ESBD_557641_1788989762797_Med HMO Cert.pdf

Your Health Care Benefits Program

Blue EssentialsSM Plan

For Employees of Brazos River Authority

Group # 401012 4010120003.0126

Effective January 1, 2026

BlueCross BlueShield of Texas

Blue Cross and Blue Shield of Texas, a Division of Health Care Services Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the

Blue Cross and Blue Shield Association

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BLUE CROSS AND BLUE SHIELD OF TEXAS

a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent License of the Blue Cross and Blue Shield Association (herein called “BCBSTX” or “HMO”)

1001 East Lookout Drive Richardson, Texas 75082

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

EVIDENCE OF COVERAGE

INTRODUCTION

NOTICE TO CONSUMER

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

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

This is your Evidence of Coverage (“Certificate”). Please read the information in this Certificate carefully so you will have a full understanding of your health care benefits. It explains your covered services and how you obtain them while you are a member, and coverage is valid. This Certificate is part of the group agreement between the group and Blue Cross and Blue Shield of Texas (“BCBSTX”)(“HMO”). It is governed by applicable federal and state law and determines the terms and conditions of your coverage.

This Certificate applies only to your HMO coverage. It does not limit your ability to receive health care services that are not covered services. No participating provider or other provider, institution, facility, or agency is an agent or employee of the HMO.

Please note: Except as shown under the GENERAL PROVISIONS: COBRA Continuation Coverage section, coverage is not provided for any services received before coverage starts or after coverage ends.

The defined terms throughout this Certificate are in bold font and defined in the GLOSSARY or applicable section.

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

This Certificate is not a Medicare supplement policy or a Workers’ Compensation insurance policy. If you are eligible for Medicare, please review the Guide to Health Insurance for people with Medicare available from BCBSTX.

http://www.bcbstx.com/

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Have a complaint or need help?

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

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

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation To get information or file a complaint with your insurance company or HMO:

Call: Blue Cross and Blue Shield of Texas Toll-Free: 1-877-299-2377 Email: BCBSTXComplaints@bcbstx.com Mail: P. O. Box 660044, Dallas, TX 75266-0044

The Texas Department of Insurance To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439 File a complaint: www.tdi.texas.gov Email: ConsumerProtection@tdi.texas.gov Mail: Consumer Protection, MC: CO-CP, Texas Department of Insurance, P.O. Box 12030, Austin, TX 78711-2030

¿Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en inglés) pueda ayudar.

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

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation Para obtener información o para presentar una queja ante su compañía de seguros o HMO:

Llame a: Blue Cross and Blue Shield of Texas Teléfono gratuito: 1-877-299-2377 Correo electrónico: BCBSTXComplaints@bcbstx.com

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

El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: www.tdi.texas.gov Correo electrónico: ConsumerProtection@tdi.texas.gov Dirección postal: Consumer Protection, MC: CO-CP, Texas Department of Insurance, P.O. Box 12030, Austin, TX 78711-2030 mailto:tion@tdi.texas.gov http://www.tdi.texas.gov/ mailto:ConsumerProtection@tdi.texas.gov

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TABLE OF CONTENTS

INTRODUCTION

QUICK REFERENCE

CUSTOMER SERVICE

SCHEDULE OF COPAYMENT AND BENEFIT LIMITS

GLOSSARY………………………………………

WHO GETS BENEFITS

UTILIZATION MANAGEMENT

HOW THE PLAN WORKS

COVERED SERVICES

PREVENTIVE CARE

MEDICAL LIMITATIONS AND EXCLUSIONS

PHARMACY BENEFITS

CLAIM FILING AND APPEALS PROCEDURES

GENERAL PROVISIONS

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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 o Customer Service o Prior Authorization o Inpatient Admissions o Appeals o Claim Forms o Prescription Drug o Mail-Order Services o Pharmacy Locator

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

Definitions Please see GLOSSARY section.

Defined terms are in bold in your booklet.

Your cost share information for covered services.

