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...............................................................................................................................32 Introduction..............................................................................................................................................32 In-Network Services ................................................................................................................................33 Out-of-Network Services .........................................................................................................................35 Surprise Billing Claims.............................................................................................................................35 Connect with Us Using Our Mobile App ..................................................................................................35 How to Find a Provider in the Network....................................................................................................35 Continuity of Care....................................................................................................................................36 Termination of Providers .........................................................................................................................36 Your Cost-Shares ....................................................................................................................................37 Crediting Prior Plan Coverage.................................................................................................................37 The BlueCard Program............................................................................................................................37 Identification Card....................................................................................................................................37 Getting Approval for Benefits..................................................................................................................38 Reviewing Where Services Are Provided................................................................................................38 Types of Reviews ....................................................................................................................................38 Decision and Notice Requirements .........................................................................................................40 Important Information ..............................................................................................................................41 Health Plan Individual Case Management ..............................................................................................41 What’s Covered .........................................................................................................................................43 Allergy Services.......................................................................................................................................43 Ambulance Services................................................................................................................................43 Important Notes on Air Ambulance Benefits........................................................................................44 Athletic Trainer Services..........................................................................................................................45 Autism Spectrum Disorder Services........................................................................................................45 Biomarker Testing Services.....................................................................................................................45 Behavioral Health Services .....................................................................................................................45 Cardiac Rehabilitation .............................................................................................................................45 Cellular and Gene Therapy Services ......................................................................................................45 Chemotherapy .........................................................................................................................................45 Chronic Pain Management Services .......................................................................................................45