EPO_Plan_Design.pdf

Metrocare Services Group #396380 - EPO Plan January 1, 2025

Managed Health Care Pharmacy Benefits

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

Metrocare Services Group #396380 – EPO Plan January 1, 2026

BlueCross BlueShield of Texas

Table of Contents Page No.

Schedule(s) of Coverage(s)………………………………………………………………….Enclosure (s)

Introduction

Who Gets Benefits

How the Plan Works

Utilization Management

Claim Filing and Appeals Procedures

Eligible Expenses, Payment Obligations, and Benefits

Covered Medical Services

Medical Limitations and Exclusions

Definitions

Pharmacy Benefits

General Provisions

Amendments

Notices

Form No. EPO-GROUP#396380-0126 Page A

SCHEDULE OF COVERAGE

Plan Provisions Network Benefits Deductibles-Per Admission None

Deductibles

• Calendar Year Deductible Applies to all Eligible Expenses

$2,000 – per individual

$4,000 – per family

Out-of-Pocket Maximum Includes Calendar Year Deductible and Copayment Amounts

$6,500 – per individual $13,000 – per family

Copayment Amounts Required

• Physician office visit/consultation $40 Physician of f ice visit

• Telehealth/Telemedicine visit/consultation

$40 Telehealth/Telemedicine visit/consultation

• Outpatient Hospital Emergency Room/Treatment Room visit

$750 Outpatient Hospital Emergency Room/Treatment Room visit

• Urgent Care Center visit $100 Urgent Care Center visit

• Retail Health Clinic $40 Retail Health Clinic visit

Inpatient Hospital Expenses

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.

80% of Allowable Amount af ter Calendar Year Deductible No penalty for failure to obtain Prior Authorization services

Medical-Surgical Expenses

• Office visit/consultation including lab and x-rays

• Allergy Injections (without office visit)

• Radiation Therapy and Chemotherapy in the office setting

• Diabetic Management (training/nutritional)

100% of Allowable Amount af ter $40 Copayment Amount

• Inpatient visits and Certain Diagnostic Procedures

• Home Infusion Therapy

• Physician surgical services in any setting

• Early Detection Tests for

Cardiovascular Disease

80% of Allowable Amount af ter Calendar Year Deductible

• Independent Lab & X-ray 100% of Allowable Amount

Form No. EPO-GROUP#396380-0126 Page B

Plan Provisions Network Benefits

Extended Care Expenses

• Skilled Nursing Facility 80% of Allowable Amount af ter Calendar Year Deductible

60 days maximum per Calendar Year

• Home Health Care 80% of Allowable Amount af ter Calendar Year Deductible

60 visits maximum per Calendar Year

• Hospice Care 80% of Allowable Amount af ter Calendar Year Deductible

Unlimited

Mental Health Care/Serious Mental Illness/Treatment of Substance Use Disorder (SUD)

Inpatient Services

• Hospital Services (facility) 80% of Allowable Amount af ter Calendar Year Deductible

• Behavioral Health Practitioner Services

80% of Allowable Amount af ter Calendar Year Deductible

Outpatient Services

• Behavioral Health Practitioner Expenses (of f ice setting)

100% of Allowable Amount af ter $40 Copayment Amount

• Other Outpatient Services 80% of Allowable Amount af ter Calendar Year Deductible

Emergency Care

Accidental Injury & Emergency Care (including Accidental Injury, Emergency and non-emergency Care for Behavioral Health Services)

• Facility Charges 100% of Allowable Amount after $750 outpatient Hospital emergency room Copayment Amount (waived if admitted)

• Lab & X-ray - without emergency room or treatment room

100% of Allowable Amount

• Physician Charges 80% of Allowable Amount af ter Calendar Year Deductible

Non-Emergency Care

• Facility Charges 80% of Allowable Amount and after $750 outpatient Hospital emergency room Copayment Amount (waived if admitted)

• Physician Charges 80% of Allowable Amount af ter Calendar Year Deductible

Urgent Care Services

• Urgent Care Center visit including Lab & x-ray (excluding Certain Diagnostic Procedures)

100% of Allowable Amount af ter $100 Copayment Amount

Ambulance Services 80% of Allowable Amount af ter Calendar Year Deductible

Retail Health Clinic 100% of Allowable Amount af ter $40 Copayment Amount

Form No. EPO-GROUP#396380-0126 Page C

Plan Provisions Network Benefits

Telehealth

• Primary Care telehealth/telemedicine visit/consultation

100% of Allowable Amount af ter $40 Copayment Amount

• Primary Care telehealth/telemedicine visit/consultation for treatment of Behavioral Health

100% of Allowable Amount af ter $40 Copayment Amount

Preventive Care Services

• Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”)

• Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved

• Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”) for infants, children, and adolescents

• With respect to women, such additional preventive care and screenings, not described in the first bullet above, as provided for in comprehensive guidelines supported by the HRSA

• Routine physical examinations, well baby care, immunizations and routine lab

• Routine X-rays, Routine EKG, Routine Diagnostic Medical Procedures (Independent Lab & X-ray Provider)

• Colonoscopy Professional (physician charges)

• Colonoscopy facility charges

• Healthy diet counseling and obesity screening/counseling

• Immunizations Birth up to age 6

100% of Allowable Amount

Form No. EPO-GROUP#396380-0126 Page D

Plan Provisions Network Benefits Other Routine Services

• Routine X-rays, Routine EKG, Routine Diagnostic Medical Procedures, routine digital rectal exam, routine prostate test

• Annual Hearing Examination

• Annual Vision Examination

100% of Allowable Amount af ter $40 Copayment Amount

Speech and Hearing Services*

• Off ice visit 100% of Allowable Amount af ter $40 Copayment Amount

• All other services 80% of Allowable Amount af ter Calendar Year Deductible

1 per ear per 36-month period for hearing aids

* Benef its for Autism Spectrum Disorder will not apply towards and are not subject to any speech services visits maximum.

