeal. • If your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 175 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) to 14 more calendar days. The independent review organization can't take extra time to make a decision if your request is for a Part B drug. Step 2: The independent review organization gives you its answer. The independent review organization will tell you its decision in writing and explain the reasons for it. • If the independent review organization says yes to part or all of a request for a medical item or service, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we get the decision from the independent review organization for standard requests. For expedited requests, we have 72 hours from the date we get the decision from the independent review organization. • If the independent review organization says yes to part or all of a request for a Part B drug, we must authorize or provide the Part B drug within 72 hours after we get the decision from the independent review organization for standard requests. For expedited requests we have 24 hours from the date we get the decision from the independent review organization. • If this organization says no to part or all of your appeal, it means it agrees with us that your request (or part of your request) for coverage for medical care shouldn't be approved. (This is called upholding the decision or turning down your appeal.) In this case, the independent review organization will send you a letter that: • Explains the decision. • Lets you know about your right to a Level 3 appeal if the dollar value of the medical care coverage meets a certain minimum. The written notice you get from the independent review organization will tell you the dollar amount you must meet to continue the appeals process. • Tells you how to file a Level 3 appeal. Step 3: If your case meets the requirements, you choose whether you want to take your appeal further. • There are 3 additional levels in the appeals process after Level 2 (for a total of 5 levels of appeal). If you want to go to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal. • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 explains the Levels 3, 4, and 5 appeals processes.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 176 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Section 5.5 If you're asking us to pay for our share of a bill you got for medical care Chapter 7 describes when you may need to ask for reimbursement or to pay a bill you got from a provider. It also tells how to send us the paperwork that asks us for payment. Asking for reimbursement is asking for a coverage decision from us If you send us the paperwork asking for reimbursement, you're asking for a coverage decision. To make this decision, we'll check to see if the medical care you paid for is covered. We'll also check to see if you followed the rules for using your coverage for medical care. • If we say yes to your request: If the medical care is covered and you followed the rules, we'll send you the payment for our share of the cost typically within 30 calendar days, but no later than 60 calendar days after we get your request. If you haven't paid for the medical care, we'll send the payment directly to the provider. • If we say no to your request: If the medical care is not covered, or you did not follow all the rules, we won't send payment. Instead, we'll send you a letter that says we won't pay for the medical care and the reasons why. If you don't agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you're asking us to change the coverage decision we made when we turned down your request for payment. To make this appeal, follow the process for appeals in Section 5.3. For appeals concerning reimbursement, note: • We must give you our answer within 60 calendar days after we get your appeal. If you're asking us to pay you back for medical care you already got and paid for, you aren't allowed to ask for a fast appeal. • If the independent review organization decides we should pay, we must send you or the provider the payment within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or the provider within 60 calendar days.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 177 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 6 Part D drugs: How to ask for a coverage decision or make an appeal Section 6.1 What to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits include coverage for many prescription drugs. To be covered, the drug must be used for a medically accepted indication. (Go to Chapter 5 for more information about a medically accepted indication.) For details about Part D drugs, rules, restrictions, and costs go to Chapters 5 and 6. This section is about your Part D drugs only. To keep things simple, we generally say drug in the rest of this section, instead of repeating covered outpatient prescription drug or Part D drug every time. We also use the term Drug List instead of List of Covered Drugs or formulary. • If you don't know if a drug is covered or if you meet the rules, you can ask us. Some drugs require you to get approval from us before we'll cover it. • If your pharmacy tells you that your prescription can't be filled as written, the pharmacy will give you a written notice explaining how to contact us to ask for a coverage decision. Part D coverage decisions and appeals Legal Term: An initial coverage decision about your Part D drugs is called a coverage determination. A coverage decision is a decision we make about your benefits and coverage or about the amount we'll pay for your drugs. This section tells what you can do if you're in any of the following situations: • Asking to cover a Part D drug that's not on our plan's Drug List. Ask for an exception. Section 6.2 • Asking to waive a restriction on our plan's coverage for a drug (such as limits on the amount of the drug you can get, prior authorization criteria, or the requirement to try another drug first). Ask for an exception. Section 6.2 • Asking to pay a lower cost-sharing amount for a covered drug on a higher cost-sharing tier. Ask for an exception. Section 6.2 • Asking to get pre-approval for a drug. Ask for a coverage decision. Section 6.4 • Pay for a prescription drug you already bought. Ask us to pay you back. Section 6.4

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 178 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) If you disagree with a coverage decision we made, you can appeal our decision. This section tells you both how to ask for coverage decisions and how to ask for an appeal. Section 6.2 Asking for an exception Legal Terms: Asking for coverage of a drug that's not on the Drug List is a formulary exception. Asking for removal of a restriction on coverage for a drug is a formulary exception. Asking to pay a lower price for a covered non-preferred drug is a tiering exception. If a drug isn't covered in the way you'd like it to be covered, you can ask us to make an exception. An exception is a type of coverage decision. For us to consider your exception request, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Here are 3 examples of exceptions that you or your doctor or other prescriber can ask us to make:

1. Covering a Part D drug that's not on our Drug List. If we agree to cover a drug not on the Drug List, you'll need to pay the cost-sharing amount that applies to drugs in Tier-5 . You can't ask for an exception to the cost-sharing amount we require you to pay for the drug.
2. Removing a restriction for a covered drug. Chapter 5 describes the extra rules or restrictions that apply to certain drugs on our Drug List. If we agree to make an exception and waive a restriction for you, you can ask for an exception to the cost-sharing amount we require you to pay for the drug.
3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Drug List is in one of 6 cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you pay as your share of the cost of the drug. • If our Drug List contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost-sharing amount that applies to the alternative drug(s). • If the drug you're taking is a biological product, you can ask us to cover your drug at a lower cost-sharing amount. This would be the lowest tier that contains biological product alternatives for treating your condition.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 179 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • If the drug you're taking is a brand name drug, you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition. • If the drug you're taking is a generic drug, you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition. • You can't ask us to change the cost-sharing tier for any drug in Specialty Tier (Tier 5). • If we approve your tiering exception request and there's more than one lower cost- sharing tier with alternative drugs you can't take, you usually pay the lowest amount. Section 6.3 Important things to know about asking for exceptions Your doctor must tell us the medical reasons Your doctor or other prescriber must give us a statement that explains the medical reasons you're asking for an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Our Drug List typically includes more than one drug for treating a particular condition. These different possibilities are called alternative drugs. If an alternative drug would be just as effective as the drug you're asking for and wouldn't cause more side effects or other health problems, we generally won't approve your request for an exception. If you ask us for a tiering exception, we generally won't approve your request for an exception unless all the alternative drugs in the lower cost-sharing tier(s) won't work as well for you or are likely to cause an adverse reaction or other harm. We can say yes or no to your request • If we approve your request for an exception, our approval usually is valid until the end of our plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. • If we say no to your request, you can ask for another review by making an appeal.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 180 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Section 6.4 How to ask for a coverage decision, including an exception Legal Term: A fast coverage decision is called an expedited coverage determination. Step 1: Decide if you need a standard coverage decision or a fast coverage decision. Standard coverage decisions are made within 72 hours after we get your doctor's statement. Fast coverage decisions are made within 24 hours after we get your doctor's statement. If your health requires it, ask us to give you a fast coverage decision. To get a fast coverage decision, you must meet 2 requirements: • You must be asking for a drug you didn't get yet. (You can't ask for fast coverage decision to be paid back for a drug you have already bought.) • Using the standard deadlines could cause serious harm to your health or hurt your ability to function. • If your doctor or other prescriber tells us that your health requires a fast coverage decision, we'll automatically give you a fast coverage decision. • If you ask for a fast coverage decision on your own, without your doctor or prescriber's support, we'll decide whether your health requires that we give you a fast coverage decision. If we don't approve a fast coverage decision, we'll send you a letter that: • Explains that we'll use the standard deadlines. • Explains if your doctor or other prescriber asks for the fast coverage decision, we'll automatically give you a fast coverage decision. • Tells you how you can file a fast complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you asked for. We'll answer your complaint within 24 hours of receipt. Step 2: Ask for a standard coverage decision or a fast coverage decision. Start by calling, writing, or faxing our plan to ask us to authorize or provide coverage for the medical care you want. You can also access the coverage decision process through our website. We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form or on our plan's form, which are available on our website www.aspirehealthplan.org. Chapter 2 has contact information. You may also submit a coverage determination request through a secure member portal. The following link will

