ESBD_557641_1788989763007_Med PPO Cert.pdf

Your Health Care Benefits Program Managed Health Care Pharmacy Benefits

Brazos River Authority

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

Group #171677 - PPO $1,600 Deductible Plan 1716770001.0126

BlueCross BlueShield of Texas

TX-G-P-LG-COC-0126(b) Enclosure d

CERTIFICATE OF COVERAGE

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

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

James Springfield

President of Blue Cross and Blue Shield of Texas

NOTICE OF SEPARATE AVAILABLE COVERAGE

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

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

CONTRACT OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR

EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’

COMPENSATION SYSTEM.

Have a complaint or need help?

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

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

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

Call: Blue Cross and Blue Shield of Texas Toll-Free: 1-800-521-2227 Email: BCBSTXComplaints@bcbstx.com Mail: PO Box 660044, Dallas, TX 75266-0044

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

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

¿Tiene una queja o necesita ayuda?

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

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

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

Llame a: Blue Cross and Blue Shield of Texas Teléfono gratuito: 1-800-521-2227 Correo electrónico: BCBSTXComplaints@bcbstx.com Dirección postal: PO Box 660044, Dallas, TX 75266-0044

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

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

TABLE OF CONTENTS

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

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

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

INTRODUCTION

GLOSSARY………………………………………

WHO GETS BENEFITS

HOW THE PLAN WORKS

COVERED SERVICES

PREVENTIVE CARE

MEDICAL LIMITATIONS AND EXCLUSIONS

PHARMACY BENEFITS

UTILIZATION MANAGEMENT

CLAIM FILING AND APPEALS PROCEDURES

GENERAL PROVISIONS

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 www.bcbstx.com/provider/clinical/clinical-resources/preventive-care

• Customer Service

• Prior Authorization

• Inpatient Admissions

• Appeals

• Claim Forms

• Prescription Drug

• Mail-Order Services

• Pharmacy Locator

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

Definitions See the GLOSSARY section.

Defined terms are in bold in your booklet

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

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

CUSTOMER SERVICE

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

Website

Provider Directory www.bcbstx.com

Identification Card www.bcbstx.com

For Medical Appeals Send via mail

Mailing Address for Non-Behavioral Health

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

Dallas, TX 75266-0044 for Behavioral Health/Mental Health/Substance Use Disorder Treatment

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

Dallas, TX 75266-0044

BLUECARD® NATIONWIDE/WORLDWIDE COVERAGE PROGRAM

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

MDLIVE®

1-888-684-4233

Prescription Drug Benefits Call Website Mailing Address

Pharmacy Benefit Manager

(PBM)

Prime Therapeutics

See Pharmacy Customer Service telephone number on the back of your identification card www.bcbstx.com

Prime Therapeutics LLC PO Box 25136

Lehigh Valley, PA 18002-

Where to Mail Completed Claim Forms:

For Medical Claims Prescription Drug Claims

Blue Cross and Blue Shield of Texas Claims Division

PO Box 660044 Dallas, TX 75266-0044

Prime Therapeutics LLC PO Box 25136

Lehigh Valley, PA 18002-5136

Medical Benefits Call Website

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

Wellness Other Online Services and Information

Prior Authorization for Behavioral Health and for Non-Behavioral Health

See telephone number on the back of your identification card

Inpatient Admissions for Behavioral Health and for Non-Behavioral Health

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

TX-G-P-LG-SOB-0126(b)

SUMMARY OF BENEFITS

PPO $1,600 Deductible Plan BlueChoice PPOSM Network

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

How cost sharing works:

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

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

• Your benefit period is a period of one year beginning on January 1 of each year. When you first enroll under this plan, your coverage begins on the date shown above and ends on the first day of the month the following year. For example 01-01-2026 to 12-31-2026.

Benefit Period Calendar year

Deductible In-Network Providers Out-of-Network Providers

Individual $1,600 $2,250

Family $3,200 $4,500

• Three-month deductible carryover applies

• Out-of-network deductible amounts will be applied toward meeting the in-network deductible

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

Individual $4,000 Unlimited

Family $8,000 Unlimited

• Out-of-network out -of-pocket maximum amounts will be applied toward meeting the in-network out-of-pocket maximum

Please review the COVERED SERVICES section of your benefit booklet for additional information about the covered services listed below.

