Benefits Summaries And Plan Comparisons

Type of Service ActiveCare 1   General Provisions Network Non-Network No primary care physician required Deductible (per plan year)   Individual - You Pay $1,100 Family - You Pay $3,000 Out-of-pocket maximum (per plan year)   Individual - You pay $2,000 plus deductible and copays Family - You pay $6,000 plus deductible and copays Maximum Lifetime Benefit Unlimited Doctor and Lab Services Doctor office visits - You pay 20% after deductible 40% after deductible Allergy injections - You Pay 20% after deductible 40% after deductible Office surgery - You Pay 20% after deductible 40% after deductible Outpatient surgery - You Pay 20% after deductible 40% after deductible Maternity care (doctor charges only; see Hospital/Facility Services for inpatient charges) - You Pay 20% after deductible 40% after deductible Inpatient doctor visits - You Pay 20% after deductible 40% after deductible Contraceptive devices - You Pay 20% after deductible 40% after deductible Preventive Care Doctor Office Visits Plan pays 100% up to the first $500 per individual, per plan year; remaining charges will be subject to deductible and coinsurance Services limited to one per person per plan year: routine physicals, OB/GYN well-woman exams, routine mammograms, and eye exams. Other services include well-baby exams, immunizations, hearing exams, and PSA, colorectal cancer, osteoporosis screenings. 40% after deductible Services limited to one per person per plan year: routine physicals, OB/GYN well-woman exams, routine mammograms, and eye exams. Hospital/Facility Services Inpatient hospital and other inpatient charges - You Pay 20% after deductible (preauthorization required) 40% after deductible (preauthorization required) Outpatient surgery - You Pay 20% after deductible 40% after deductible Outpatient hospital/facilities - You Pay 20% after deductible 40% after deductible Emergency room care - You Pay 20% after deductible Behavioral Health (Mental Health and Chemical Dependency) Mental Health Preauthorization required Inpatient facility - You Pay 20% after deductible 40% after deductible Maximum per plan year 30 days Inpatient physician charges - You pay 20% after deductible 40% after deductible Maximum per plan year 30 visits Outpatient/Office visit 20% after deductible 40% after deductible (maximum $60 allowable per visit) Maximum per plan year 30 visits Chemical dependency Maximum of two separate series per lifetime Inpatient facility - You pay 20% after deductible 40% after deductible Inpatient physician charges - You pay 20% after deductible 40% after deductible Outpatient - You pay 20% after deductible 40% after deductible Office visits - You pay 20% after deductible 40% after deductible Serious Mental Illness   Preauthorization required Inpatient facility - You Pay 20% after deductible 40% after deductible Maximum per plan year 45 days Inpatient physician charges - You pay 20% after deductible 40% after deductible Maximum per plan year 45 visits Outpatient/Office visit - You pay 20% after deductible 40% after deductible Maximum per plan year 60 visits Prescription Drugs Drug deductible (per person, per plan year) Subject to $1,100 plan year deductible Retail Short-Term Up to 30-day supply Up to 30-day supply Generic - You Pay Preferred Brand - You pay Non-preferred Brand - You pay 100% of discounted cost at the time of purchase; 80% will be reimbursed by Blue Cross and Blue Shield of Texas after deductible 100% at the time of purchase; 80% will be reimbursed by Blue Cross and Blue Shield of Texas after deductible Retail Maintenance (after second fill) Up to 30-day supply Up to 30-day supply Generic - You Pay Preferred Brand - You pay Non-preferred Brand - You pay 100% of discounted cost at the time of purchase; 80% will be reimbursed by Blue Cross and Blue Shield of Texas after deductible 100% at the time of purchase; 80% will be reimbursed by Blue Cross and Blue Shield of Texas after deductible Medco by Mail Up to 90-day supply N/A Generic - You Pay Preferred Brand - You pay Non-preferred Brand - You pay 100% of discounted cost at the time of purchase; 80% will be reimbursed by Blue Cross and Blue Shield of Texas after deductible N/A Maximum Plan Year Prescription Benefit Unlimited

This is a general summary of your TRS-ActiveCare plan options. Please refer to your Benefits Booklet/Evidence of Coverage for details specific to your plan. Please see the Limitations and Exclusions section at the back of your enrollment guide.