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 181 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) allow you to submit a coverage request electronically to our partner, MedImpact (https://mp.medimpact.com/partdcoveragedeterminations). To help us process your request, include your name, contact information, and information that shows which denied claim is being appealed. You, your doctor (or other prescriber), or your representative can do this. You can also have a lawyer act on your behalf. Section 4 tells how you can give written permission to someone else to act as your representative. • If you're asking for an exception, provide the supporting statement which is the medical reasons for the exception. Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary. Step 3: We consider your request and give you our answer. Deadlines for a fast coverage decision • We must generally give you our answer within 24 hours after we get your request. • For exceptions, we'll give you our answer within 24 hours after we get your doctor's supporting statement. We'll give you our answer sooner if your health requires us to. • If we don't meet this deadline, we're required to send your request to Level 2 of the appeals process, where it will be reviewed by an independent review organization. • If our answer is yes to part or all of what you asked for, we must provide the coverage we agreed to within 24 hours after we get your request or doctor's statement supporting your request. • If our answer is no to part or all of what you asked for, we'll send you a written statement that explains why we said no. We'll also tell you how you can appeal. Deadlines for a standard coverage decision about a drug you didn't get yet • We must generally give you our answer within 72 hours after we get your request. • For exceptions, we'll give you our answer within 72 hours after we get your doctor's supporting statement. We'll give you our answer sooner if your health requires us to. • If we don't meet this deadline, we're required to send your request to Level 2 of the appeals process, where it'll be reviewed by an independent review organization.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 182 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • If our answer is yes to part or all of what you asked for, we must provide the coverage we agreed to within 72 hours after we get your request or doctor's statement supporting your request. • If our answer is no to part or all of what you asked for, we'll send you a written statement that explains why we said no. We'll also tell you how you can appeal. Deadlines for a standard coverage decision about payment for a drug you have already bought • We must give you our answer within 14 calendar days after we get your request. • If we don't meet this deadline, we're required to send your request to Level 2 of the appeals process, where it will be reviewed by an independent review organization. • If our answer is yes to part or all of what you asked for, we're also required to make payment to you within 14 calendar days after we get your request. • If our answer is no to part or all of what you asked for, we'll send you a written statement that explains why we said no. We'll also tell you how you can appeal. Step 4: If we say no to your coverage request, you can make an appeal. • If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the drug coverage you want. If you make an appeal, it means you're going to Level 1 of the appeals process. Section 6.5 How to make a Level 1 appeal Legal Terms: An appeal to our plan about a Part D drug coverage decision is called a plan redetermination. A fast appeal is called an expedited redetermination. Step 1: Decide if you need a standard appeal or a fast appeal. A standard appeal is usually made within 7 calendar days. A fast appeal is generally made within 72 hours. If your health requires it, ask for a fast appeal. • If you're appealing a decision we made about a drug you didn't get yet, you and your doctor or other prescriber will need to decide if you need a fast appeal.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 183 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • The requirements for getting a fast appeal are the same as those for getting a fast coverage decision in Section 6.4 of this chapter. Step 2: You, your representative, doctor or other prescriber must contact us and make your Level 1 appeal. If your health requires a quick response, you must ask for a fast appeal. • For standard appeals, submit a written request or call us. Chapter 2 has contact information. • For fast appeals either submit your appeal in writing or call us at (Toll Free: (888) 495-3160). Chapter 2 has contact information. • We must accept any written request, including a request submitted on the CMS Model Redetermination Request Form, which is available on our website www.aspirehealthplan.org. Include your name, contact information, and information about your claim to help us process your request. • You must make your appeal request within 65 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for asking for an appeal. • You can ask for a copy of the information in your appeal and add more information. You and your doctor may add more information to support your appeal. We're allowed to charge a fee for copying and sending this information to you. Step 3: We consider your appeal and give you our answer. • When we review your appeal, we take another careful look at all the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information. Deadlines for a fast appeal • For fast appeals, we must give you our answer within 72 hours after we get your appeal. We'll give you our answer sooner if your health requires us to. • If we don't give you an answer within 72 hours, we're required to send your request to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 6.6 explains the Level 2 appeal process.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 184 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • If our answer is yes to part or all of what you asked for, we must provide the coverage we agreed to within 72 hours after we get your appeal. • If our answer is no to part or all of what you asked for, we'll send you a written statement that explains why we said no and how you can appeal our decision. Deadlines for a standard appeal for a drug you didn't get yet • For standard appeals, we must give you our answer within 7 calendar days after we get your appeal. We'll give you our decision sooner if you didn't get the drug yet and your health condition requires us to do so. • If we don't give you a decision within 7 calendar days, we're required to send your request to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 6.6 explains the Level 2 appeal process. • If our answer is yes to part or all of what you asked for, we must provide the coverage as quickly as your health requires, but no later than 7 calendar days after we get your appeal. • If our answer is no to part or all of what you asked for, we'll send you a written statement that explains why we said no and how you can appeal our decision. Deadlines for a standard appeal about payment for a drug you already bought • We must give you our answer within 14 calendar days after we get your request. • If we don't meet this deadline, we're required to send your request to Level 2 of the appeals process, where it will be reviewed by an independent review organization. • If our answer is yes to part or all of what you asked for, we're also required to make payment to you within 30 calendar days after we get your request. • If our answer is no to part or all of what you asked for, we'll send you a written statement that explains why we said no. We'll also tell you how you can appeal. Step 4: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal. • If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 185 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Section 6.6 How to make a Level 2 appeal Legal Term: The formal name for the independent review organization is the Independent Review Entity. It is sometimes called the IRE. The independent review organization is an independent organization hired by Medicare. It is not connected with us and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: You (or your representative or your doctor or other prescriber) must contact the independent review organization and ask for a review of your case. • If we say no to your Level 1 appeal, the written notice we send you will include instructions on how to make a Level 2 appeal with the independent review organization. These instructions will tell who can make this Level 2 appeal, what deadlines you must follow, and how to reach the independent review organization. • You must make your appeal request within 65 calendar days from the date on the written notice. • If we did not complete our review within the applicable timeframe, or make an unfavorable decision regarding an at-risk determination under our drug management program, we'll automatically forward your request to the IRE. • We'll send the information about your appeal to the independent review organization. This information is called your case file. You have the right to ask us for a copy of your case file. We're allowed to charge you a fee for copying and sending this information to you. • You have a right to give the independent review organization additional information to support your appeal. Step 2: The independent review organization reviews your appeal. Reviewers at the independent review organization will take a careful look at all the information about your appeal. Deadlines for fast appeal • If your health requires it, ask the independent review organization for a fast appeal. • If the organization agrees to give you a fast appeal, the organization must give you an answer to your Level 2 appeal within 72 hours after it receives your appeal request.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 186 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Deadlines for standard appeal • For standard appeals, the independent review organization must give you an answer to your Level 2 appeal within 7 calendar days after it receives your appeal if it is for a drug you didn't get yet. If you're asking us to pay you back for a drug you already bought, the independent review organization must give you an answer to your Level 2 appeal within 14 calendar days after it gets your request. Step 3: The independent review organization gives you its answer. For fast appeals: • If the independent review organization says yes to part or all of what you asked for, we must provide the drug coverage that was approved by the independent review organization within 24 hours after we get the decision from the independent review organization. For standard appeals: • If the independent review organization says yes to part or all of your request for coverage, we must provide the drug coverage that was approved by the independent review organization within 72 hours after we get the decision from the independent review organization. • If the independent review organization says yes to part or all of your request to pay you back for a drug you already bought, we're required to send payment to you within 30 calendar days after we get the decision from the independent review organization. What if the independent review organization says no to your appeal? If this organization says no to part or all of your appeal, it means they agree with our decision not to approve your request (or part of your request). (This is called upholding the decision. It's also called turning down your appeal.). In this case, the independent review organization will send you a letter that: • Explains the decision. • Lets you know about your right to a Level 3 appeal if the dollar value of the drug coverage you're asking for meets a certain minimum. If the dollar value of the drug coverage you're asking for is too low, you can't make another appeal and the decision at Level 2 is final. • Tells you the dollar value that must be in dispute to continue with the appeals process.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 187 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Step 4: If your case meets the requirements, you choose whether you want to take your appeal further. • There are 3 additional levels in the appeals process after Level 2 (for a total of 5 levels of appeal). • If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think you're being discharged too soon When you're admitted to a hospital, you have the right to get all covered hospital services necessary to diagnose and treat your illness or injury. During your covered hospital stay, your doctor and the hospital staff will work with you to prepare for the day you leave the hospital. They'll help arrange for care you may need after you leave. • The day you leave the hospital is called your discharge date. • When your discharge date is decided, your doctor or the hospital staff will tell you. • If you think you're being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. Section 7.1 During your inpatient hospital stay, you'll get a written notice from Medicare that tells you about your rights Within 2 calendar days of being admitted to the hospital, you'll be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice. If you don't get the notice from someone at the hospital (for example, a caseworker or nurse), ask any hospital employee for it. If you need help, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) or 1-800-MEDICARE (1-800-633-4227) (TTY users call 1-877-486-2048).