Please see SCHEDULE OF COPAYMENTS AND

BENEFIT LIMITS section.

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

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

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CUSTOMER SERVICE

Medical Benefits Call Website

Customer Service

Please 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)

Please see telephone number on the back of your identification card

Inpatient Admissions

(for Behavioral Health and for Non-Behavioral Health)

Please see telephone number on the back of your identification card

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

Alternate Service Area Access

An “Alternate Service Area” means the service area(s) covered by health maintenance organizations participating in the Blue Cross and Blue Shield Association Away From Home Care® Program outside of the state of Texas. For the names of those health maintenance organizations and their service areas, or for a list of participating providers in an alternate service area, please contact customer service at the toll-free telephone number on your identification card.

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SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS

Blue EssentialsSM Network

This is your SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. It shows your cost share for your coverage offered by your HMO plan. You should review this along with the MEDICAL LIMITATIONS AND EXCLUSIONS section.

All covered services (except in emergencies) must be provided by or through your participating primary care physician/practitioner (PCP). Your PCP may refer you for further treatment by providers in the applicable network of participating specialists and hospitals.

Members may visit a participating OB/GYN physician in their PCP’s provider network without a referral from their PCP.

The following services do not require a referral from your PCP:

• Urgent care

• Outpatient professional behavioral health

• Retail health clinics

• Virtual visits

NOTE: The copayments and, if applicable, coinsurance below show the amount you must pay as either a fixed dollar amount or a percentage of the allowable amount. Copayments and any applicable coinsurance or deductibles will be applied for each covered service given by a participating provider or emergency care received from a non-participating provider unless otherwise indicated. You will not be responsible for any copayments/coinsurance once the deductible(s) and out-of-pocket maximum(s) listed below have been met. Copayments/coinsurance, deductibles and out-of-pocket maximums may be adjusted for various reasons allowed by applicable law. Some services may require prior authorization.

Please review the COVERED SERVICES section for more information about the covered services listed below.

Benefit Period Calendar year

Deductible

Deductible Per Calendar Year

You Pay

Individual $1,600

Family $3,200

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Out-of-Pocket Maximum

Out-of-Pocket Maximums

Individual $4,000

Family $8,000

Allergy Care

Description In-Network

You Pay

Allergy Evaluations, Injections, Serum and Testing

20% coinsurance after deductible

Ambulance Services

In-Network

Ambulance Services 20% coinsurance after deductible

Autism Spectrum Disorder

In-Network

You Pay

Autism Spectrum Disorder Covered based on type of service and where it is received

Bariatric Surgery

In-Network

You Pay

Bariatric Surgery Covered based on type of service and where it is received

Behavioral Health Services (Mental Health/Substance Use Disorder)

In-Network

You Pay

Chemical Dependency Services $30 copay for in-office or home visit or benefits paid same as any other illness for other services, as applicable.

Inpatient Mental Health Care 20% coinsurance after deductible

Outpatient Mental Health Care $30 copay for in-office or home visit or benefits paid same as any other illness for other services, as applicable.

Serious Mental Illness $30 copay for in-office or home visit or benefits paid same as any other illness for other services, as applicable.

Telehealth and Telemedicine Services

$30 copay

Office Visit $30 copay

• A referral is not needed for an in-network HMO outpatient behavior health services.

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Chiropractic Care

In-Network

You Pay

Chiropractic Care $30 copay for PCP or $30 copay for specialist

Limits Prior Authorization is Required

Cosmetic, Reconstructive or Plastic Surgery

In-Network

You Pay

Cosmetic, Reconstructive or Plastic Surgery

(Limited Covered Services)

$30 copay for PCP or $30 copay for specialist, 20% coinsurance after deductible for inpatient hospital services or 20% coinsurance after deductible for outpatient surgery, as applicable.

Dental and Oral Surgical Procedures

In-Network

You Pay

Dental and Oral Surgical Procedures (Limited Covered

Services)

$30 copay for PCP or $30 copay for specialist, 20% coinsurance after deductible for inpatient hospital services or 20% coinsurance after deductible for outpatient surgery, as applicable.

