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 ............................................................................................................................... 31 Introduction .............................................................................................................................................. 31 In-Network Services ................................................................................................................................ 31 Out-of-Network Services ......................................................................................................................... 32 Surprise Billing Claims ............................................................................................................................. 32 Connect with Us Using Our Mobile App .................................................................................................. 32 How to Find a Provider in the Network .................................................................................................... 32 Continuity of Care .................................................................................................................................... 33 Termination of Providers ......................................................................................................................... 33 Your Cost-Shares .................................................................................................................................... 33 Crediting Prior Plan Coverage ................................................................................................................. 33 The BlueCard Program ............................................................................................................................ 34 Identification Card .................................................................................................................................... 34 Getting Approval for Benefits .................................................................................................................. 35 Reviewing Where Services Are Provided ................................................................................................ 35 Types of Reviews .................................................................................................................................... 35 Decision and Notice Requirements ......................................................................................................... 37 Important Information .............................................................................................................................. 38 Health Plan Individual Case Management .............................................................................................. 38 What’s Covered ......................................................................................................................................... 40 Allergy Services ....................................................................................................................................... 40 Ambulance Services ................................................................................................................................ 40 Important Notes on Air Ambulance Benefits ........................................................................................ 41 Athletic Trainer Services .......................................................................................................................... 42 Autism Spectrum Disorder Services ........................................................................................................ 42 Biomarker Testing Services..................................................................................................................... 42 Behavioral Health Services ..................................................................................................................... 42 Cardiac Rehabilitation ............................................................................................................................. 42 Cellular and Gene Therapy Services ...................................................................................................... 42 Chemotherapy ......................................................................................................................................... 42 Chronic Pain Management Services ....................................................................................................... 43 8