Your Health Care Benefits Program Managed Health Care Pharmacy Benefits

Manor Independent School District

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

Group #370294 - PPO Plan 3702940001.0925

BlueCross BlueShield of Texas

TX-G-P-LG-COC-0125 Enclosure d

CERTIFICATE OF COVERAGE

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 (herein called “BCBSTX”, “we” or “us”)

Hereby certifies that it has issued a group preferred provider organization (PPO) benefits and pharmacy benefits contract (herein called the “plan”). Subject to the provisions of the plan, each employee to whom a Blue Cross and Blue Shield identification card is issued, together with their eligible dependents for whom application is initially made and accepted, shall have coverage under the plan, beginning on the effective date shown on the identification card, if the employer makes timely payment of total premium due to us. Issuance of this benefit booklet by BCBSTX does not waive the eligibility and effective date provisions stated in the plan. Any reference to “applicable law” will include applicable laws and rules, including but not limited to statutes, ordinances, and administrative decisions and regulations.

James Springfield

President of Blue Cross and Blue Shield of Texas

NOTICE OF SEPARATE AVAILABLE COVERAGE

This notice is required by Texas legislation to be provided to you. It is to inform you, the employee, that your employer has selected this health benefit coverage. BCBSTX does not offer a rider or separate insurance contact through your employer that would provide coverage in addition to the coverage under this contract.

THE INSURANCE CONTRACT UNDER WHICH THIS BENEFIT BOOKLET IS ISSUED IS NOT A

CONTRACT OF WORKER’S COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR

EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKER’S

COMPENSATION SYSTEM

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: 1-800-521-2227 Email: BCBSTXComplaints@bcbstx.com Mail: PO 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, PO 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: 1-800-521-2227 Correo electrónico: BCBSTXComplaints@bcbstx.com Dirección postal: PO 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, PO Box 12030, Austin, TX 78711-2030 mailto:BCBSTXComplaints@bcbstx.com http://www.tdi.texas.gov/ mailto:tion@tdi.texas.gov mailto:BCBSTXComplaints@bcbstx.com http://www.tdi.texas.gov/ mailto:ConsumerProtection@tdi.texas.gov

TX-G-P-LG-COC-0125

TABLE OF CONTENTS

QUICK REFERENCE ..................................................................................................................... ENCLOSURE

CUSTOMER SERVICE .................................................................................................................. ENCLOSURE

SUMMARY OF BENEFITS ........................................................................................................... ENCLOSURE

INTRODUCTION

WHO GETS BENEFITS

HOW THE PLAN WORKS

COVERED SERVICES

MEDICAL LIMITATIONS AND EXCLUSIONS

PHARMACY BENEFITS

UTILIZATION MANAGEMENT

CLAIM FILING AND APPEALS PROCEDURES

GENERAL PROVISIONS

GLOSSARY………………………………………

Quick Reference

W h e r e t o F i n d t h e A n s w e r

Provider Directory www.bcbstx.com

Prescription Drug List www.bcbstx.com

Prior Authorization List www.bcbstx.com

Preventive Services https://www.bcbstx.com/provider/clinical/clinical-resources/preventive-care

• Customer Service

• Prior Authorization

• Inpatient Admissions

• Appeals

• Claim Forms

• Prescription Drug

• Mail-Order Services

• Pharmacy Locator

See CUSTOMER SERVICE section in this benefit booklet for contact information such as websites and mailing addresses where available

Definitions See GLOSSARY section.

Defined terms are in bold in your booklet

Your cost share information for covered services See SUMMARY OF BENEFITS section.

Cost shares for medical and pharmacy services are listed separately in this section.

CUSTOMER SERVICE

Self-Service Member Portal Blue Access for Members (BAM)

Website

Provider Directory www.bcbstx.com

Identification Card www.bcbstx.com

For Medical Appeals Send via mail

Mailing Address

(for Non-Behavioral Health)

Blue Cross and Blue Shield of Texas Appeals Division P.O. Box 660044

Dallas, TX 75266-0044

(for Behavioral Health/Mental Health/Substance Use Disorder Treatment)

Blue Cross and Blue Shield of Texas Appeals Division P.O. Box 660044

Dallas, TX 75266-0044

BLUECARD® NATIONWIDE/WORLDWIDE COVERAGE PROGRAM

1-800-810-BLUE (2583) – http://provider.bcbs.com

MDLIVE®

1-888-684-4233

Prescription Drug Benefits Call Website Mailing Address

Pharmacy Benefit Manager

(PBM)

Prime Therapeutics

See Pharmacy customer service telephone number on the back of your identification card www.bcbstx.com

Prime Therapeutics LLC PO Box 25136

Lehigh Valley, PA 18002-

Where to Mail Completed Claim Forms:

