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Summary of Benefits and Coverage What this Plan Covers What You Pay for Covered Services MTBCP019 Blue Choice PPOSM 019 CCoovveerraaggeePPeerrioiodd 0110 0 10 12 0220323 1029 3310 22002234 CovCeoravgereafgoer foInr dIinvdidivuidaul al FFaammiillyy PPllaann TTyyppee PPPPOO The Summary of Benefits and Coverage SBC document will help you choose a health plan The SBC shows you how you and the plan would share the cost for covered health care services NOTE Information about the cost of this plan called the premium will be provided separately This is only a summary For more information about your coverage or to get a copy of the complete terms of coverage visit www bcbstx com member policy forms 2023 or by calling 1 800 521 2227 For general definitions of common terms such as allowed amount balance billing coinsurance copayment deductible provider or other underlined terms see the Glossary You can view the Glossary at www healthcare gov sbc glossary or call 1 855 756 4448 to request a copy Important Questions Answers Why This Matters What is the overall deductible Network 2 000 Individual 6 000 Generally you must pay all of the costs from providers up to the deductible amount before this plan Family begins to pay If you have other family members on the plan each family member must meet their Out of Network 4 000 own individual deductible until the total amount of deductible expenses paid by all family members Individual 12 000 Family meets the overall family deductible Are there services covered before you meet your deductible Yes Network office visits prescription drugs and preventive care services are covered before you meet your deductible This plan covers some items and services even if you haven t yet met the deductible amount But a copayment or coinsurance may apply For example this plan covers certain preventive services without cost sharing and before you meet your deductible See a list of covered preventive services at www healthcare gov coverage preventive care benefits Are there other deductibles for specific No services You don t have to meet deductibles for specific services Network 5 000 What is the out of pocket Individual 14 700 Family limit for this plan Out of Network Unlimited Individual Unlimited Family The out of pocket limit is the most you could pay in a year for covered services If you have other family members in this plan they have to meet their own out of pocket limits until the overall family out of pocket limit has been met What is not included in the out of pocket limit Premiums balance billed charges and health care this plan doesn t Even though you pay these expenses they don t count toward the out of pocket limit cover Will you pay less if you use a network provider Yes See www bcbstx com go bcppo or call 1 800 810 2583 for a list of network providers This plan uses a provider network You will pay less if you use a provider in the plan s network You will pay the most if you use an out of network provider and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays balance billing Be aware your network provider might use an out of network provider for some services such as lab work Check with your provider before you get services Do you need a referral to No see a specialist You can see the specialist you choose without a referral SLMR MTBCP0192023E01012023 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 Page 1 of 8

All copayment and coinsurance costs shown in this chart are after your deductible has been met if a deductible applies Common Medical Event Services You May Need Primary care visit to treat an injury or illness If you visit a health care provider s office or clinic Specialist visit Preventive care screening immunization Diagnostic test x ray blood work If you have a test Imaging CT PET scans MRIs If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www bcbstx com rxdrugs drug lists drug lists Preferred generic drugs Non preferred generic drugs What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most 30 visit deductible does not apply 40 coinsurance 60 visit deductible does not apply 40 coinsurance No Charge deductible does not apply 40 coinsurance No Charge deductible does not apply 40 coinsurance 20 coinsurance 40 coinsurance Retail Preferred No Charge Non Preferred 10 prescription Mail No Charge deductible does not apply Retail Preferred 10 prescription Non Preferred 20 prescription Mail 30 prescription deductible does not apply Retail 10 prescription deductible does not apply plus 50 additional charge Retail 20 prescription deductible does not apply plus 50 additional charge Limitations Exceptions Other Important Information Virtual visits are available See your benefit booklet for details None You may have to pay for services that aren t preventive Ask your provider if the services needed are preventive Then check what your plan will pay for Inpatient Certain services may require Preauthorization for out of network failure to preauthorize may result in 250 reduction in benefits Outpatient Certain services may require Preauthorization for out of network failure to preauthorize may result in 50 reduction in benefits not to exceed 500 see your benefit booklet for details Limited to a 30 day supply at retail or a 90 day supply at a network of select retail pharmacies Up to a 90 day supply at mail order Specialty drugs limited to a 30 day supply Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available Additional charge will not apply to any deductible or out of pocket amounts Cost sharing for insulin included in the drug list will not exceed 25 per prescription for a 30 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 2 of 8

Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Preferred brand drugs Non preferred brand drugs Preferred specialty drugs Non preferred specialty drugs Facility fee e g ambulatory surgery center Physician surgeon fees Emergency room care Emergency medical transportation Urgent care Facility fee e g hospital room What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most Retail Preferred 50 prescription Non Preferred 70 prescription Mail 150 prescription deductible does not apply Retail 70 prescription deductible does not apply plus 50 additional charge Retail Preferred 100 prescription Non Preferred 120 prescription Mail 300 prescription deductible does not apply Retail 120 prescription deductible does not apply plus 50 additional charge 150 prescription deductible does not apply 150 prescription deductible does not apply plus 50 additional charge 250 prescription deductible does not apply 250 prescription deductible does not apply plus 50 additional charge 20 coinsurance 40 coinsurance 20 coinsurance 500 visit plus 20 coinsurance 40 coinsurance 500 visit plus 20 coinsurance 20 coinsurance 20 coinsurance 75 visit deductible does not apply 20 coinsurance 40 coinsurance 40 coinsurance Limitations Exceptions Other Important Information day supply regardless of the amount or type of insulin needed to fill the prescription Certain services may require preauthorization for out of network failure to preauthorize may result in 50 reduction in benefits not to exceed 500 For Outpatient Infusion Therapy see your benefit booklet for details Copayment waived if admitted None Preauthorization required Preauthorization penalty 250 out of network See your benefit For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 3 of 8

Common Medical Event Services You May Need Physician surgeon fees What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most 20 coinsurance 40 coinsurance Limitations Exceptions Other Important Information booklet for details If you need mental health behavioral health or substance abuse services Outpatient services Inpatient services If you are pregnant Office visits Childbirth delivery professional services Childbirth delivery facility services 30 office visit or 20 coinsurance for other outpatient services 40 coinsurance 20 coinsurance 40 coinsurance Primary Care 30 initial visit Specialist 60 initial visit deductible does not apply 20 coinsurance 40 coinsurance 40 coinsurance 20 coinsurance 40 coinsurance Home health care 20 coinsurance 40 coinsurance If you need help recovering or have other special health needs Rehabilitation services Habilitation services Skilled nursing care 20 coinsurance 20 coinsurance 20 coinsurance 40 coinsurance 40 coinsurance 40 coinsurance Durable medical equipment Hospice services 20 coinsurance No Charge deductible does not apply 40 coinsurance 40 coinsurance Certain services must be preauthorized failure to preauthorize at least two business days prior to service will result in 50 reduction in benefits not to exceed 500 refer to benefit booklet for details Preauthorization required out of network failure to preauthorize at least two business days prior to admission will result in 250 reduction in benefits Copayment applies to first prenatal visit per pregnancy Cost sharing does not apply to certain preventive services Depending on the type of services coinsurance may apply Maternity care may include tests and services described elsewhere in the SBC i e ultrasound 60 visits year Preauthorization may be required for out of network Failure to preauthorize may result in 50 reduction in benefits not to exceed 500 See your benefit booklet for details For Outpatient limited to combined 35 visits per year including Chiropractic 25 day maximum per calendar year Preauthorization may be required for out ofnetwork Failure to preauthorize may result in 250 reduction in benefits See your benefit booklet for details 60 day maximum per calendar year None Inpatient Preauthorization may be required for out of network failure to preauthorize may For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 4 of 8

Common Medical Event Services You May Need If your child needs dental or eye care Children s eye exam Children s glasses Children s dental check up What You Will Pay Network Provider Out of Network Provider You will pay the least You will pay the most Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Limitations Exceptions Other Important Information result in a 250 reduction in benefits Outpatient Preauthorization may be required for out of network failure to preauthorize may result in 50 reduction in benefits not to exceed 500 See your benefit booklet for details None None For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 5 of 8

