Summary of Benefits and Coverage: Health Select of Texas (In-Area) Plan

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 09/01/2021 – 08/31/2022

HealthSelect® of Texas (In-Area) Plan Coverage for: Individual + Family Plan Type: POS

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would

share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium

) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-252-8039 or visit

www.healthselectoftexas.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or

other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-800-252-8039 to request a copy.

Important Questions Answers Why This Matters:

What is the overall

deductible?

Network

$0 Individual / $0 Family

Non-network

$500 Individual / $1,500 Family

Generally, you must pay all of the costs from providers up to the deductible

amount before this plan begins to pay. If you have other family members on the

plan, each family member must meet their own individual deductible until the

total amount of deductible expenses paid by all family members meets the

overall family deductible.

Are there services

covered before you

meet your deductible?

Yes. Preventive services and network services are

covered before you meet your deductible.

In-network and out-of-network COVID-19 diagnostic

testing and related services are covered before you

meet your deductible throughout the Declaration of a

National Emergency due to the novel coronavirus.

This plan covers some items and services even if you haven’t yet met the

deductible amount. But a copayment or coinsurance may apply. For example,

this plan covers certain preventive services without cost sharing and before you

meet your deductible. See a list of covered preventive services at

www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other

deductibles for specific

services?

Yes. $50 for prescription drug expenses per person,

$5,000 for bariatric surgery for active employees, and

$200 per service for certain non-prior authorized

services.

You must pay all of the costs for these services up to the specific deductible

amount before this plan begins to pay for these services.

What is the out-of-

pocket limit for this

plan?

Network

: $7,000 Individual / $14,000 Family

Non-network: No Limit

Coinsurance Limit:

$2,000 Network /$7,000 Non-network

The out-of-pocket limit is the most you could pay in a year for covered services.

If you have other family members in this plan, they have to meet their own out-

of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in

the out-of-pocket limit?

Contributions

, balance-billing

charges, health care

this plan doesn’t cover, and bariatric surgery benefits.

Even though you pay these expenses, they don’t count toward the out-of-pocket

limit

Will you pay less if you

use a network

provider?

Yes. See www.healthselectoftexas.com or call

1-800-252-8039 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the

plan’s network. You will pay the most if you use an out-of-network provider, and

you might receive a bill from a provider for the difference between the provider’s

charge and what your plan pays (balance billing)

. Be aware, your network

provider might use an out-of-network provider for some services (such as lab

work). Check with your provider before you get services.

Do you need a referral

to see a specialist?

Yes. A valid written referral from your primary care

provider is required to see a specialist.

This plan will pay some or all of the costs to see a specialist for covered

services but only if you have an approved referral before you see the specialist.

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* For more information about limitations and exceptions, see the plan or policy document at www.healthselectoftexas.com.

1 Out-of-pocket limits under this plan reset each calendar year. The network out-of-pocket limit that applies to this plan from 9/1/2021 through 12/31/2021 is $6,750

per Individual and $13,500 per Family

2Under this plan, payment for your health plan coverage is called a contribution rather than a premium.

Non-network providers may not balance bill you for certain services effective January 1, 2020. Refer to the Master Benefit Plan Document for details.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common

Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other

Important Information

In-Network Provider

(you will pay the least)

Out-of-Network Provider

(you will pay the most)

If you visit a health care

provider’s office or

clinic

Primary care visit to treat an

injury or illness

$25 copayment/visit 40% coinsurance

In-network and out-of-network COVID-19

diagnostic testing and related services are

covered without cost share throughout the

Declaration of a National Emergency due to

the novel coronavirus.

Specialist visit $40 copayment/visit 40% coinsurance

A valid referral to see a network specialist

(including telemedicine visits) is required to

access network benefits excluding

OB/Gynecologists, chiropractors, and eye

exams by ophthalmologists and optometrists.

In-network and out-of-network COVID-19

diagnostic testing and related services are

covered without cost share throughout the

Declaration of a National Emergency due to

the novel coronavirus.

