10 Table of Contents Consolidated Appropriations Act of 2021 Notice ................................ ................................ .................... 2 No Surprises Act Requirements ................................ ................................ ................................ .................. 2 Provider Directories ................................ ................................ ................................ ................................ ..... 3 Transparency Requirements ................................ ................................ ................................ ....................... 3 Notice Regarding Retiree - Only Plans ................................ ................................ ................................ ......... 4 Federal Patient Protection and Affordable Care Act Notices ................................ ................................ . 5 Choice of Primary Care Physician ................................ ................................ ................................ ............... 5 Access to Obstetrical and Gynecological (ObGyn) Care ................................ ................................ ............ 5 Additional Federal Notices ................................ ................................ ................................ ......................... 6 Statement of Rights under the Newborns’ and Mother’s Health Protection Act ................................ .......... 6 Statement of Rights under the Women’s Cancer Rights Act of 1998 ................................ ......................... 6 Coverage for a Child Due to a Qualified Medical Support Order (“QMCSO”) ................................ ............. 6 Mental Health Parity and Addiction Equity Act ................................ ................................ ............................ 6 Special Enrollment Notice ................................ ................................ ................................ ........................... 7 Introduction ................................ ................................ ................................ ................................ ................. 9 High - Deductible Health Plan for Use with Health Savings Accounts ................................ .......................... 9 How to Get Language Assistance ................................ ................................ ................................ ............... 9 Table of Contents ................................ ................................ ................................ ................................ ...... 10 Schedule of Benefits ................................ ................................ ................................ ................................ . 14 How Your Plan Works ................................ ................................ ................................ ............................... 30 Introduction ................................ ................................ ................................ ................................ ................ 30 In - Network Services ................................ ................................ ................................ ................................ .. 30 Out - of - Network Services ................................ ................................ ................................ ........................... 31 Connect with Us Using Our Mobile App ................................ ................................ ................................ .... 31 How to Find a Provider in the Network ................................ ................................ ................................ ...... 31 Continuity of Care ................................ ................................ ................................ ................................ ...... 32 Your Cost - Shares ................................ ................................ ................................ ................................ ...... 32 Crediting Prior Plan Coverage ................................ ................................ ................................ ................... 32 The BlueCard Program ................................ ................................ ................................ .............................. 33 Identification Card ................................ ................................ ................................ ................................ ...... 33 Getting Approval for Benefits ................................ ................................ ................................ .................. 34 Reviewing Where Services Are Provided ................................ ................................ ................................ .. 34 Types of Reviews ................................ ................................ ................................ ................................ ...... 34 Decision and Notice Requirements ................................ ................................ ................................ ........... 36 Important Information ................................ ................................ ................................ ................................ 37 Health Plan Individual Case Management ................................ ................................ ................................ 37 What’s Covered ................................ ................................ ................................ ................................ ......... 39 Allergy Services ................................ ................................ ................................ ................................ ......... 39 Ambulance Services ................................ ................................ ................................ ................................ .. 39 Important Notes on Air Ambulance Benefits ................................ ................................ .......................... 40 Athletic Trainer Services ................................ ................................ ................................ ............................ 40 Autism Spectrum Disorder Services ................................ ................................ ................................ .......... 40 Behavioral Health Services ................................ ................................ ................................ ....................... 41 Biomarker Testing Services ................................ ................................ ................................ ....................... 41 Cardiac Rehabilitation ................................ ................................ ................................ ............................... 41 Cellular Services ................................ ................................ ................................ ................................ ........ 41 Chemotherapy ................................ ................................ ................................ ................................ ........... 41 Chronic Pain Management Services ................................ ................................ ................................ ......... 41 Clinical Trials ................................ ................................ ................................ ................................ ............. 42