For Medical Claims Prescription Drug Claims

Blue Cross and Blue Shield of Texas Claims Division

PO Box 660044 Dallas, TX 75266-0044

Prime Therapeutics LLC PO Box 25136

Lehigh Valley, PA 18002-5136

Medical Benefits Call Website

Customer Service Helpline See telephone number on the back of your identification card www.bcbstx.com BCBSTX Provider Directory

Wellness Other Online Services and Information

Prior authorization (for Behavioral Health and for Non-Behavioral Health

See telephone number on the back of your identification card

INPATIENT ADMISSIONS

(for Behavioral Health and for Non-Behavioral Health

See telephone number on the back of your identification card http://provider.bcbs.com/

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SUMMARY OF BENEFITS

PPO Plan BlueChoice PPOSM Network

This is your SUMMARY OF BENEFITS. It shows your cost share including deductible amounts, copayment amounts and coinsurance amounts and how they apply to the covered services you receive under this plan. The information below summarizes your cost share and any limits that may apply to covered services. You may contact Customer Service at the telephone number on the back of your member identification card for any questions or additional information.

How cost sharing works:

• The deductible amounts and copayment amounts listed in the charts below show the amounts you pay for covered services.

• Coinsurance amounts, if any, listed in the charts below are the percentage of the allowable amount you pay. You may have to satisfy deductible amount(s), copayment amount(s) and/or coinsurance amount(s) before you receive services.

• All copayment and coinsurance costs shown in the charts below are after your deductible has been met, if a deductible applies.

• Your benefit period is a period of one year beginning on January 1 of each year. When you first enroll under this plan, your coverage begins on the date shown above and ends on the first of the first day of the month the following year. For example 01-01-2025 to 12-31-2025.

Benefit Period Calendar year

Deductible In-Network Providers Out-of-Network Providers

Individual $1,400 $2,000

Family $4,000 $6,000

• In-network deductible amounts will not be applied to out-of-network deductible amounts

Out-of-Pocket Maximum In-Network Providers Out-of-Network Providers

Individual $7,000 $23,700

Family $14,000 $47,400

• In-network out-of-pocket maximum amounts will not be applied to out-of-network maximum amounts

• All applicable pharmacy claims apply toward the in-network out-of-pocket maximum only

All limits are combined for in-network and out-of-network benefits unless stated otherwise.

Allergy Injections

Description In-network

You pay Out-of-network

You pay

Allergy Injections When billed separately from an office visit 20% coinsurance 40% coinsurance

Ambulance Services Description You pay

Air ambulance 20% coinsurance

Ground ambulance 20% coinsurance

Behavioral Health Services (Mental Health/Substance Use Disorder)

In-network

You pay Out-of-network

You pay

Inpatient facility services 20% coinsurance 40% coinsurance

Inpatient physician services 20% coinsurance 40% coinsurance

Outpatient facility services 20% coinsurance 40% coinsurance

Outpatient physician services 20% coinsurance 40% coinsurance

Office visit $50 copay then no charge deductible does not apply

40% coinsurance

Chiropractic Care

In-network

You pay Out-of-network

You pay

Office visit $70 copay then no charge deductible does not apply

40% coinsurance

Chiropractic care in the office

$70 copay then no charge deductible does not apply

40% coinsurance

Chiropractic care in an outpatient setting

20% coinsurance 40% coinsurance

Limits 120 visits each benefit period

Visit limit applied to a combination of physical therapy, occupational therapy and chiropractic care.

Durable Medical Equipment (DME)

In-network

You pay Out-of-network

You pay

DME 20% coinsurance 40% coinsurance

Emergency & Non-Emergency Services

Description In-network

You pay Out-of-network

You pay

Emergency care facility charges 20% coinsurance then $500 outpatient Hospital emergency room copay

(waived if admitted) deductible does not apply

Emergency care physician charges 20% coinsurance

Non-Emergency care facility charges

20% coinsurance then $500 outpatient Hospital emergency room copay (waived if admitted) deductible does not apply

40% coinsurance then $500 outpatient Hospital emergency room copay (waived if admitted)

Non-Emergency care physician charges

20% coinsurance 40% coinsurance

• Excluding certain diagnostic procedures

Hearing Aids

In-network

You pay Out-of-network

You pay

Hearing aids 20% coinsurance 40% coinsurance

Limits Limited to one hearing aid per ear each 36-month period

Home Health Care

In-network

You pay Out-of-network

You pay

Home health care 20% coinsurance 40% coinsurance

Limits 60 days each benefit period

Hospice Care

In-network

You pay Out-of-network

You pay

Hospice services 20% coinsurance 40% coinsurance

Limits Unlimited

Hospice care that is provided in a hospital will include charges as described in the COVERED SERVICES section of your benefit booklet

Infusion Therapy

In-network

You pay Out-of-network

Home Infusion therapy 20% coinsurance 40% coinsurance

Inpatient Hospital Services

In-network

You pay Out-of-network

You pay

Inpatient facility services 20% coinsurance 40% coinsurance

Inpatient physician services 20% coinsurance 40% coinsurance

• Certain services will require prior authorization

• All usual hospital services and supplies, including semiprivate room, intensive care, and coronary care units

