11-Manor Independent School District TX370294 BA0001 PPO Final SBC 09012025.pdf

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 09/01/2025 – 08/31/2026 Manor Independent School District: BLUECH PPO $1,400 Plan Coverage for: Individual / Family | Plan Type: PPO

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-521-2227 or at

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 www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

In-Network: $1,400 Individual / $4,000 Family Out-of-Network: $2,000 Individual / $6,000 Family

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Services that charge a copayment, emergency room services, certain preventive care, and In-Network diagnostic tests are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes. $200 Individual drug deductible. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

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

In-Network: $7,000 Individual / $14,000 Family Out-of-Network: $23,700 Individual / $47,400 Family

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

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

Premiums, balance-billing charges, and health care this plan doesn’t cover.

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

Will you pay less if you use a network provider?

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing).

Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

https://policy-srv.box.com/s/vk7tbcb1u0nzcqfo9wfds005v7ifhnm6.

*For more information about limitations and exceptions, see the plan or policy document at Page 2 of 7

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

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important

Information In-Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

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

Primary care visit to treat an injury or illness

$50 copayment/visit;

deductible does not apply

40% coinsurance after deductible

Virtual visits are available, please refer to your plan policy for more details.

Specialist visit $70 copayment/visit;

deductible does not apply

40% coinsurance after deductible None

Preventive care/screening/ immunization

No Charge;

deductible does not apply

40% coinsurance after deductible

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

No Charge for child immunizations Out-of- Network through the 6th birthday.

If you have a test Diagnostic test (x-ray, blood work)

No Charge;

deductible does not apply

40% coinsurance after deductible Office visit copayment may apply.

Imaging (CT/PET scans, MRIs) 20% coinsurance after deductible

40% coinsurance after deductible None

*For more information about limitations and exceptions, see the plan or policy document at Page 3 of 7

Information In-Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

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

Generic drugs $20 retail/$50 mail order copayment/prescription after deductible

$20 copayment/prescription plus 50% coinsurance after deductible

Prescription drug deductible:

$200 Individual Retail covers a 30-day supply. With appropriate prescription, up to a 90-day supply is available. Mail order covers a 90-day supply.

Out-of-Network mail order is not covered.

Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available.

For Out-of-Network pharmacy, member must file claim.

Certain drugs require approval before they will be covered.

The cost-sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.

Preferred brand drugs $45 retail/$112.50 mail order copayment/prescription after deductible

$45 copayment/prescription plus 50% coinsurance after deductible

Non-preferred brand drugs $95 retail/$237.50 mail order copayment/prescription after deductible

$95 copayment/prescription plus 50% coinsurance after deductible

Specialty drugs $20/$45/$95 copayment/prescription after deductible

$20/$45/$95 copayment/prescription plus 50% coinsurance after deductible

For In-Network benefit, specialty drugs must be obtained from In-Network specialty pharmacy provider. Specialty drugs are limited to a 30-day supply except for certain FDA-designated dosing regimens. Mail order is not covered.

If you have outpatient surgery

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

20% coinsurance after deductible

40% coinsurance after deductible None

Physician/surgeon fees 20% coinsurance after deductible

40% coinsurance after

*For more information about limitations and exceptions, see the plan or policy document at Page 4 of 7

Information In-Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you need immediate medical attention

Emergency room care

Facility Charges:

$500 copayment/visit plus 20% coinsurance;

deductible does not apply ER Physician Charges:

20% coinsurance after deductible

Facility Charges:

$500 copayment/visit plus 20% coinsurance;

deductible does not apply ER Physician Charges:

20% coinsurance after deductible

Emergency room copayment waived if admitted.

Emergency medical transportation

20% coinsurance after deductible

20% coinsurance after deductible Ground and air transportation covered.

Urgent care $50 copayment/visit;

deductible does not apply

40% coinsurance after deductible

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance after deductible

40% coinsurance after deductible None

Physician/surgeon fees 20% coinsurance after deductible

40% coinsurance after deductible None

If you need mental health, behavioral health, or substance abuse services

Outpatient services

$50 copayment/office visit;

deductible does not apply 20% coinsurance after deductible for other outpatient services

40% coinsurance after deductible

Certain services must be preauthorized; refer to your benefit booklet* for details.

Virtual visits are available, please refer to your plan policy for more details.

Inpatient services 20% coinsurance after deductible

40% coinsurance after deductible None

If you are pregnant

Office visits $50 copayment PCP/ $70 copayment SPC;

deductible does not apply

40% coinsurance after deductible

Copayment applies to first prenatal visit (per pregnancy).

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

ultrasound).

Childbirth/delivery professional services

20% coinsurance after deductible

40% coinsurance after deductible

Childbirth/delivery facility services

20% coinsurance after deductible

40% coinsurance after

*For more information about limitations and exceptions, see the plan or policy document at Page 5 of 7

Information In-Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you need help recovering or have other special health needs

Home health care 20% coinsurance after deductible

40% coinsurance after deductible

Limited to 60 visits per calendar year.

Preauthorization is required.

Rehabilitation services

$50 PCP/

$70 SPC copayment/visit;

deductible does not apply 20% coinsurance after deductible for other outpatient services

40% coinsurance after deductible

Limited to 120 visits combined for all therapies per calendar year. Includes, but is not limited to, occupational, physical, and manipulative therapy.

Habilitation services

$50 PCP/

$70 SPC copayment/visit;

deductible does not apply 20% coinsurance after deductible for other outpatient services

40% coinsurance after deductible

Skilled nursing care 20% coinsurance after deductible

40% coinsurance after deductible Limited to 25 days per calendar year.

Durable medical equipment 20% coinsurance after deductible

40% coinsurance after deductible None

Hospice services 20% coinsurance after deductible

40% coinsurance after deductible None

If your child needs dental or eye care

Children’s eye exam $50 copayment PCP/$70 copayment SPC;

deductible does not apply

40% coinsurance after deductible None

Children’s glasses Not Covered Not Covered None Children’s dental check-up Not Covered Not Covered None

Excluded Services & Other Covered Services:

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

Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult)

Infertility treatment Long-term care Non-emergency care when traveling outside the

U.S.

Private-duty nursing Routine foot care Weight loss programs

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

Chiropractic care (120 visits per year) Hearing aids (1 per ear per 36-month period) Routine eye care (Adult)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.

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 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese ( ): 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

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

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 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 be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

The plan’s overall deductible $1,400 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services like:

Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $1,400 Copayments $50 Coinsurance $2,000

What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,510

Hospital (facility) coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services like:

Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:

Cost Sharing

Deductibles $1,000 Copayments $1,000 Coinsurance $0

What isn’t covered Limits or exclusions $20 The total Joe would pay is $2,020

Hospital (facility) coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services like:

Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:

Cost Sharing

Deductibles $1,400 Copayments $800 Coinsurance $70

What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,270

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

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

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