Diabetes Care

In-Network

You Pay

Diabetes Self-Management Training, for each visit

$30 copay for PCP or $30 copay for specialist

Diabetes Equipment 20% coinsurance after deductible

Diabetes Supplies 20% coinsurance after deductible

• Some diabetes supplies are only available utilizing pharmacy benefits, through a participating pharmacy. You must pay the applicable PHARMACY BENEFITS amount shown in the PHARMACY SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences.

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Durable Medical Equipment (DME)

Description In-Network

You Pay

Durable Medical Equipment

(DME)

Emergency Services

In-Network

You Pay

Emergency Care Facility Charges 20% coinsurance after deductible, waived if admitted.

Emergency Care Physician Charges

• If admitted, any charges described in inpatient hospital services will apply.

Fertility Treatment and Infertility Services

In-Network

You Pay

Diagnostic Counseling, Consultations, Planning and

Treatment Services $30 copay for PCP or $30 copay for specialist

Hearing and Speech Services and Hearing Aids

In-Network

You Pay

Hearing and Speech Services Benefits paid same as any other physical illness

Hearing Aids 20% coinsurance after deductible

Limits One(1) hearing aid per ear each 36-month period

One (1) audiometric examination every thirty-six (36) months

Cochlear Implants 20% coinsurance after deductible

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

• Benefits for autism spectrum disorder will not apply towards, and are not subject to, any rehabilitation service visits maximum.

• For cochlear implants additional charges as described in Outpatient Hospital Services may also apply.

Home Health Care

In-Network

You Pay

Home Health Care 20% coinsurance per visit

Limits 60 visits per benefit period

• Covered when prescribed by a PCP and authorized by the HMO.

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Hospice Care

Description In-Network

Hospice 20% coinsurance

Infusion Therapy

In-Network

You Pay

Outpatient Infusion Therapy Performed in hospital setting

Inpatient Hospital Services

In-Network

You Pay

Inpatient Services 20% coinsurance after deductible

Inpatient Rehabilitation 20% coinsurance after deductible

Maternity Services

In-Network

You Pay

Maternity Care 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

• For maternity care: prenatal and postnatal visit - copayment is applied to the first office visit only. Afterwards, office visits are covered in full.

• Inpatient prior authorization is not needed for the following length of stays:

o 48 hours following an uncomplicated vaginal delivery.

o 96 hours following an uncomplicated delivery by caesarean section.

Occupational Therapy Services

In-Network

You Pay

Occupational Therapy in the office

$30 copay for PCP or $30 copay for specialist

Occupational Therapy in an outpatient setting

20% coinsurance after deductible

Limits Prior Authorization is Required

• Benefits for autism spectrum disorder will not apply towards and are not subject to any rehabilitation services visits

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Outpatient Hospital Services

Description In-Network

You Pay

Certain Diagnostic Procedures & Imaging Services

(MRI, CT Scan, PET Scan) 20% coinsurance after deductible

Certain Diagnostic Procedures & Imaging Services

(Lab, X-Ray & Other Diagnostic Services)

No copay

Outpatient Surgery 20% coinsurance after deductible

Radiation Therapy 20% coinsurance after deductible

Dialysis 20% coinsurance after deductible

Physical Therapy Services

In-Network

You Pay

Physical Therapy in the Office $30 copay for PCP or $30 copay for specialist

Physical Therapy in an Outpatient Setting

20% coinsurance after deductible

Limits Prior Authorization is Required

• Benefits for autism spectrum disorder will not apply towards and are not subject to, any rehabilitation service visits

