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.................................................................................................................................12 How Your Plan Works...............................................................................................................................29 Introduction................................................................................................................................................29 In-Network Services ..................................................................................................................................29 Out-of-Network Services ...........................................................................................................................30 Connect with Us Using Our Mobile App ....................................................................................................30 How to Find a Provider in the Network......................................................................................................30 Continuity of Care......................................................................................................................................31 Your Cost-Shares ......................................................................................................................................31 Crediting Prior Plan Coverage...................................................................................................................31 The BlueCard Program..............................................................................................................................32 Identification Card......................................................................................................................................32 Getting Approval for Benefits ..................................................................................................................33 Reviewing Where Services Are Provided..................................................................................................33 Types of Reviews ......................................................................................................................................33 Decision and Notice Requirements ...........................................................................................................35 Important Information ................................................................................................................................36 Health Plan Individual Case Management ................................................................................................36 What’s Covered .........................................................................................................................................38 Acupuncture ..............................................................................................................................................38 Allergy Services.........................................................................................................................................38 Ambulance Services..................................................................................................................................38 Important Notes on Air Ambulance Benefits..........................................................................................39 Athletic Trainer Services............................................................................................................................39 Autism Spectrum Disorder Services..........................................................................................................40 Behavioral Health Services .......................................................................................................................40 Biomarker Testing Services.......................................................................................................................40 Cardiac Rehabilitation ...............................................................................................................................40 Cellular and Gene Therapy Services ........................................................................................................40 Chemotherapy ...........................................................................................................................................40 Chronic Pain Management Services .........................................................................................................40 Clinical Trials .............................................................................................................................................41