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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesWells Fargo & Company: Higher Use Plan with HSACoverage Period: 01/01/2021-12/31/2021Coverage for: All coverage levels Plan Type: High-deductibleThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the costfor covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary.For more information about your coverage, or to get a copy of the complete terms of coverage, employees visit Benefits on Teamworks or access teamworks.wellsfargo.com;or call 1-877-479-3557. COBRA participants visit https://cobra.ehr.com or call 1-877-292-6272. For general definitions of common terms, such as allowed amount, balance billing,coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or request a copy bycalling 1-877-479-3557 (employees) or 1-877-292-6272 (COBRA).Important QuestionsAnswersCoverage LevelWhat is the overalldeductible?YouYou spouse/partnerYou childrenYou spouse/partner children*Why This Matters:In-network(or Out of Area* coverage) Out-of-networkGenerally, you must pay all of the costs from providers up to the 2,000 4,000deductible amount before this plan begins to pay. If you have other 3,200 6,400family members on the policy, the overall family deductible must 2,800 5,400be met before the plan begins to pay. 3,800 7,600Are there services covered Yes. Eligible preventive care, telemedicine/virtual visit charge atbefore you meet yourcertain in-network providers, and drugs on the eligible preventivedeductible?drug therapy list.Are there other deductiblesNo.for specific services?Coverage LevelWhat is the out-of-pocketlimit for this plan?YouYou spouse/partnerYou childrenYou spouse/partner children*You don’t have to meet deductibles for specific services.In-network(or Out of Area* coverage) Out-of-network 3,500 6,000The out-of-pocket limit is the most you could pay in a year for 5,600 9,600covered services. If you have other family members in this plan, 4,550 7,800the overall family out-of-pocket limit must be met. 6,650 11,400What is not included in the Penalties for failure to obtain pre-service authorization, premiums,out-of-pocket limit?balance-billing charges, and health care this plan doesn’t cover.HRS7261 v4.0This plan covers some items and services even if you haven’t yetmet the deductible amount. But a copayment or coinsurance mayapply. For example, this plan covers certain preventive serviceswithout cost sharing and before you meet your deductible. See alist of covered preventive services at e-benefits/Even though you pay these expenses, they don’t count toward theout-of-pocket limit.Page 1 of 7

Generally, yes. Contact your claims administrator for a list ofnetwork providers.Will you pay less if youuse a network provider? For Aetna visit, Aetna.com or call 1-877-320-4577 For Anthem BCBS, visit anthem.com or call 1-866-418-7749 For UnitedHealthcare, visit myuhc.com or call 1-800-842-9722This plan uses a provider network. You will pay less if you use aprovider in the plan’s network. You will pay the most if you use anout-of-network provider, and you might receive a bill from a providerfor the difference between the provider’s charge and what your planpays (balance billing). Be aware that your network provider mightuse an out-of-network provider for some services (such as labwork). Check with your provider before you get services.Do you need a referral tosee a specialist?No.You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommonMedical EventServicesYou May NeedPrimary care visit totreat an injury or illness50% coinsuranceNone50% coinsurance Infertility/fertility: pre-service authorization required, 25,000lifetime max for medical services and 10,000 lifetime maxfor related prescriptions Chiropractic: 26-visit limit annually Acupuncture: 26-visit limit annually Therapies (all physical, occupational, and speech combined):90-visit limit annuallyPreventive care/No chargescreening/immunization50% coinsuranceDeductible doesn’t apply. Category also includes women’spreventive health care services. You may have to pay forservices that aren’t preventive. Ask your provider if the servicesneeded are preventive. Then check what your plan will pay for.Diagnostic test(x-ray, blood work)20% coinsurance50% coinsuranceImaging (CT/PET scans, MRIs)20% coinsurance50% coinsuranceIf you visit a health Specialist visitcare provider’soffice or clinicIf you have a testLimitations, Exceptions, &Other Important Information*In-network ProviderOut-of-network Provideror Out of Area coverage(You will pay the most)(You will pay the least)20% coinsurance20% coinsurance If more than one test is performed within the samediagnostic family during the same session, the first eligibleprocedure is considered at 100% of allowed amount; allother procedures may be considered at a reduced amount Pre-service authorization required for imaging services* For more information about limitations and exceptions, see the summary plan description at teamworks.wellsfargo.com; or for COBRA at https://cobra.ehr.com.Page 2 of 7