Physician and Specialist Services

In-Network

You Pay

Primary Care Office Visit or Consultation

$30 copay

Retail Health Clinic Visit $30 copay

Specialty (Specialist) Office Visit or Consultation

$30 copay

Telehealth, Teledentistry & Telemedicine Services

Primary care Consultation $30 copay

Telehealth, Teledentistry & Telemedicine Services Specialty Consultation

$30 copay

Virtual Visits $30 copay

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Preventive Care Services

Description In-Network

You pay

All Other Preventive Care Services No copay

Diagnostic eye, and Ear Screenings for Members through Age 17

$30 copay for PCP or $30 copay for specialist

Diagnostic eye, and Ear Screening for Members Age 18 and Older

$30 copay for PCP or $30 copay for specialist

Early Detection Test for Cardiovascular Disease

$30 copay for PCP or $30 copay after deductible for specialist

Early Detection Test for Ovarian Cancer (CA125 blood test)

$30 copay for PCP or $30 copay for specialist

Exam for Prostate Cancer $30 copay for PCP or $30 copay for specialist

• Please see the COVERED SERVICES section for benefit limitations on preventive care services.

Prosthetic Appliances and Orthotic Devices

In-Network

You Pay

Prosthetic Appliances and Orthotic Devices

Speech Therapy

For information on speech therapy please refer to the Hearing and Speech Services table in this section

Skilled Nursing Facility

In-Network

You Pay

Skilled Nursing Facility 20% coinsurance

Limits Up to 60 days per benefit period

Sterilization

In-Network

You Pay

Vasectomy $30 copay for PCP or $30 copay for specialist or 20% coinsurance after deductible for outpatient surgery, as applicable.

Urgent Care

In-Network

You Pay

Urgent Care Services $50 copay

• Additional charges described under Outpatient Hospital Services may apply.

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Wigs

Description In-Network

You Pay

Wigs 20% coinsurance after deductible

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

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PHARMACY SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS

This is your summary of benefits for prescription drugs. It shows your cost share including deductible amounts, coinsurance amounts and copayment 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 identification card or access your self-service online member portal, Blue Access for Members℠ (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 out-of-pocket maximums

• How copayment/coinsurance amounts apply.

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

• Prior authorizations

• Limitations and exclusions

Out-of-Pocket Maximum Pharmacy Out-of-Pocket Maximum

Individual $1,000

Family $2,000

Retail Pharmacy

Retail Pharmacy

Tier 1 $5 copay

Tier 2 $35 copay

Tier 3 $60 copay

Out-of-Area Drug $60 copay

• One copayment amount per 30-day supply, up to a 30-day supply only.

• Extended Prescription Drug Supply Program (if allowed by the prescription order) – One copayment amount per 30-day supply, up to a 90-day supply.

Mail-Order Pharmacy Program

Mail-Order Pharmacy

Tier 1 $5 copay

Tier 2 $35 copay

Tier 3 $60 copay

• Extended Prescription Drug Supply Program (if allowed by the prescription order) – One copayment amount per -day supply, up to a -day supply only

• 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

Tier 4 $150 copay

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• One copayment amount per 30-day supply, up to a 30-day supply only.

• 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 limits and may be allowed greater than a 30-day supply, if allowed by your plan benefits.

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

Vaccines Select Vaccinations Obtained through the Pharmacy Vaccine Network

Pharmacy Vaccine Network Pharmacy

$0 copay

Please Note:

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

BENEFITS will apply, including copayment/coinsurance, deductibles, and any pricing differences.

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

• Certain covered drugs may be available at no cost through a participating pharmacy for the following categories of medication: severe allergic reactions, hypoglycemia, opioid overdoses and nitrates. For further information, call the number on the back of your identification card.

• Select covered drugs determined by the plan may be covered with no member cost share to make these medications affordable to members.

• Note: For members with a chronic, complex, rare, or life-threatening medical condition, covered drugs that will be administered by a provider in a physician’s office may be obtained from a non-participating pharmacy by the provider, after the provider has determined that disease progression, patient harm, or death is probable, or where the provider has concerns about patient adherence or timely delivery. These services are covered under the medical benefit and the cost-sharing requirements will be the same as if they were obtained from a participating pharmacy.

