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TRSACTIVECARE PRIMARYTRSACTIVECARE PRIMARY+TRS-ACTIVECARE HDTRS-ACTIVECARE 2NOTE: CLOSED PLAN;NO NEW ENROLLMENTSOTHER SERVICES (CONTINUED)Type of Coverage In-Network Coverage OnlyIn-Network Coverage OnlyIn-NetworkCoverageOut-of-Network CoverageIn-Network CoverageOut-of-NetworkCoverageBariatric 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)*Facility %u2013 You pay 20% after deductibleProfessional %u2013 You pay $5,000 copay + 20% after deductible(Only covered at select BDC+ facilities with an in-network physician)*Not Covered Not CoveredFacility %u2013 You pay $150 facility copay per day + 20% after deductible Professional %u2013 You pay $5,000 copay + 20% after deductible(Only covered at select BDC+ facilities with an in-network physician)*Not CoveredAnnual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist) Specialist $70 copaySpecialist $70 copayYou pay 30% after deductibleYou pay 50% after deductibleSpecialist $70 copayYou pay 40% after deductibleAnnual Hearing Exam (one per plan year)PCP $30 copaySpecialist $70 copayPCP $15 copaySpecialist $70 copayYou pay 30% after deductibleYou pay 50% after deductiblePCP $30 copaySpecialist $70 copayYou pay 40% after deductible Blue 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, 24 hours a day, seven days a week.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 under your 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.*Call a PHG at 1-866-355-5999 to confirm which providers are eligible or for help finding a qualifying facility.www.bcbstx.com/trsactivecare 25