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

Allergy Injections

Description In-Network

You Pay Out-of-Network

You Pay

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

Ambulance Services Description You Pay

Air Ambulance 20% coinsurance after deductible

Ground Ambulance 20% coinsurance after deductible

Bariatric Surgery

Description In-Network

You Pay Out-of-Network

You Pay

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

Behavioral Health Services (Mental Health/Substance Use Disorder)

In-Network

You Pay Out-of-Network

You Pay

Office Visit $30 copay then No charge deductible does not apply

40% coinsurance after deductible

Virtual Visit $30 copay then No charge deductible does not apply

Not covered

Outpatient Facility Services 20% coinsurance after deductible 40% coinsurance after deductible

Outpatient Physician Services 20% coinsurance after deductible 40% coinsurance after deductible

Inpatient Facility Services 20% coinsurance after deductible 40% coinsurance after deductible

Inpatient Physician Services 20% coinsurance after deductible 40% coinsurance after deductible

Chiropractic Care

In-Network

You Pay Out-of-Network

You Pay

Office Visit $30 copay then No charge deductible does not apply

40% coinsurance after deductible

Limits 35 visits each benefit period

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

Durable Medical Equipment (DME)

In-Network

You Pay Out-of-Network

You Pay

DME 20% coinsurance after deductible 40% coinsurance after deductible

Emergency & Non-Emergency Services

Description In-Network

You Pay Out-of-Network

You Pay

Emergency Care Facility Charges 20% coinsurance after deductible

Emergency Care Physician Charges

20% coinsurance after deductible

Non-Emergency Care Facility Charges

20% coinsurance after deductible 40% coinsurance after deductible

Non-Emergency Care Physician Charges

20% coinsurance after deductible 40% coinsurance after deductible

• Excluding certain diagnostic procedures

Hearing Aids

In-Network

You Pay Out-of-Network

You Pay

Hearing Aids 20% coinsurance after deductible 40% coinsurance after deductible

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

Home Health Care

In-Network

You Pay Out-of-Network

You Pay

Home Health Care 20% coinsurance deductible does not apply 40% coinsurance after deductible

Limits 60 days each benefit period

Hospice Care

In-Network

You Pay Out-of-Network

You Pay

Hospice Services 20% coinsurance deductible does not apply 40% coinsurance after deductible

Limits Unlimited

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

Infusion Therapy

In-Network

You Pay Out-of-Network

Home Infusion Therapy 20% coinsurance after deductible 40% coinsurance after deductible

Inpatient Hospital Services

In-Network

You Pay Out-of-Network

You Pay

Inpatient Facility Services 20% coinsurance after deductible 40% coinsurance after deductible

Inpatient Physician Services 20% coinsurance after deductible 40% coinsurance after deductible

• Certain services will require prior authorization

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

• Includes treatment of behavioral health services

Maternity Services

Description In-Network

You Pay Out-of-Network

You Pay

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

Maternity Related Newborn Care Covered based on type of service and where it is received Covered based on type of service and where it is received

Prior Authorization

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

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

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

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

Maternity care is globally billed meaning:

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

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

Occupational Therapy Services

In-Network

You Pay Out-of-Network

You Pay

Office Visit $30 copay then No charge deductible does not apply

40% coinsurance after deductible

Occupational Therapy Performed in the office

20% coinsurance after deductible 40% coinsurance after deductible

Occupational Therapy Performed in an outpatient setting

20% coinsurance after deductible 40% coinsurance after deductible

Limits 35 visits each benefit period

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

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

Outpatient Hospital Services

In-Network

You Pay Out-of-Network

You Pay

Outpatient Facility Services 20% coinsurance after deductible 40% coinsurance after deductible

Outpatient Physician Services 20% coinsurance after deductible 40% coinsurance after deductible

Lab & X-ray Services Performed in an outpatient setting

$30 copay then No charge deductible does not apply

40% coinsurance after deductible

Advanced Imaging Services Performed in an outpatient setting

20% coinsurance after deductible 40% coinsurance after deductible

Penalty for Failure to Obtain Prior Authorization

For outpatient services None $250

• Certain services will require prior authorization

• Advanced Imaging Services includes bone scan, cardiac stress test, CT, MRI, myelogram, and PET scans

