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 High-Deductible Health Plan for Use with Health Savings Accounts..........................................................7 How to Get Language Assistance ...............................................................................................................7 Table of Contents ........................................................................................................................................8 Schedule of Benefits.................................................................................................................................12 How Your Plan Works...............................................................................................................................28 Introduction................................................................................................................................................28 In-Network Services ..................................................................................................................................28 Out-of-Network Services ...........................................................................................................................29 Connect with Us Using Our Mobile App ....................................................................................................29 How to Find a Provider in the Network......................................................................................................29 Continuity of Care......................................................................................................................................30 Your Cost-Shares ......................................................................................................................................30 Crediting Prior Plan Coverage...................................................................................................................30 The BlueCard Program..............................................................................................................................31 Identification Card......................................................................................................................................31 Getting Approval for Benefits ..................................................................................................................32 Reviewing Where Services Are Provided..................................................................................................32 Types of Reviews ......................................................................................................................................32 Decision and Notice Requirements ...........................................................................................................34 Important Information ................................................................................................................................35 Health Plan Individual Case Management ................................................................................................35 What’s Covered .........................................................................................................................................37 Acupuncture ..............................................................................................................................................37 Allergy Services.........................................................................................................................................37 Ambulance Services..................................................................................................................................37 Important Notes on Air Ambulance Benefits..........................................................................................38 Athletic Trainer Services............................................................................................................................38 Autism Spectrum Disorder Services..........................................................................................................39 Behavioral Health Services .......................................................................................................................39 Biomarker Testing Services.......................................................................................................................39 Cardiac Rehabilitation ...............................................................................................................................39 Cellular and Gene Therapy Services ........................................................................................................39 Chemotherapy ...........................................................................................................................................39 Chronic Pain Management Services .........................................................................................................39