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

https://www.bcbstx.com/

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GLOSSARY

Allowable Amount means the maximum amount determined by the HMO to be eligible for consideration of payment for a particular covered service, covered drug, or covered supply provided by a participating provider. Your copayment/coinsurance and any deductibles are based on the provisions of the participating provider and participating pharmacy contracts and the terms of this plan.

Benefits mean the payment, reimbursement, and indemnification of any kind which you will receive from and through the plan under the Certificate.

Benefit Period means the period during which you receive covered services for which the plan will provide benefits.

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

Calendar Year means the period commencing on a January 1 and ending December 31 of the next succeeding December 31, inclusive.

Coinsurance means the percentage of the allowable amount you pay as a share of the bill. For example if your plan pays 80% of the allowed amount, 20% would be your coinsurance.

Contract Month means the period of each succeeding month beginning on the group agreement effective date.

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

Copayment or Copay means the set amount you pay each time you receive a certain service.

Covered Drug(s) means any prescription drug:

• Which is included on the applicable drug list.

• Which is medically necessary and is ordered by an authorized provider for you or your dependent.

• For which a separate charge is customarily made.

• Which is not consumed at the time and place that the prescription order is written.

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

• Which is dispensed by a pharmacy, and you received while covered under the plan, except when received from a provider’s office, or during confinement while a patient in a hospital or other acute care institution or facility (please refer to the MEDICAL LIMITATIONS AND EXCLUSIONS section).

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

Covered Services means a service or supply in this Certificate for which benefits will be provided.

• Non-Covered Service means a service or supply for which benefits will not be provided.

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Custodial Care means

• Any service primarily for personal comfort or convenience that provides general maintenance, preventive, and/or protective care without any clinical likelihood of improvement of your condition.

• Care that is not a necessary part of medical treatment for recovery including, but not limited to:

o Helping you bathe.

o Helping you with daily living activities o Helping you dress.

o Helping you eat and prepare special diets.

o Helping you with medication.

o Helping you with routine medical needs o Helping you walk

Custodial Care Services means those services that can be safely provided by trained or capable non-professional personnel which do not require the technical skills, professional training, and clinical assessment ability of medical and/or nursing personnel.

Deductible means the amount you pay for a covered service before benefits are paid by the plan.

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

Dietary and Nutritional Services means the education, counseling, or training (including printed material) regarding:

• Diet

• Regulation or management of diet or

• The assessment or management of nutrition.

Drug List means a list of drugs that may be covered under the PHARMACY BENEFITS portion of the plan.

This list is available by accessing the website at www.bcbstx.com. You may also contact Customer Service at the number on your identification card for more information.

Effective Date of Coverage (Effective Date) means the date the coverage for a participant begins.

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

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

Experimental/Investigational means the use of any treatment, procedure, facility, equipment, drug, device or supply (including emerging technologies, services, procedures, and service paradigms) not accepted as standard medical treatment of the condition being treated and any of such items requiring Federal or other governmental agency approval not granted at the time services were provided.

Approval by a Federal agency means that the treatment, procedure, facility, equipment, drug, device or supply has been approved for the condition being treated and, in the case of a drug, in the dosage used on the patient. Approval by a federal agency will be taken into consideration by the HMO in assessing experimental/investigational status but will not be determinative. As used herein, medical treatment includes medical, surgical or dental treatment.

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• Standard Medical Treatment means the services or supplies that are in general use in the medical community in the United States, and:

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

o Are appropriate for the hospital or other provider in which they are performed.

o The physician or other professional has had the appropriate training and experience to provide the treatment or procedure.

The medical staff of BCBSTX will determine whether any treatment, procedure, facility, equipment, drug, device, new existing technologies, or supplies are experimental/investigational, and will consider factors such as the guidelines and practices of Medicare, Medicaid, or other government-financed programs and approval by a federal agency in making its determination. Prescription drugs that are approved by the FDA through the accelerated approval program may be considered experimental/investigational.

Although a provider may have prescribed treatment, and the services or supplies may have been provided as the treatment of last resort, we still may decide such services or supplies still to be experimental/investigational within this definition. Treatment provided as part of a clinical trial or a research study is experimental/investigational.