What You Will PayCommonMedical EventServicesYou May NeedGeneric drugsIn-network ProviderOut-of-network Provideror Out of Area coverage(You will pay the most)(You will pay the least) 10 copay per retailprescription 20 copay per ExpressScripts Home Delivery(mail order) prescription 10 copay per retailprescription Mail order – not covered Preferred brand drugsIf you need drugsto treat yourillness or conditionMore informationabout prescriptiondrug coverageNon-preferredis available atexpress-scripts.com brand drugsIf you haveoutpatientsurgery 90 copay1, 2 perExpress ScriptsHome Delivery(mail order) prescription 45 copay2 per retailprescription Mail order – not covered 75 copay2 per retailprescription 75 copay2 per retail 150 copay2 perprescriptionExpress Scripts Home Delivery(mail order) prescriptionSpecialty drugsOnly covered throughAccredo SpecialtyPharmacy 150 copay forNot covereda 90-day supply (copay isprorated for 30- or60-day supply)Facility fee(e.g., ambulatorysurgery center)20% coinsurance50% coinsurancePhysician/surgeon fees20% coinsurance50% coinsuranceLimitations, Exceptions, &Other Important Information* You must satisfy your annual deductible before the copaysapply. The deductible doesn’t apply to prescription drugs on thepreventive drug therapy list. Copays for drugs on the preventivedrug therapy list don’t count toward the deductible. Deductible doesn’t apply to copay. Copay doesn’t counttoward deductible. Retail: covers up to a 30-day supply; CVS/Pharmacy storealso covers 31- to 90-day supply for Express Scripts HomeDelivery copay Out-of-network retail: you pay the copay plus differencebetween full cost and the Express Scripts discounted amount In-network Express Scripts Home Delivery: 31- to90-day supply Generic and single-source brand name contraceptivesin-network coverage: 100% Pre-service authorization required for some medications1. Certain insulins may be available for a 25 copay/30-daysupply or 75 copay/90-day supply through the ExpressScripts Patient Assurance Program.2. If generic is available, you pay based on cost of generic pluscost difference between generic and brand drug, does notapply to deductible or out-of-pocket limit.To obtain specialty drugs, you must call Accredo SpecialtyPharmacy at 1-800-803-2523 Pre-service authorization required You must satisfy your annual deductible before thecopay applies. If more than one surgical procedure, all other proceduresconsidered at 50% of allowed amount. Out-of-network asst. surgeon fees considered aspercentage of allowed amount for primary surgeon.* For more information about limitations and exceptions, see the summary plan description at teamworks.wellsfargo.com; or for COBRA at https://cobra.ehr.com.Page 3 of 7

What You Will PayCommonMedical EventIf you needimmediatemedical attentionIf you have ahospital stayIf you needmental health,behavioral health,or substanceabuse servicesServicesYou May NeedLimitations, Exceptions, &Other Important Information*In-network ProviderOut-of-network Provideror Out of Area coverage(You will pay the most)(You will pay the least)Emergency room care20% coinsurance20% coinsuranceIn-network deductible and out-of-pocket appliesEmergency medicaltransportation20% coinsurance20% coinsuranceIn-network deductible and out-of-pocket appliesUrgent care20% coinsurance50% coinsuranceNoneFacility fee(e.g., hospital room)20% coinsurance50% coinsurancePhysician/surgeon fees20% coinsurance50% coinsuranceOutpatient services20% coinsurance50% coinsuranceNoneInpatient services20% coinsurance50% coinsurancePre-service authorization required; out-of-network services20% noncompliance penalty50% coinsuranceMaternity care may include tests and services describedelsewhere in the SBC (such as ultrasound). Cost sharing doesnot apply for preventive services.Office visits20% coinsurance Pre-service authorization required; out-of-network services20% noncompliance penalty. If more than one surgical procedure, all other procedures areconsidered at 50% of allowed amount. Out-of-network asst. surgeon fees considered as percentageof allowed amount for primary surgeon. For eligible spine and joint procedures, completion oftreatment decision support and use of a designated facilitycovered 100% after deductible. No out-of-network coverage. Pre-service authorization required for hospital stay greaterthan 48 hours for vaginal delivery, 96 hours for Cesareandelivery; out-of-network services 20% noncompliance penalty Global bill: claims processing varies, see the “Maternity care”section in Chapter 2: Medical Plans of the Benefits BookChildbirth/delivery20% coinsurance50% coinsurance The baby’s charges are covered only if the child is added tofacility servicesyour coverage through Wells Fargo within 60 days from thedate of birth* For more information about limitations and exceptions, see the summary plan description at teamworks.wellsfargo.com; or for COBRA at https://cobra.ehr.com.Page 4 of 7Childbirth/deliveryIf you are pregnant professional services20% coinsurance50% coinsurance

