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OTHER SERVICESType of Coverage In-Network Coverage OnlyDiagnostic LabsOffice/Independent lab: $0 per labOutpatient hospital: You pay 30% after deductibleHigh-Tech Radiology You pay 30% after deductibleOutpatient Costs(Professional and facility) You pay 30% after deductibleInpatient Costs(Professional and facility) You pay 30% after deductibleBariatric SurgeryFacility %u2013 You pay 30% after deductibleProfessional %u2013 You pay a $5,000 copay* + 30% after deductible(Only covered if rendered at a BDC+ facility)**Annual Vision Examination (One per plan year; performed by an ophthalmologist or optometrist) Specialist $70 copayAnnual Hearing Exam (One per plan year)PCP $30 copaySpecialist $70 copayOverview of Plan Benefits and CostsTRS-ACTIVECARE PRIMARYPLAN FEATURESType of Coverage In-Network Coverage OnlyIndividual/Family Deductible $2,500/$5,000Coinsurance You pay 30% after deductibleIndividual/Family MOOP $8,050/$16,100Network StatewidePCP Required YesDOCTOR VISITSPrimary Care $30 copaySpecialist $70 copayTRS Virtual HealthTeladocMedicalMental HealthRediMD$12 copay$0 copay - Psychiatrist, Psychologist, Licensed Clinical Social Worker $0 copayIMMEDIATE CAREUrgent Care $50 copayEmergency Care You pay 30% after deductibleFreestanding Emergency Room You pay a $500 copay + 30% after deductible**Blue Distinction%u00ae CentersBlue Distinction%u00ae Centers+ are designated specialty care facilities that meet national measures for quality and costefficient care. When you use a BDC+ facility, you receive the most from your benefits and know the facility has a track record of providing quality care, treatment expertise and better overall patient results. To find a BDC+ facility go towww.bcbstx.com/trsactivecare, then Doctors and Hospitals. Click on TRS-ActiveCare Primary. Once logged in to your BAM account in Provider Finder, in the Browse by Category section, choose Medical Care then Hospital. From the blue bar at the top of the page, select All Blue Distinction Programs from the menu to filter search results.Note: Designation as BDC+ means these facilities%u2019 overall experience and aggregate data met objective criteria established in collaboration with expert clinicians and leading professional organizations%u2019 recommendations. Individual outcomes may vary. To find out which services are covered under your policy at any facilities, please call a Personal Health Guide at 1-866-355-5999. Call your provider before making an appointment to verify the most current information on its network participation status. Neither the Blue Cross and Blue Shield Association nor any of its licensees are responsible for any damages, losses or noncovered charges that may result from receiving care from a provider designated as a BDC+ facility.*Copay for bariatric surgery doesn%u2019t apply toward the MOOP30 www.bcbstx.com/trsactivecare