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Summary of Benefits and Coverage What this Plan Covers What You Pay for Covered Services MTBEE035 Blue EssentialsSM 035 CCoovveerraaggeePPeerrioiodd 0110 0 10 12 0220323 1029 3310 22002234 CovCeoravgereafgoer foInr dIinvdidivuidaul al FFaammiillyy PPllaann TTyyppee HHMMOO 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 1 877 299 2377 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 Generally you must pay all of the costs from providers up to the deductible amount before this plan 4 000 Individual 12 000 Family begins to pay If you have other family members on the plan each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members 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 services Yes ER 500 There are no other You must pay all of the costs for these services up to the specific deductible amount before this plan specific deductibles begins to pay for these services What is the out of pocket limit for this plan 8 150 Individual 16 300 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 This plan uses a provider network You will pay less if you use a provider in the plan s network You Will you pay less if you use a network provider Yes See www bcbstx com go be will pay the most if you use an out of network provider and you might receive a bill from a provider or call 1 877 299 2377 for a list of for the difference between the provider s charge and what your plan pays balance billing Be aware Participating Providers 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 Yes This plan will pay some or all of the costs to see a specialist for covered services but only if you see a specialist have a referral before you see the specialist SLMR MTBEE0352023E01012023 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 7

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 If you have a test Diagnostic test x ray blood work Imaging CT PET scans MRIs Preferred generic drugs 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 Non preferred generic drugs Preferred brand drugs What You Will Pay Participating Provider You will pay the least Non Participating Provider You will pay the most 35 visit deductible does not apply Not Covered 70 visit deductible does not apply Not Covered No Charge deductible does not apply Not Covered 20 coinsurance Not Covered 20 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 Preferred 50 prescription Non Preferred 70 prescription Mail 150 prescription deductible does not apply Not Covered Not Covered Not Covered Not Covered Limitations Exceptions Other Important Information Virtual visits are available See your benefit booklet for details Referral required 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 None 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 Cost sharing for insulin included in the drug list will not exceed 25 per prescription for a 30day supply regardless of the amount or type of insulin needed to fill the prescription For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 2 of 7

Common Medical Event Services You May Need Non preferred brand drugs Preferred specialty drugs Non preferred specialty drugs What You Will Pay Participating Provider You will pay the least Non Participating Provider You will pay the most Retail Preferred 100 prescription Non Preferred 120 prescription Not Covered Mail 300 prescription deductible does not apply 150 prescription deductible does not apply Not Covered 250 prescription deductible does not apply Not Covered Limitations Exceptions Other Important Information If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health behavioral health or substance abuse services Facility fee e g ambulatory surgery center Physician surgeon fees Emergency room care Emergency medical transportation Urgent care Facility fee e g hospital room Physician surgeon fees Outpatient services Inpatient services 20 coinsurance 20 coinsurance 500 visit plus 20 coinsurance 20 coinsurance 75 visit deductible does not apply 20 coinsurance 20 coinsurance 35 office visit or 20 coinsurance for other outpatient services 20 coinsurance Not Covered Not Covered 500 visit plus 20 coinsurance 20 coinsurance Not Covered Not Covered Not Covered Not Covered Not Covered For Outpatient Infusion Therapy see your benefit booklet for details Per Occurrence Deductible waived if admitted None None None None Primary Care 35 initial Copayment applies to first prenatal visit per If you are pregnant Office visits visit Specialist 70 initial visit deductible does not apply Not Covered pregnancy Cost sharing does not apply to certain preventive services Depending on the type of services coinsurance may apply For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 3 of 7

Common Medical Event Services You May Need If you need help recovering or have other special health needs If your child needs dental or eye care Childbirth delivery professional services Childbirth delivery facility services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services Children s eye exam Children s glasses Children s dental check up What You Will Pay Participating Provider You will pay the least Non Participating Provider You will pay the most 20 coinsurance Not Covered 20 coinsurance Not Covered 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance 20 coinsurance Primary Care 35 Specialist 70 deductible does not apply Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Limitations Exceptions Other Important Information Maternity care may include tests and services described elsewhere in the SBC i e ultrasound None None 60 day maximum per calendar year None None Eye screenings only Does not include refractions One visit per year for members ages 17 and younger None For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 4 of 7

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 Children s dental check up Children s glasses Cosmetic surgery Dental care Adult Long term care Non emergency care when traveling outside the U S 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 Preauthorization required Hearing aids Limited to one hearing aid per ear every 36 months Infertility treatment Invitro not covered Private duty nursing Only when ordered or authorized by the Primary Care Physician Routine eye care Adult One visit every two years for members ages 18 and older 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 1 877 299 2377 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 1 877 299 2377 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 1 877 299 2377 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 Page 5 of 7

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 Language Access Services Spanish Espa ol Para obtener asistencia en Espa ol llame al 1 877 299 2377 Tagalog Tagalog Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1 877 299 2377 Chinese 1 877 299 2377 Navajo Dine Dinek ehgo shika at ohwol ninisingo kwiijigo holne 1 877 299 2377 To see examples of how this plan might cover costs for a sample medical situation see the next section Page 6 of 7

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 4 000 70 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 4 000 40 1 700 60 5 800 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 4 000 70 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 5 600 900 700 0 20 1 620 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 4 000 70 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 2 100 600 0 0 2 700 The plan would be responsible for the other costs of these EXAMPLE covered services Page 7 of 7

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