• Includes treatment of behavioral health services

Maternity Services

Description In-network

You pay Out-of-network

You pay

Maternity care Covered based on type of service and where it is received Covered based on type of service and where it is received

Maternity related newborn care Covered based on type of service and where it is received Covered based on type of service and where it is received

Prior authorization

Inpatient prior authorization not required for the following length of stays:

48 hours following an uncomplicated vaginal delivery 96 hours following an uncomplicated delivery by caesarean section

Inpatient prior authorization not required for the following length of stays:

48 hours following an uncomplicated vaginal delivery 96 hours following an uncomplicated delivery by caesarean section

Maternity care is globally billed meaning:

• Physician and Specialist Services office visit or consultation benefit located in this SUMMARY OF BENEFITS applies to initial prenatal visit (per pregnancy) to an in-network provider.

• Benefit period deductible and coinsurance apply to subsequent visits and to all out-of-network provider services.

Occupational Therapy Services

In-network

You pay Out-of-network

You pay

Office Visit $70 copay then no charge deductible does not apply

40% coinsurance

Occupational therapy in the office

$70 copay then no charge deductible does not apply

40% coinsurance

Occupational therapy in an outpatient setting

20% coinsurance 40% coinsurance

Limits 120 visits each benefit period

• Benefits for autism spectrum disorder will not apply towards and are not subject to any occupational therapy services visits maximum.

• Visit limit applied to a combination of physical therapy, occupational therapy and chiropractic care.

Outpatient Hospital Services

In-network

You pay Out-of-network

You pay

Outpatient facility services 20% coinsurance 40% coinsurance

Outpatient physician services 20% coinsurance 40% coinsurance

Penalty for failure to obtain prior authorization for outpatient services None $250

• Certain services will require prior authorization

Pharmacy Services For information on prescription drugs benefit and cost share please refer to your SUMMARY OF BENEFITS FOR PHARMACY BENEFITS directly following this SUMMARY OF BENEFITS

Physical Therapy Services

Description In-network

You pay Out-of-network

You pay

Office visit $70 copay then no charge deductible does not apply

40% coinsurance

Physical therapy in the office

$70 copay then no charge deductible does not apply

40% coinsurance

Physical therapy in an outpatient setting

20% coinsurance 40% coinsurance

Limits 120 visits each benefit period

• Benefits for autism spectrum disorder will not apply towards and are not subject to any physical therapy services visits maximum.

• Visit limit applied to a combination of physical therapy, occupational therapy and chiropractic care.

Physician and Specialist Services

In-network

You pay Out-of-network

You pay

Primary care office visit or consultation

$50 copay then no charge deductible does not apply

40% coinsurance

Retail health clinic visit $50 copay then no charge deductible does not apply

40% coinsurance

Specialty (Specialist) office visit or consultation

$70 copay then no charge deductible does not apply

40% coinsurance

Virtual Visits Medical

$15 copay then no charge deductible does not apply

Not covered

Virtual Visits Behavioral Health

$15 copay then no charge deductible does not apply

Not covered

Diagnostic Services performed in a physician’s office

20% coinsurance 40% coinsurance

Lab & X-ray services Performed in a physician’s office

$50 copay/$70 copay then no charge deductible does not apply

40% coinsurance

Surgical procedures performed in the physician’s office

20% coinsurance 40% coinsurance

All other covered services not otherwise noted

20% coinsurance 40% coinsurance

• Includes treatment of behavioral health services

• Copays applicable only to covered services which are subject to the office visit copayment. For services which are not subject to the office visit copayment, this percentage amount is reduced to coinsurance and benefit period deductible.

• Cost shares for covered services provided through telemedicine visits will be the same as if provided in person, except where otherwise noted

Preventive Care Services

In-network

You pay Out-of-network

Preventive care services no charge 40% coinsurance

Skilled Nursing Facility

Description In-network

You pay Out-of-network

You pay

Skilled nursing facility 20% coinsurance 40% coinsurance

Limits 25 days each benefit period

Speech Therapy

In-network

You pay Out-of-network

You pay

Speech therapy in the office

$70 copay then no charge deductible does not apply

40% coinsurance

Speech therapy in an outpatient setting

20% coinsurance 40% coinsurance

• Benefits for autism spectrum disorder will not apply towards and are not subject to any speech therapy services visits maximum.

Surgery

In-network

You pay Out-of-network

You pay

Physician & Facility Services Covered based on type of service and where it is received Covered based on type of service and where it is received

Transplant Services (Organ and Tissue Transplants)

In-network

You pay Out-of-network

Organ and Tissue Transplant 20% coinsurance 40% coinsurance

Urgent Care

In-network

You pay Out-of-network

You pay

Urgent care center visit $50 copay then no charge deductible does not apply

40% coinsurance

• Includes lab & x-ray services

• Excludes certain diagnostic procedure.