Chiropractic Services

• Off ice visit/Of f ice services 100% of Allowable Amount af ter $40 Copayment Amount

• All other services in the outpatient setting

80% of Allowable Amount af ter Calendar Year Deductible

35 visits maximum per Calendar Year combined with Physical Therapy, Occupational Therapy and Hydrotherapy

Physical Therapy**

• Off ice visit/Of f ice services 100% of Allowable Amount af ter $40 Copayment Amount

• All other services in the outpatient setting

80% of Allowable Amount af ter Calendar Year Deductible

35 visits maximum per Calendar Year combined with Occupational Therapy, Hydrotherapy and Chiropractic Services

** Benef its for Autism Spectrum Disorder will not apply towards and are not subject to any Physical Medicine Services visits maximum.

Occupational Therapy

• Off ice visit/Of f ice services 100% of Allowable Amount af ter $40 Copayment Amount

• All other services in the outpatient setting

80% of Allowable Amount af ter Calendar Year Deductible

35 visits maximum per Calendar Year combined with Physical Therapy, Hydrotherapy and Chiropractic Services

Hydrotherapy

80% of Allowable Amount af ter Calendar Year Deductible

35 visits maximum per Calendar Year combined with Physical Therapy, Occupational Therapy and Chiropractic Serivices

Form No. EPO-GROUP#396380-0126 Page E

PHARMACY BENEFITS

Plan Provisions Participating Pharmacy Non-Participating

Pharmacy Retail Pharmacy 30 day supply with 1 Copayment Amount per 30-day supply at a Participating Pharmacy

$10 Copayment Amount – Generic Drug

$35 Copayment Amount* – Preferred Brand Name Drug $60 Copayment Amount* –

Non-Preferred Brand Name Drug

Not Covered

Extended Retail Prescription Drug Supply (if allowed by the Prescription Order) - one Copayment Amount per 30-day supply, up to a 90-day supply

$10 Copayment Amount – Generic Drug

$35 Copayment Amount* – Preferred Brand Name Drug $60 Copayment Amount* –

Non-Preferred Brand Name Drug

Not Covered

Specialty Pharmacy Program Specialty Drugs - limited to a Specialty Pharmacy Provider Coverage for Specialty Drugs are limited to a 30-day supply.

However, some Specialty Drugs have FDA approved dosing regimens exceeding the 30-day supply limited and may be allowed greater than a 30 day-supply, if allowed by your plan benefits.

Specialty Pharmacy Provider $60 Copayment Amount –

Specialty Drug

Not Covered

Mail Service Prescription Mail-Order Pharmacy Mail-Order Program One Copayment Amount per 90 day supply up to a 90-day supply only

$25 Copayment Amount – Generic Drugs

$88 Copayment Amount* – Preferred Brand Name Drugs $150 Copayment Amount* –

Non-Preferred Brand Name Drugs

Not Covered

Plan Provisions Participating Pharmacy Non-Participating Pharmacy

Select Vaccinations Obtained through Participating Pharmacies**

Select Participating Pharmacy - 100% of Allowable Amount

Any other Participating Pharmacy Not Covered

Not Covered

Prior Authorization Provision Applies

Step Therapy Provision Applies

Limitations on Quantities Dispensed

Applies

Form No. EPO-GROUP#396380-0126 Page F

Diabetes Supplies are available under the Pharmacy Benefits portion of your Plan. All provisions of this portion of the Plan will apply including any Copayment Amounts, Co-Share Amounts and any pricing dif ferences.

The Copayment Amount for insulin included on the Drug List will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to f ill the prescription.

Contraceptive drugs and devices obtained from a Participating Pharmacy that are identified on the BCBSTX website under Contraceptive - Pharmacy information (referenced in the medical portion of the Plan as part of Benefits for Preventive Care Services) will not be subject to Deductibles, Copayment Amounts and Co-Share Amounts.

Additional contraceptive devices are covered under the Pharmacy portion of the Plan and are subject to the applicable Copayment Amounts, Co-Share Amount and any pricing dif ferences.

Tobacco cessation drugs (including both prescription and over-the-counter drugs) prescribed by a Health Care Practitioner are covered at no cost share and will not be subject to Deductibles, Copayment Amounts and Co-Share Amounts for two 90-day treatment regimens per benef it period as required by the United States Preventive Services Task Force as referenced in the Preventive Care subsection of the PHARMACY BENEFITS portion of the Plan.