1. Read this notice carefully and ask questions if you don't understand it. It tells you: • Your right to get Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them. • Your right to be involved in any decisions about your hospital stay.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 188 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • Where to report any concerns you have about the quality of your hospital care. • Your right to request an immediate review of the decision to discharge you if you think you're being discharged from the hospital too soon. This is a formal, legal way to ask for a delay in your discharge date so we'll cover your hospital care for a longer time.

2. You'll be asked to sign the written notice to show that you got it and understand your rights. • You or someone who is acting on your behalf will be asked to sign the notice. • Signing the notice shows only that you got the information about your rights. The notice doesn't give your discharge date. Signing the notice doesn't mean you're agreeing on a discharge date.
3. Keep your copy of the notice so you have the information about making an appeal (or reporting a concern about quality of care) if you need it. • If you sign the notice more than 2 calendar days before your discharge date, you'll get another copy before you're scheduled to be discharged. • To look at a copy of this notice in advance, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) or 1-800 MEDICARE (1-800-633-4227). TTY users call 1- 877-486-2048. You can also get the notice online at www.CMS.gov/Medicare/forms- notices/beneficiary-notices-initiative/ffs-ma-im. Section 7.2 How to make a Level 1 appeal to change your hospital discharge date To ask us to cover your inpatient hospital services for a longer time, use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are. • Follow the process • Meet the deadlines • Ask for help if you need it. If you have questions or need help, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). Or call your State Health Insurance Assistance Program (SHIP) for personalized help. Local: (831) 655-4249 Toll Free: (800) 434-0222 (TTY users call 1-800-735-2929). SHIP contact information is available in Chapter 2, Section 3. During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you. The Quality Improvement Organization is a group of doctors and other health care professionals paid by the federal government to check on and help improve the quality of

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 189 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare. These experts aren't part of our plan. Step 1: Contact the Quality Improvement Organization for your state and ask for an immediate review of your hospital discharge. You must act quickly. How can you contact this organization? • The written notice you got (An Important Message from Medicare About Your Rights) tells you how to reach this organization. Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2. Act quickly: • To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than midnight the day of your discharge. • If you meet this deadline, you can stay in the hospital after your discharge date without paying for it while you wait to get the decision from the Quality Improvement Organization. • If you don't meet this deadline, contact us. If you decide to stay in the hospital after your planned discharge date, you may have to pay the costs for hospital care you get after your planned discharge date. • Once you ask for an immediate review of your hospital discharge, the Quality Improvement Organization will contact us. By noon of the day after we're contacted, we'll give you a Detailed Notice of Discharge. This notice gives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date. • You can get a sample of the Detailed Notice of Discharge by calling Member Services at Toll Free: (855) 570-1600 (TTY users call 711) or 1-800-MEDICARE (1-800-633-4227). (TTY users call 1-877-486-2048.) Or you can get a sample notice online at www.CMS.gov/Medicare/forms-notices/beneficiary-notices-initiative/ffs-ma-im. Step 2: The Quality Improvement Organization conducts an independent review of your case. • Health professionals at the Quality Improvement Organization (the reviewers) will ask you (or your representative) why you believe coverage for the services should continue. You don't have to prepare anything in writing, but you can if you want. • The reviewers will also look at your medical information, talk with your doctor, and review information that we and the hospital gave them.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 190 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • By noon of the day after the reviewers told us of your appeal, you'll get a written notice from us that gives your planned discharge date. This notice also explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date. Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes? • If the independent review organization says yes, we must keep providing your covered inpatient hospital services for as long as these services are medically necessary. • You'll have to keep paying your share of the costs (such as deductibles or copayments if these apply). In addition, there may be limitations on your covered hospital services. What happens if the answer is no? • If the independent review organization says no, they're saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal. • If the independent review organization says no to your appeal and you decide to stay in the hospital, you may have to pay the full cost of hospital care you get after noon on the day after the Quality Improvement Organization gives you its answer to your appeal. Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal. • If the Quality Improvement Organization said no to your appeal, and you stay in the hospital after your planned discharge date, you can make another appeal. Making another appeal means you are going on to Level 2 of the appeals process. Section 7.3 How to make a Level 2 appeal to change your hospital discharge date During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at its decision on your first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay the full cost for your stay after your planned discharge date.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 191 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Step 1: Contact the Quality Improvement Organization again and ask for another review. • You must ask for this review within 60 calendar days after the day the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you stay in the hospital after the date your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. • Reviewers at the Quality Improvement Organization will take another careful look at all the information about your appeal. Step 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the reviewers will decide on your appeal and tell you its decision. If the independent review organization says yes: • We must reimburse you for our share of the costs of hospital care you got since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary. • You must continue to pay your share of the costs and coverage limitations may apply. If the independent review organization says no: • It means they agree with the decision they made on your Level 1 appeal. This is called upholding the decision. • The notice you get will tell you in writing what you can do if you want to continue with the review process. Step 4: If the answer is no, you need to decide whether you want to take your appeal further by going to Level 3. • There are 3 additional levels in the appeals process after Level 2 (for a total of 5 levels of appeal). If you want to go to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 192 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon When you're getting covered home health services, skilled nursing care, or rehabilitation care (Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. When we decide it's time to stop covering any of these 3 types of care for you, we're required to tell you in advance. When your coverage for that care ends, we'll stop paying our share of the cost for your care. If you think we're ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal. Section 8.1 We'll tell you in advance when your coverage will be ending Legal Term: Notice of Medicare Non-Coverage. It tells you how you can ask for a fast-track appeal. Asking for a fast-track appeal is a formal, legal way to ask for a change to our coverage decision about when to stop your care.