Gender Transition means a medical process by which an individual’s anatomy, physiology, or mental state is treated or altered, including by the removal of otherwise healthy organs or tissue, the introduction of implants or performance of other plastic surgery, hormone treatment, or the use of drugs, counseling, or therapy, for the purpose of furthering or assisting the individual’s identification as a member of the opposite biological sex or group or demographic category that does not correspond to the individual’s biological sex.

Gender Transition Procedure or Treatment means a medical procedure or treatment performed or provided for the purpose of assisting an individual with a gender transition.

Generic Drug means a drug that has the same active ingredient as a brand name drug and is allowed to be produced after the brand name drug’s patent has expired. In determining the brand or generic classification for covered drugs we utilize the generic/brand status assigned by a nationally recognized provider of drug product database information. You should know that not all drugs identified as a “generic” by the drug product database, manufacturer, pharmacy, or your provider will be considered generic by the HMO.

Grace Period means a period of thirty (30) days after all but the first premium due date, during which period premiums may be paid to the HMO without lapse of coverage occurring. If payment is not received within thirty (30) days, coverage will be terminated after the 30th day and you will be liable for the cost of services received during the grace period.

Group means the employer or party that has entered into a group agreement with the HMO under which the HMO will provide for or arrange health services for eligible members of the group who enroll.

Group Agreement means the agreement the group has with the HMO.

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

Health Care Professional(s) means physicians, nurses, audiologists, physician assistants, advanced practice nurses, nurse first assistants, acupuncturists, clinical psychologists, pharmacists, occupational therapists, physical therapists, speech and language pathologists, surgical assistants and other professionals engaged in the delivery of health services who are licensed, practice under an institutional

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license, or certified, or practice under authority of a physician or legally constituted professional association, or other authority consistent with state law.

HMO (Health Maintenance Organization) means Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation. The Certificate may refer to the HMO as “We”, “Us” and/or “BCBSTX”.

Hospital means a short-term acute care facility which:

• Is duly licensed as a hospital by the state in which it is located and meets the standards established for such licensing and is either accredited by the Joint Commission or is certified as a hospital provider under Medicare.

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

• Provides all services on its premises under the supervision of a staff of physicians or behavioral health providers.

• Provides 24-hour a day nursing services by or under the supervision of a registered nurse.

• Has in effect a hospital utilization review plan.

Hospital Services (except as expressly limited or excluded in this Certificate) means those medically necessary covered services that are generally and customarily provided by acute general hospitals; and prescribed, directed or authorized by the PCP.

Identification Card means the card issued to the employee by the HMO indicating pertinent information applicable to their coverage.

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

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

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

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

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

• Not primarily for the convenience of the member or participating provider.

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

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

When applied to hospitalization, this further means that you require acute care as an inpatient due to the nature of the services provided or your condition, and you cannot receive safe or adequate care as an outpatient. In determining whether a service is medically necessary, the HMO may consider the views of the state and national medical communities and the guidelines and practices of Medicare, Medicaid, or other government-financed programs and peer reviewed literature. Although a participating provider may have prescribed treatment, such treatment may not be medically necessary within this definition. This definition applies only to the HMO’s determination of whether health care services are covered services under this Certificate. The HMO does not determine your course of treatment or whether You receive particular health care services. The decision regarding the course of

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treatment and receipt of particular health care service is entirely between You and your participating provider. The HMO’s determination of medically necessary care is limited to merely whether a proposed admission, continued hospitalization, outpatient service or other health care service is medically necessary under this Certificate.

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

Member means a subscriber or dependent(s) covered under the HMO. This Certificate may refer to a member as “you” or “your”.

Network means identified physicians, behavioral health providers, other professional providers, hospitals, and other facilities that have entered into agreements with the HMO (and in some instances with other participating Blue Cross and/or Blue Shield Plans) for participation in a managed care arrangement.

Out-of-Area means not within the service area.

