8 Table of Contents Consolidated Appropriations Act of 2021 Notice ....................................................................................1 No Surprises Act Requirements ................................................................................................................1 Provider Directories ...................................................................................................................................2 Transparency Requirements .....................................................................................................................2 Notice Regarding Retiree-Only Plans .......................................................................................................3 Federal Patient Protection and Affordable Care Act Notices .................................................................4 Choice of Primary Care Physician.............................................................................................................4 Access to Obstetrical and Gynecological (ObGyn) Care ..........................................................................4 Additional Federal Notices.........................................................................................................................5 Statement of Rights under the Newborns’ and Mother’s Health Protection Act........................................5 Statement of Rights under the Women’s Cancer Rights Act of 1998 .......................................................5 Coverage for a Child Due to a Qualified Medical Support Order (“QMCSO”)...........................................5 Mental Health Parity and Addiction Equity Act..........................................................................................5 Special Enrollment Notice .........................................................................................................................6 Introduction .................................................................................................................................................7 How to Get Language Assistance .............................................................................................................7 Table of Contents........................................................................................................................................8 Schedule of Benefits.................................................................................................................................13 How Your Plan Works...............................................................................................................................28 Introduction..............................................................................................................................................28 Connect with Us Using Our Mobile App .............................................................................................29 How to Find a Participating Provider .......................................................................................................29 Continuity of Care....................................................................................................................................29 Your Cost-Shares ....................................................................................................................................30 Crediting Prior Plan Coverage.................................................................................................................30 The BlueCard Program............................................................................................................................30 Identification Card....................................................................................................................................30 Getting Approval for Benefits..................................................................................................................31 Reviewing Where Services Are Provided................................................................................................31 Types of Reviews ....................................................................................................................................31 Decision and Notice Requirements .........................................................................................................33 Important Information ..............................................................................................................................34 Health Plan Individual Case Management ..............................................................................................34 What’s Covered .........................................................................................................................................36 Allergy Services.......................................................................................................................................36 Ambulance Services................................................................................................................................36 Important Notes on Air Ambulance Benefits........................................................................................37 Athletic Trainer Services..........................................................................................................................37 Autism Spectrum Disorder Services........................................................................................................37 Behavioral Health Services .....................................................................................................................38 Biomarker Testing Services.....................................................................................................................38 Cardiac Rehabilitation .............................................................................................................................38 Please see “Therapy Services” later in this section. ...............................................................................38 Cellular and Gene Therapy Services ......................................................................................................38 Chemotherapy .........................................................................................................................................38 Please see “Therapy Services” later in this section. ...............................................................................38 Chronic Pain Management Services .......................................................................................................38 Clinical Trials ...........................................................................................................................................39 Dental Services .......................................................................................................................................40