1. You get a notice in writing at least 2 calendar days before our plan is going to stop covering your care. The notice tells you: • The date when we'll stop covering the care for you. • How to ask for a fast-track appeal to ask us to keep covering your care for a longer period of time.
2. You, or someone who is acting on your behalf, will be asked to sign the written notice to show that you got it. Signing the notice shows only that you have got the information about when your coverage will stop. Signing it doesn't mean you agree with our plan's decision to stop care. Section 8.2 How to make a Level 1 appeal to have our plan cover your care for a longer time If you want to ask us to cover your care for a longer period of time, you'll need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are. • Follow the process.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 193 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • Meet the deadlines. • Ask for help if you need it. If you have questions or need help, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). Or call your State Health Insurance Assistance Program (SHIP) for personalized help. Local: (831) 655-4249 Toll Free: (800) 434-0222 (TTY users call 1-800-735-2929). SHIP contact information is available in Chapter 2, Section 3. During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It decides if the end date for your care is medically appropriate. The Quality Improvement Organization is a group of doctors and other health care experts paid by the federal government to check on and help improve the quality of care for people with Medicare. This includes reviewing plan decisions about when it's time to stop covering certain kinds of medical care. These experts aren't part of our plan. Step 1: Make your Level 1 appeal: contact the Quality Improvement Organization and ask for a fast-track appeal. You must act quickly. How can you contact this organization? • The written notice you got (Notice of Medicare Non-Coverage) tells you how to reach this organization. Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2. Act quickly: • You must contact the Quality Improvement Organization to start your appeal by noon of the day before the effective date on the Notice of Medicare Non-Coverage. • If you miss the deadline and you want to file an appeal, you still have appeal rights. Contact the Quality Improvement Organization using the contact information on the Notice of Medicare Non-coverage. The name, address, and phone number of the Quality Improvement Organization for your state may also be found in Chapter 2.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 194 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Step 2: The Quality Improvement Organization conducts an independent review of your case. Legal Term: Detailed Explanation of Non-Coverage. Notice that gives details on reasons for ending coverage. What happens during this review? • Health professionals at the Quality Improvement Organization (the reviewers) will ask you, or your representative) why you believe coverage for the services should continue. You don't have to prepare anything in writing, but you can if you want. • The independent review organization will also look at your medical information, talk with your doctor, and review information our plan gives them. • By the end of the day the reviewers tell us of your appeal, you'll get the Detailed Explanation of Non-Coverage from us that explains in detail our reasons for ending our coverage for your services. Step 3: Within one full day after they have all the information they need, the reviewers will tell you its decision. What happens if the reviewers say yes? • If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it's medically necessary. • You'll have to keep paying your share of the costs (such as deductibles or copayments, if these apply). There may be limitations on your covered services. What happens if the reviewers say no? • If the reviewers say no, then your coverage will end on the date we told you. • If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, you'll have to pay the full cost of this care yourself. Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal. • If reviewers say no to your Level 1 appeal - and you choose to continue getting care after your coverage for the care has ended - then you can make a Level 2 appeal.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 195 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Section 8.3 How to make a Level 2 appeal to have our plan cover your care for a longer time During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at the decision on your first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end. Step 1: Contact the Quality Improvement Organization again and ask for another review. • You must ask for this review within 60 calendar days after the day when the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you continued getting care after the date your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. • Reviewers at the Quality Improvement Organization will take another careful look at all the information about your appeal. Step 3: Within 14 calendar days of receipt of your appeal request, reviewers will decide on your appeal and tell you its decision. What happens if the independent review organization says yes? • We must reimburse you for our share of the costs of care you got since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it's medically necessary. • You must continue to pay your share of the costs and there may be coverage limitations that apply. What happens if the independent review organization says no? • It means they agree with the decision made to your Level 1 appeal. • The notice you get will tell you in writing what you can do if you want to continue with the review process. It will give you details about how to go to the next level of appeal, which is handled by an Administrative Law Judge or attorney adjudicator.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 196 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Step 4: If the answer is no, you'll need to decide whether you want to take your appeal further. • There are 3 additional levels of appeal after Level 2, for a total of 5 levels of appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 tells more about Levels 3, 4, and 5 of the appeals process. SECTION 9 Taking your appeal to Levels 3, 4, and 5 Section 9.1 Appeal Levels 3, 4, and 5 for Medical Service Requests This section may be right for you if you made a Level 1 appeal and a Level 2 appeal, and both of your appeals were turned down. If the dollar value of the item or medical service you appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you can't appeal any further. The written response you get to your Level 2 appeal will explain how to make a Level 3 appeal. For most situations that involve appeals, the last 3 levels of appeal work in much the same way as the first 2 levels. Here's who handles the review of your appeal at each of these levels. Level 3 appeal An Administrative Law Judge or an attorney adjudicator who works for the federal government will review your appeal and give you an answer. • If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process may or may not be over. Unlike a decision at a Level 2 appeal, we have the right to appeal a Level 3 decision that's favorable to you. If we decide to appeal, it will go to a Level 4 appeal. • If we decide not to appeal, we must authorize or provide you with the medical care within 60 calendar days after we get the Administrative Law Judge's or attorney adjudicator's decision. • If we decide to appeal the decision, we'll send you a copy of the Level 4 appeal request with any accompanying documents. We may wait for the Level 4 appeal decision before authorizing or providing the medical care in dispute.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 197 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process may or may not be over. • If you decide to accept the decision that turns down your appeal, the appeals process is over. • If you don't want to accept the decision, you can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal. Level 4 appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the federal government. • If the answer is yes, or if the Council denies our request to review a favorable Level 3 appeal decision, the appeals process may or may not be over. Unlike a decision at Level 2, we have the right to appeal a Level 4 decision that is favorable to you. We'll decide whether to appeal this decision to Level 5. • If we decide not to appeal the decision, we must authorize or provide you with the medical care within 60 calendar days after getting the Council's decision. • If we decide to appeal the decision, we'll let you know in writing. • If the answer is no or if the Council denies the review request, the appeals process may or may not be over. • If you decide to accept this decision that turns down your appeal, the appeals process is over. • If you don't want to accept the decision, you may be able to continue to the next level of the review process. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you to go to a Level 5 appeal and how to continue with a Level 5 appeal. Level 5 appeal A judge at the Federal District Court will review your appeal. • A judge will review all the information and decide yes or no to your request. This is a final answer. There are no more appeal levels after the Federal District Court. Section 9.2 Appeal Levels 3, 4, and 5 for Part D Drug Requests This section may be right for you if you made a Level 1 appeal and a Level 2 appeal, and both of your appeals were turned down.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 198 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) If the value of the drug you appealed meets a certain dollar amount, you may be able to go to additional levels of appeal. If the dollar amount is less, you can't appeal any further. The written response you get to your Level 2 appeal will explain who to contact and what to do to ask for a Level 3 appeal. For most situations that involve appeals, the last 3 levels of appeal work in much the same way as the first 2 levels. Here's who handles the review of your appeal at each of these levels. Level 3 appeal An Administrative Law Judge or an attorney adjudicator who works for the federal government will review your appeal and give you an answer. • If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we get the decision. • If the answer is no, the appeals process may or may not be over. • If you decide to accept the decision that turns down your appeal, the appeals process is over. • If you don't want to accept the decision, you can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal. Level 4 appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the federal government. • If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that was approved by the Council within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we get the decision. • If the answer is no, the appeals process may or may not be over. • If you decide to accept the decision that turns down your appeal, the appeals process is over. • If you don't want to accept the decision, you may be able to continue to the next level of the review process. If the Council says no to your appeal or denies your request to review the appeal, the notice will tell you whether the rules

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 199 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) allow you to go on to a Level 5 appeal. It will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 appeal A judge at the Federal District Court will review your appeal. • A judge will review all the information and decide yes or no to your request. This is a final answer. There are no more appeal levels after the Federal District Court. Making complaints SECTION 10 How to make a complaint about quality of care, waiting times, customer service, or other concerns Section 10.1 What kinds of problems are handled by the complaint process? The complaint process is only used for certain types of problems. This includes problems about quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the complaint process. Complaint Example Quality of your medical care • Are you unhappy with the quality of the care you got (including care in the hospital)? Respecting your privacy • Did someone not respect your right to privacy or share confidential information? Disrespect, poor customer service, or other negative behaviors • Has someone been rude or disrespectful to you? • Are you unhappy with our Member Services? • Do you feel you're being encouraged to leave our plan? Waiting times • Are you having trouble getting an appointment, or waiting too long to get it? • Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Member Services or other staff at our plan? • Examples include waiting too long on the phone, in the waiting or exam room, or getting a prescription.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 200 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) Complaint Example Cleanliness • Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor's office? Information you get from us • Did we fail to give you a required notice? • Is our written information hard to understand? Timeliness (These types of complaints are all about the timeliness of our actions related to coverage decisions and appeals) If you asked for a coverage decision or made an appeal, and you think we aren't responding quickly enough, you can make a complaint about our slowness. Here are examples: • You asked us for a fast coverage decision or a fast appeal, and we said no; you can make a complaint. • You believe we aren't meeting the deadlines for coverage decisions or appeals; you can make a complaint. • You believe we aren't meeting deadlines for covering or reimbursing you for certain medical items or services or drugs that were approved; you can make a complaint. • You believe we failed to meet required deadlines for forwarding your case to the independent review organization; you can make a complaint. Section 10.2 How to make a complaint Legal Terms: A complaint is also called a grievance. Making a complaint is called filing a grievance. Using the process for complaints is called using the process for filing a grievance. A fast complaint is called an expedited grievance. Step 1: Contact us promptly - either by phone or in writing. • Calling Member Services at Toll Free: (855) 570-1600 (TTY users call 711) is usually the first step. If there's anything else you need to do, Member Services will let you know.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 201 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) • If you don't want to call (or you called and weren't satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we'll respond to your complaint in writing. • To submit a complaint, usually you call Member Services at the phone numbers found in Chapter 2. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing and send it to us, we will respond in writing. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If possible, we will give you an answer right away but most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If you are filing an expedited grievance because we denied your request for a fast coverage decision or fast appeal, we will respond within 24 hours. • The deadline for making a complaint is 60 calendar days from the time you had the problem you want to complain about. Step 2: We look into your complaint and give you our answer. • If possible, we'll answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. • Most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we decide to take extra days, we'll tell you in writing. • If you're making a complaint because we denied your request for a fast coverage decision or a fast appeal, we'll automatically give you a fast complaint. If you have a fast complaint, it means we'll give you an answer within 24 hours. • If we don't agree with some or all of your complaint or don't take responsibility for the problem you're complaining about, we'll include our reasons in our response to you. Section 10.3 You can also make complaints about quality of care to the Quality Improvement Organization When your complaint is about quality of care, you have 2 extra options: • You can make your complaint directly to the Quality Improvement Organization. The Quality Improvement Organization is a group of practicing doctors and other