* If you receive a Preferred Brand Name Drug or a Non-Preferred Brand Name Drug when a Generic Drug is available, you may incur additional costs. Refer to the Pharmacy Benefits portion of this Benefit Booklet for details.

** Select Participating Pharmacies that have 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. A Select Participating Pharmacy is a Pharmacy that has specifically contracted with BCBSTX to administer vaccinations to Participants. Not all Participating Pharmacies are Select Participating Pharmacies.

NOTE: In the How Member Payment is Determined subsection of the PHARMACY BENEFITS section, an explanation of how the prescription drug products are separated into tiers is shown.

Form No. EPO-GROUP#396380-0126 Page G

Dependent Eligibility Dependent Child Age Limit to age 26.

Dependent children are eligible for Maternity Care benefits.

Preexisting Conditions Preexisting conditions are covered immediately.

Form No. EPO-GROUP#396380-0126 Page 1

INTRODUCTION

This Plan is offered by your Employer as one of the benefits of your employment. The benefits provided are intended to assist you with many of your health care expenses for Medically Necessary services and supplies.

Coverage under this Plan is provided regardless of your race, color, national origin, disability, age, sex, gender identity or sexual orientation. There are provisions throughout this Benefit Booklet that affect your health care coverage. It is important that you read the Benefit Booklet carefully so you will be aware of the benefits and requirements of this Plan.

The defined terms in this Benefit Booklet are capitalized and shown in the appropriate provision in the Benefit Booklet or in the DEFINITIONS section of the Benefit Booklet. Whenever these terms are used, the meaning is consistent with the definition given. Terms in italics may be section headings describing provisions or they may be defined terms.

The terms “you” and “your” as used in this Benefit Booklet refer to the Employee.

Managed Health Care - Network Benefits

To receive Network Benefits as indicated on your Schedule of Coverage, you must choose Providers within the Network for all care (other than for emergencies or unless otherwise authorized by the Claim Administrator).

The Network has been established by BCBSTX and consists of Physicians, Specialty Care Providers, Hospitals, and other health care facilities to serve Participants throughout the Network Plan Service Area. Refer to your Provider directory or visit the BCBSTX website at www.bcbstx.com to make your selections. The listing may change occasionally, so make sure the Providers you select are still Network Providers. An updated directory will be available at least annually. You may access our website, www.bcbstx.com, for the most current listing to assist you in locating a Provider.

If you choose a Network Provider, the Provider will bill the Claim Administrator - not you - for services provided.

The Provider has agreed to accept as payment in full the least of...

• The billed charges, or

• The Allowable Amount as determined by the Claim Administrator, or

• Other contractually determined payment amounts.

You are responsible for paying any Deductibles, Copayment Amounts, and Co-Share Amounts. You may be required to pay for limited or non-covered services. No claim forms are required.

Managed Health Care - Out-of-Network Benefits

If you choose to use Out-of-Network Providers, no benefits will be available under this Plan. You will be responsible for all charges billed by the Out-of-Network Provider.

Pharmacy Benefits

Benefits are provided for those Covered Drugs as explained in the PHARMACY BENEFITS section and shown on your Schedule of Coverage in this Benefit Booklet. The amount of your payment under the Plan depends on whether:

• the Prescription Order is filled at a Participating Pharmacy or through the mail-order program; or

• the Prescription Order is filled by a provider contracting with BCBSTX; or

• a Generic Drug is dispensed; or

• a Preferred or Non-Preferred Brand Name Drug is dispensed; or

• a Specialty Drug is dispensed.

Form No. EPO-GROUP#396380-0126 Page 2

Important Contact Information

Resource Contact Information Accessible Hours Customer Service Helpline 1-800-521-2227 Monday – Friday

8:00 a.m. – 8:00 p.m.

Website www.bcbstx.com 24 hours a day 7 days a week

Medical Prior Authorization Helpline

1-800-441-9188 Monday – Friday 6:00 a.m. – 6:00 p.m.

Mental Health/Substance Use Disorder Prior Authorization

Helpline

1-800-528-7264 24 hours a day 7 days a week

Customer Service Helpline

Customer Service Representatives can:

• Identify your Plan Service Area

• Give you information about ParPlan and other Providers contracting with BCBSTX

• Distribute claim forms

• Answer your questions on claims

• Assist you in identifying a Network Provider (but will not recommend specific Network Providers)

• Provide information on the features of the Plan

• Record comments about Providers

• Assist you with questions regarding the PHARMACY BENEFITS Health Advocate

The Plan provides Health Advocates to assist Participants with understanding their benefit options, navigating the health care system and receiving general health information.

When you engage a Health Advocate they may assist Participants with the following:

• Assistance with health care information;

• Understanding benefit options;

• Connecting with a clinical health advocate to answer specific health questions and concerns;

• Locating Network Providers for quality, cost-effective health care services;

• Assisting with submission Prior Authorization requests; and

• Assisting with engagement requirements.

The Plan does not provide medical care. Health Advocates do not replace the care of a doctor and you should consult your doctor about any medical questions or concerns.

BCBSTX Website

Visit the BCBSTX website at www.bcbstx.com for information about BCBSTX, access to forms referenced in this Benefit Booklet, and much more.