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

Physical Therapy Services

In-Network

You Pay Out-of-Network

You Pay

Office Visit $30 copay then No charge deductible does not apply

40% coinsurance after deductible

Physical Therapy Performed in the office

20% coinsurance after deductible 40% coinsurance after deductible

Physical Therapy Performed in an outpatient setting

20% coinsurance after deductible 40% coinsurance after deductible

Limits 35 visits each benefit period

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

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

Physician and Specialist Services

In-Network

You Pay Out-of-Network

You Pay

Primary Care Office Visit or Consultation

$30 copay then No charge deductible does not apply

40% coinsurance after deductible

Retail Health Clinic Visit $30 copay then No charge deductible does not apply

40% coinsurance after deductible

Specialty (Specialist) Office Visit or Consultation

$30 copay then No charge deductible does not apply

40% coinsurance after deductible

Virtual Visit $30 copay then No charge deductible does not apply

Not covered

Diagnostic Services Performed in a physician’s office

$30 copay then No charge deductible does not apply

40% coinsurance after deductible

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

20% coinsurance after deductible 40% coinsurance after deductible

Advanced Imaging Services Performed in a physician’s office

20% coinsurance after deductible 40% coinsurance after deductible

Surgical Procedures Performed in a physician’s office

20% coinsurance after deductible 40% coinsurance after deductible

All Other Covered Services Not Otherwise Noted

20% coinsurance after deductible 40% coinsurance after deductible

• Includes treatment of behavioral health services

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

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

• Advanced Imaging Services includes bone scan, cardiac stress test, CT, MRI, myelogram, and PET scans

Preventive Care Services

In-Network

You Pay Out-of-Network

Preventive Care Services No charge 40% coinsurance after deductible

Skilled Nursing Facility

In-Network

You Pay Out-of-Network

You Pay

Skilled Nursing Facility 20% coinsurance deductible does not apply 40% coinsurance after deductible

Limits 60 days each benefit period

Speech Therapy

In-Network

You Pay Out-of-Network

You Pay

Speech Therapy Performed in the office

20% coinsurance after deductible 40% coinsurance after deductible

Speech Therapy Performed in an outpatient setting

20% coinsurance after deductible 40% coinsurance after deductible

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

Surgery

In-Network

You Pay Out-of-Network

You Pay

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

Transplant Services (Organ and Tissue Transplants)

In-Network

You Pay Out-of-Network

Organ and Tissue Transplants 20% coinsurance after deductible 40% coinsurance after deductible

Urgent Care

In-Network

You Pay Out-of-Network

You Pay

Urgent Care Center Visit $50 copay then No charge deductible does not apply

40% coinsurance after deductible

• Includes lab & x-ray services

• Excludes certain diagnostic procedures.

Prior Authorization Penalty

In-Network

You Pay Out-of-Network

You Pay

Inpatient Admissions None None

Outpatient Services None $250

TX-G-P-LG-RXSOB-0126(b)

SUMMARY OF BENEFITS

FOR PHARMACY BENEFITS

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

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

• Pharmacy out-of-pocket maximums

• How copayment and/coinsurance amounts apply

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

• Prior authorizations

• Limitations and exclusions

Your plan does not include a separate pharmacy deductible or. Your prescription drugs apply to the medical deductible and.

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

Maximum Participating Pharmacies Non-Participating Pharmacies

Individual $1,000 Unlimited

Family $2,000 Unlimited

Retail Pharmacy Cost Share

Retail Pharmacy Program Participating Pharmacy

You Pay

Non-Participating Retail Pharmacy

You Pay

Tier 1 $5 copay deductible does not apply $5 copay plus 40% penalty deductible does not apply

Tier 2 $35 copay deductible does not apply $35 copay plus 40% penalty deductible does not apply

Tier 3 $60 copay deductible does not apply $60 copay plus 40% penalty deductible does not apply

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

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

PHARMACY BENEFITS section of your benefit booklet for details.