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 202 Chapter 9 If you have a problem or complaint (coverage decisions, appeals, complaints) health care experts paid by the federal government to check and improve the care given to Medicare patients. Chapter 2 has contact information. Or • You can make your complaint to both the Quality Improvement Organization and us at the same time. Section 10.4 You can also tell Medicare about your complaint You can submit a complaint about Aspire Health Advantage (HMO) directly to Medicare. To submit a complaint to Medicare, go to www.Medicare.gov/my/medicare-complaint. You can also call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users call 1-877-486-2048.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 203 Chapter 10 Ending membership in our plan CHAPTER 10: Ending membership in our plan SECTION 1 Ending your membership in our plan Ending your membership in Aspire Health Advantage (HMO) may be voluntary (your own choice) or involuntary (not your own choice): • You might leave our plan because you decide you want to leave. Sections 2 and 3 give information on ending your membership voluntarily. • There are also limited situations where we're required to end your membership. Section 5 tells you about situations when we must end your membership. If you're leaving our plan, our plan must continue to provide your medical care and prescription drugs and you'll continue to pay your cost share until your membership ends. SECTION 2 When can you end your membership in our plan? Section 2.1 You can end your membership during the Open Enrollment Period You can end your membership in our plan during the Open Enrollment Period each year. During this time, review your health and drug coverage and decide about coverage for the upcoming year. • The Open Enrollment Period is from October 15 to December 7. • Choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans: • Another Medicare health plan, with or without drug coverage, • Original Medicare with a separate Medicare drug plan, or • Original Medicare without a separate Medicare drug plan. • If you choose this option and receive Extra Help, Medicare may enroll you in a drug plan, unless you opt out of automatic enrollment. Note: If you disenroll from Medicare drug coverage and go without creditable prescription drug coverage for 63 or more days in a row, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 204 Chapter 10 Ending membership in our plan • Your membership will end in our plan when your new plan's coverage starts on January 1. Section 2.2 You can end your membership during the Medicare Advantage Open Enrollment Period You can make one change to your health coverage during the Medicare Advantage Open Enrollment Period each year. • The Medicare Advantage Open Enrollment Period is from January 1 to March 31 and, for new Medicare beneficiaries who are enrolled in an MA plan, from the month of entitlement to Part A and Part B until the last day of the 3rd month of entitlement. • During the Medicare Advantage Open Enrollment Period you can: • Switch to another Medicare Advantage Plan with or without drug coverage. • Disenroll from our plan and get coverage through Original Medicare. If you switch to Original Medicare during this period, you can also join a separate Medicare drug plan at the same time. • Your membership will end on the first day of the month after you enroll in a different Medicare Advantage plan or we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare drug plan, your membership in the drug plan will start the first day of the month after the drug plan gets your enrollment request. Section 2.3 In certain situations, you can end your membership during a Special Enrollment Period In certain situations, members of Aspire Health Advantage (HMO) may be eligible to end their membership at other times of the year. This is known as a Special Enrollment Period. You may be eligible to end your membership during a Special Enrollment Period if any of the following situations apply. These are just examples. For the full list you can contact our plan, call Medicare, or visit www.Medicare.gov. • Usually, when you move. • If you have Medicaid. • If you're eligible for Extra Help paying for Medicare drug coverage • If we violate our contract with you • If you're getting care in an institution, such as a nursing home or long-term care (LTC) hospital • If you enroll in the Program of All-inclusive Care for the Elderly (PACE)

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 205 Chapter 10 Ending membership in our plan Note: If you're in a drug management program, you may not be able to change plans. Chapter 5, Section 10 tells you more about drug management programs. Enrollment time periods vary depending on your situation. To find out if you're eligible for a Special Enrollment Period, call Medicare at 1-800- MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. If you're eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. You can choose: • Another Medicare health plan with or without drug coverage, • Original Medicare with a separate Medicare drug plan, or • Original Medicare without a separate Medicare drug plan. Note: If you disenroll from Medicare drug coverage and go without creditable prescription drug coverage for 63 days or more in a row, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. • Your membership will usually end on the first day of the month after we get your request to change plans. • If you get Extra Help from Medicare to pay your drugs coverage costs: If you switch to Original Medicare and don't enroll in a separate Medicare drug plan, Medicare may enroll you in a drug plan, unless you opt out of automatic enrollment. Section 2.4 Get more information about when you can end your membership If you have questions about ending your membership you can: • Call Member Services at Toll Free: (855) 570-1600 (TTY users call 711) • Find the information in the Medicare & You 2026 handbook • Call Medicare at 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-2048

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 206 Chapter 10 Ending membership in our plan SECTION 3 How to end your membership in our plan The table below explains how you can end your membership in our plan. To switch from our plan to: Here's what to do: Another Medicare health plan • Enroll in the new Medicare health plan. • You'll automatically be disenrolled from Aspire Health Advantage (HMO) when your new plan's coverage starts. Original Medicare with a separate Medicare drug plan • Enroll in the new Medicare drug plan. • You'll automatically be disenrolled from Aspire Health Advantage (HMO) when your new drug plan's coverage starts. Original Medicare without a separate Medicare drug plan • Send us a written request to disenroll. Call Member Services at Toll Free: (855) 570- 1600 (TTY users call 711) if you need more information on how to do this. • You can also call Medicare at 1-800- MEDICARE (1-800-633-4227) and ask to be disenrolled. TTY users call 1-877-486-2048. • You'll be disenrolled from Aspire Health Advantage (HMO) when your coverage in Original Medicare starts. SECTION 4 Until your membership ends, you must keep getting your medical items, services, and drugs through our plan Until your membership ends, and your new Medicare coverage starts, you must continue to get your medical services, items, and prescription drugs through our plan. • Continue to use our network providers to get medical care. • Continue to use our network pharmacies or mail order to get your prescriptions filled. • If you're hospitalized on the day your membership ends, your hospital stay will be covered by our plan until you're discharged (even if you're discharged after your new health coverage starts).

