11-Manor ISD HMO SPD 09012025.pdf

Your Health Care Benefits Program

Blue EssentialsSM Plan

For Employees of Manor Independent School

District

Group # 370296 3702960004.0925

Effective September 1, 2025

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

BlueCross BlueShield of Texas

TX-LG-HMO-CC-COC-25

BLUE CROSS AND BLUE SHIELD OF TEXAS

a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent License of the Blue Cross and Blue Shield Association

(herein called “BCBSTX” or “HMO”)

1001 East Lookout Drive Richardson, Texas 75082

1-877-299-2377 www.bcbstx.com

CERTIFICATE OF COVERAGE

NOTICE TO CONSUMER

This Consumer Choice of Benefits - Health Maintenance Organization (HMO) health care plan, either in whole, or in part, excludes or limits certain state mandated benefits normally required under Texas law.

This health care plan may provide a more affordable health care plan for You; however, it may provide You with fewer health care plan benefits than those normally afforded as state mandated health care benefits under Texas law. Please consult with Your insurance agent to determine which state mandated health care benefits are excluded under this Certificate of Coverage.

This Certificate of Coverage (“Certificate”) is part of the Group Agreement (“Group Agreement”) between the Group and Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation (“HMO”). The Group Agreement governs the terms and conditions of coverage. Provisions of this Certificate include the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any amendments, or attachments, which may be delivered with the Certificate or added later.

The HMO agrees to provide You coverage for health care benefits in keeping with the conditions, rights, and privileges set forth under this Certificate. Your coverage under this Certificate is subject to the terms, conditions, and provisions of the Group Agreement.

This Certificate explains Your covered health care benefits. Coverage for services or supplies is provided only if furnished while You are a Member, and this coverage is in force. Except as shown under the GENERAL

PROVISIONS: COBRA Continuation Coverage and State Continuation Coverage section, coverage is not provided for any services received before coverage starts or after coverage ends.

The defined terms are capitalized and shown under the appropriate provision or GLOSSARY section of this Certificate; and, if applicable, in the amendments or attachments to this Certificate. Whenever these terms are used, the meaning is consistent with the definition given.

The Group Agreement concerning this Certificate is not a Workers’ Compensation insurance policy.

Consult with Your employer to determine if they maintain a Workers’ Compensation policy. This Certificate is governed by applicable federal law and the laws of Texas. Any reference to “applicable law” will include applicable laws and rules, including, but not limited to, statutes, ordinances, and administrative decisions and regulations.

This Certificate may be delivered to You electronically; however, a paper copy is available upon request. Please read this entire Certificate carefully and take the time getting to know Your benefit program, including its benefit limits, exclusions, Your rights and obligations and those of the HMO. Learning how this plan works can help make the best use of your health care benefits. It is the Group’s and Your responsibility to understand the terms and conditions under this Certificate, because in some circumstances, certain medical services are not covered or may require Prior Authorization by the HMO.

No services are covered by this Certificate if current Premiums have not been paid. If the Group Agreement is terminated for nonpayment of Premiums, You are responsible for the cost of services received during the thirty

(30) day Grace Period.

This Certificate applies only to Your HMO coverage. It does not limit Your ability to receive health care services that are not Covered Services. No Participating Provider or other Provider, institution, facility, or agency is an agent or employee of the HMO.

THIS "CERTIFICATE" IS NOT A MEDICARE SUPPLEMENT POLICY. If You are eligible for

Medicare, please review the Guide to Health Insurance for people with Medicare available from BCBSTX.

Have a complaint or need help?

If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help.

Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation

To get information or file a complaint with your insurance company or HMO:

Call: Blue Cross and Blue Shield of Texas

Toll-Free: 1-877-299-2377

Email: BCBSTXComplaints@bcbstx.com

Mail: P. O. Box 660044, Dallas, TX 75266-0044

The Texas Department of Insurance

To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439

File a complaint: www.tdi.texas.gov

Email: ConsumerProtection@tdi.texas.gov

Mail: Consumer Protection, MC: CO-CP, Texas Department of Insurance, P.O. Box 12030, Austin, TX 78711-2030

¿Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas

(Texas Department of Insurance, por su nombre en inglés) pueda ayudar.

Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una queja a través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace, podría perder su derecho para apelar.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation

Para obtener información o para presentar una queja ante su compañía de seguros o HMO:

Llame a: Blue Cross and Blue Shield of Texas

Teléfono gratuito: 1-877-299-2377

Correo electrónico: BCBSTXComplaints@bcbstx.com Dirección postal: P. O. Box 660044, Dallas, TX 75266-0044

El Departamento de Seguros de Texas

Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439

Presente una queja en: www.tdi.texas.gov

Correo electrónico: ConsumerProtection@tdi.texas.gov

Dirección postal: Consumer Protection, MC: CO-CP, Texas Department of Insurance, P.O. Box

12030, Austin, TX 78711-2030 mailto:tion@tdi.texas.gov http://www.tdi.texas.gov/ mailto:ConsumerProtection@tdi.texas.gov

