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Baylor College of MedicineStudent Health Insurance PlanDear Student:Under the Affordable Care Act, all health insurers and group health plans are required to provide consumerswith a Summary of Benefits and Coverage (SBC). The SBC is a summary of the benefits and health coverageoffered by a particular plan.Attached is the SBC for the Baylor College of Medicine Student Health Plan covering plans purchased between6/21/21-6/30/22. In accordance with your College/University, coverage may be purchased for varying periodsof time. The coverage periods for Baylor College of Medicine are listed below:Coverage PeriodIncoming School of Health Professionals (except Genetic Counseling students)Psychology Interns AnnualAnnualIncoming Medical, Graduate and Genetic Counseling 6/30/227/23/21-6/30/22If you have any questions regarding your coverage or the length of time you purchased, please contact customerservice at 855-267-0214.1001 East Lookout Drive Richardson, Texas 75082 bcbstx.comA Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesBaylor College of Medicine: Student Health PlanCoverage Period: 07/01/2021 – 06/30/2022Coverage for: Individual Family Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare 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, call 1-855-267-0214 or athttps://bcm.myahpcare.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined 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 QuestionsAnswersWhat is the overalldeductible?In-Network: 0 IndividualOut-of-Network: 500 IndividualAre there services coveredYes. Services that charge a copay and prescriptionbefore you meet yourdrugs.deductible?Are there other deductiblesNo.for specific services?What is the out-of-pocketlimit for this plan?In-Network: 1,250 Individual / 2,500 FamilyOut-of-Network: 2,500 Individual / 5,000 FamilyWhy This Matters:Generally, you must pay all of the costs from providers up to the deductibleamount before this plan begins to pay. See the Common Medical Eventschart below for your costs for services this plan covers.This plan covers some items and services even if you haven’t yet met thedeductible amount. But a copayment or coinsurance may apply.For example, this plan covers certain preventive services without cost sharingand before you meet your deductible. See a list of covered preventiveservices at ts/.You don’t have to meet deductibles for specific services.The out-of-pocket limit is the most you could pay in a year for coveredservices. If you have other family members in this plan, they have to meettheir own out-of-pocket limits until the overall family out-of-pocket limit hasbeen met.What is not included in the Premiums, preauthorization penalties, balanced-billedout-of-pocket limit?charges, and healthcare this plan doesn’t cover.Will you pay less if youuse a network provider?Do you need a referral tosee a specialist?Even though you pay these expenses, they don’t count toward the out-ofpocket limit.This plan uses a provider network. You will pay less if you use a provider inthe plan’s network. You will pay the most if you use an out-of-networkprovider, and you might receive a bill from a provider for the differenceYes. See www.bcbstx.com or call 1-855-267-0214 for abetween the provider’s charge and what your plan pays (balance billing). Belist of network providers.aware, your network provider might use an out-of-network provider for someservices (such as lab work). Check with your provider before you getservices.No.You can see the specialist you choose without a referral.A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationPage 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedPrimary care visit to treat an injury orillnessIf you visit a healthcare provider’soffice or clinicIf you have a testIf you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable atwww.bcbstx.comIf you haveoutpatient surgerySpecialist visitWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most) 10 copay/visit;30% coinsurancedeductible does not apply 10 copay/visit;30% coinsurancedeductible does not applyPreventive care/screening/immunizationNo Charge;deductible does not applyDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)20% coinsurance20% coinsuranceGeneric drugs 10 copay/prescription;deductible does not applyPreferred brand drugs 40 copay/prescription;deductible does not applyNon-preferred brand drugs 60 copay/prescription;deductible does not applySpecialty drugs 10/ 40/ 60copay/prescription;deductible does not applyFacility fee (e.g., ambulatory surgerycenter)Physician/surgeon fees30% coinsurance40% coinsurance40% coinsurance 10 copay/prescriptionplus 30% coinsurance;deductible does not apply 40 copay/prescriptionplus 30% coinsurance;deductible does not apply 60 copay/prescriptionplus 30% coinsurance;deductible does not apply 10/ 40/ 60copay/prescription plus30% coinsurance;deductible does not applyLimitations, Exceptions, & OtherImportant InformationNoneNoneYou may have to pay for services thataren’t preventive. Ask your provider ifthe services needed are preventive.Then check what your plan will pay for.No Charge for child immunizationsOut-of-Network through the 6th birthday.NoneNoneRetail copay covers a 30-day supply.With appropriate prescription, up to a90-day supply is available.Mail order is not covered.Payment of the difference between thecost of a brand name drug and ageneric may be required if a genericdrug is available, member must fileclaim.For In-Network benefit, must obtainspecialty drugs from In-NetworkSpecialty Pharmacy provider.20% coinsurance40% coinsuranceNone20% coinsurance40% coinsuranceNone* For more information about limitations and exceptions, see the plan or policy document at m/s/unrxk0g5fucauctbl5qpbwqop889rf6o.Page 2 of 7