Form No. EPO-GROUP#396380-0126 Page 3

Mental Health/Substance Use Disorder Prior Authorization Helpline

To satisfy Prior Authorization requirements for Participants seeking treatment for Behavioral Health Services, Mental Health Care, Serious Mental Illness, and Substance Use Disorder, you, your Behavioral Health Practitioner, or a family member may call the Mental Health/Substance Use Disorder Prior Authorization Helpline at any time, day or night.

Medical Prior Authorization Helpline

To satisfy all medical Prior Authorization requirements for inpatient Hospital Admissions, Extended Care Expenses, or Home Infusion Therapy, call the Medical Prior Authorization Helpline.

Authorization For Out-Of-Network Services

To receive authorization to use Out-of-Network Providers for specialty care or when services are not available from Network Providers, call the Medical Prior Authorization Helpline prior to using the Out-of-Network services.

Form No. EPO-GROUP#396380-0126 Page 4

WHO GETS BENEFITS

Eligibility Requirements for Coverage

The Eligibility Date is the date a person becomes eligible to be covered under the Plan. A person becomes eligible to be covered when the person becomes an Employee or a Dependent and is in a class eligible to be covered under the Plan as determined by your Employer or the Plan Administrator. The Eligibility Date is:

1. The date the Employee, including any Dependents to be covered, completes the Waiting Period, if any, for coverage;

2. Described in the Dependent Enrollment Period subsection for a new Dependent of an Employee already having coverage under the Plan.

No eligibility rules or variations in rates 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. Coverage under this Plan is provided regardless of your race, color, national origin, disability, age, sex, gender identity or sexual orientation. 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.

Employee Eligibility Any person eligible under this Plan as determined by your Employer or the Plan Administrator and covered by the Employer’s previous Health Benefit Plan on the date prior to the Plan Effective Date, including any person who has continued group coverage under applicable federal or state law, is eligible on the Plan Effective Date. Otherwise, you are eligible for coverage under the Plan when you satisfy the definition of an Employee as determined by your Employer or the Plan Administrator.

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

1. Your spouse or your Domestic Partner;

2. A child under the limiting age shown in your Schedule of Coverage;

3. A child of your child who is your Dependent for federal income tax purposes at the time application for coverage of the child is made;

4. Any other child included as an eligible Dependent under the Plan.

A detailed description of Dependent is in the DEFINITIONS section of this Benefit Booklet. An Employee must be covered first in order to cover their eligible Dependents. No Dependent shall be covered hereunder prior to the Employee’s Effective Date. If you are married to another Employee or have a Domestic Partner who is an Employee, you may not cover your spouse or Domestic Partner as a Dependent, and only one of you may cover any Dependent children.

Effective Dates of Coverage

In order for an Employee’s coverage to take effect, the Employee must submit written enrollment for coverage for himself and any Dependents. The Effective Date is the date the coverage for a Participant actually begins. The Effective Date under the Plan is shown on your Identification Card. It may be different from the Eligibility Date.

Timely Applications It is important that your application for coverage under the Plan is received timely by the Claim Administrator through the Plan Administrator.

Form No. EPO-GROUP#396380-0126 Page 5

If you apply for coverage and make the required contributions for yourself or for yourself and your eligible Dependents and if you:

1. Are eligible on the Plan Effective Date and the application is received by the Claim Administrator through the Plan Administrator prior to or within 31 days following such date, your coverage will become effective on the Plan Effective Date;

2. Enroll for coverage for yourself or for yourself and your Dependents during an Open Enrollment Period, coverage shall become effective on the Plan Anniversary Date; or

3. Become eligible after the Plan Effective Date and if the application is received by the Claim Administrator through the Plan Administrator within the first 31 days following your Eligibility Date, the coverage will become effective in accordance with eligibility information provided by your Employer.

Effective Dates - Delay of Benefits Provided Coverage becomes effective for you and/or your Dependents on the Plan Effective Date upon completion of an application for coverage. If you or your eligible Dependent(s) are confined in a Hospital or Facility Other Provider on the Plan Effective Date, your coverage is effective on the Plan Effective Date. However, if this Plan is replacing a discontinued Health Benefit Plan or self-funded Health Benefit Plan, benefits for any Employee or Dependent may be delayed until the expiration of any applicable extension of benefits provided by the previous Health Benefit Plan or self-funded Health Benefit Plan.

Effective Dates - Late Enrollee 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 Plan Anniversary Date.