What You Will PayCommonMedical EventServicesYou May NeedHome health care20% coinsurance50% coinsurance 100-visit limit annually combined with extended skillednursing care services Pre-service authorization required; out-of-network services20% noncompliance penalty50% coinsurance 90-visit limit annually: combined physical, occupational,and speech therapy, rehabilitation and habilitationservices combined Habilitation services are only covered for children up to their18th birthdayRehabilitation servicesIf you need helprecovering orhave other specialhealth needsIf your child needsdental or eye careLimitations, Exceptions, &Other Important Information*In-network ProviderOut-of-network Provideror Out of Area coverage(You will pay the most)(You will pay the least)20% coinsuranceHabilitation servicesSkilled nursing care20% coinsurance50% coinsurance 100-day limit annually in a skilled nursing facility Extended skilled nursing care – 100-visit limit annuallycombined with home health care Pre-service authorization requiredDurablemedical equipment20% coinsurance50% coinsurancePre-service authorization required for single itemcosting 1,000 or more; out-of-network services 20%noncompliance penaltyHospice services20% coinsurance50% coinsurancePre-service authorization requiredChildren’s eye examNot coveredNot coveredRoutine vision screenings as part of well child care may becovered – see preventive care servicesChildren’s glassesNot coveredNot coveredNot coveredChildren’sdental check-upNot coveredNot coveredNot covered* For more information about limitations and exceptions, see the summary plan description at teamworks.wellsfargo.com; or for COBRA at https://cobra.ehr.com.Page 5 of 7

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Out-of-network specialty drugs Cosmetic surgery Long-term care Dental care (adult) Non-emergency care when travelling Routine eye care (adult) Dental care (children)outside the U.S. Routine foot care Private-duty nursing Glasses Weight loss programs Out-of-network mail order prescriptionsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Hearing aids, coverage is limited to once every 3 years. (Bone-anchored hearing Acupuncture, covered only for pain therapy or treatment of nausea related tochemotherapy, pregnancy, or post-operative, 26-visit limit annually.aids are only covered per claims administrator’s medical policy.) Batteries are Bariatric surgery, with pre-service authorization.not covered. Chiropractic care, 26-visit limit annually. (Not covered: treatment for asthma, Infertility treatment, pre-service authorization required, coverage is limited toallergies, recreational therapy, educational therapy, or self-care training; and care 25,000 lifetime benefit combined with any other infertility- or fertility-relatedwhen measurable improvement has ceased.)medical services, plus 10,000 lifetime maximum for related prescription drugs.Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: BenefitConnectTM COBRA at 1-877-292-6272 or https://cobra.ehr.com, or the Department of Labor’s Employee Benefits Security Administration at1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage throughthe Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is calleda grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, orassistance, contact: the claims administrator on your ID card or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272)or www.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? Yes.Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:[Spanish (Español): Para obtener asistencia en Español, llame al – Employees: 1-877-479-3557; COBRA participants: 1-877-292-6272.]):,– Employees: 1-877-479-3557; COBRA participants: 1-877-292-6272.][Chinese ([Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' – Employees: 1-877-479-3557; COBRA participants: 1-877-292-6272.]To see examples of how this plan might cover costs for a sample medical situation, see the next section* For more information about limitations and exceptions, see the summary plan description at teamworks.wellsfargo.com; or for COBRA at https://cobra.ehr.com.Page 6 of 7

About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will bedifferent depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharingamounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion ofcosts you might pay under different health plans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natal care and ahospital delivery) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance 2,00020%20%20%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example CostIn this example, Peg would pay:Cost SharingDeductiblesCopaymentsCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Peg would pay is 12,700 2,000 0 1,500 60 3,560Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsuranceMia’s Simple Fracture(in-network emergency room visit and follow up care) 2,00020%20%20%This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)Total Example CostIn this example, Joe would pay:Cost SharingDeductiblesCopaymentsCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Joe would pay is 5,600 2,000 400 50 20 2,470 The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance 2,00020%20%20%This EXAMPLE event includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example CostIn this example, Mia would pay:Cost SharingDeductiblesCopaymentsCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Mia would pay is 2,800 2,000 0 200 0 2,200The plan would be responsible for the other costs of these EXAMPLE covered services.Page 7 of 7