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 207 Chapter 10 Ending membership in our plan SECTION 5 Aspire Health Advantage (HMO) must end our plan membership in certain situations Aspire Health Advantage (HMO) must end your membership in our plan if any of the following happen: • If you no longer have Medicare Part A and Part B • If you move out of our service area • If you're away from our service area for more than 6 months • If you move or take a long trip, call Member Services at Toll Free: (855) 570- 1600 (TTY users call 711) to find out if the place you're moving or traveling to is in our plan's area • If you become incarcerated (go to prison) • If you're no longer a United States citizen or lawfully present in the United States • If you lie or withhold information about other insurance you have that provides prescription drug coverage • If you intentionally give us incorrect information when you're enrolling in our plan and that information affects your eligibility for our plan. (We can't make you leave our plan for this reason unless we get permission from Medicare first.) • If you continuously behave in a way that's disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We can't make you leave our plan for this reason unless we get permission from Medicare first.) • If you let someone else use your membership card to get medical care. (We can't make you leave our plan for this reason unless we get permission from Medicare first.) • If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General. • If you don't pay our plan premiums for 90 days. • We must notify you in writing that you have 90 days to pay our plan premium before we end your membership. • If you're required to pay the extra Part D amount because of your income and you don't pay it, Medicare will disenroll you from our plan and you'll lose drug coverage.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 208 Chapter 10 Ending membership in our plan If you have questions or want more information on when we can end your membership call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). Section 5.1 We can't ask you to leave our plan for any health-related reason Aspire Health Advantage (HMO) isn't allowed to ask you to leave our plan for any health- related reason. What should you do if this happens? If you feel you're being asked to leave our plan because of a health-related reason, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. Section 5.2 You have the right to make a complaint if we end your membership in our plan If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can file a grievance or make a complaint about our decision to end your membership.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 209 Chapter 11 Legal notices CHAPTER 11: Legal notices SECTION 1 Notice about governing law The principal law that applies to this Evidence of Coverage document is Title XVIII of the Social Security Act and the regulations created under the Social Security Act by the Centers for Medicare & Medicaid Services (CMS). In addition, other federal laws may apply and, under certain circumstances, the laws of the state you live in. This may affect your rights and responsibilities even if the laws aren't included or explained in this document. SECTION 2 Notice about nondiscrimination We don't discriminate based on race, ethnicity, national origin, color, religion, sex, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. All organizations that provide Medicare Advantage Plans, like our plan, must obey federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get federal funding, and any other laws and rules that apply for any other reason. If you want more information or have concerns about discrimination or unfair treatment, call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. You can also review information from the Department of Health and Human Services' Office for Civil Rights at www.HHS.gov/ocr/index.html. If you have a disability and need help with access to care, call Member Services at Toll Free: (855) 570-1600 (TTY users call 711). If you have a complaint, such as a problem with wheelchair access, Member Services can help. SECTION 3 Notice about Medicare Secondary Payer subrogation rights We have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Aspire Health Advantage (HMO), as a Medicare Advantage Organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 210 Chapter 11 Legal notices subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 211 Chapter 12 Definitions CHAPTER 12: Definitions Ambulatory Surgical Center - An Ambulatory Surgical Center is an entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center doesn't exceed 24 hours. Appeal - An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already got. You may also make an appeal if you disagree with our decision to stop services that you're getting. Balance Billing - When a provider (such as a doctor or hospital) bills a patient more than our plan's allowed cost-sharing amount. As a member of Aspire Health Advantage (HMO), you only have to pay our plan's cost-sharing amounts when you get services covered by our plan. We don't allow providers to balance bill or otherwise charge you more than the amount of cost sharing our plan says you must pay. Benefit Period - The way that both our plan and Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven't gotten any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods. Biological Product - A prescription drug that is made from natural and living sources like animal cells, plant cells, bacteria, or yeast. Biological products are more complex than other drugs and can't be copied exactly, so alternative forms are called biosimilars. (Go to “Original Biological Product” and “Biosimilar.”) Biosimilar - A biological product that's very similar, but not identical, to the original biological product. Biosimilars are as safe and effective as the original biological product. Some biosimilars may be substituted for the original biological product at the pharmacy without needing a new prescription (go to “Interchangeable Biosimilar”). Brand Name Drug - A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 212 Chapter 12 Definitions Catastrophic Coverage Stage - The stage in the Part D Drug Benefit that begins when you (or other qualified parties on your behalf) have spent $2,100 for Part D covered drugs during the covered year. During this payment stage, you pay nothing for your covered Part D drugs. Centers for Medicare & Medicaid Services (CMS) - The federal agency that administers Medicare. Chronic-Care Special Needs Plan (C-SNP) - C-SNPs are SNPs that restrict enrollment to MA eligible people who have specific severe and chronic diseases. Coinsurance - An amount you may be required to pay, expressed as a percentage (for example 20%) as your share of the cost for services or prescription drugs. Complaint - The formal name for making a complaint is filing a grievance. The complaint process is used only for certain types of problems. This includes problems about quality of care, waiting times, and the customer service you get. It also includes complaints if our plan doesn't follow the time periods in the appeal process. Comprehensive Outpatient Rehabilitation Facility (CORF) - A facility that mainly provides rehabilitation services after an illness or injury, including physical therapy, social or psychological services, respiratory therapy, occupational therapy and speech-language pathology services, and home environment evaluation services. Copayment (or copay) - An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount (for example $10), rather than a percentage. Cost Sharing - Cost sharing refers to amounts that a member has to pay when services or drugs are gotten. (This is in addition to our plan's monthly premium.) Cost sharing includes any combination of the following 3 types of payments: 1) any deductible amount a plan may impose before services or drugs are covered; 2) any fixed copayment amount that a plan requires when a specific service or drug is gotten; or 3) any coinsurance amount, a percentage of the total amount paid for a service or drug, that a plan requires when a specific service or drug is gotten. Cost-Sharing Tier - Every drug on the list of covered drugs is in one of 6 cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 213 Chapter 12 Definitions Coverage Determination - A decision about whether a drug prescribed for you is covered by our plan and the amount, if any, you're required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under our plan, that isn't a coverage determination. You need to call or write to our plan to ask for a formal decision about the coverage. Coverage determinations are called coverage decisions in this document. Covered Drugs - The term we use to mean all the prescription drugs covered by our plan. Covered Services - The term we use to mean all the health care services and supplies that are covered by our plan. Creditable Prescription Drug Coverage - Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later. Custodial Care - Custodial care is personal care provided in a nursing home, hospice, or other facility setting when you don't need skilled medical care or skilled nursing care. Custodial care, provided by people who don't have professional skills or training, includes help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. Medicare doesn't pay for custodial care. Daily cost-sharing rate - A daily cost-sharing rate may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you're required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month's supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-month's supply in our plan is 30 days, then your daily cost-sharing rate is $1 per day. Deductible - The amount you must pay for health care or prescriptions before our plan pays. Disenroll or Disenrollment - The process of ending your membership in our plan. Dispensing Fee - A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription, such as the pharmacist's time to prepare and package the prescription.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 214 Chapter 12 Definitions Dual Eligible Special Needs Plans (D-SNP) - D-SNPs enroll people who are entitled to both Medicare (Title XVIII of the Social Security Act) and medical assistance from a state plan under Medicaid (Title XIX). States cover some Medicare costs, depending on the state and the person's eligibility. Dually Eligible Individual - A person who is eligible for Medicare and Medicaid coverage. Durable Medical Equipment (DME) - Certain medical equipment that is ordered by your doctor for medical reasons. Examples include: walkers, wheelchairs, crutches, powered mattress systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, or hospital beds ordered by a provider for use in the home. Emergency - A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life (and, if you're a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a limb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. Emergency Care - Covered services that are: 1) provided by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition. Evidence of Coverage (EOC) and Disclosure Information - This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan. Exception - A type of coverage decision that, if approved, allows you to get a drug that isn't on our formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also ask for an exception if our plan requires you to try another drug before getting the drug you're asking for, if our plan requires a prior authorization for a drug and you want us to waive the criteria restriction, or if our plan limits the quantity or dosage of the drug you're asking for (a formulary exception). Extra Help - A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. Generic Drug - A prescription drug that's approved by the FDA as having the same active ingredient(s) as the brand name drug. Generally, a generic drug works the same as a brand name drug and usually costs less.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 215 Chapter 12 Definitions Grievance - A type of complaint you make about our plan, providers, or pharmacies, including a complaint concerning the quality of your care. This doesn't involve coverage or payment disputes. Home Health Aide - A person who provides services that don't need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Hospice - A benefit that provides special treatment for a member who has been medically certified as terminally ill, meaning having a life expectancy of 6 months or less. Our plan must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums, you're still a member of our plan. You can still get all medically necessary services as well as the supplemental benefits we offer. Hospital Inpatient Stay - A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an outpatient. Income Related Monthly Adjustment Amount (IRMAA) - If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you'll pay the standard premium amount and an Income Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your premium. Less than 5% of people with Medicare are affected, so most people won't pay a higher premium. Initial Coverage Stage - This is the stage before your out-of-pocket costs for the year have reached the out-of-pocket threshold amount. Initial Enrollment Period - When you're first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. If you're eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. Institutional Special Needs Plan (I-SNP) - I-SNPs restrict enrollment to MA eligible people who live in the community but need the level of care a facility offers, or who live (or are expected to live) for at least 90 days straight in certain long-term facilities. I-SNPs include the following types of plans: Institutional-equivalent SNPs (IE-SNPs) Hybrid Institutional SNPs (HI-SNPs), and Facility-based Institutional SNPs (FI-SNPs). Institutional-Equivalent Special Needs Plan (IE-SNP) - An IE-SNP restricts enrollment to MA eligible people who live in the community but need the level of care a facility offers.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 216 Chapter 12 Definitions Interchangeable Biosimilar - A biosimilar that may be used as a substitute for an original biosimilar product at the pharmacy without needing a new prescription because it meets additional requirements about the potential for automatic substitution. Automatic substitution at the pharmacy is subject to state law. List of Covered Drugs (formulary or Drug List) - A list of prescription drugs covered by our plan. Low Income Subsidy (LIS) - Go to Extra Help. Manufacturer Discount Program - A program under which drug manufacturers pay a portion of our plan's full cost for covered Part D brand name drugs and biologics. Discounts are based on agreements between the federal government and drug manufacturers. Maximum Fair Price - The price Medicare negotiated for a selected drug. Maximum Out-of-Pocket Amount - The most that you pay out of pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for our plan premiums, Medicare Part A and Part B premiums, and prescription drugs don't count toward the maximum out-of-pocket amount. Medicaid (or Medical Assistance) - A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. State Medicaid programs vary, but most health care costs are covered if you qualify for both Medicare and Medicaid. Medically Accepted Indication - A use of a drug that is either approved by the FDA or supported by certain references, such as the American Hospital Formulary Service Drug Information and the Micromedex DRUGDEX Information system. Medically Necessary - Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Medicare - The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). Medicare Advantage Open Enrollment Period - The time period from January 1 to March 31 when members in a Medicare Advantage plan can cancel their plan enrollment and switch to another Medicare Advantage plan or get coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you can also join a separate Medicare prescription drug plan at that time. The Medicare Advantage Open Enrollment Period is also available for a 3-month period after a person is first eligible for Medicare.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 217 Chapter 12 Definitions Medicare Advantage (MA) Plan - Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be i) an HMO, ii) a PPO, iii) a Private Fee- for-Service (PFFS) plan, or iv) a Medicare Medical Savings Account (MSA) plan. Besides choosing from these types of plans, a Medicare Advantage HMO or PPO plan can also be a Special Needs Plan (SNP). In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Medicare-Covered Services - Services covered by Medicare Part A and Part B. All Medicare health plans must cover all the services that are covered by Medicare Part A and B. The term Medicare-Covered Services doesn't include the extra benefits, such as vision, dental or hearing, that a Medicare Advantage plan may offer. Medicare Health Plan - A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in our plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Special Needs Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE). Medicare Prescription Drug Coverage (Medicare Part D) - Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B. Medication Therapy Management (MTM) program - A Medicare Part D program for complex health needs provided to people who meet certain requirements or are in a Drug Management Program. MTM services usually include a discussion with a pharmacist or health care provider to review medications. Medigap (Medicare Supplement Insurance) Policy - Medicare supplement insurance sold by private insurance companies to fill gaps in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.) Member (Member of our Plan, or Plan Member) - A person with Medicare who is eligible to get covered services, who has enrolled in our plan, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS). Member Services - A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. Network Pharmacy - A pharmacy that contracts with our plan where members of our plan can get their prescription drug benefits. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 218 Chapter 12 Definitions Network Provider - Provider is the general term for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the state to provide health care services. Network providers have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Network providers are also called plan providers. Open Enrollment Period - The time period of October 15 until December 7 of each year when members can change their health or drug plans or switch to Original Medicare. Optional Supplemental Benefits - Non-Medicare-covered benefits that can be purchased for an additional premium and aren't included in your package of benefits. You must voluntarily elect Optional Supplemental Benefits to get them. Organization Determination - A decision our plan makes about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called coverage decisions in this document. Original Biological Product - A biological product that has been approved by the FDA and serves as the comparison for manufacturers making a biosimilar version. It is also called a reference product. Original Medicare (Traditional Medicare or Fee-for-Service Medicare) - Original Medicare is offered by the government, and not a private health plan like Medicare Advantage plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has 2 parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States. Out-of-Network Pharmacy - A pharmacy that doesn't have a contract with our plan to coordinate or provide covered drugs to members of our plan. Most drugs you get from out-of- network pharmacies aren't covered by our plan unless certain conditions apply. Out-of-Network Provider or Out-of-Network Facility - A provider or facility that doesn't have a contract with our plan to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that aren't employed, owned, or operated by our plan. Out-of-Pocket Costs - Go to the definition for cost sharing above. A member's cost-sharing requirement to pay for a portion of services or drugs gotten is also referred to as the member's out-of-pocket cost requirement.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 219 Chapter 12 Definitions Out-of-Pocket Threshold - The maximum amount you pay out of pocket for Part D drugs. PACE plan - A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term services and supports (LTSS) for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible. People enrolled in PACE plans get both their Medicare and Medicaid benefits through our plan. Part C - Go to Medicare Advantage (MA) Plan. Part D - The voluntary Medicare Prescription Drug Benefit Program. Part D Drugs - Drugs that can be covered under Part D. We may or may not offer all Part D drugs. Certain categories of drugs have been excluded as covered Part D drugs by Congress. Certain categories of Part D drugs must be covered by every plan. Part D Late Enrollment Penalty - An amount added to your monthly plan premium for Medicare drug coverage if you go without creditable coverage (coverage that's expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more after you're first eligible to join a Part D plan. Preferred Provider Organization (PPO) Plan - A Preferred Provider Organization plan is a Medicare Advantage Plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they're received from network or out-of-network providers. Member cost sharing will generally be higher when plan benefits are gotten from out-of-network providers. PPO plans have an annual limit on your out-of-pocket costs for services gotten from network (preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both in-network (preferred) and out-of-network (non-preferred) providers. Premium - The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. Preventive services - Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms). Primary Care Provider (PCP) - The doctor or other provider you see first for most health problems. In many Medicare health plans, you must see your primary care provider before you see any other health care provider.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 220 Chapter 12 Definitions Prior Authorization - Approval in advance to get services and/or certain drugs based on specific criteria. Covered services that need prior authorization are marked in the Medical Benefits Chart in Chapter 4. Covered drugs that need prior authorization are marked in the formulary and our criteria are posted on our website. Prosthetics and Orthotics - Medical devices including, but not limited to: arm, back and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies and enteral and parenteral nutrition therapy. Quality Improvement Organization (QIO) - A group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. Quantity Limits - A management tool that is designed to limit the use of a drug for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time. “Real-Time Benefit Tool” - A portal or computer application in which enrollees can look up complete, accurate, timely, clinically appropriate, enrollee-specific formulary and benefit information. This includes cost-sharing amounts, alternative formulary medications that may be used for the same health condition as a given drug, and coverage restrictions (Prior Authorization, Step Therapy, Quantity Limits) that apply to alternative medications. Referral - A written order from your primary care doctor for you to visit a specialist or get certain medical services. Without a referral, our plan may not pay for services from a specialist. Rehabilitation Services - These services include inpatient rehabilitation care, physical therapy (outpatient), speech and language therapy, and occupational therapy. Selected Drug - A drug covered under Part D for which Medicare negotiated a Maximum Fair Price. Service Area - A geographic area where you must live to join a particular health plan. For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services. Our plan must disenroll you if you permanently move out of our plan's service area. Skilled Nursing Facility (SNF) Care - Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