TABLE OF CONTENTS

CERTIFICATE OF COVERAGE

IMPORTANT NOTICE

SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS………………………….………………………ENCLOSURE

GLOSSARY

WHO GETS BENEFITS

Eligibility Requirements Applying for Coverage When Coverage Begins

HOW THE PLAN WORKS

Provider Information Utilization Management Prior Authorization Selecting a PCP Your PCP Changing Your PCP Continuity of Care Specialist as PCP Availability of Providers Out-of-Network Services Inpatient Care by Non-PCP Provider Communication Your Responsibilities Refusal to Accept Treatment Premium Payment Failure to Render Payments Change in Premium Rates Federal Balance Billing and Other Protections Member Complaint Procedure Your Insurance Identification Card Member Claims Refund Claim or Benefit Reconsideration Copayments/Coinsurance Deductibles Out-of-Pocket Maximums

SERVICE AREA

COMPLAINT AND APPEAL PROCEDURES

Customer Inquiries How to File a Complaint with the HMO How to Appeal an HMO Complaint Decision How to Appeal to the Texas Department of Insurance How to Appeal an Adverse Determination Expedited Appeal of Adverse Determination (Emergencies or Continued Hospitalization Situations) How to Appeal to an Independent Review Organization (IRO)

COVERED SERVICES AND BENEFITS

Requirements Professional Services Allergy Care Covered Services include:

Ambulance Services

Covered Services include:

Autism Spectrum Disorder Behavioral Health Services Biomarker Testing Clinical Trials Clinician-Administered Drugs Cosmetic, Reconstructive or Plastic Surgery Dental Surgical Procedures Diabetes Care Diagnostic Mammograms and Other Breast Imaging Durable Medical Equipment Emergency Services Extended Care Services Health Maintenance and Preventive Services Hearing and Speech Services Hearing Aids Inpatient Hospital Services Maternity Care and Family Planning Services Organ and Tissue Transplants Outpatient Facility Services Outpatient Diagnostic Services Prosthetic Appliances and Orthotic Devices Rehabilitation Services Retail Health Clinics Telehealth, Teledentistry, and Telemedicine Services Therapies for Children with Developmental Delays Urgent Care Services Virtual Visits

LIMITATIONS AND EXCLUSIONS

PHARMACY BENEFITS

Your Cost Selecting a Pharmacy About Your Benefits Limitations and Exclusions

GENERAL PROVISIONS

Termination of Coverage COBRA Continuation Coverage State Continuation Coverage Coordination of Benefits Reimbursement - Acts of Third Parties Alternate Service Area Access Assignment Cancellation Clerical Error Entire Certificate Force Majeure Form or Content of Certificate Gender Identity Theft Protection Incontestability Interpretation of Certificate Limitation of Liability Member Data Sharing Modifications Notice Patient/Provider Relationship Refund of Benefit Payments

Relationship of Parties Reports and Records Rescission of Coverage Subtitles

RIDERS

AMENDMENTS

SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS

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

TX-LG-HMO-CC-SOC-BH-25

Blue EssentialsSM Network

Blue EssentialsSM Plan

The following chart summarizes the coverage available under Your HMO Certificate. For details, please refer to the COVERED SERVICES AND BENEFITS sections of this Certificate. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner (PCP), who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Female Members may visit a Participating OB/GYN Physician in their PCP’s Provider network for diagnosis and treatment without a Referral from their PCP. Urgent Care, Virtual Visits, Outpatient Professional Behavioral Health, and Retail Health Clinics do not require Primary Care Physician/Practitioner Referral.

IMPORTANT NOTE: Copayments and, if applicable, Coinsurance shown below indicate the amount You are required to pay, expressed as either a fixed dollar amount or a percentage of the Allowable Amount. Copayments and any applicable Coinsurance or Deductibles will be applied for each Covered Service rendered by a Participating Provider or Emergency Care received from a non-Participating Provider unless otherwise indicated. You will not be responsible for any Copayments/Coinsurance once the Deductible(s) and Out-of-Pocket Maximum(s) listed below have been met. Copayments/Coinsurance, Deductibles and Out-of-Pocket Maximums may be adjusted for various reasons as permitted by applicable law. Some services may require Prior Authorization by the HMO.