Loss of Other Health Insurance Coverage An Employee who is eligible, but not enrolled for coverage under the terms of the Plan (and/or a Dependent, if the Dependent is eligible, but not enrolled for coverage under such terms) shall become eligible to apply for coverage if each of the following conditions is met:

1. The Employee or Dependent was covered under a Health Benefit Plan, self-funded Health Benefit Plan, or had other health insurance coverage at the time this coverage was previously offered; and

2. Coverage was declined under this Plan in writing, on the basis of coverage under another Health Benefit Plan or self-funded Health Benefit Plan; and

3. There is a loss of coverage under such prior Health Benefit Plan or self-funded Health Benefit Plan as a result of:

a. Exhaustion of continuation under Title X of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended; or

b. Cessation of Dependent status (such as divorce or attaining the maximum age to be eligible as a dependent child under the Plan), termination of employment, a reduction in the number of hours of employment, or employer contributions toward such coverage were terminated; or

c. Termination of the other plan’s coverage, a situation in which an individual incurs a claim that would meet or exceed a lifetime limit on all benefits, a situation in which the other plan no longer offers any benefits to the class of similarly situated individuals that include you or your Dependent, or, in the case of coverage offered through an HMO, you or your Dependent no longer reside, live, or work in the service area of that HMO and no other benefit option is available; and

4. You request to enroll no later than 31 days after the date coverage ends under the prior Health Benefit Plan or self-funded Health Benefit Plan or, in the event of the attainment of a lifetime limit on all benefits, the request to enroll is made not later than 31 days after a claim is denied due to the attainment of a lifetime limit on all benefits.

Coverage will become effective the first day of the Plan Month following receipt of the application by the Claim Administrator through the Plan Administrator.

If all conditions described above are not met, you will be considered a Late Enrollee.

Form No. EPO-GROUP#396380-0126 Page 6

Loss of Governmental Coverage An individual who is eligible to enroll and who has lost coverage under Medicaid (Title XIX of the Social Security Act), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s) or under the Children’s Health Insurance Program (CHIP), Chapter 62, Health and Safety Code, is not a Late Enrollee provided appropriate enrollment application/change forms and applicable contributions are received by the Claim Administrator within sixty (60) days after the date on which such individual loses coverage. Coverage will be effective the day after prior coverage terminated.

Health Insurance Premium Payment (HIPP) Reimbursement Program An individual who is eligible to enroll and who is a recipient of medical assistance under the Medicaid Program or enrolled in CHIP, and who is a participant in the HIPP Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after the Claim Administrator receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from you, provided such forms and applicable contributions are received by the Claim Administrator within sixty (60) days after the date the individual becomes eligible for participation in the HIPP Reimbursement Program.

Dependent Enrollment Period

1. Special Enrollment Period for Newborn Children

Coverage of a newborn child will be automatic for the first 31 days following the birth of your newborn child.

For coverage to continue beyond this time, you must notify the Claim Administrator through the Plan Administrator within 31 days of birth and pay any required contributions within that 31-day period or a period consistent with the next billing cycle. Coverage will become effective on the date of birth. If the Claim Administrator is notified through the Plan Administrator after that 31-day period, the newborn child’s coverage will become effective on the Plan Anniversary Date following the Employer’s next Open Enrollment Period.

2. Special Enrollment Period for Adopted Children or Children Involved in a Suit for Adoption Coverage of an adopted child or child involved in a suit for adoption will be automatic for the first 31 days following the adoption or date on which a suit for adoption is sought. For coverage to continue beyond this time, the Claim Administrator through the Plan Administrator must receive all necessary forms and the required contributions within the 31-day period or a period consistent with the next billing cycle. Coverage will become effective on the date of adoption or date on which a suit for adoption is sought. If you notify the Claim Administrator through the Plan Administrator after that 31-day period, the child’s coverage will become effective on the Plan Anniversary Date following the Employer’s next Open Enrollment Period.

3. Court Ordered Dependent Children If a court has ordered an Employee to provide coverage for a child, coverage will be automatic for the first 31 days after the date your Employer receives notification of the court order. To continue coverage beyond the 31 days, the Claim Administrator through the Plan Administrator must receive all necessary forms and the required contributions within the 31-day period. If you notify the Claim Administrator through the Plan Administrator after that 31-day period, the Dependent child’s coverage will become effective on the Plan Anniversary Date following your Employer’s next Open Enrollment Period.

4. Other Dependents Written application must be received within 31 days of the date that a spouse or Domestic Partner or child first qualifies as a Dependent. If the written application is received within 31 days, coverage will become effective on the date the child or spouse or Domestic Partner first becomes an eligible Dependent. If application is not made within the initial 31 days, then your Dependent’s coverage will become effective on the Plan Anniversary Date following your Employer’s next Open Enrollment Period.

If you ask that your Dependent be provided health care coverage after having canceled their coverage while your Dependent was still entitled to coverage, your Dependent’s coverage will become effective in accordance with the provisions of the Plan.

Form No. EPO-GROUP#396380-0126 Page 7

In no event will your Dependent’s coverage become effective prior to your Effective Date.

Other Employee Enrollment Period

1. As a special enrollment period event, if you acquire a Dependent through birth, adoption, or through suit for adoption, and you previously declined coverage for reasons other than under Loss of Other Health Insurance Coverage, as described above, you may apply for coverage for yourself, your spouse or Domestic Partner, and a newborn child, adopted child, or child involved in a suit for adoption. If the written application is received within 31 days of the birth, adoption, or suit for adoption, coverage for the child, you, or your spouse or Domestic Partner will become effective on the date of the birth, adoption, or date suit for adoption is sought.

If you marry or enter into a Domestic Partnership and you previously declined coverage for reasons other than under Loss of Other Health Insurance Coverage as described above, you may apply for coverage for yourself and your spouse or Domestic Partner. If the written application is received within 31 days of the marriage or establishment of a Domestic Partnership, coverage for you and your spouse or Domestic Partner will become effective on the first day of the month following receipt of the application by the Claim Administrator through the Plan Administrator.