Preventive care/screening/

Immunization

No charge 40% coinsurance

You may have to pay for services that aren’t

preventive. Ask your provider if the services

needed are preventive. Then check what

your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood

work)

20% coinsurance 40% coinsurance

In-network and out-of-network COVID-19

diagnostic testing and related services are

covered without cost share throughout the

Declaration of a National Emergency due to

the novel coronavirus.

Imaging (CT/PET scans,

MRIs)

$100 copayment/visit

plus 20% coinsurance

$100 copayment/visit

plus 40% coinsurance

Preauthorization may be required. Failure to

obtain preauthorization may increase your

cost.

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* For more information about limitations and exceptions, see the plan or policy document at www.healthselectoftexas.com.

Common

Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other

Important Information

In-Network Provider

(you will pay the least)

Out-of-Network Provider

(you will pay the most)

If you need drugs to

treat your illness or

condition

More information about

prescription drug

coverage is available at

www.healthselectrx.com.

Generic drugs (Tier 1)

$10 copayment (non-

maintenance),

$10 copayment

(maintenance);

$30 copayment

(mail order or extended

day supply)

$10 copayment plus 40%

coinsurance

(non-maintenance)

$10 copayment plus 40%

coinsurance (maintenance);

$30 copayment plus 40%

coinsurance

(mail order or extended day

supply)

Preauthorization may be required. Failure to

obtain preauthorization may increase your

cost. Note: If a generic drug is available and

you choose to buy the preferred or non-

preferred brand drug, you will pay the generic

copayment plus the cost difference between

the preferred or non-preferred brand drug

and the generic drug.

Preferred brand drugs (Tier 2)

$35 copayment (non-

maintenance),

$45 copayment

(maintenance);

$105 copayment (mail

order or extended day

supply)

$35 copayment plus 40%

coinsurance

(non-maintenance)

$45 copayment plus 40%

coinsurance (maintenance);

$105 copayment plus 40%

coinsurance (mail order or

extended day supply)

Non-preferred brand drugs

(Tier 3)

$60 copayment

(non-maintenance),

$75 copayment

(maintenance);

$180 copayment (mail

order or extended day

supply)

$60 copayment plus 40%

coinsurance

(non-maintenance)

$75 copayment plus 40%

coinsurance (maintenance);

$180 copayment plus 40%

coinsurance (mail order or

extended day supply)

Specialty drugs

If purchased through a

pharmacy, specialty

drugs are covered as

preferred brand drugs or

non-preferred brand

drugs as listed above.

Otherwise, covered as a

medical benefit.

If purchased through a

pharmacy, specialty drugs are

covered as preferred brand

drugs or non-preferred brand

drugs as listed above.

Otherwise, covered as a

medical benefit.

Preauthorization may be required. Failure to

obtain preauthorization may increase your

cost. Note: If a generic drug is available and

you choose to buy the preferred or non-

preferred brand drug, you will pay the generic

copayment plus the cost difference between

the preferred or non-preferred brand drug

and the generic drug.

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* For more information about limitations and exceptions, see the plan or policy document at www.healthselectoftexas.com.

Common

Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other

Important Information

In-Network Provider

(you will pay the least)

Out-of-Network Provider

(you will pay the most)

If you have outpatient

surgery

Facility fee (e.g., ambulatory

surgery center)

$100 copayment/visit

plus 20% coinsurance

$100 copayment/visit

plus 40% coinsurance

Preauthorization may be required. Failure to

obtain preauthorization may increase your

cost.

Physician/surgeon fees 20% coinsurance 40% coinsurance None

If you need immediate

medical attention

Emergency room care

$150 copayment/visit

plus 20% coinsurance

$150 copayment/visit

plus 20% coinsurance

Non-network deductible does

not apply

$300 copayment/visit plus 20% coinsurance

applies to any non-network freestanding

emergency room not affiliated with a hospital,

and you may be responsible for balance

billing

. Non-network deductible does not

apply. Emergency room copayment waived if

admitted.