Prior Authorization Penalty

In-network

You pay Out-of-network

You pay

Inpatient Admissions None None

Outpatient Services None $250

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SUMMARY OF BENEFITS

for

PHARMACY BENEFITS

This is your summary of benefits for prescription drugs. It shows your cost share including deductible amounts, copayment amounts and coinsurance amounts and how they apply to the covered prescription drugs you receive under this plan. The information below summarizes your cost share and any limits that may apply to prescription drugs. You may contact Customer Service at the telephone number on the back of your member identification card or access your self-service online member portal, Blue Access for MembersSM (BAM) for any questions or additional information.

The PHARMACY BENEFITS section of this benefit booklet includes details on how the following pharmacy benefits work:

• Pharmacy deductible

• Pharmacy out-of-pocket maximums

• How copayment and/coinsurance amounts apply

• How payment is determined (i.e., what are the tiers)

• Prior authorizations

• Limitations and exclusions

Pharmacy Deductible Pharmacy Benefit Period

Deductible Participating Pharmacies Non-Participating Pharmacies

Individual $200

Family $0

• All drugs (generic and brand) apply to the pharmacy deductible

Retail Pharmacy Cost Share

Retail Pharmacy Program Participating Pharmacy

You pay

Non-Participating Retail Pharmacy

You pay

Tier 1 $20 copay $20 copay plus 50% coinsurance

Tier 2 $45 copay $45 copay plus 50% coinsurance

Tier 3 $95 copay $95 copay plus 50% coinsurance

• In addition to any copayments and/or coinsurance amounts, you are also responsible for any charges which exceed the allowable amounts

• If you receive a brand name drug when a generic drug is available, you may incur additional costs. Refer to the

PHARMACY BENEFITS section of your benefit booklet for details.

• One copayment per 30-day supply, no more than a 30-day supply

Extended Prescription Drug Supply Program

Extended Prescription Drug Supply Program

Quantity Dispensed

Participating Extended Supply Pharmacy

You pay

Non-Participating Extended Supply

Pharmacy

Tier 1

1 to 30 days $20 copay Not covered 31 to 60 days $40 copay Not covered

61 to 90 days $60 copay Not covered

Tier 2

1 to 30 days $45 copay Not covered

31 to 60 days $90 copay Not covered 61 to 90 days $135 copay Not covered

Tier 3

1 to 30 days $95 copay Not covered 31 to 60 days $190 copay Not covered

61 to 90 days $285 copay Not covered

• In addition to any copayments and/or coinsurance amounts, you are also responsible for any charges which exceed the allowable amounts

• If you receive a brand name drug when a generic drug is available, you may incur additional costs. Refer to the

PHARMACY BENEFITS section of your benefit booklet for details.

• Up to a 90-day supply

• Cost share will be based on day supply (1-30-day supply, 31-60-day supply, 61-90-day supply) dispensed

Mail-Order Pharmacy Program

Mail-Order Pharmacy Program

Quantity Dispensed

Participating Mail-Order Pharmacy You pay

Any Pharmacy other than the Participating Mail-Order Pharmacy

You pay

Tier 1 1 to 90 days $50 copay Not covered

Tier 2 1 to 90 days $112.50 copay Not covered

Tier 3 1 to 90 days $237.50 copay Not covered

• In addition to any copayments and/or coinsurance amounts, you are also responsible for any charges which exceed the allowable amounts

• If you receive a brand name drug when a generic drug is available, you may incur additional costs. Refer to the

PHARMACY BENEFITS section of your benefit booklet for details.

• Up to a 90-day supply

• Cost share will be based on day supply (1-30-day supply, 31-60-day supply, 61-90-day supply) dispensed

Specialty Pharmacy Program

Specialty Pharmacy Program (30-Day Supply)

Specialty Network Pharmacy

You pay

Any Pharmacy other than a Specialty Network Pharmacy

You pay

Tier 1 $20 copay $20 copay plus 50% coinsurance

Tier 2 $45 copay $45 copay plus 50% coinsurance

Tier 3 $95 copay $95 copay plus 50% coinsurance

• In addition to any copayments and/or coinsurance amounts, you are also responsible for any charges which exceed the allowable amounts

• One Copayment Amount per 30 day supply – limited to a 30 day supply

• Coverage for Specialty Drugs is limited to a 30-day supply. However, some Specialty Drugs have FDA approved dosing regimens exceeding the 30-day supply limits and may be allowed greater than a 30-day supply, if allowed by your plan benefits. Cost share will be based on a day supply (1-30 day supply, 31-60 day supply, 61-90 day supply) dispensed.

Vaccines

Select Vaccines Obtained through Pharmacies

Pharmacy Vaccine Network Pharmacy You pay

Other Pharmacy You pay

Covered Vaccine(s) - $0 Copay Not covered

Each participating pharmacy that has contracted with BCBSTX to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations

Diabetes supplies are available under the Pharmacy Benefits portion of this plan.