2. If you are required to provide coverage for a child as described in Court Ordered Dependent Children above, and you previously declined coverage for reasons other than under Loss of Other Health Insurance Coverage, you may apply for coverage for yourself. If the written application is received within 31 days of the date your Employer receives notification of the court order, coverage for you will become effective on the date your Employer receives notification of the court order.

Enrollment Application/Change Form

Use this form to...

• Notify the Plan of a change to your name

• Add Dependents

• Drop Dependents

• Cancel all or a portion of your coverage

• Notify the Plan of all changes in address for yourself and your Dependents.

You may obtain this form from your Employer, or by calling the Claim Administrator’s Customer Service Helpline telephone number shown in this Benefit Booklet or on your Identification Card, or by accessing the BCBSTX website. If a Dependent’s address and zip code are different from yours, be sure to indicate this information on the form. After you have completed the form, return it to your Employer.

Changes In Your Family

You should promptly notify the Claim Administrator through the Plan Administrator in the event of a birth or follow the instructions below when events, such as but not limited to, the following take place:

• If you are adding a Dependent due to marriage or establishment of a Domestic Partnership, adoption, or a child being involved in a suit for which an adoption of the child is sought, or your Employer receives a court order to provide health coverage for a Participant’s child or your spouse, you must submit an Enrollment Application/Change Form and the coverage of the Dependent will become effective as described in Dependent Enrollment Period.

• When you divorce or terminate a Domestic Partnership or your child reaches the age indicated on your Schedule of Coverage as “Dependent Child Age Limit,” or a Participant in your family dies, coverage under the Plan terminates in accordance with the Termination of Coverage provisions selected by your Employer.

Form No. EPO-GROUP#396380-0126 Page 8

Notify your Employer promptly if any of these events occur. Benefits for expenses incurred after termination are not available. If your Dependent’s coverage is terminated, refund of contributions will not be made for any period before the date of notification. If benefits are paid prior to notification to the Claim Administrator by the Plan Administrator, refunds will be requested.

Please refer to the Continuation of Group Coverage - Federal subsection in this Benefit Booklet for additional information.

Form No. EPO-GROUP#396380-0126 Page 9

HOW THE PLAN WORKS

Allowable Amount

The Allowable Amount is the maximum amount of benefits the Claim Administrator will pay for Eligible Expenses you incur under the Plan. The Claim Administrator has established an Allowable Amount for Medically Necessary services, supplies, and procedures provided by Providers that have contracted with the Claim Administrator or any other Blue Cross and/or Blue Shield Plan, and Providers that have not contracted with the Claim Administrator or any other Blue Cross and/or Blue Shield Plan. When you choose to receive services, supplies, or care from a Provider that does not contract with the Claim Administrator, you will be responsible for any difference between the Claim Administrator’s Allowable Amount and the amount charged by the non-contracting Provider. You will also be responsible for charges for services, supplies, and procedures limited or not covered under the Plan, any applicable Deductibles, Co-Share Amounts, and Copayment Amounts.

Review the definition of Allowable Amount in the DEFINITIONS section of this Benefit Booklet to understand the guidelines used by the Claim Administrator.

Authorization for Out-of-Network Services

If authorization to use Out-of-Network Providers is needed, you or your Network Provider must contact the Claim Administrator to receive a referral authorization prior to use of the Out-of-Network Provider. If you receive the referral authorization, Network benefits will be paid, otherwise no benefits will be paid by the Plan. To request authorization ask your Network Provider to contact the Claim Administrator or you may contact the Medical Prior Authorization Helpline at the number shown on your Identification Card.

Case Management

Under certain circumstances, the Plan allows the Claim Administrator the flexibility to offer benefits for expenses which are not otherwise Eligible Expenses. The Claim Administrator, at its sole discretion, may offer such benefits if:

• The Participant, their family, and the Physician agree;

• Benefits are cost effective; and

• The Claim Administrator anticipates future expenditures for Eligible Expenses which may be reduced by such benefits.

Any decision by the Claim Administrator to provide such benefits shall be made on a case-by-case basis. The case coordinator for the Claim Administrator will initiate case management in appropriate situations.

Identification Card

The Identification Card tells Providers that you are entitled to benefits under your Employer’s Health Benefit Plan.

The card offers a convenient way of providing important information specific to your coverage including, but not limited to, the following:

• Your Subscriber identification number. This unique identification number is preceded by a three character alpha prefix that identifies Blue Cross and Blue Shield of Texas as your Claim Administrator.

• Your group number. This is the number assigned to identify your Employer’s Health Benefit Plan with the Claim Administrator.

• Any Copayment Amounts that may apply to your coverage.

• Important telephone numbers.

Always remember to carry your Identification Card with you and present it to your Providers or Participating Pharmacies when receiving health care services or supplies.

Form No. EPO-GROUP#396380-0126 Page 10

Please remember that any time a change in your family takes place it may be necessary for a new Identification Card to be issued to you (refer to the WHO GETS BENEFITS section for instructions when changes are made). Upon receipt of the change in information, the Claim Administrator will provide a new Identification Card.