Out-of-Pocket Maximum means once you pay this amount in copayment/coinsurance and any deductibles for covered services, we pay 100% of the allowed amount for covered services for the rest of the benefit period.

Participating Provider or Participating means a provider that has entered into a contractual agreement with the HMO for the provision of covered services to members.

• Non-Participating Provider means a provider that has not entered into a contractual agreement with the HMO.

Participating Pharmacy means an independent retail pharmacy, chain of retail pharmacies, mail-order program pharmacy or a specialty drug pharmacy which has entered into a written agreement with the HMO to provide pharmaceutical services to you under this Certificate.

• Non-Participating Pharmacy means a pharmacy which has not entered into a written agreement with the HMO to provide pharmaceutical services to you under this Certificate.

Pharmacy means a state and federally licensed establishment where the practice of pharmacy occurs, that is physically separate and apart from any provider’s office, and where legend drugs and devices are dispensed under prescription orders to the general public by a pharmacist licensed to dispense such drugs and devices under the laws of the state in which they practice.

Pharmacy Vaccine Network means the network of select participating pharmacies which have entered into a written agreement with the HMO to provide certain vaccinations to you under this plan.

Physician means a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) who is properly licensed or certified to provide medical care (within the scope of their license) under the laws of the state where the individual practices.

Plan or Benefit Plan means Blue Cross and Blue Shield of Texas (BCBSTX), a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association issued group benefits contract.

Preferred Participating Pharmacy means a participating pharmacy which has a written agreement with the HMO to provide pharmaceutical services to members or an entity chosen by the HMO to administer its prescription drug program that has been designated as a preferred participating pharmacy.

Premium means the amount the group or you are required to pay to the HMO to continue coverage.

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Prescription Order means a written or verbal order from your authorized provider to a pharmacist for a drug or device to be dispensed.

Prior Authorization means a determination by the HMO that health care services proposed to be provided to a patient are medically necessary and appropriate. The prior authorization processes will be conducted in accordance with Texas Insurance Code, chapter843, or in accordance with the laws in the state of Texas.

Primary Care Physician/Practitioner or PCP means the participating physician, physician assistant (PA) or advanced practice nurse (APN) who is primarily responsible for providing, arranging and coordinating all aspects of your health care. You and your dependents must each select a PCP from those listed by the HMO to provide primary care services. You may choose a PCP who is a family practitioner, internist, pediatrician and/or obstetrician/gynecologist (OB/GYN). The PA or APN must work under the supervision of a participating family practitioner, internist, pediatrician and/or OBGYN in the same HMO network.

Professional Services means those medically necessary covered services provided by physicians and other health care professionals in accordance with this Certificate. All services must be performed, prescribed, directed, or authorized in advance by the PCP.

Provider means any duly licensed institution, physician, health care professional or other entity which is licensed to provide health care services.

Referral means specific directions or instructions from your PCP, in conformance with the HMO’s policies and procedures that direct you to a participating provider for covered services.

Rider(s) means additional or expanded benefits which are made available to the group. Such rider(s), when purchased, will be attached to and incorporated into the Certificate.

Service Area means the geographical area or areas served by the HMO and approved by state regulatory authorities. The service area includes the area shown and described in this Certificate.

Specialist means a duly licensed physician, other than a PCP.

Specialty Drug means a drug used to treat complex medical conditions. Specialty drugs are typically given by injection but may be topical or taken by mouth. They also often require careful adherence to treatment plans, may have special handling or storage requirements, and may not be stocked by retail pharmacies.

Subscriber means a person who meets all applicable eligibility and enrollment requirements of this Certificate, and whose enrollment application and premium payment have been received by the HMO.

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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. Coverage under this Certificate is provided regardless of your race, color, national origin, disability, existence of pregnancy, age, sex, gender identity, sexual orientation, political affiliation, or expression. Coverage under this plan does not require documentation certifying a COVID-19 vaccination or require documentation of post-transmission recovery as a condition for obtaining coverage or receiving benefits under this plan. No person, however, is eligible to re-enroll who had coverage terminated under the General Provisions, Termination of Coverage section. Variations in the administration, processes or benefits under this Certificate are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives; disincentives, and/or other programs that 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 Certificate when you satisfy the following:

• Reside, live, or work in the service area.