The copayment amount 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.

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INTRODUCTION

This is your health insurance benefit booklet. It describes your covered services, what they are and how you obtain them.

The defined terms throughout this booklet are in bold font and are defined in the GLOSSARY.

The terms “you”, “your”, “participant” and “member” are used in this benefit booklet in reference to the employee or subscriber.

In-Network Benefits

To receive in-network benefits as shown under your SUMMARY OF BENEFITS (SOB), you must choose providers within the network (except for emergencies). We have established a network of physicians, providers, specialists, hospitals, and other health care facilities that may offer care and covered services to you and your dependents. They are listed in our provider directory. For help in finding an in-network provider you can view our provider directory by visiting our website at www.bcbstx.com.

When you choose an in-network provider, the provider will bill us, not you, for services

Out-of-Network Benefits

If you choose an out-of-network provider, only out-of-network benefits will be available. If you go to a provider outside the network, then benefits will be paid at the out-of-network benefit level. You may have to pay in full and then submit a claim to us for reimbursement.

If you are not able to receive reasonable care from an in-network provider as defined by applicable law, and we authorize your visit to an out-of-network provider to be covered as in-network level prior to your visit, benefits will be paid as in-network. If not, the benefits will be paid as out-of-network.

Your Insurance Identification Card We will mail you your identification card. Show your identification card each time you receive services from a provider. If you haven’t received it before you need covered services, or if you lose it, you can print a temporary card on the member website at www.bcbstx.com/member. Only members on your plan can use your identification card.

About Your SUMMARY OF BENEFITS Your SUMMARY OF BENEFITS shows the out-of-pocket costs you are responsible for when you receive covered services. It may also show benefit limitations or other useful information that apply to your plan.

Out-of-pocket costs include things like deductibles, copayments and coinsurance. Limitations include things like maximum age, visits, days, hours, and admissions.

Your SUMMARY OF BENEFITS will also show any total maximum out-of-pocket limit(s) that may apply.

You are responsible for paying your part of the cost sharing. You are also responsible for costs not covered by us.

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See HOW THE PLAN WORKS below and your SUMMARY OF BENEFITS for more information.

What Medical Necessity/Medically Necessary Means You will see the terms medical necessity or medically necessary in your benefit booklet. The GLOSSARY defines it but resources like Customer Service or Blue Access for Members℠ (BAM) can give help with questions on if specific services meet the requirements to be considered medically necessary or meet medical necessity.

Your plan pays for its share of the costs for covered services when these requirements are met:

• The service is medically necessary and/or meets medical necessity requirements.

• For in-network benefits, you get the service from an in-network provider.

• Your provider or you get prior authorization on services when required.

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WHO GETS BENEFITS

No eligibility rules or variations in premium will be imposed based on your health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or any other health status related factor. Benefits under this plan are provided regardless of your race, color, national origin, disability, age, sex, gender identity, sexual orientation, political affiliation or expression. This plan does not require documentation certifying a COVID-19 vaccination or documentation of post-transmission recovery. Variations in the administration, processes or benefits of this plan that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination.

Eligibility Requirements The eligibility date is the date you or your dependents qualify to be covered under this plan.

Employee Eligibility You are eligible for coverage under this benefit booklet when you satisfy the following:

• Meet the definition of an eligible person as specified by your employer

• Have applied for this coverage

• Have received a Blue Cross and Blue Shield of Texas insurance identification card

• You must reside or work in the geographic area “network service area” designated by the plan

Dependent Eligibility If you apply for coverage, you may include your dependents. Eligible dependents are:

• Your spouse

• Your domestic partner (Note: domestic partner coverage is available at your employer’s discretion. Contact your employer for information on whether domestic partner coverage is available for your group).

• Your child until the month they turn age 26

• Your grandchild who is your dependent for federal income tax purposes at the time application for coverage of the child is made

• Any other child such as a stepchild, an eligible foster child, an adopted child or child placed for adoption (including a child for whom you, your spouse or your domestic partner is a party in a legal action in which the adoption of the child is sought), under 26 years of age.

• A child of any age who is medically certified as disabled and dependent upon you, your spouse or domestic partner.

Applying For Coverage You and your eligible dependents can apply for coverage during the following time periods by contacting your employer:

• During the open enrollment period

• At special enrollment periods during the year

Note: Some employers may only offer coverage to their employees and not to their employee’s dependents.

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Open Enrollment Period Your group will designate an open enrollment period during which you may apply for or change coverage for you and your eligible dependents.

Special Enrollment Period

You may apply for or change coverage for yourself and your eligible dependents during the following qualifying events:

• You or your dependent lose other health insurance coverage or COBRA continuation coverage.