O u t - o f - P o c k e t M a x i m u m s P e r C a l e n d a r Y e a r i n c l u d i n g P h a r m a c y B e n e f i t s Per Individual Member

Per Family

$9,000

$16,300

D e d u c t i b l e P e r C a l e n d a r Y e a r

Per Individual Member

Per Family

$3,000

$6,000

P r o f e s s i o n a l S e r v i c e s

Primary Care Physician/Practitioner (“PCP”) Office or Home Visit

$50 Copay

Participating Specialist Physician (“Specialist”) Office or Home Visit

$70 Copay

I n p a t i e n t H o s p i t a l S e r v i c e s

Inpatient Hospital Services 30% Coinsurance after Deductible

O u t p a t i e n t F a c i l i t y S e r v i c e s

Outpatient Surgery 30% Coinsurance after Deductible

Outpatient Hospital Based Infusion Therapy 30% Coinsurance after Deductible

Radiation Therapy 30% Coinsurance after Deductible

Dialysis 30% Coinsurance after Deductible

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, TX-LG-HMO-CC-SOC-BH-25

O u t p a t i e n t L a b o r a t o r y a n d X - R a y S e r v i c e s

Arteriograms, Computerized Tomography (CT Scan), Magnetic Resonance Imaging (MRI), Electroencephalogram (EEG), Myelogram, Positron Emission Tomography (PET Scan), per procedure

30% Coinsurance after Deductible

Other X-Ray Services 30% Coinsurance after Deductible

Outpatient Lab 30% Coinsurance after Deductible

R e h a b i l i t a t i o n S e r v i c e s

Rehabilitation Services and Therapies

Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any rehabilitation services visit maximums.

$50 Copay for PCP or $70 Copay for Specialist, 30% Coinsurance after Deductible for Inpatient Hospital Services or 30% Coinsurance after Deductible for Outpatient Facility Services, as applicable.

M a t e r n i t y C a r e a n d F a m i l y P l a n n i n g S e r v i c e s

Maternity Care

Prenatal and Postnatal Visit – Copay is applied to the first office visit only. Subsequent office visits are covered in full.

$50 Copay for PCP or $70 Copay for Specialist

Inpatient Hospital Services 30% Coinsurance after Deductible

Family Planning Services:

• Diagnostic counseling, consultations and planning services

• Insertion or removal of intrauterine device (IUD), including cost of device

• Diaphragm or cervical cap fitting, including cost of device

• Insertion or removal of birth control device implanted under the skin, including cost of device

• Injectable contraceptive drugs, including cost of drug

$50 Copay for PCP or $70 Copay for

Specialist; unless otherwise covered under

Contraceptive Services described in Health

Maintenance and Preventive Services.

• Vasectomy $50 Copay for PCP or $70 Copay for Specialist or 30% Coinsurance after Deductible for Outpatient Surgery, as applicable.

Infertility Services

Diagnostic counseling, consultations, planning and treatment services

$50 Copay for PCP or $70 Copay for Specialist

Artificial insemination, for each procedure and all services related to procedure (cost of sperm not covered)

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, TX-LG-HMO-CC-SOC-BH-25

B e h a v i o r a l H e a l t h S e r v i c e s

Outpatient Mental Health Care $50 Copay for in-office or home visit or benefits paid same as any other illness for other services, as applicable.

Inpatient Mental Health Care 30% Coinsurance after Deductible

Serious Mental Illness $50 Copay for in-office or home visit or benefits paid same as any other illness for other services, as applicable.

Chemical Dependency Services $50 Copay for in-office or home visit or benefits paid same as any other illness for other services, as applicable.

E m e r g e n c y S e r v i c e s

Emergency Care Facility 30% Coinsurance after Deductible, waived if admitted. (If admitted, any charges described in

Inpatient Hospital Services will apply.)

Emergency Care - Physician

30% Coinsurance after Deductible

U r g e n t C a r e S e r v i c e s

Urgent Care $50 Copay

Any additional charges as described in Outpatient Laboratory and X-Ray Services may also apply.

R e t a i l H e a l t h C l i n i c s

Retail Health Clinics PCP amount listed in Professional Services.

V i r t u a l V i s i t s

Virtual Visits PCP amount listed in Professional Services.

A m b u l a n c e S e r v i c e s

Ambulance Services 30% Coinsurance after Deductible

E x t e n d e d C a r e S e r v i c e s

Skilled Nursing Facility Services, for each day, up to 60 days per Calendar Year

30% Coinsurance after Deductible

Hospice Care, for each day 30% Coinsurance after Deductible

Home Health Care, per visit

30% Coinsurance after Deductible

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, TX-LG-HMO-CC-SOC-BH-25

H e a l t h M a i n t e n a n c e a n d P r e v e n t i v e S e r v i c e s

Well child care through age 17 No Copay

Periodic health assessments for Members age 18 and older No Copay

Immunizations

• Childhood immunizations required by law for Members through age 6

No Copay

• Immunizations for Members over age 6 No Copay

Bone mass measurement for osteoporosis No Copay

Well-woman exam, once every twelve months, includes, but not limited to, exam for cervical cancer (Pap smear)

No Copay

Screening mammogram for female Members age 35 and over and for female Members with other risk factors, once every twelve months

No Copay

• Outpatient facility or imaging centers No Copay

Contraceptive Services and Supplies

• Contraceptive education, counseling and certain female FDA approved contraceptive methods, female sterilization procedures and devices

No Copay

Breastfeeding Support, Counseling and Supplies

• Electric breast pumps limited to one (1) per Calendar Year.