Unauthorized, Fraudulent, Improper, or Abusive Use of Identification Cards

1. The unauthorized, fraudulent, improper, or abusive use of Identification Cards issued to you and your covered

Dependents will include, but not be limited to, the following actions, when intentional:

a. Use of the Identification Card prior to your Effective Date;

b. Use of the Identification Card after your date of termination of coverage under the Plan;

c. Obtaining prescription drugs or other benefits for persons not covered under the Plan;

d. Obtaining prescription drugs or other benefits that are not covered under the Plan;

e. Obtaining Covered Drugs for resale or for use by any person other than the person for whom the Prescription

Order is written, even though the person is otherwise covered under the Plan;

f. Obtaining Covered Drugs without a Prescription Order or through the use of a forged or altered Prescription

Order;

g. Obtaining quantities of prescription drugs in excess of Medically Necessary or prudent standards of use or in circumvention of the quantity limitations of the Plan;

h. Obtaining prescription drugs using Prescription Orders for the same drugs from multiple Providers;

i. Obtaining prescription drugs from multiple Pharmacies through use of the same Prescription Order.

2. The fraudulent or intentionally unauthorized, abusive, or other improper use of Identification Cards by any Participant can result in, but is not limited to, the following sanctions being applied to all Participants covered under your coverage:

a. Denial of benefits;

b. Cancellation of coverage under the Plan for all Participants under your coverage;

c. Recoupment from you or any of your covered Dependents of any benefit payments made;

d. Pre-approval of drug purchases and medical services for all Participants receiving benefits under your coverage;

e. Notice to proper authorities of potential violations of law or professional ethics.

Medical Necessity

All services and supplies for which benefits are available under the Plan must be Medically Necessary as determined by the Claim Administrator. Charges for services and supplies which the Claim Administrator determines are not Medically Necessary will not be eligible for benefit consideration and may not be used to satisfy Deductibles or to apply to the Out-of-Pocket Maximum.

Preexisting Conditions Provision

Benefits for Eligible Expenses incurred for treatment of a preexisting condition will be available immediately with no preexisting condition Waiting Period.

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 a 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 a Network Provider.

• If specialty care by an Out-of-Network Provider is needed, Network Benefits may still be available if a Network Physician notifies the Claim Administrator and the Claim Administrator authorizes your visit to an Out-of-Network Provider prior to the visit; otherwise, no benefits will be paid by the Plan, or

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• If the services you require are covered by this Plan, but are not available from Network Providers, Network Benefits will be provided when you use Out-of-Network Providers.

Network Benefits for authorized Out-of-Network services will be paid based on the Allowable Amount for Hospitals and Facility Other Providers, and Physicians or Professional Other Providers not contracting with BCBSTX (or any other Blue Cross and Blue Shield Plan outside of Texas.) If the Allowable Amount is less than the amount charged by the Provider, you may be billed for the balance. (See Allowable Amount definition.)

If you choose to see an Out-of-Network Provider without prior authorization, no benefits will be paid by the Plan.

Form No. EPO-GROUP#396380-0126 Page 12

UTILIZATION MANAGEMENT

Utilization Management

Utilization management may be referred to as Medical Necessity reviews, utilization review (UR) or medical management reviews. A Medical Necessity review for a procedure/service, inpatient admission, and length of stay is based on BCBSTX medical policy and/or level of care review criteria. Medical Necessity reviews may occur prior to services rendered, during the course of care, or after care has been completed for a Post-Service Medical Necessity Review. Some services may require a Prior Authorization before the start of services, while other services will be subject to a Post-Service Medical Necessity Review. If requested, services normally subject to a Post-Service Medical Necessity Review may be reviewed for Medical Necessity prior to the service through a Recommended Clinical Review.

Refer to the definition of Medical Necessity or Medically Necessary in the DEFINITIONS section of this Benefit Booklet for additional information regarding any limitations and/or special conditions pertaining to your benefits.

Prior Authorization Requirements

Prior Authorization establishes in advance the Medical Necessity or Experimental/Investigational nature of certain care and services covered under this Plan. It ensures that the care and services described below for which you have obtained Prior Authorization will not be denied on the basis of Medical Necessity or Experimental/Investigational.

However, Prior Authorization does not guarantee payment of benefits.

Coverage is always subject to other requirements of the Plan, such as limitations and exclusions, payment of contributions, and eligibility at the time care and services are provided.

The following types of services require Prior Authorization:

• All inpatient Hospital Admissions,

• Extended Care Expenses,

• Home Health,

• Home Infusion Therapy,

• Home hemodialysis,

• Home Hospice,

• Dialysis obtained from an Out-of-Network Provider,

• Transplants and transplant evaluations,

• Outpatient Surgery performed at a Hospital or Ambulatory Surgical Facility for Out-of-Network services only,

• Non-emergency Air Ambulance: Fixed Wing, Please refer to Fixed-Wing Air Ambulance definition in the DEFINITIONS section of this Benefit Booklet.