• You lose a dependent

• You gain a dependent through marriage, establishment of a domestic partnership or court ordered coverage

• You gain a dependent through birth, adoption or placement for adoption, legal guardianship or placement of a foster child

• You or your dependent lose eligibility for coverage under a Medicaid plan or a state child health plan under Title XXI of the Social Security Act

• You or your dependent become eligible for assistance under a Medicaid plan or a state child health plan

Benefits for expenses incurred after termination are not available. If your dependent’s coverage is terminated, premium refunds will not be made for any period before the notification date. If benefits are paid to you prior to notification to us, refunds will be requested.

Please refer to the Continuation Privilege subsection in this Benefit Booklet for additional information.

Other Special Enrollment Periods You may apply for or change coverage for yourself and your eligible dependents during the following qualifying events:

• You get a divorce or end a domestic partnership

• The month your child reaches 26 years of age

• You or any of your dependents die

• You lose coverage under your plan as specified under the Termination of Coverage section of this benefit booklet

Employee Application / Change Form You can obtain an employee application / change form from your employer, by calling the number on your identification card or by accessing your self-service member portal, Blue Access for Members℠ (BAM) for the qualifying events listed above in addition to:

• Updating you and your dependents’ name

• Updating you and your dependents’ address

• Cancel all or a portion of your coverage

An address change may result in benefit changes for you and your dependents if you move out of the service area of the network.

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Late Enrollment If your application is not received within 31 days from the eligibility date, you will be considered a late enrollee. You will become eligible to apply for coverage during your employer’s next open enrollment period. Your coverage will become effective on the contract date.

When Coverage Begins Coverage begins after you have applied for coverage for yourself and your eligible dependents. The effective date is the date coverage begins. It may be different from the eligibility date.

Dependent Special Enrollment Coverage Coverage begins from the date of event if you apply for this change within 31 days of any of the following qualifying events:

• You gain a dependent through marriage, establishment of a domestic partnership or court ordered coverage

However, if a court has ordered you to provide coverage, coverage begins on the first day of the month following the date the application for coverage is received.

Coverage is automatic for the first 31 days for the following qualifying events. For coverage to continue beyond this time, you must apply for this change within the 31 day period:

• You gain a dependent through birth, adoption or placement for adoption, legal guardianship or placement of a foster child

If you ask that your dependent be insured after having canceled their coverage while your dependent was still entitled to coverage, your dependent’s coverage will become effective in accordance with the Late Enrollment provision.

In no event will your dependent’s coverage become effective prior to your effective date.

Medicaid or Child Health Plan Special Enrollment Coverage Coverage begins no later than the first of the month if you apply within 60 days of the following qualifying event:

• You or your dependent lose eligibility for coverage under a Medicaid plan or a state child health plan under Title XXI of the Social Security Act

• You or your dependent become eligible for assistance under such Medicaid plan or state child health plan

Loss of Other Health Insurance Special Enrollment Coverage Coverage begins no later than the first of the month if you apply within 31 days of any of the following qualifying events:

• You or your dependent lose other health insurance coverage or COBRA continuation coverage

The special enrollment period for loss of other health insurance coverage is available to you and your dependent who meet the following requirements:

• You and your dependent were covered under other health insurance coverage or COBRA continuation coverage when you were first eligible to enroll for this coverage

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• You and your dependent lost the other health insurance coverage due to:

o Legal separation o Divorce or the end of a domestic partnership o Death of a spouse or domestic partner o Termination of employment or reduction of hours o COBRA continuation coverage is terminated as explained in the Continuation Privilege section of this benefit booklet

• You and your dependent did not lose coverage due to failure to pay premiums or fraud

• If it was required, you stated in writing that you and your dependent were covered by other health insurance or COBRA continuation coverage as reason for declining enrollment in this coverage.

If all conditions described above are not met, you will be considered a late enrollee.

Health Insurance Premium Payment (HIPP) Reimbursement Program You will be eligible to enroll if you:

• Receive medical assistance under the Texas Medicaid Program or CHIP and if you are a participant in Texas HIPP Reimbursement Program. You may enroll with no enrollment period restrictions

• Are not eligible unless a family member is enrolled, then both you and the family member may enroll

The effective date of coverage is on the first day of the month after we receive the following:

• Written notice from the Texas Health and Human Services Commission

• Enrollment forms and applicable premium payments within 60 days after the date the individual becomes eligible to participate

In addition to the GLOSSARY section of this benefit booklet, the following definitions apply to enrollment due to participation in HIPP program:

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

Open Enrollment Period means the 31-day period preceding the next contract date during which employees and dependents may enroll for coverage.

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HOW THE PLAN WORKS

Your SUMMARY OF BENEFITS lists what you pay for each type of covered service. In general, this is how your benefits works:

• You pay the deductible when it applies. Then we, the plan and you, the participant, share the expense. Your share is called a copayment or a coinsurance amount

• After you reach your out-of-pocket maximum, then we, the plan, pay the entire expense

• Expenses in this general rule means the allowable amount for services received from an in-network provider and an out-of-network provider

Allowable Amount

The allowable amount is the maximum amount of benefits we will pay for expenses you incur under the plan. We have established an allowable amount for:

• Medically necessary services, supplies, and procedures provided by in-network providers that have contracted with us or any other Blue Cross and/or Blue Shield Plan; and

• Medically necessary services, supplies, and procedures provided by out-of-network providers that have not contracted with us or any other Blue Cross and/or Blue Shield Plan

When you choose to receive medically necessary services, supplies, or care from a provider that does not contract with us, you will be responsible for any difference between our allowable amount and the amount charged by the out-of-network provider.