Excluded Services Other Covered Services Services Your Plan Generally Does NOT Cover Check your policy or plan document for more information and a list of any other excluded services Abortion Except for a pregnancy that as certified by a physician places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed Acupuncture Bariatric surgery Cosmetic surgery Dental care Adult and Child Long term care Non emergency care when traveling outside the U S Private duty nursing Routine eye care Child Weight loss programs Other Covered Services Limitations may apply to these services This isn t a complete list Please see your plan document Chiropractic care Outpatient Max 35 visits year combined with habilitation and rehabilitation services Hearing aids Limited to one hearing aid per ear every 36 months Infertility treatment Invitro and artificial insemination are not covered unless shown in your plan document Routine eye care Adult Routine foot care Only covered in connection with diabetes circulatory disorders of the lower extremities peripheral vascular disease peripheral neuropathy or chronic arterial or venous insufficiency Your Rights to Continue Coverage There are agencies that can help if you want to continue your coverage after it ends The contact information for those agencies is For group health coverage contact the plan Blue Cross and Blue Shield of Texas at 1 800 521 2227 or visit www bcbstx com For group health coverage subject to ERISA contact the U S Department of Labor s Employee Benefits Security Administration at 1 866 444 EBSA 3272 or www dol gov ebsa healthreform For non federal governmental group health plans contact Department of Health and Human Services Center for Consumer Information and Insurance Oversight at 1 877 267 2323 x61565 or www cciio cms gov Church plans are not covered by the Federal COBRA continuation coverage rules If the coverage is insured individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law Other coverage options may be available to you too including buying individual insurance coverage through the Health Insurance Marketplace For more information about the Marketplace visit www HealthCare gov or call 1 800 318 2596 Your Grievance and Appeals Rights There are agencies that can help if you have a complaint against your plan for a denial of a claim This complaint is called a grievance or appeal For more information about your rights look at the explanation of benefits you will receive for that medical claim Your plan documents also provide complete information to submit a claim appeal or a grievance for any reason to your plan For more information about your rights this notice or assistance contact For group health coverage subject to ERISA Blue Cross and Blue Shield of Texas at 1 800 521 2227 or visit www bcbstx com the U S Department of Labor s Employee Benefits Security Administration at 1 866 444 EBSA 3272 or www dol gov ebsa healthreform and the Texas Department of Insurance Consumer Protection at 1 800 252 3439 or www tdi texas gov For non federal governmental group health plans and church plans that are group health plans Blue Cross and Blue Shield of Texas at 1 800 521 2227 or www bcbstx com or contact the Texas Department of Insurance Consumer Protection at 1 800 252 3439 or www tdi texas gov Additionally a consumer assistance program can help you file your appeal Contact the Texas Department of Insurance s Consumer Health Assistance Program at 1 800 252 3439 or visit www cms gov CCIIO Resources Consumer Assistance Grants tx html Does this plan provide Minimum Essential Coverage Yes Minimum Essential Coverage generally includes plans health insurance available through the Marketplace or other individual market policies Medicare Medicaid CHIP TRICARE and certain other coverage If you are eligible for certain types of Minimum Essential Coverage you may not be eligible for the premium tax credit Does this plan meet the Minimum Value Standards Yes If your plan doesn t meet the Minimum Value Standards you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace Page 6 of 8

Language Access Services Spanish Espa ol Para obtener asistencia en Espa ol llame al 1 800 521 2227 Tagalog Tagalog Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1 800 521 2227 Chinese 1 800 521 2227 Navajo Dine Dinek ehgo shika at ohwol ninisingo kwiijigo holne 1 800 521 2227 To see examples of how this plan might cover costs for a sample medical situation see the next section Page 7 of 8

About these Coverage Examples This is not a cost estimator Treatments shown are just examples of how this plan might cover medical care Your actual costs will be different depending on the actual care you receive the prices your providers charge and many other factors Focus on the cost sharing amounts deductibles copayments and coinsurance and excluded services under the plan Use this information to compare the portion of costs you might pay under different health plans Please note these coverage examples are based on self only coverage Peg is Having a Baby 9 months of in network pre natal care and a hospital delivery The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 2 000 60 20 20 This EXAMPLE event includes services like Specialist office visits prenatal care Childbirth Delivery Professional Services Childbirth Delivery Facility Services Diagnostic tests ultrasounds and blood work Specialist visit anesthesia Total Example Cost In this example Peg would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Peg would pay is 12 700 2 000 30 1 900 60 3 990 Managing Joe s Type 2 Diabetes a year of routine in network care of a wellcontrolled condition The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 2 000 60 20 20 This EXAMPLE event includes services like Primary care physician office visits including disease education Diagnostic tests blood work Prescription drugs Durable medical equipment glucose meter Total Example Cost In this example Joe would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Joe would pay is 5 600 800 700 0 20 1 520 Mia s Simple Fracture in network emergency room visit and follow up care The plan s overall deductible Specialist copayment Hospital facility coinsurance Other coinsurance 2 000 60 20 20 This EXAMPLE event includes services like Emergency room care including medical supplies Diagnostic test x ray Durable medical equipment crutches Rehabilitation services physical therapy Total Example Cost In this example Mia would pay Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Mia would pay is 2 800 2 000 500 20 0 2 520 The plan would be responsible for the other costs of these EXAMPLE covered services Page 8 of 8

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