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GPSL07BCASTXO2023E01012023 SLMR Summary of Benefits and Coverage What this Plan Covers What You Pay for Covered Services G9L7CHC Blue Choice Gold PPOSM 204 Coverage CoveragePeriod Period 01 01 2023 01 01 2023 112 31 2023 2 31 2023 CovCoverage erage for for IndIndividual Family ividual Family P lan Type Type PPO PPO Plan 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 policyforms 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 What is the overall deductible Answers Network 3 000 Individual 9 000 Family Out of Network 6 000 Individual 18 000 Family Are there services covered Yes In Network Preventive Health before you meet your Care services services with a deductible copayment and prescription drugs are covered before you meet your deductible Are there other deductibles No for specific services What is the out of pocket Network 8 500 Individual 17 000 limit for this plan Family Out of Network Unlimited Individual Unlimited Family What is not included in the Premiums balance billing charges and health care this plan doesn t out of pocket limit cover Will you pay less if you use Yes See www bcbstx com go bcppo or call 1 800 521 2227 for a list of a network provider network providers Do you need a referral to see a specialist No Why This Matters Generally you must pay all of the costs from providers up to the deductible amount before this plan 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 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 You don t have to meet deductibles for specific services 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 ofpocket limit has been met Even though you pay these expenses they don t count toward the out of pocket limit 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 You can see the specialist you choose without a referral 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 What You Will Pay Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Network Providers You will pay the least Limitations Exceptions Other Out of Network Important Information Providers You will pay the most 20 coinsurance Virtual Visits are available See your benefit booklet Your PCP for details Primary care visit to treat an injury or illness Specialist visit Preventive care screening immunization 30 visit deductible does not apply 60 visit deductible does not apply No Charge deductible does not apply 20 coinsurance 20 coinsurance 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 Diagnostic test xray blood work Lab 10 coinsurance X Rays 100 test plus 10 coinsurance 20 coinsurance Imaging CT PET scans MRIs 150 test deductible does not apply 20 coinsurance Preauthorization may be required See your benefit booklet Outpatient Lab and X Ray services for details Preauthorization may be required See your benefit booklet Outpatient Lab and X Ray services for details Preferred generic drugs Retail Preferred Participating No Charge Participating 10 prescription Mail No Charge 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 If you need drugs to treat Non preferred your illness or condition generic drugs More information about prescription drug coverage is available at www bcbstx com rx23 6T Preferred brand drugs Retail Preferred Participating 10 prescription Participating 20 prescription Mail 30 prescription deductible does not apply Retail Preferred Participating 50 prescription Participating 70 prescription Mail 150 prescription deductible does not apply Limited to a 30 day supply at retail or a 90day 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 Out of Network charge will not apply to any deductible or out ofpocket amounts Certain drugs require Retail 70 prescription approval before they will be covered Cost deductible does not apply sharing for insulin included in the drug list will plus 50 additional not exceed 25 per prescription for a 30 day charge 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

What You Will Pay Common Medical Event Services You May Need Network Providers You will pay the least Non preferred brand Retail Preferred Participating drugs 100 prescription Participating 120 prescription Mail 300 prescription deductible does not apply Preferred specialty 150 prescription deductible does not apply drugs If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Limitations Exceptions Other Out of Network Important Information Providers You will pay the most Retail 120 prescription supply regardless of the amount or type of deductible does not apply insulin needed to fill the prescription plus 50 additional charge 150 prescription deductible does not apply plus 50 additional charge 250 prescription deductible does not apply plus 50 additional charge Non preferred specialty drugs 250 prescription deductible does not apply Facility fee e g ambulatory surgery center Physician surgeon fees 250 visit plus 10 coinsurance 300 visit plus 20 coinsurance 10 coinsurance 20 coinsurance Emergency room care 400 visit plus 10 coinsurance 400 visit plus 10 coinsurance Emergency medical 10 coinsurance transportation 10 coinsurance Urgent care 75 visit deductible does not apply 20 coinsurance Facility fee e g hospital room 350 visit plus 10 coinsurance 400 visit plus 20 coinsurance Physician surgeon fees 10 coinsurance 20 coinsurance Preauthorization may be required For Outpatient Infusion Therapy see your benefit booklet Outpatient Facility Services for details Copayment waived if admitted Out ofNetwork cost share is subject to Network deductible Preauthorization may be required for nonemergency transportation see your benefit booklet Ambulance Services for details None Preauthorization required Preauthorization penalty 250 Out of Network See your benefit booklet Inpatient Hospital Services for details Preauthorization required Preauthorization penalty 250 Out of Network See your benefit booklet Inpatient Professional Services for details 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