• One copayment per 30-day supply, no more than a 90-day supply

Extended Prescription Drug Supply Program

Extended Prescription Drug Supply Program

Quantity Dispensed

Participating Extended Supply Pharmacy

You Pay

Non-Participating Extended Supply

Pharmacy You Pay

Tier 1

1 to 30 days $5 copay deductible does not apply Not covered

31 to 60 days $10 copay deductible does not apply Not covered

61 to 90 days $15 copay deductible does not apply Not covered

Tier 2

1 to 30 days $35 copay deductible does not apply Not covered

31 to 60 days $70 copay deductible does not apply Not covered

61 to 90 days $105 copay deductible does not apply Not covered

Tier 3

1 to 30 days $60 copay deductible does not apply Not covered

31 to 60 days $120 copay deductible does not apply Not covered

61 to 90 days $180 copay deductible does not apply Not covered

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

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

PHARMACY BENEFITS section of your benefit booklet for details.

• Up to a 90-day supply

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

Mail-Order Pharmacy Program

Mail-Order Pharmacy Program

Quantity Dispensed

Participating Mail-Order Pharmacy You Pay

Any Pharmacy other than the Participating Mail-Order Pharmacy

You Pay

Tier 1

1 to 30 days $5 copay deductible does not apply Not covered

31 to 60 days $10 copay deductible does not apply Not covered

61 to 90 days $15 copay deductible does not apply Not covered

Tier 2

1 to 30 days $35 copay deductible does not apply Not covered

31 to 60 days $70 copay deductible does not apply Not covered

61 to 90 days $105 copay deductible does not apply Not covered

Tier 3

1 to 30 days $60 copay deductible does not apply Not covered

31 to 60 days $120 copay deductible does not apply Not covered

61 to 90 days $180 copay deductible does not apply Not covered

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

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

PHARMACY BENEFITS section of your benefit booklet for details.

• Up to a 90-day supply

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

Specialty Pharmacy Program

Specialty Pharmacy Program (30-Day Supply)

Specialty Network Pharmacy

You Pay

Any Pharmacy other than a Specialty Network Pharmacy

You Pay

Tier 4 $60 copay deductible does not apply $60 copay plus 40% penalty deductible does not apply

Tier 5 $150 copay deductible does not apply $150 copay plus 40% penalty deductible does not apply

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

• One copayment amount per 30 day supply – limited to a 30 day supply

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

Vaccines

Select Vaccines Obtained through Pharmacies

Pharmacy Vaccine Network Pharmacy You Pay

Other Pharmacy You Pay

Covered Vaccine(s) - $0 Copay Not covered

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

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

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

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

Select covered drugs, determined by BCBSTX, may be available at no cost, to make these medications more affordable to participants.

TX-G-P-LG-COC-0126(b) 1

INTRODUCTION

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

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

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

In-Network Benefits

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

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

Out-of-Network Benefits

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

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

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

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

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

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

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

TX-G-P-LG-COC-0126(b) 2

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

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

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

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

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

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

TX-G-P-LG-COC-0126(b) 3

GLOSSARY

Advanced Imaging Services means the specialized imaging tests used to visualize internal structures and functions of the body. This includes:

• Bone Scan

• Cardiac Stress Test

• Computerized tomography (CT scan)

• Magnetic resonance imaging (MRI)

• Myelogram

• Positron emission tomography (PET scan)

Allowable Amount means the maximum amount determined by us to be eligible for consideration of payment for a particular service, supply, or procedure.

• For hospitals and facility other providers, physicians, and professional other providers contracting with us in Texas or any other Blue Cross and Blue Shield Plan – The allowable amount is based on the terms of the provider contract and the payment methodology in effect on the date of service. The payment methodology used may include diagnosis-related groups (DRG), fee schedule, package pricing, global pricing, per diems, case-rates, discounts, or other payment methodologies.

• For hospitals and facility other providers, physicians, professional other providers, and any other provider not contracting with us in Texas or any other Blue Cross and Blue Shield Plan outside of Texas (non-contracting allowable amount) – The allowable amount will be the lesser of:

o The provider's billed charges o Our non-contracting allowable amount

Except as otherwise provided in this section, the non-contracting allowable amount is developed from base Medicare participating reimbursements adjusted by a predetermined factor established by us. Such factor shall be not less than 75% and will exclude any Medicare adjustment(s) which is/are based on information on the claim.