Hearing Loss

• Screening test from birth through 30 days and for infants, children, and adolescents as otherwise required by HRSA guidelines

No Copay

• Follow-up care from birth through 24 months No Copay

Rectal screening for the detection of colorectal cancer for Members age 45 and older:

• Annual fecal occult blood test, once every twelve months

• Flexible sigmoidoscopy with hemoccult of the stool, limited to 1 every 5 years

• Colonoscopy, limited to 1 every 10 years No Copay

Preventive eye screenings for infants, children, and adolescents as required by HRSA guidelines

No Copay

Diagnostic eye, and ear screenings for Members through age 17, once every twelve months

$50 Copay for PCP or $70 Copay for Specialist

Diagnostic eye, and ear screening for Members age 18 and older, once every two years

$50 Copay for PCP or $70 Copay for Specialist

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, TX-LG-HMO-CC-SOC-BH-25

Early detection test for cardiovascular disease, limited to 1 every 5 years

• Computer tomography (CT) scanning 30% Coinsurance after Deductible

• Ultrasonography 30% Coinsurance after Deductible

Early detection test for ovarian cancer (CA125 blood test), once every twelve months

$50 Copay for PCP or $70 Copay for Specialist

Exam for prostate cancer, once every twelve months $50 Copay for PCP or $70 Copay for Specialist

D e n t a l S u r g i c a l P r o c e d u r e s

Dental Surgical Procedures (limited Covered Services) $50 Copay for PCP or $70 Copay for Specialist, 30% Coinsurance after Deductible for Inpatient Hospital Services or 30% Coinsurance after Deductible for Outpatient Surgery, as applicable.

C o s m e t i c , R e c o n s t r u c t i v e o r P l a s t i c S u r g e r y

Cosmetic, Reconstructive or Plastic Surgery (limited Covered Services)

$50 Copay for PCP or $70 Copay for Specialist, 30% Coinsurance after Deductible for Inpatient Hospital Services or 30% Coinsurance after Deductible for Outpatient Surgery, as applicable.

A l l e r g y C a r e

Testing and Evaluation 30% Coinsurance after Deductible

Injections 30% Coinsurance after Deductible

Serum 30% Coinsurance after Deductible

D i a b e t e s C a r e

Diabetes Self-Management Training, for each visit $50 Copay for PCP or $70 Copay for Specialist

Diabetes Equipment 30% Coinsurance after Deductible

Diabetes Supplies

Some Diabetes Supplies are only available utilizing pharmacy benefits, through a Participating Pharmacy. You must pay the applicable PHARMACY BENEFITS amount shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences.

30% Coinsurance after Deductible

P r o s t h e t i c A p p l i a n c e s a n d O r t h o t i c D e v i c e s

Prosthetic Appliances and Orthotic Devices

$300 maximum benefit for purchase of one (1) wig needed as a result of current chemotherapy or radiation treatment for cancer.

30% Coinsurance after Deductible

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, TX-LG-HMO-CC-SOC-BH-25

Cochlear Implants

Limit one (1) per impaired ear, with replacements as Medically Necessary or audiologically necessary.

30% Coinsurance after Deductible

Any additional charges as described in

Outpatient Surgery may also apply.

D u r a b l e M e d i c a l E q u i p m e n t

Durable Medical Equipment 30% Coinsurance after Deductible

H e a r i n g A i d s

Hearing Aids

Maximum benefit – one per ear, every 36 months

30% Coinsurance after Deductible

S p e e c h a n d H e a r i n g S e r v i c e s

Speech and Hearing Services

Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any speech and hearing services visit maximums.

Benefits paid same as any other physical illness

T e l e h e a l t h , T e l e d e n t i s t r y , a n d T e l e m e d i c i n e S e r v i c e s

Telehealth, Teledentistry, and Telemedicine Services

Primary Care Telehealth, Teledentistry, and Telemedicine visit/consultation

Primary Care Telehealth, Teledentistry, and Telemedicine visit/consultation for treatment of Behavioral Health

Specialty Telehealth, Teledentistry, and Telemedicine visit/consultation

$70 Copay

TX-LG-HMO-CC-SOC-BH-25

P h a r m a c y B e n e f i t s

Participating Pharmacy

Retail Pharmacy

Benefit payment amounts are based on a

30-day supply, up to a 30-day supply only.

Extended Prescription Drug Supply

Program (if allowed by the Prescription

Order) – Benefit payment amounts are based on a 30-day supply, up to a 90-day supply.

Tier 1

Tier 2

Tier 3

Out-of-Area Drug

$15 Copay

30% Copay

50% Copay

Mail-Order Program

Extended Prescription Drug Supply

Program (if allowed by the Prescription

Order) – Benefit payment amounts are based on a 90-day supply, up to a 90-day supply only. Cost share will be based on day supply (1-30-day supply, 31-60 day supply, 61-90 day supply) dispensed.

Tier 1

Tier 2

Tier 3

$30 Copay

30% Copay

Specialty Pharmacy Program

Benefit payment amounts are based on a

30-day supply, up to a 30-day supply only.