You will also be responsible for the charges incurred for services, supplies, and procedures limited or not covered under the plan.

Deductible(s) Benefits under your plan will be available after you meet your deductible(s) as shown on your

SUMMARY OF BENEFITS.

How individual deductibles work:

• Benefits will be available after your individual deductible amount, shown under your SUMMARY

OF BENEFITS, have been met

How family deductibles work:

• A family member may not apply more than the individual deductible amount toward the family deductible amount.

• Should two or more members of your family ever receive covered services due to injuries received in the same accident, only one program deductible will be applied against those covered services.

Should the federal government adjust the deductible amount(s) applicable to this type of coverage, the deductible amount(s) will be adjusted accordingly.

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Until the benefit period deductible is satisfied, benefits will be available only for those services or supplies subject to a copayment, such as physician office visits, and emergency room facility charges, and covered drugs under pharmacy benefits.

Copayments Some of the care and treatment you receive under the plan will require that a copayment be paid at the time you receive the services. Refer to your SUMMARY OF BENEFITS for your copayments.

Copayments do not apply to services received from out-of-network providers.

The following covered services are not subject to an office visit copayment. Benefits will be provided at the payment levels shown in your SUMMARY OF BENEFITS. Services may be subject to deductible and/or coinsurance (if applicable):

• Surgery performed in the physician’s office

• Surgery performed in the urgent care center

• Physical therapy billed separately from an office visit

• Physical therapy billed separately from an urgent care visit

• Occupational modalities in conjunction with physical therapy

• Allergy injections billed separately from an office visit

• Any services requiring prior authorization

• Certain diagnostic procedures

• Services provided by an independent laboratory, imaging center, radiologist, pathologist, and anesthesiologist

• Outpatient treatment therapies or services such as radiation therapy, chemotherapy, and renal dialysis

Out-of-Pocket Maximum The out-of-pocket maximum is the total amount of deductibles, copayments and/or coinsurance which must be satisfied during your benefit period for all covered services received from providers before we (your plan) will begin to cover all charges up to the allowable amount at 100% for the remainder of the benefit period.

How Individual Out-of-Pocket Maximums Work When you have met the out-of-pocket maximum specified in your SUMMARY OF BENEFITS, no additional deductible, copayment and/or coinsurance will be required for covered services you receive during the remainder of your benefit period.

How Family Out-of-Pocket Maximums Work

If you have family coverage and your family’s out-of-pocket payments during the benefit period equals the family out-of- pocket maximum shown under the SUMMARY OF BENEFITS then for the rest of the benefit period, all family members will have benefits for covered services (except for those charges specifically excluded below) paid by us at 100% of the allowable amount.

The out-of-pocket maximum will not include:

• Any penalty incurred due to your failure to follow the plan’s requirements for prior authorization

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• Services, supplies, or charges limited or excluded by the plan

• Expenses not covered because a benefit maximum has been reached

• Any expense paid by the primary plan when BCBSTX is the secondary plan for purposes of coordination of benefits

• Any additional charge for non-participating pharmacy

The following are exceptions to the out-of-pocket maximum described above:

• There are separate out-of-pocket maximums for in-network benefits and out-of-network benefits

ParPlan When you consult a physician or professional provider who does not participate in the network, you should ask if they participate in our ParPlan. If the provider participates in the ParPlan, they agree to:

• File all of you claims

• Accept our allowable amount determination as payment for medically necessary services

• Not bill you for services over the allowable amount determination

You will receive out-of-network benefits and be responsible for:

• Any deductibles

• Coinsurance amounts

• Services that are limited or not covered under the plan

Specialty Care Providers A wide range of specialty care providers is included in the network. When you need a specialist’s care, in-network benefits will be available, but only if you use an in-network provider.

There may be occasions however, when you need the services of an out-of-network provider. This could occur if you have a complex medical problem that cannot be taken care of by an in-network provider.

• If the services you need are not available from in-network providers, in-network benefits will be provided when you use out-of-network providers

• If you choose to see an out-of-network provider when the services could have been provided by an in-network provider, only out-of-network benefits will be available

Use of Non-Contracting Providers When you choose to receive services, supplies, or care from a provider that does not contract with us (a non-contracting provider), you receive out-of-network benefits (the lower level of benefits). Benefits for covered services will be paid based on our non-contracting allowable amount. This amount, in most cases, is less than the allowable amount applicable for our contracted providers. Please see the definition of allowable amount in the GLOSSARY section of this benefit booklet.