CommonMedical EventIf you needimmediate medicalattentionIf you have ahospital stayServices You May NeedWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Emergency room care 100 copay/visitplus 20% coinsurance;deductible does not apply 100 copay/visitplus 20% coinsurance;deductible does not applyEmergency medical transportation20% coinsurance20% coinsuranceUrgent care 10 copay/visit;deductible does not apply30% coinsuranceFacility fee (e.g., hospital room)20% coinsurance40% coinsurancePhysician/surgeon fees20% coinsurance40% coinsuranceLimitations, Exceptions, & OtherImportant InformationEmergency room copay waived ifadmitted.Non-emergency use of ER is 100copay plus 20% coinsurance.Ground and air transportation covered.You may have to pay for services thatare not covered by the visit fee. For anexample, see “If you have a test” onpage 2.Preauthorization is required; 250penalty if services are not preauthorizedOut-of-Network.None 10 copay/office visit;30% coinsurance office visitdeductible does not applyCertain services must be preauthorized;If you need mentalOutpatient services40% coinsurance for other20% coinsurance for otherrefer to your benefit booklet* for details.health, behavioraloutpatient servicesoutpatient serviceshealth, or substanceabuse servicesPreauthorization is required; 250Inpatient services20% coinsurance40% coinsurancepenalty if services are not preauthorizedOut-of-Network.Copay applies to first prenatal visit (per 10 copay/visit;pregnancy).Office visits30% coinsurancedeductible does not applyCost sharing does not apply forpreventive services. Depending on thetype of services, a copayment,coinsurance, or deductible may apply.If you are pregnantChildbirth/delivery professional services 20% coinsurance40% coinsuranceMaternity care may include tests andservices described elsewhere in theSBC (i.e. ultrasound).Preauthorization is required; 250Childbirth/delivery facility services20% coinsurance40% coinsurancepenalty if services are not preauthorizedOut-of-Network.* For more information about limitations and exceptions, see the plan or policy document at m/s/unrxk0g5fucauctbl5qpbwqop889rf6o.Page 3 of 7

CommonMedical EventIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careServices You May NeedWhat You Will PayIn-Network ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Home health care20% coinsurance40% coinsuranceRehabilitation services 25 copay/visit;deductible does not apply30% coinsuranceSkilled nursing care 25 copay/visit;deductible does not apply20% coinsuranceDurable medical equipmentHabilitation servicesLimitations, Exceptions, & OtherImportant InformationLimited to 60 visits per calendar year.Preauthorization is required.None30% coinsurance40% coinsurancePreauthorization is required.20% coinsurance40% coinsuranceNoneHospice services20% coinsurance40% coinsurancePreauthorization is required.Children’s eye examCoveredCoveredSee the benefits booklet for details.Children’s glassesCoveredCoveredSee the benefits booklet for details.Children’s dental check-upCoveredCoveredSee the benefits booklet for details.* For more information about limitations and exceptions, see the plan or policy document at m/s/unrxk0g5fucauctbl5qpbwqop889rf6o.Page 4 of 7

Excluded 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.) AcupunctureBariatric surgeryCosmetic surgeryDental care (Adult) Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care (with the exception of person withdiagnosis of diabetes) Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care Hearing aids (1 per ear per 36-month period) Routine eye care (Adult)* For more information about limitations and exceptions, see the plan or policy document at m/s/unrxk0g5fucauctbl5qpbwqop889rf6o.Page 5 of 7