Tier 4 30% Copay

Select Vaccinations obtained through the

Pharmacy Vaccine Network $0 Copay

Diabetes Supplies are covered as described in PHARMACY BENEFITS. All provisions listed in

PHARMACY BENEFITS will apply, including Copayments/Coinsurance, Deductibles, and any pricing differences.

The Copayment 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.

Certain Covered Drugs may be available at no cost through a Participating Pharmacy for the following categories of medication: severe allergic reactions, hypoglycemia, opioid overdoses, and nitrates. For further information, call the number on the back of Your Identification Card.

Note: For Members with a chronic, complex, rare, or life-threatening medical condition, Covered Drugs that will be administered by a Provider in a Physician’s office may be obtained from a non-Participating

Pharmacy by the Provider, after the Provider has determined that disease progression, patient harm, or death is probable, or where the Provider has concerns about patient adherence or timely delivery. These services are covered under the medical benefit and the cost-sharing requirements will be the same as if they were obtained from a Participating Pharmacy.

For additional information regarding the applicable Drug List, please call customer service or visit the website at https://www.bcbstx.com.

TX-LG-HMO-CC-COC-25 1

GLOSSARY

Acquired Brain Injury means a neurological insult to the brain, which is not hereditary, congenital, or degenerative. The injury to the brain has occurred after birth and results in a change in neuronal activity, which results in an impairment of physical functioning, sensory processing, cognition, or psychosocial behavior.

Advanced Practice Nurse (APN) means a registered nurse approved by the Texas Board of Nursing to practice as an advanced practice nurse based on completing an advanced educational program acceptable to the Board. The term includes a nurse practitioner, nurse-midwife, nurse anesthetist, and a clinical nurse specialist. An Advanced Practice Nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including but not limited to homes, Hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. An Advanced Practice Nurse acts independently and/or in collaboration with other Health Care Professionals in the delivery of health care services.

Allowable Amount means the maximum amount determined by the HMO to be eligible for consideration of payment for a particular Covered Service, Covered Drug, or covered supply rendered by a Participating Provider.

Your Deductible, Copay, and Coinsurance are based on the provisions of the Participating Provider and Participating Pharmacy contracts and the terms of this Plan.

Approved Clinical Trial means a Phase I, Phase II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other Life-Threatening Disease or Condition The trial must be:

• Conducted under an investigational new drug application reviewed by the United States Food and Drug Administration

• Exempt from obtaining an investigational new drug application

• Approved or funded by:

o The National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, or a cooperative group or center of any of the foregoing entities o A cooperative group or center of the United States Department of Defense or the United States Department of Veterans Affairs o A qualified nongovernmental research entity identified in the guidelines issued by the National Institutes of Health for center support groups o The United States Departments of Veterans Affairs, Defense, or Energy if the study or investigation has been reviewed and approved through a system of peer review determined by the United States Secretary of Health and Human Services to:

▪ Be comparable to the system of peer review of studies and investigations used by the National Institutes of Health

▪ Provide unbiased scientific review by individuals who have no interest in the outcome of the review

▪ Conducted and approved by an institutional review board of an institution in this state that has an agreement with the Office for Human Research Protections of the United States Department of Health and Human Services

Autism Spectrum Disorder means a Neurobiological Disorder that includes autism, Asperger's syndrome, or pervasive developmental disorder not otherwise specified. “Neurobiological Disorder” means an illness of the nervous system caused by genetic, metabolic, or other biological factors.

Behavioral Health means any condition or disorder involving a mental health condition or substance use disorder listed under any of the diagnostic categories in the mental disorders section of the most recent edition of the International Classification of Disease or in the mental disorders section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders.

Behavioral Health Administrator means a Physician or other professional Provider who renders services for mental and Behavioral Health conditions or substance use disorder and is operating within the scope of such license.

Benefits mean the payment, reimbursement, and indemnification of any kind which You will receive from and through this HMO Plan.

TX-LG-HMO-CC-COC-25 2

Benefit Period means the period during which you receive covered services for which this Plan will provide Benefits.

Biomarker means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to the specific therapeutic intervention. Includes gene mutations and protein expression.

Biomarker Testing means the analysis of a patient’s tissue, blood, or other biospecimen for the presence of a biomarker. The term includes single-analyte tests, multiplex panel tests and whole genome sequencing.

Brand Name Drug means a drug or product manufactured by a single manufacturer as defined by a nationally recognized provider of drug product database information. There may be some cases where multiple manufacturers will produce the same product under one license, known as a co-licensed product, which would also be considered as a Brand Name Drug. There may also be situations where a drug’s classification changes from generic to brand name due to a change in the market resulting in the generic being a single source, or the drug product database information changing, which would also result in a corresponding change in Copayment/Coinsurance obligations from generic to brand name.

Brand Name Drug (Non-Preferred) means a Brand Name Drug which appears on the applicable Drug List as Non-Preferred Brand Name Drug. The Drug List is available by accessing the website at https://www.bcbstx.com.