However, if you:

Note: Non-contracted providers are not required to accept our non-contracting allowable amount as payment in full. They may balance bill you for the difference between our non-contracting allowable amount and the non-contracting provider’s billed charges. You will be responsible for this balance bill amount, which may be very large.

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• pay the non-contracting provider a rate less that the average discounted rate which would be paid by us to an in-network provider directly for a covered and medically necessary service or supply; and

• the non-contracting provider does not submit a claim to us for that service or supply;

then you may submit the appropriate document with a claim form to us, and allowable credit will, as applicable, be applied towards your in-network deductible and out-of-pocket maximum.

You will also be responsible for charges for services, supplies and procedures limited or not covered under this plan and any applicable cost share.

Federal Balance Billing and Other Protections This section is based upon the No Surprises Act, a federal law enacted in 2020. Unless otherwise required by federal or Texas law, if there is a conflict between the terms of this Federal Balance Billing and Other Protections section and the terms in the rest of this certificate, the terms of this section will apply.

Protections from Unexpected Costs for Medical Services from Non-Participating Providers Your certificate contains provisions related to protection from surprise balance billing under Texas law.

The federal laws provide additional financial protections for you when you receive some types of care from providers who do not participate in your network. If you receive the types of care listed below, your in-network cost-sharing levels will apply to any network deductible and out-of-pocket maximums.

Additionally, for services below that are governed by federal law (instead of state law), your cost-share amount may be calculated on an amount that generally represents the median payment rate that we have negotiated with participating providers for similar services in the area:

• Emergency care from facilities or providers who do not participate in your network

• Care furnished by out-of-network providers during your visit to an in-network facility

• Air ambulance services from out-of-network providers if the services would be covered by an in-network providers

Out-of-network or non-participating providers may not bill you for more than your deductible, coinsurance amount or copayments for the service types referenced above. There are limited instances when an out-of-network or non-participating provider may send you a bill (for the care services referenced above) for up to the amount of that provider’s billed charges.

You are only responsible for payment of the non-participating provider’s billed charges if, in advance of receiving services, you signed a written notice form that complies with applicable state and/or federal law.

The requirements of federal law that impact your costs for care from non-participating providers may not apply in all cases. Sometimes, Texas law provisions relating to balance billing prohibitions may apply.

You may contact us at the number on the back of your identification card with questions about claims or bills you have received from providers.

To the extent state and federal regulations are adopted or additional guidance is issued by federal regulatory agencies that alter the terms of this section, the regulations and any additional guidance will control over conflicting language in this section.

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Continuity of Care In the event you are under the care of an in-network provider and the provider stops participating in the network (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), we will continue providing coverage for you at the in-network benefit level if you have one of the following special circumstances:

• You are undergoing a course of treatment for a serious and complex condition

• You are undergoing institutional or inpatient care

• You are scheduled to undergo non-elective surgery from the provider (including receipt of post-operative care from such provider with respect to such surgery)

• You are pregnant or undergoing a course of treatment for the pregnancy

• You are terminally ill

The continuity of coverage under this subsection shall continue until the treatment is complete but shall not extend for more than ninety (90) days, or more than nine (9) months if you have been diagnosed with a terminal illness, beyond the date the provider’s termination from the network takes effect. If you are pregnant and you are in your second or third trimester of pregnancy at the time the provider’s termination takes effect, continuity of coverage may be extended through delivery of the child, immediate postpartum care, and the follow-up check-up within the first six (6) weeks of delivery.

Coverage Determinations

Please note that we must determine services are medically necessary in order to be covered under this plan.

Coverage of items and services provided to you is subject to our policies and guidelines, including, but not limited to:

• Medical

• Medical management

• Utilization or clinical review

• Utilization management

• Clinical payment and coding policies

The items and services will be updated throughout the plan year.

These policies are resources we use when making coverage determinations and lay out the procedure and/or criteria to determine if the following is medically necessary, eligible as a covered service, or is experimental/investigational, cosmetic, or a convenience item:

• Procedure

• Treatment

• Facility

• Equipment

• Drug

• Device

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The clinical payment and coding policies are intended to ensure accurate documentation for services performed and require all providers to submit claims for services rendered using valid code combinations from Health Insurance Portability and Accountability Act (HIPAA) approved code sets.

Under the clinical payment and coding policies, claims are required to be coded correctly according to industry standard coding guidelines including, but not limited to:

• Uniform Billing (UB ) Editor

• American Medical Association (AMA)

• Current Procedural Terminology (CPT®)

• CPT® Assistant

• Healthcare Common Procedure Coding System (HCPCS)

• ICD-10 CM and PCS

• National Drug Codes (NDC)

• Diagnosis Related Group (DRG) guidelines

• Centers for Medicare and Medicaid Services (CMS)

• National Correct Coding Initiative (NCCI) Policy Manual

• CCI table edits

• Other CMS guidelines

Coverage for covered services is subject to the code edit protocols for services/procedures billed and…