Cardiac (heart related):

- Cardiology advanced imaging,

- Cardiology - lipid apheresis, Orthopedic (Musculoskeletal):

- MSK - joint and spine surgery,

- MSK - pain management, Pain Management:

- Occipital nerve stimulation, Radiology:

- Advanced Imaging, Form No. EPO-GROUP#396380-0126 Page 13

Sleep Medicine:

- Sleep studies, Positive airway pressure (PAP) therapy and supply, Therapy compliance monitoring, Specialty Pharmacy:

- Specialty Pharmacy Medications covered by Medical Benefits including Infusion Site of Care, Medical Oncology & Supportive Care and Provider Administered Drug Therapies,

• All inpatient treatment of Mental Health Care/Serious Mental Illness including treatment received at Residential Treatment Centers,

• All inpatient treatment of Substance Use Disorder (SUD) including treatment received at Residential Treatment Centers, and

• If you transfer to another facility or to or from a specialty unit within the facility.

• The following outpatient treatment of Mental Health Care, Serious Mental Illness and Substance Use Disorder

(SUD):

- Psychological Testing or Neuropsychological Testing in some cases (BCBSTX will notify your Provider if

Prior Authorization is required for these testing services),

- Applied Behavioral Analysis (Please see coverage details as described in the Benefits for Autism Spectrum

Disorder in the COVERED MEDICAL SERVICES section of this Benefit Booklet),

- Electroconvulsive therapy,

- Intensive Outpatient Program, and

- Repetitive Transcranial Magnetic Stimulation.

For specific details about the Prior Authorization requirement for the above referenced outpatient procedures/services, please call Customer Service at the number on the back of your Identification Card. BCBSTX reserves the right to no longer require Prior Authorization during the Calendar Year. Updates to the list of services requiring Prior Authorization may be confirmed by calling Customer Service.

Network Benefits will be available if you use a Network Provider or Network Specialty Care Provider. Network Providers will obtain Prior Authorization of services for you, when required.

If you elect to use Out-of-Network Providers for services and supplies available in theNetwork, no benefits will be paid under this Plan.

However, if care is not available from Network Providers as determined by the Claim Administrator, and the Claim Administrator authorizes your visit to an Out-of-Network Provider prior to the visit, Network Benefits will be paid based on the Allowable Amount for Out-of-Network Providers. You may be billed for any difference between the Allowable Amount and the amount charged by the Provider. If you are receiving any of the services listed above, you are responsible for ensuring the services have obtained Prior Authorization. Failure to obtain Prior Authorization of services will be subject to guidelines described below.

Your Network Provider is required to obtain Prior Authorization for inpatient Hospital admissions. You are responsible for satisfying all other Prior Authorization requirements. This means that you must ensure that you, an authorized representative, your Physician, Behavioral Health Practitioner or Provider of services must comply with the guidelines below. Failure to obtain Prior Authorization of services will require additional steps and/or benefit reductions as described in the subsection entitled Failure to Obtain Prior Authorization.

Prior Authorization for Inpatient Hospital Admissions In the case of an elective inpatient Hospital Admission, the call for Prior Authorization should be made at least two working days before you are admitted unless it would delay Emergency Care. In an emergency, Prior Authorization should take place within two working days after admission, or as soon thereafter as reasonably possible.

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Your Network Provider is required to obtain Prior Authorization for any inpatient admissions. If Prior Authorization is not obtained, the Network Provider will be sanctioned based on BCBSTX’s contractual agreement with the Provider, and you will be held harmless for the Provider sanction.

If the Physician or Provider of services is not a Network Provider then you, your Physician, the participating Provider of services, or an authorized representative should obtain Prior Authorization by the Plan by calling one of the toll-free numbers shown on the back of your Identification Card. The call should be made between 6:00 a.m. and 6:00 p.m., Central Time, on business days and 9:00 a.m. and 12:00 p.m., Central Time on Saturdays, Sundays and legal holidays. Calls made after these hours will be recorded and returned no later than 24 hours after the call is received. We will follow-up with your Provider’s office. After working hours or on weekends, please call the Medical Prior Authorization Helpline toll-free number listed on the back of your Identification Card. Your call will be recorded and returned the next working day. A benefits management nurse will follow up with your Provider’s office. All timelines for Prior Authorization requirements are provided in keeping with applicable state and federal regulations.

In-Network Benefits will be available if you use a Network Provider or Network Specialty Care Provider. If you elect to use Out-of-Network Providers for services and supplies available In-Network, Out-of-Network Benefits will not be paid. In-Network and Out-of-Network Providers may obtain Prior Authorization of services for you, when required, but it is your responsibility to ensure Prior Authorization requirements are satisfied.

However, if care is not available from Network Providers as determined by BCBSTX, and BCBSTX authorizes your visit to an Out-of-Network Provider to be covered at the In-Network Benefit level prior to the visit, In-Network Benefits will be paid; otherwise, Out-of-Network Benefits will be paid.

When Prior Authorization of an inpatient Hospital Admission is obtained, a length-of-stay is assigned. If you require a longer stay, your Provider may seek an extension for the additional days. Benefits will not be available for room and board charges for medically unnecessary days. For more information regarding lengths of stay, refer to the Length of Stay/Service Review subsection of this Benefit Booklet.

Prior Authorization not Required for Maternity Care and Treatment of Breast Cancer Unless Extension of Minimum Length of Stay Requested…