Brand Name Drug (Preferred) means a Brand Name Drug which appears on the applicable Drug List as Preferred Brand Name Drug. The Drug List is available by accessing the website at https://www.bcbstx.com.

Calendar Year means the period beginning January 1 of any year and ending December 31 of the same year.

Chemical Dependency means the abuse of or psychological or physical dependence on or addiction to alcohol or a Controlled Substance.

Chemical Dependency Treatment Center means a facility that provides a program for the treatment of Chemical Dependency pursuant to a written treatment plan approved by the HMO or its designated Behavioral Health Administrator. The facility must be:

• Affiliated with a Hospital under a contractual agreement with an established system for patient Referral

• Accredited as such a facility by the Joint Commission on Accreditation of Healthcare Organizations

• Licensed, certified or approved as a Chemical Dependency treatment program or center by an agency of the state of Texas having legal authority to so license, certify or approve

• If outside Texas, licensed, certified or approved as a Chemical Dependency treatment program or center by the appropriate agency of the state in which it is located having the legal authority to so license, certify or approve

Clinical Ecology means the inpatient or outpatient diagnosis or treatment of allergic symptoms by:

• Cytotoxicity testing (testing the result of food or inhalant by whether or not it reduces or kills white blood cells)

• Urine auto injection (injecting one’s own urine into the tissue of the body)

• Skin irritation by Rinkel method

• Subcutaneous provocative and neutralization testing (injecting the patient with allergen)

• Sublingual provocative testing (droplets of allergenic extracts are placed in mouth)

Coinsurance means the percentage of the Allowable Amount You pay to a Participating Provider or Participating Pharmacy for Covered Services and Prescription Orders provided as described in COVERED SERVICES AND

BENEFITS and in PHARMACY BENEFITS.

Complications of Pregnancy means conditions, requiring Hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed miscarriage, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, Physician

TX-LG-HMO-CC-COC-25 3

prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and non-elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible.

Contract Month means the period of each succeeding month beginning on the Group Agreement effective date.

Controlled Substance means an abusable volatile chemical as defined in the Texas Health and Safety Code, or a substance designated as a Controlled Substance in the Texas Health and Safety Code.

Copayment or Copay means the set dollar amount or percentage amount You pay each time You receive a Covered Service or Pharmacy benefit.

Cosmetic, Reconstructive or Plastic Surgery means surgery that can be expected or is intended to improve Your physical appearance, is performed for psychological purposes, or restores form but does not correct or materially restore a bodily function.

Covered Drug(s) means any prescription drug:

• Which is included on the applicable Drug List

• Which is Medically Necessary and is ordered by an authorized Provider for You or Your dependent

• For which a separate charge is customarily made

• Which is not consumed at the time and place that the Prescription Order is written

• For which the U.S. Food and Drug Administration (FDA) has given approval for at least one indication

• Which is dispensed by a Participating Pharmacy and is received by the Member while covered under this

Certificate, except when received from a Provider’s office, or during confinement while a patient in a Hospital or other acute care institution or facility (please refer to the Limitations and Exclusions section of this Certificate)

Note: Covered Drug(s) under PHARMACY BENEFITS also means insulin, insulin analogs, insulin pens, and prescriptive and non-prescriptive oral agents for controlling blood sugar levels, including disposable syringes and needles needed for self-administration.

Covered Services means those Medically Necessary services or supplies for which Benefits will be provided as described under this Certificate.

Crisis Stabilization Unit means a 24-hour hour residential program that is usually short-term in nature and provides intensive supervision and highly structured activities to Members who show signs of an acute demonstrable psychiatric crisis of moderate to severe proportions.

Custodial Care means any service primarily for personal comfort or convenience that provides general maintenance, preventive, and/or protective care without any clinical likelihood of improvement of Your condition.

Custodial Care services also means those services which do not require the technical skills, professional training and clinical assessment ability of medical and/or nursing personnel in order to be safely and effectively performed.

These services can be safely provided by trained or capable non-professional personnel, are to assist with routine medical needs (e.g. simple care and dressings, administration of routine medications, etc.) and are to assist with activities of daily living (e.g. bathing, eating, dressing, etc.).

Deductible means the amount, if any, you must pay before the HMO pays Benefits. You do not send this amount to the HMO. The HMO will subtract the amount from covered expenses on claims You and Health Care Professionals submit. Some services can be covered before the Deductible is met. Please refer to the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS section for any Deductibles applicable to Your coverage.

Dependent(s) or Dependent Child(ren) means the Subscriber’s family members who meet the eligibility requirements of the WHO GETS BENEFITS Dependent Eligibility section of this Certificate and have been enrolled by the Subscriber.

Dietary and Nutritional Services means the education, counseling, or training (including printed material) regarding diet, regulation or management of diet, or the assessment or management of nutrition.

Domestic Partner means a person with whom You have entered into a Domestic Partnership in accordance with the Group’s guidelines and who has been determined eligible for coverage by the HMO. Note: Domestic Partner

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coverage is available at Your Employer’s discretion. Contact Your Employer for information on whether Domestic Partner coverage is available for Your Group and if COBRA-like Benefits are available.