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

• Satisfy any probationary or waiting period requirements established by the group.

Please Note: No waiting period may exceed 90 days unless permitted by applicable law. If the HMO’s records show that your group has a waiting period that exceeds the time permitted by applicable law, then the HMO reserves the right to begin your coverage on a date that we believe is within the required period. Regardless of whether we exercise that right, your group is responsible for your waiting period. If you have questions about your waiting period, please contact your group.

Dependent Eligibility If you apply for coverage, you may also include coverage for your dependents.

You may be required to submit proof of dependent eligibility with the dependent’s enrollment application/change form before coverage will be extended. This includes documents certifying marriage, dependent child disability status, and/or proof of legal guardianship.

Eligible dependents must:

• Meet all eligibility criteria established by the group.

• Reside in the service area or live with a subscriber who works in the service area, unless coverage is court ordered.

Eligible dependents are:

• Your spouse.

• Your natural child until the month they turn age 26.

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

• A child for whom you or your spouse is a court-appointed legal guardian, until 26 years of age, provided proof of such guardianship is submitted with the prospective dependent’s enrollment application/change form.

• Your grandchild, until 26 years of age, who is claimed as a dependent on your Federal income tax return. Proof must be furnished at time of enrollment.

• Dependent child for whom you are responsible for economic support and maintenance by reason of intellectual disability or physical handicap. You must provide the HMO with the dependent child’s Statement of Disability form. The disability form must include a medical certification of disability. This must be done within thirty-one (31) days of the date of such medical certification.

The HMO may require this on a yearly basis.

Please Note: A child’s financial dependency, residency, student status, employment status, marital status, eligibility for other coverage or any combination of these factors does not affect eligibility.

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

• During the initial enrollment period.

• During the open enrollment period.

• At special enrollment periods during the year.

Coverage will be effective as specified below if you apply during a qualifying enrollment period.

Eligibility Changes You must notify the HMO of any changes that will affect your or your dependent’s eligibility for services or benefits under this Certificate within thirty-one (31) days of the change. Your coverage will not be terminated by the HMO due to health status or health care needs.

Initial Enrollment Period Each eligible employee of the group shall be entitled to apply for coverage for themself and eligible dependents during the initial enrollment period. Everyone included for coverage must be listed on the enrollment application/change form. No proof of insurability is required. The effective date of coverage is the first day of the month after the enrollment period, unless otherwise specified and agreed upon by the group and the HMO.

Open Enrollment Period Your employer will designate an open enrollment period during which time you may apply for or change coverage for you and your eligible dependents. No proof of insurability will be required. The effective date of coverage is the first day of the month after the enrollment period, unless otherwise specified and agreed upon by the group and the HMO.

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Special Enrollment Periods Coverage under this Certificate for persons becoming eligible at times other than the initial enrollment period or the open enrollment period will become effective no later than the first of the month following the event.

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 of coverage.

• You lose a dependent though death, divorce.

• You gain a dependent through marriage, or court ordered coverage.

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

• You become newly eligible for coverage because of entering a class of employees who are eligible to participate in the group plan.

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.

Other Special Enrollment Periods

• Your child reaches the maximum age of 26.

• You lose coverage under your plan as specified under the Termination of Coverage section.

Late Enrollment If your application is not received by the HMO within 31 days from the eligibility date or date of the event, you will be considered a late enrollee, unless otherwise specified and agreed upon by the employer and the HMO. 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 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 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 60 days for the following qualifying events. For coverage to continue

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beyond this time, you must apply for this change within the 60-day period:

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

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

• You or your dependent(s) lose other health insurance coverage or COBRA continuation of coverage.

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

• You or your dependent(s) were covered under other health insurance coverage at the time you were initially…