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OTHER SERVICESType of Coverage In-Network Coverage OnlyDiagnostic LabsOffice/Independent lab: You pay $0Outpatient: You pay 30% after deductibleHigh-Tech Radiology You pay 30% after deductible*Outpatient 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 $5,000 copay + 30% after deductible(Only covered at select BDC+ facilities with an in-network physician)*Annual Vision Examination (One per plan year; performed by an ophthalmologist or optometrist) Specialist Tier 1: $55 copay Tier 2: $85 copayAnnual Hearing Exam (One per plan year)PCP Tier 1: $20 copay Tier 2: $40 copaySpecialist Tier 1: $55 copay Tier 2: $85 copayPLAN 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 Tier 1: $20 copayTier 2: $40 copaySpecialist Tier 1: $55 copay Tier 2: $85 copayMental Health $20 copayTRS Virtual HealthTeladocMedicalMental HealthRediMD$12 copayPsychiatrist (initial visit) $0(ongoing visit) $0Psychologist, Licensed Clinical Social Worker $0$0 copayIMMEDIATE CAREUrgent Care $50 copayEmergency Care You pay 30% after deductibleFreestanding Emergency Room You pay a $500 copay + 30% after deductibleTRS-ACTIVECARE PRIMARY X ARLINGTON ISDBlue Distinction%u00ae CentersBlue Distinction%u00ae Centers+ are designated specialty care facilities that meet national measures for quality and cost-efficient care. When you use a BDC+, you get the most from your benefits. BDC+ facilities have a record of quality care, expert treatment and better overall patient results. To find a BDC+, call a PHG at 1-866-355-5999.Note: Designation as BDC+ facility means these facilities%u2019 overall experience and aggregate data met objective criteria established in collaboration with expert clinicians%u2019 and leading professional organizations%u2019 recommendations. Individual outcomes may vary. To find out which services are covered underyour policy at any facilities, call a PHG. Call your provider before making an appointment to verify the most current information on their network participation status. Neither 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 Blue Distinction Center.www.bcbstx.com/trsactivecare 15