Domestic Partnership means long-term committed relationship of indefinite duration with a person which meets the following criteria:

• You and your domestic partner have lived together for at least 6 months

• Neither you nor your domestic partner is married to anyone else or has another domestic partner

• Your domestic partner is at least 18 years of age and mentally competent to consent to contract

• Your domestic partner resides with you and intends to do so indefinitely

• You and your domestic partner have an exclusive mutual commitment similar to marriage

• You and your domestic partner are jointly responsible for each other’s common welfare and share financial obligations.

Drug List means a list of drugs that may be covered under the PHARMACY BENEFITS portion of the Plan. The Drug List is available by accessing the website at www.bcbstx.com. You may also contact customer service at the toll-free number on Your Identification Card for more information.

Durable Medical Equipment (DME) means equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in absence of illness or injury and is appropriate for use in the home.

Effective Date of Coverage means the commencement date of coverage under this Certificate as shown in the records of the HMO.

Emergency Care means health care services provided in a Hospital emergency facility, freestanding emergency medical care facility, or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that their condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

• Placing the patient’s health in serious jeopardy

• Serious impairment of a bodily function

• Serious dysfunction of any bodily organ or part

• Serious disfigurement

• In the case of a pregnant woman, serious jeopardy to the health of the fetus

Employee means an individual employed by a group/Employer. For purposes of this Plan, the term Employee will also include those individuals who are no longer an Employee of the Employer, but who are participants covered under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or continued under the appropriate provisions of the Texas Insurance Code.

Employer means a group, as defined, in which there exists an employment relationship between a participant and the group.

Environmental Sensitivity means the inpatient or outpatient treatment of allergic symptoms by controlling environment, sanitizing the surroundings (removal of toxic materials), or use of special nonorganic, nonrepetitive diet techniques.

Experimental/Investigational means the use of any treatment, procedure, facility, equipment, drug, device or supply not accepted as Standard Medical Treatment of the condition being treated and any of such items requiring federal or other governmental agency approval not granted at the time services were provided. “Approval” by a federal agency means that the treatment, procedure, facility, equipment, drug, device or supply has been approved for the condition being treated and, in the case of a drug, in the dosage used on the patient. Approval by a federal agency will be taken into consideration by the HMO in assessing Experimental/Investigational status but will not

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be determinative. Medical treatment includes medical, surgical or dental treatment. “Standard Medical Treatment” means the services or supplies that are in general use in the medical community in the United States, and:

1) Have been demonstrated in peer-reviewed literature to have scientifically established medical value for curing or alleviating the condition being treated

2) Are appropriate for the Hospital or Participating Provider

3) The Health Care Professional has had the appropriate training and experience to provide the treatment or procedure.

The HMO shall determine whether any treatment, procedure, facility, equipment, drug, device, or supply is Experimental/Investigational, and will consider factors such as the guidelines and practices of Medicare, Medicaid, or other government-financed programs and approval by a federal agency in making its determination.

Although a Health Care Professional may have prescribed treatment, and the services or supplies may have been provided as the treatment of last resort, such services or supplies still may be Experimental/Investigational within this definition. Treatment provided as part of a clinical trial or a research study is Experimental/Investigational.

Fertility Preservation Services means the collection and preservation of sperm, unfertilized oocytes, and ovarian tissue; and does not include the storage of such unfertilized genetic materials.

Grace Period means a period of thirty (30) days after all but the first Premium due date, during which period Premiums may be paid to the HMO without lapse of coverage occurring. If payment is not received within thirty

(30) days, coverage will be terminated after the 30th day and You will be liable for the cost of services received during the Grace Period.

Group means the Employer or party that has entered into a Group Agreement with the HMO under which the HMO will provide for or arrange health services for eligible Members of the Group who enroll.

Health Benefit Plan means a group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group Hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides Benefits for health care services.

Health Care Practitioner means an Advanced Practice Nurse, Doctor of Medicine, Doctor of Dentistry, Physician Assistant, Doctor of Osteopathy, Doctor of Podiatry, or other licensed person with prescription authority.

Health Care Professional(s) means Physicians, nurses, audiologists, Physician Assistants, Advanced Practice Nurses, nurse first assistants, acupuncturists, clinical psychologists, pharmacists, occupational therapists, physical therapists, speech and language pathologists, surgical assistants and other professionals engaged in the delivery of health services who are licensed, practice under an institutional license, or certified, or practice under authority of a Physician or legally constituted professional association, or other authority consistent with state law.

HMO (Health Maintenance Organization) means Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation.

Hospice means an organization, licensed by appropriate regulatory authority or certified by Medicare as a supplier of Hospice care, which has entered into an agreement with the HMO to render Hospice care to Members.