In-network and out-of-network COVID-19

diagnostic testing and related services are

covered without cost share throughout the

Declaration of a National Emergency due to

the novel coronavirus.

Emergency medical

transportation

20% coinsurance

Non-network deductible does

not apply

None

Urgent care

$50 copayment/ visit

plus 20% coinsurance

40% coinsurance

In-network and out-of-network COVID-19

diagnostic testing and related services are

covered without cost share throughout the

Declaration of a National Emergency due to

the novel coronavirus.

If you have a hospital

stay

Facility fee (e.g., hospital

room)

$150/day copayment per

admission plus

20% coinsurance

$150/day copayment per

admission plus

40% coinsurance

$750 copayment max per admission. $2,250

copayment max per calendar year per

person. Preauthorization may be required.

Failure to obtain preauthorization may

increase your cost.

In-network and out-of-network COVID-19

diagnostic testing and related services are

covered without cost share throughout the

Declaration of a National Emergency due to

the novel coronavirus.

Physician/surgeon fees 20% coinsurance 40% coinsurance None

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* For more information about limitations and exceptions, see the plan or policy document at www.healthselectoftexas.com.

Common

Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other

Important Information

In-Network Provider

(you will pay the least)

Out-of-Network Provider

(you will pay the most)

If you need mental

health, behavioral

health, or substance

abuse services

Outpatient services

$25 copayment for office

visits and 20%

coinsurance for other

outpatient services

40% coinsurance

Certain services must be preauthorized; refer

to Master Benefit Plan Document for details.

Inpatient services

$150/day copayment per

admission plus

20% coinsurance

$150/day copayment per

admission plus

40% coinsurance

$750 copayment max per admission. $2,250

copayment max per calendar year per

person. Preauthorization may be required.

Failure to obtain preauthorization may

increase your cost.

If you are pregnant

Office visits

$25 copayment for

primary care provider/$40

copayment for specialist

for initial office visit

No Charge after initial

visit

40% coinsurance

Cost sharing does not apply for preventive

services. Depending on the type of services,

a copayment, coinsurance, or deductible may

apply. Maternity care may include tests and

services described elsewhere in the SBC (i.e.

ultrasound.)

In-network and out-of-network COVID-19

diagnostic testing and related services are

covered without cost share throughout the

Declaration of a National Emergency due to

the novel coronavirus.

Childbirth/delivery

professional services

No Charge 40% coinsurance

Childbirth/delivery facility

services

$150/day copayment per

admission plus

20% coinsurance

$150/day copayment per

admission plus

40% coinsurance

$750 copayment max per admission. $2,250

copayment max per calendar year per

person. Preauthorization may be required.

Failure to obtain preauthorization may

increase your cost.

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Common

Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other

Important Information

In-Network Provider

(you will pay the least)

Out-of-Network Provider

(you will pay the most)

If you need help

recovering or have

other special health

needs

Home health care 20% coinsurance 40% coinsurance

Preauthorization may be required. Failure to

obtain preauthorization may increase your

cost. Max of 100 non-network visits per

calendar year per person. Non-network home

infusion therapy is not covered.

Rehabilitation services 20% coinsurance 40% coinsurance

None

Habilitation services 20% coinsurance 40% coinsurance

Skilled nursing care 20% coinsurance 40% coinsurance

Preauthorization may be required. Failure to

obtain preauthorization may increase your

cost.

Durable medical equipment 20% coinsurance 40% coinsurance

Repair or replacement limit of one every 3

years per person unless change in condition

or physical status. Preauthorization may be

required. Failure to obtain preauthorization

may increase your cost.

Hospice services 20% coinsurance 40% coinsurance

Preauthorization may be required. Failure to

obtain preauthorization may increase your

cost.

If your child needs

dental or eye care

Children’s eye exam $40 copayment/visit; 40% coinsurance

Limit of one routine exam per calendar year

per person. No referral is required for eye

exams. One preventive care visual acuity

screening covered with no copayment at

network provider.