2026 Evidence of Coverage for Aspire Health Advantage (HMO) 221 Chapter 12 Definitions Special Enrollment Period - A set time when members can change their health or drug plan or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you're getting Extra Help with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you. Special Needs Plan - A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who live in a nursing home, or who have certain chronic medical conditions. Step Therapy - A utilization tool that requires you to first try another drug to treat your medical condition before we'll cover the drug your physician may have initially prescribed. Supplemental Security Income (SSI) - A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits aren't the same as Social Security benefits. Urgently Needed Services - A plan-covered service requiring immediate medical attention that's not an emergency is an urgently needed service if either you're temporarily outside our plan's service area, or it's unreasonable given your time, place, and circumstances to get this service from network providers. Examples of urgently needed services are unforeseen medical illnesses and injuries, or unexpected flare-ups of existing conditions. Medically necessary routine provider visits (like annual checkups) aren't considered urgently needed even if you're outside our plan's service area or our plan network is temporarily unavailable.

Aspire Health Advantage (HMO) Member Services Method Member Services - Contact Information Call Toll Free: (855) 570-1600 Calls to this number are free. 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Member Services at Toll Free: (855) 570-1600 (TTY users call 711) also has free language interpreter services available for non-English speakers. TTY 711 Calls to this number are free. 8 am to 8 pm PT Monday through Friday from April 1 through September 30 and 8 am to 8 pm PT seven days a week for the period of October 1 through March 31 (except certain holidays) Fax Local: (831) 574-4939 Toll Free: (855) 519-5769 Write Aspire Health 10 Ragsdale Drive, Suite 101 Monterey, CA 93940 Website www.aspirehealthplan.org California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP) California Department of Aging Health Insurance Counseling and Advocacy Program or HICAP (SHIP) is a state program that gets money from the federal government to give free local health insurance counseling to people with Medicare. Method Contact Information Call Local: (831) 655-4249 Toll Free: (800) 434-0222 TTY 1-800-735-2929 This number requires special telephone equipment and is only for people who have difficulty hearing or speaking.