Hospital means an acute care facility that:

• Is duly licensed as a Hospital by the state in which it is located and must be accredited by the Joint Commission on Accreditation of Healthcare Organizations or certified under Medicare

• Is primarily engaged in providing inpatient medical care and treatment of sick and injured persons through medical, diagnostic, and major surgical services

• Provides all services on its premises under the supervision of a staff of Physicians or Behavioral Health Providers

• Provides 24-hour a day nursing services by or under the supervision of a Registered Nurse

• Has in effect a Hospital utilization review plan

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Hospital Services (except as expressly limited or excluded in this Certificate) means those Medically Necessary Covered Services that are generally and customarily provided by acute general Hospitals; and prescribed, directed or authorized by the PCP.

Identification Card means the card issued to the Member by us indicating pertinent information applicable to their coverage.

Infertility means the condition of a presumably healthy Member who is unable to conceive or produce conception after a period of one year of frequent, unprotected heterosexual sexual intercourse. This does not include conditions for male Members when the cause is a vasectomy or orchiectomy or for female Members when the cause is a tubal ligation or hysterectomy.

Infusion Therapy involves the administration of medication through a needle or catheter. It is prescribed when a patient’s condition is so severe that it cannot be treated effectively by oral medications. Typically, “infusion therapy” means that a drug is administered intravenously, but the term also may refer to situations where drugs are provided through other non-oral routes, such as intramuscular injections and epidural routes (into the membranes surrounding the spinal cord). Infusion therapy in most cases requires Health Care Professional services for the safe and effective administration of the medication.

Insulin means an insulin analog and an insulin-like medication, regardless of the activation period or whether the solution is mixed before the prescription is dispensed.

Insulin-Related Equipment or Supplies means needles, syringes, cartridge systems, prefilled pen systems, glucose meters, continuous glucose monitor supplies, and text strips but does not include insulin pumps.

Late Enrollee means any Employee or Dependent eligible for enrollment who requests enrollment in an Employer’s health benefit plan:

• After the expiration of the initial enrollment period established under the terms of the first plan for which that participant was eligible through the Employer

• At the expiration of an Open Enrollment Period

• After the expiration of a special enrollment period

Legend Drug means a drug, biological, or compounded prescription which is required by law to have a label stating “Caution – Federal Law Prohibits Dispensing Without a Prescription,” and which are approved by the FDA for a particular use or purpose.

Life-Threatening Disease or Condition means, for the purposes of a clinical trial, any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

Medical Director means a Physician of the HMO, or his designee, who is responsible for monitoring the provision of Covered Services to Members.

Medically Necessary/Medical Necessity means services or supplies (except as limited or excluded herein) that are:

• Essential to, consistent with, and provided for the diagnosis or the direct care and treatment of the condition, sickness, disease, injury, or bodily malfunction

• Provided in accordance with and are consistent with generally accepted standards of medical practice in the United States

• Not primarily for the convenience of the Member or Participating Provider

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• The most economical supplies or levels of service appropriate for the safe and effective treatment of the Member

• If more than one health intervention meets the requirements listed above, Medically Necessary means the most cost effective in terms of type of intervention or settings, frequency, extent, or duration, which is safe and effective for the patient's illness, injury, or disease and supports improved health.

When applied to hospitalization, this further means that You require acute care as an inpatient due to the nature of the services rendered or Your condition, and You cannot receive safe or adequate care as an outpatient. In determining whether a service is Medically Necessary, the HMO may consider the views of the state and national medical communities and the guidelines and practices of Medicare, Medicaid, or other government-financed programs and peer reviewed literature. Although a Participating Provider may have prescribed treatment, such treatment may not be Medically Necessary within this definition. This definition applies only to the HMO’s determination of whether health care services are Covered Services under this Certificate. The HMO does not determine Your course of treatment or whether You receive particular health care services. The decision regarding the course of treatment and receipt of particular health care service is entirely between You and Your Participating Provider. The HMO's determination of Medically Necessary care is limited to merely whether a proposed admission, continued hospitalization, outpatient service or other health care service is Medically Necessary under this Certificate.

Medicare means Title XVIII of the Social Security Act and all amendments thereto.

Member means a Subscriber or Dependent(s) covered under the HMO. This Certificate may refer to a Member as You or Your.

Mental Health Care means any one or more of the following:

1. The diagnosis or treatment of a mental disease, disorder, or condition listed in the Diagnostic and

Statistical Manual of Mental Disorders of the American Psychiatric Association, as revised, or any other diagnostic coding system as used by the HMO or its designated Behavioral Health Administrator, whether or not the cause of the disease, disorder, or condition is physical, chemical, or mental in nature or origin

2. The diagnosis or treatment of any symptom, condition, disease, or disorder by a Participating Provider when the Covered Service is:

o Individual, group, family, or conjoint psychotherapy o Counseling o Psychoanalysis o Psychological testing and assessment o The administration or monitoring of psychotropic drugs o Hospital visits (if applicable) or consultations in a facility listed in item 5, below

3. Electroconvulsive treatment

4. Psychotropic drugs

5. Any of the services listed in items 1-4, above, performed in or by a Hospital (if applicable), or other licensed facility or unit providing such…