What You Will Pay Common Medical Event If you need mental health behavioral health or substance abuse services If you are pregnant Services You May Need Network Providers You will pay the least Out of Network Providers You will pay the most Outpatient services 30 office visit deductible does not apply 20 coinsurance 10 coinsurance for other outpatient services Inpatient services 350 visit plus 10 coinsurance 400 visit plus 20 coinsurance Office visits Primary Care 30 initial visit Specialist 60 initial visit deductible does not apply 10 coinsurance 20 coinsurance Childbirth delivery professional services Childbirth delivery 350 visit plus 10 coinsurance facility services 20 coinsurance Home health care 10 coinsurance 20 coinsurance Rehabilitation 10 coinsurance services Habilitation services 10 coinsurance 20 coinsurance If you need help recovering or have other special health Skilled nursing care needs 400 visit plus 20 coinsurance 20 coinsurance 10 coinsurance 20 coinsurance Durable medical equipment 10 coinsurance 20 coinsurance Hospice services 10 coinsurance 20 coinsurance Limitations Exceptions Other Important Information Preauthorization may be required see your benefit booklet Behavioral Health Services for details Preauthorization required Preauthorization penalty 250 Out of Network See your benefit booklet Behavioral Health Services for details Copayment applies to first prenatal visit per pregnancy Cost sharing does not apply for preventive services Depending on the type of services copayment coinsurance or deductible may apply Maternity care may include tests and services described elsewhere in the SBC i e ultrasound 60 visits year Preauthorization may be required see your benefit booklet Extended Care Services for details Separate 35 visit maximum per benefit period for Habilitation and Rehabilitation services including chiropractic care Preauthorization may be required see your benefit booklet Rehabilitation Services and Habilitation Services for details 25 days year Preauthorization may be required see your benefit booklet Extended Care Services for details Preauthorization may be required Referral required Preauthorization may also be required See your benefit booklet Durable Medical Equipment for details Preauthorization may be required See your benefit booklet Extended Care Services for details 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

What You Will Pay Common Medical Event Services You May Need Network Providers You will pay the least Children s eye exam No Charge deductible does not apply Children s glasses No Charge deductible does not apply Children s dental check up 30 coinsurance If your child needs dental or eye care Out of Network Providers You will pay the most Limitations Exceptions Other Important Information Up to a 30 reimbursement is available deductible does not apply Up to a 75 reimbursement is available deductible does not apply One visit per year Out of Network reimbursement will not exceed the retail cost See your benefit booklet Pediatric Vision Care Benefits for details One pair of glasses every 12 months Reimbursement for frames lenses and lens options purchased Out of Network is available not to exceed the retail cost See your benefit booklet Pediatric Vision Care Benefits for details Oral exams are limited to two every benefit period Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months See your benefit booklet Pediatric Dental Benefits Rider for details 30 coinsurance 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 except for the correction of congenital deformities or for conditions resulting from accidental injuries scars tumors or diseases when medically necessary Dental care Adult Infertility treatment diagnosis and treatment covered in vitro not covered Long term care Non emergency care when traveling outside the U S Private duty nursing except for extended care Routine eye care Adult Routine foot care except when medically necessary 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 35 visits year combined with habilitation and rehabilitation services Hearing aids limited to one hearing aid per ear every 36 months For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 Page 5 of 7

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 the plan at Blue Cross and Blue Shield of Texas at 1 888 697 0683 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 on how 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 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 ConsumerAssistance 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 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 For more information about limitations and exceptions see the plan or policy document at www bcbstx com member policy forms 2023 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 Managing Joe s Type 2 Diabetes Mia s Simple Fracture 9 months of in network pre natal care and a hospital delivery a year of routine in network care of a wellcontrolled condition in network emergency room visit and follow up care The plan s overall deductible 3 000 Specialist copayment 60 Hospital facility copayment coinsurance 350 10 Other coinsurance 10 The plan s overall deductible 3 000 Specialist copayment 60 Hospital facility copayment coinsurance 350 10 Other coinsurance 10 The plan s overall deductible 3 000 Specialist copayment 60 Hospital facility copayment coinsurance 350 10 Other coinsurance 10 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 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 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 12 700 In this example Peg would pay Cost sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Peg would pay is 3 000 700 900 60 4 660 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 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 2 000 700 0 0 2 700 The plan would be responsible for the other costs of these EXAMPLE covered services Page 7 of 7