Method Contact Information Write Alliance On Aging, Inc. 247 Main Street Salinas, CA 93901 Website https://aging.ca.gov/Programs_and_Services/Medicare_Counseling PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1051. If you have comments or suggestions for improving this form, write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Notice of Availability of Language Assistance Services and Auxiliary Aids and Services English: ATTENTION: If you speak English, free language assistance services
are available to you. Appropriate auxiliary aids and services to provide information in accessible formats are also available free of charge. Call 855-570-1600, (TTY: 711) or speak to your provider. Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. También están disponibles de forma gratuita ayuda y servicios auxiliares apropiados para proporcionar información en formatos accesibles. Llame al 855-570-1600, (TTY: 711) o hable con su proveedor. Simplified Chinese: 中文: 注意：如果您说[中文]，我们将免费为您提供语言协助服务。我 们还免费提供适当的辅助工具和服务，以无障碍格式提供信息。致电 1-855-570-1600,（文本 电话：711）或咨询您的服务提供商。 Tagalog: PAALALA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga libreng serbisyong tulong sa wika. Magagamit din nang libre ang mga naaangkop na auxiliary na tulong at serbisyo upang magbigay ng impormasyon sa mga naa-access na format. Tumawag sa 1-855-570-1600, (TTY: 711) o makipag-usap sa iyong provider. Vietnamese: Việt: LƯU : Nếu bạn nói tiếng Việt, chúng tôi cung cấp miễn phí các dịch vụ hỗ trợ ngôn ngữ. Các hỗ trợ dịch vụ phù hợp để cung cấp thông tin theo các định dạng dễ tiếp cận cũng được cung cấp miễn phí. Vui lòng gọi theo số 1-855-570-1600 (Người khuyết tật: 711) hoặc trao đổi với người cung cấp dịch vụ của bạn. Korean: 한국어: 주의: [한국어]를 사용하시는 경우 무료 언어 지원 서비스를 이용하실 수 있습니다. 이용 가능한 형식으로 정보를 제공하는 적절한 보조 기구 및 서비스도 무료로 제공됩니다. 1-855-570-1600 (TTY: 711) 번으로 전화하거나 서비스 제공업체에 문의하십시오. French: Français: ATTENTION: Si vous parlez Français, des services d'assistance linguistique gratuits sont à votre disposition. Des aides et services auxiliaires appropriés pour fournir des informations dans des formats accessibles sont également disponibles gratuitement. Appelez le 1-855-570-1600, (TTY: 711) ou parlez à votre fournisseur.
Brazilian Portuguese: Português do Brasil: ATENÇÃO: Se você fala [inserir idioma], serviços gratuitos de assistência linguística estão disponíveis para você. Auxílios e serviços auxiliares apropriados para fornecer informações em formatos acessíveis também estão disponíveis gratuitamente. Ligue para 1-855-570-1600, (TTY: 711) ou fale com seu provedor. Hindi: िहंदी : ान दें: यिद आप िहंदी बोलते हैं, तो आपके िलए िनःशु भाषा सहायता सेवाएं उपल होती हैं। सुलभ प्रारूपों में जानकारी प्रदान करने के िलए उपयु सहायक साधन और सेवाएँ भी िनःशु उपल हैं। 1-855-570-1600, (TTY: 711) पर कॉल करें या अपने प्रदाता से बात करें। language Multi-language Interpreter Services

: Farsi ﻓﺎر ي

ﺗﻮﺟﻪ:

ا ﺮ ] وارد ﮐﺮدن ز ﺎن[ ﺻﺤبﺖ
ﮐﻨ ﺪ، ﺧﺪﻣﺎت ﺸتﯿبﺎین
ز ﺎین را گﺎن در دﺳ ت س ﺷﻤﺎ ﻗﺮار دارد.

ﻫﻤﭽﻨنی ن کﻤﮏ ﻫﺎ و ﺧﺪﻣﺎت ﺸتﯿبﺎین ﻣﻨﺎﺳﺐ ﺑﺮای اراﺋﻪ اﻃﻼﻋﺎت در ﻗﺎﻟﺐ ﻫﺎی ﻗﺎبﻞ دﺳ ت س، بﻪ ﻃﻮر را گﺎن ﻣﻮﺟﻮد

بﺎﺷﻨﺪ.

بﺎ ﺷﻤﺎرە 1-855-570-1600

)ﺗﻠﻪ ﺗﺎ ﭗ: 711 (ﺗﻤﺎس بﮕ ی ﺪ ﺎ بﺎ اراﺋﻪ دﻫﻨﺪە ﺧﻮد ﺻﺤبﺖ ﮐﻨ ﺪ.

: Arabic

اﻟﻌرﺑﯾﺔ

ﺗﻧﺑﯾﮫ:

إذا ﻛﻧت ﺗﺗﺣدث اﻟﻠﻐﺔ اﻟﻌرﺑﯾﺔ ، ﻓﺳﺗﺗوﻓر ﻟك ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ اﻟﻣﺟﺎﻧﯾﺔ.

ﻛﻣﺎ ﺗﺗوﻓر وﺳﺎﺋل ﻣﺳﺎﻋدة وﺧدﻣﺎت ﻣﻧﺎﺳﺑﺔ ﻟﺗوﻓﯾر اﻟﻣﻌﻠوﻣﺎت ﺑﺗﻧﺳﯾﻘﺎت ﯾﻣﻛن اﻟوﺻول إﻟﯾﮭﺎ ﻣﺟﺎﻧًﺎ.

اﺗﺻل ﻋﻠﻰ اﻟرق1-855-570-1600, (TTY: 711)

."أو ﺗﺣدث إﻟﻰ ﻣﻘدم اﻟﺧدﻣﺔ

Armenian: ՀԱՅԵՐԵՆ: ՈՒՇԱԴՐՈՒԹՅՈՒՆ. Եթե խոսում եք հայերեն, Դուք կարող եք օգտվել լեզվական աջակցության անվճար ծառայություններից: Մատչելի ձևաչափերով տեղեկատվություն տրամադրելու համապատասխան օժանդակ միջոցներն ու ծառայությունները նույնպես տրամադրվում են անվճար: Զանգահարեք 1-855-570-1600, (TTY: 711) հեռախոսահամարով (TTY: 711) կամ խոսեք Ձեր մատակարարի հետ: Russian: РУССКИЙ: ВНИМАНИЕ: Если вы говорите на русский, вам доступны бесплатные услуги языковой поддержки. Соответствующие вспомогательные средства и услуги по предоставлению информации в доступных форматах также предоставляются бесплатно. Позвоните по телефону 1-855-570-1600, (TTY: 711) или обратитесь к своему поставщику услуг. Punjabi: ਪੰਜਾਬੀ: ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਤੁਹਾਡੇ ਲਈ ਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਸੇਵਾਵਾਂ ਉਪਲਬਧ ਹੁੰਦੀਆਂ ਹਨ। ਪਹੁੰਚਯੋਗ ਫਾਰਮੈਟਾਂ ਿਵੱਚ ਜਾਣਕਾਰੀ ਪ ਦਾਨ ਕਰਨ ਲਈ ਢੁਕਵੇਂ ਪੂਰਕ ਸਹਾਇਕ ਸਾਧਨ ਅਤੇ ਸੇਵਾਵਾਂ ਵੀ ਮੁਫ਼ਤ ਿਵੱਚ ਉਪਲਬਧ ਹੁੰਦੀਆਂ ਹਨ। 1-855-570-1600, (TTY: 711) ‘ਤੇ ਕਾਲ ਕਰੋ ਜਾਂ ਆਪਣੇ ਪ ਦਾਤਾ ਨਾਲ ਗੱਲ ਕਰੋ। Japanese: 日本語: 注：日本語を話される場合、無料の言語支援サービスをご利 用いただけます。アクセシブル（誰もが利用できるよう配慮された）な形式で情報を 提供するための適切な補助支援やサービスも無料でご利用いただけます。1-855- 570-1600, (TTY: 711) までお電話ください。または、ご利用の事業者にご相談ください。 German: Deutsch: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlose Sprachassistenzdienste zur Verfügung. Entsprechende Hilfsmittel und Dienste zur Bereitstellung von Informationen in barrierefreien Formaten stehen ebenfalls kostenlos zur Verfügung. Rufen Sie 1-855-570-1600, (TTY: 711) an oder sprechen Sie mit Ihrem Provider. H8764NOA0825_C

Member Services (855) 570-1600 (TTY:711) 10 Ragsdale Drive, Suite 101 | Monterey, CA 93940 www.aspirehealthplan.org Your Medicare Advantage. All-in-one plans. Exceptional service. Great value. PRESENTED BY Other providers are available in our network. We are open 8 a.m.–8 p.m. PT Monday through Friday from April 1 through September 30 and 8 a.m.–8 p.m. PT seven days a week from October 1 through March 31 (except certain holidays).