Notwithstanding the preceding sentence, the non-contracting allowable amount for home health care is developed from base Medicare national per visit amounts for low utilization payment adjustment, or LUPA, episodes by home health discipline type adjusted for duration and adjusted by a predetermined factor established by us. Such factor shall be not less than 75% and shall be updated on a periodic basis.

When a Medicare reimbursement rate is not available or is unable to be determined based on the information submitted on the claim, the allowable amount for non-contracting providers will represent an average contract rate in aggregate for in-network providers adjusted by a predetermined factor established by us. Such factor shall be not less than 75% and shall be updated not less than every two years.

We will utilize the same standard claim processing rules and/or edits that it utilizes in processing standard in-network provider claims for processing claims submitted by non-contracted

TX-G-P-LG-COC-0126(b) 4 providers which may also alter the allowable amount for a particular service. In the event we do not have any claim edits or rules, we may utilize the Medicare claim rules or edits that are used by Medicare in processing the claims. The allowable amount will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific claim, including, but not limited to, disproportionate share and graduate medical education payments.

Any change to the Medicare reimbursement amount will be implemented by us within ninety

(90) days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor.

The non-contracting allowable amount does not equate to the provider’s billed charges and participants receiving services from a non-contracted provider will be responsible for the difference between the non-contracting allowable amount and the non-contracted provider’s billed charge, and this difference may be considerable. To find out our non-contracting allowable amount for a particular service, you may call Customer Service at the number on the back of your identification card.

Notwithstanding the above, where applicable state or federal law requires another standard for a non-contracting claim, the allowable amount shall be the lessor of billed charge or the amount prescribed by law.

• For multiple surgeries – The allowable amount for all surgical procedures performed on the same patient on the same day will be the amount for the single procedure with the highest allowable amount plus a determined percentage of the allowable amount for each of the other covered procedures performed.

• For procedures, services, or supplies provided to Medicare recipients – The allowable amount will not exceed Medicare’s limiting charge.

• For covered drugs as applied to participating and non-participating pharmacies – The allowable amount for participating pharmacies and the mail-order program will be based on the provisions of the contract between us and the participating pharmacy or pharmacy for the mail-order program in effect on the date of service. The allowable amount for non-participating pharmacies will be based on the participating pharmacy contract rate.

• For non-emergency medical care provided by an out-of-network provider when a contracting provider is not reasonably available as defined by applicable law or when services are preapproved or have received prior authorization based upon the unavailability of an in-network provider and balance billing is not prohibited by Texas or Federal law – The allowable amount will be our usual and customary rate as defined by Texas law or as prescribed under applicable law and regulations, or at a rate agreed to between us and the out-of-network provider, not to exceed billed charges.

• For out-of-network emergency medical care, care provided by an out-of-network facility-based provider in an in-network hospital, ambulatory surgery center or birthing center, or services provided by an out-of-network laboratory or diagnostic imaging service in connection with care

TX-G-P-LG-COC-0126(b) 5 delivered by an in-network provider – The allowable amount will be our usual and customary rate or at a rate agreed to between us and the out-of-network provider as prescribed by the Texas Insurance Code, not to exceed billed charges. Our usual and customary rate will be based upon our rate information for the same or similar services. The usual and customary rate shall not be less than the non-contracting allowable amount as defined in this benefit booklet.

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

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

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

Benefit Booklet means the booklet (and any amendments to such booklet) issued by Blue Cross Blue Shield of Texas that describes the Plan’s benefits, terms, conditions, limitations, and exclusions, Schedules of Benefits, and any Riders.

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 obligations from generic to brand name.

Brand Name Drug (Non-Preferred) means a brand name drug which appears on the applicable drug list as a non-preferred brand name drug. You can access this drug list at www.bcbstx.com.

Brand Name Drug (Preferred) means a brand name drug which appears on the drug list as a preferred brand name drug. This list is available by accessing the website at www.bcbstx.com.

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

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

Contract means your employer issued group benefits contract.

TX-G-P-LG-COC-0126(b) 6

Contract Date means the corresponding date in each year after the contract effective date for as long as the contract is in force.

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

Covered Drugs 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

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

• For which the 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 (refer to Limitations and Exclusions)

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 mean a service or supply shown in this certificate for which benefits will be provided.