Children’s glasses Not covered Not covered None

Children’s dental check-up Not covered Not covered None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture

• Cosmetic surgery

• Dental care (Adult)

• Educational services, excluding Diabetes Self-

Management Training Programs

• Glasses and Contact Lenses

• Infertility treatment

• Long-term care

• Personal comfort items

• Routine foot care

* For more information about limitations and exceptions, see the plan or policy document at www.healthselectoftexas.com.

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Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Bariatric surgery for active employees

• Chiropractic care

• Hearing aids (limited to $1,000 per ear

per 36-month period) Eligible minors

18 and under are not subject to $1,000

hearing aid maximum

• Non-emergency care when traveling outside the U.S.

• Private-duty nursing (limited to 96 hours per year for non-

network)

• In-network diagnostic mammograms are covered at 100%

• Routine eye care (Adult)

• Weight loss programs (Limited to certain

programs. See Master Benefit Plan Document for

details on covered programs)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those

agencies is: the HealthSelect of Texas plan at 1-800-892-2803, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or

www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323

x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance

Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a

grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also

provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,

contact: Blue Cross and Blue Shield of Texas at 1-800-252-8039 or visit www.healthselectoftexas.com, or contact the U.S. Department of Labor's Employee Benefits

Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your

appeal. Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the

requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-252-8039.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-252-8039.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-252-8039.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-252-8039.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be

different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing

amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of

costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a

hospital delivery)

◼ The plan’s overall deductible $0

◼ Specialist copayments $40

◼ Hospital (facility) coinsurance 20%

◼ Hospital (facility) copayments $150

◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Specialist office visits (prenatal care)

Childbirth/Delivery Professional Services

Childbirth/Delivery Facility Services

Diagnostic tests (ultrasounds and blood work)

Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:

Cost sharing

Deductibles $10

Copayments $400

Coinsurance $2,200

What isn’t covered

Limits or exclusions $60

The total Peg would pay is $2,670

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-

controlled condition)

◼ The plan’s overall deductible $0

◼ Specialist copayments $40

◼ Hospital (facility) coinsurance 20%

◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Primary care physician office visits (including

disease education)

Diagnostic tests (blood work)

Prescription drugs

Durable medical equipment (glucose meter)

Total Example Cost

$5,600

In this example, Joe would pay:

Cost sharing

Deductibles $50

Copayments $900

Coinsurance $0

What isn’t covered

Limits or exclusions $20

The total Joe would pay is $970

Mia’s Simple Fracture

(in-network emergency room visit and follow

up care)

◼ The plan’s overall deductible $0

◼ Specialist copayments $40

◼ Hospital (facility) coinsurance 20%

◼ Hospital (ER) copayments $150

◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Emergency room care (including medical

supplies)

Diagnostic test (x-ray)

Durable medical equipment (crutches)

Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:

Cost sharing

Deductibles $10

Copayments $400

Coinsurance $400

What isn’t covered

Limits or exclusions $0

The total Mia would pay is $810

The plan would be responsible for the other costs of these EXAMPLE covered services.

you,

someone

you

are

helping,

have

questions,

you

have

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right

get

help

and

information

your

language

cost

speak

interpreter,

call

the

customer

service

number

the

back

your

member

card.

you

are

not

member,

don't

have

card,

call

855-710-6984.

usted

alguien

quien

usted

está

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tiene

preguntas,

tiene

derecho

obtener

ayuda

información

idioma

sin

costo

alguno.

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comuniqúese

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Servicio

Cliente

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llame

855-710-6984.

bcbstx.com

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator

300 E. Randolph St.

35th Floor

Chicago, IL 60601

Phone: 855-664-7270 (voicemail)

TTY/TDD: 855-661-6965

Fax: 855-661-6960

Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services

200 Independence Avenue SW

Room 509F, HHH Building 1019

Washington, DC 20201

Phone: 800-368-1019

TTY/TDD: 800-537-7697

Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html