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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023 – 12/31/2023 : MTBAB015H Blue Advantage HSA 015HSM Coverage for: Individual/Family | Plan Type: HMOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 6 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, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-877-299-2377. 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 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?$6,000 Individual/$12,000 FamilyGenerally, 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. In-Network preventive care services are covered before you meet your deductible.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?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?$6,000 Individual/$12,000 FamilyThe 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?Premiums, balance-billing charges, and health care this plan doesn't cover.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.bcbstx.com/go/bahmo or call 1-877-299-2377 for a list of Participating 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.This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.SLMR MTBAB015H2023E01012023 0000008 0850C :doireP egarevo 0 3202/10/9 -0 4202/13/8C :rof egarevo I ylimaF + laudividn | P :epyT nal H OM

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023 Page 2 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedParticipating Provider (You will pay the least)Non-Participating Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illnessNo Charge after deductibleNot CoveredVirtual visits are available. See your benefit booklet* for details.Specialist visitNo Charge after deductibleNot CoveredReferral requiredIf you visit a health care provider’s office or clinicPreventive care/screening/immunizationNo Charge; deductible does not applyNot CoveredYou 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.Diagnostic test (x-ray, blood work)No Charge after deductibleNot CoveredIf you have a testImaging (CT/PET scans, MRIs)No Charge after deductibleNot CoveredNonePreferred generic drugsNo Charge after deductibleNot CoveredNon-preferred generic drugsNo Charge after deductibleNot CoveredPreferred brand drugsNo Charge after deductibleNot CoveredNon-preferred brand drugsNo Charge after deductibleNot CoveredPreferred specialty drugsNo Charge after deductibleNot CoveredIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx-drugs/drug-lists/drug-listsNon-preferred specialty drugsNo Charge after deductibleNot CoveredLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Cost Sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)No Charge after deductibleNot CoveredIf you have outpatient surgeryPhysician/surgeon feesNo Charge after deductibleNot CoveredFor Outpatient Infusion Therapy, see your benefit booklet* for details.Emergency room careNo Charge after deductibleNo Charge after deductibleNoneEmergency medical transportationNo Charge after deductibleNo Charge after deductibleIf you need immediate medical attentionUrgent careNo Charge after deductibleNot CoveredNoneIf you have a hospital stayFacility fee (e.g., hospital room)No Charge after deductibleNot CoveredNone0000008 0850

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023 Page 3 of 6 What You Will PayCommon Medical EventServices You May NeedParticipating Provider (You will pay the least)Non-Participating Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationPhysician/surgeon feesNo Charge after deductibleNot CoveredOutpatient servicesNo Charge after deductibleNot CoveredNoneIf you need mental health, behavioral health, or substance abuse servicesInpatient servicesNo Charge after deductibleNot CoveredNoneOffice visitsNo Charge after deductibleNot CoveredChildbirth/delivery professional servicesNo Charge after deductibleNot CoveredIf you are pregnantChildbirth/delivery facility servicesNo Charge after deductibleNot CoveredCost sharing does not apply to certain preventive services. Depending on the type of services, deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).Home health careNo Charge after deductibleNot CoveredNoneRehabilitation servicesNo Charge after deductibleNot CoveredHabilitation servicesNo Charge after deductibleNot CoveredNoneSkilled nursing careNo Charge after deductibleNot Covered60 day maximum per calendar year.Durable medical equipmentNo Charge after deductibleNot CoveredNoneIf you need help recovering or have other special health needsHospice servicesNo Charge after deductibleNot CoveredNoneChildren’s eye examNo Charge after deductibleNot CoveredEye screenings only. Does not include refractions. One visit per year for members ages 17 and younger.Children’s glassesNot CoveredNot CoveredIf your child needs dental or eye careChildren’s dental check-upNot CoveredNot CoveredNone0000008 0850

Page 4 of 6Excluded 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.) Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture Bariatric surgery Children's dental check-up Children's glasses Cosmetic surgery Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (Preauthorization required) Hearing aids (Limited to one hearing aid per ear every 36 months) Infertility treatment (Invitro not covered) Private-duty nursing (Only when ordered or authorized by the Primary Care Physician) Routine eye care (Adult - One visit every two years for members ages 18 and older) Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)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: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. 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: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. 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.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.0000008 0850

Page 5 of 6Does this plan meet the Minimum Value Standards? YesIf 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 1-877-299-2377.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-299-2377.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000008 0850

Page 6 of 6About 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. The plan’s overall deductible $6,000 Specialist $0 Hospital (facility) $0 Other $0This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example Cost$12,700In this example, Peg would pay:Cost SharingDeductibles$6,000Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$60The total Peg would pay is$6,060 The plan’s overall deductible $6,000 Specialist $0 Hospital (facility) $0 Other $0This 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$5,600In this example, Joe would pay:Cost SharingDeductibles$2,300Copayments$300Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$2,620 The plan’s overall deductible $6,000 Specialist $0 Hospital (facility) $0 Other $0This 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$2,800In this example, Mia would pay:Cost SharingDeductibles$2,800Copayments$0Coinsurance$0What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,800The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)Mia’s Simple Fracture(in-network emergency room visit and follow up care)0000008 0850

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