Custodial Care means any service primarily for personal comfort for convenience that provides general maintenance, preventive, and/or protective care without any clinical likelihood of improvement of your condition. Custodial care services also means those services which do not require the technical skills, professional training and clinical assessment ability of medical and/or nursing personnel to be safely and effectively performed. These services can be safely provided by trained or capable non-professional personnel, are to assist with routine medical needs (e.g., simple care and dressings, administration of routine drugs, etc.) and are to assist with activities of daily living (e.g., bathing, eating, dressing, etc.).

Deductible means the amount, if any, you must pay before we start paying contract benefits. You do not send this amount to us. We subtract this amount from covered expenses on claims you and health care professionals send us. Some services can be covered before the deductible is met. Refer to your SUMMARY OF BENEFITS for any deductibles applicable to your coverage.

Dependent means your spouse or any child covered under the plan.

• Child means a:

o Natural child o A stepchild o A foster child o A grandchild who is your dependent for federal income tax purposes at the time application for coverage of the child is made o An adopted child including those placed with you for adoption (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)

• A child must also be under twenty-six (26) years of age, regardless of:

TX-G-P-LG-COC-0126(b) 7 o Financial dependency o Residency o Student status o Employment status o Marital status

A dependent can also be a child of any age who is medically certified as disabled and dependent upon you or your spouse.

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

• Diet

• Regulation or management of diet or

• The assessment or management of nutrition

Disabled means any medically determinable physical or mental condition that prevents the child from engaging in self-sustaining employment. The disability must begin while the child is covered under the plan and before the child reaches the limiting age. You must give satisfactory proof of the disability and dependency through your employer to us within 31 days following the child’s attainment of the limiting age. As a condition to the continued coverage of a child as a disabled dependent beyond the limiting age, we may require periodic certification of the child’s physical or mental condition but not more often than annually after the two-year period following the child’s attainment of the limiting age.

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 toll-free number on your identification card for more information.

Effective Date means the date the coverage for a participant begins.

Eligible Employee means an employee who works on a full-time basis, who usually works at least 30 hours a week, and who otherwise meets the participation criteria established by a large employer. The term includes a sole proprietor, a partner, and an independent contractor, if the individual is included as an employee under a health benefit plan of a large employer regardless of the number of hours the sole proprietor, partner, or independent contractor works weekly, but only if the plan includes at least two other eligible employees who work on a full-time basis and who usually work at least 30 hours a week.

Participation criteria means any criteria or rules established by a large employer to determine the employees who are eligible for enrollment or continued enrollment under the terms of a health benefit plan. The participation criteria may not be based on health status related factors.

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

• Placing the patient’s health in serious jeopardy

• Serious impairment of bodily functions

TX-G-P-LG-COC-0126(b) 8

• Serious dysfunction of any bodily organ or part

• Serious disfigurement; or

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

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

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

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 us in assessing experimental/investigational status but will not be determinative.

As used herein, medical treatment includes medical, surgical, or dental treatment.

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

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

• Are appropriate for the hospital or other provider in which they were performed.

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

The medical staff of BCBSTX shall determine whether any treatment, procedure, facility, equipment, drug, device, new or 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 physician or other professional provider may have prescribed treatment, and the services or supplies may have been provided as the treatment of last resort, we still may determine such services or supplies 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

TX-G-P-LG-COC-0126(b) 9 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 us.

Health Status Related Factor means:

• Health status

• Medical condition, including both physical and mental health

• Claims experience

• Receipt of health care

• Medical history

• Genetic information

• Evidence of insurability, including conditions arising out of acts of family violence

• Disability

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 diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of physicians or behavioral health providers for compensation from its patients

• Has organized departments of medicine and major surgery, either on its premises or in facilities available to the hospital on a contractual prearranged basis, and maintains clinical records on all patients

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

• Has in effect a hospital utilization review plan

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

Intensive Outpatient Program means a freestanding or hospital-based program that provides services for at least 3 hours per day, 2 or more days per week, to treat mental health or substance use disorder or specializes in the treatment of co-occurring mental health conditions and substance use disorder.

Program Requirements:

• Our claims administrator requires that any mental health and/or substance use disorder intensive outpatient program must be licensed in the state where it is located, or accredited by a national organization that is recognized by our claims administrator, as set forth in the current

TX-G-P-LG-COC-0126(b) 10 credentialing policy, and otherwise meets all other credentialing requirements set…