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IntroductionWelcome to participation in the self-funded group health plan provided for You by Your employer. Youremployer has chosen Regence BlueShield to administer claims for Your group health plan.As You read this Booklet, references to "You" and "Your" refer to both the Participant and Dependents,except in specifically noted sections.The following terms and definitions will assist you in understanding your benefits. Other terms are definedin the Definitions section at the back of this Booklet or where they are first used and are designated bythe first letter being capitalized.Agreement: The administrative services contract between the Plan Sponsor and the Claims Administrator.Dependents: Your eligible and enrolled spouse/domestic partner, Your eligible children and/or the eligiblechildren of Your spouse/domestic partner.Claims Administrator: Regence BlueShieldParticipant: The eligible, enrolled employee, and enrolled retireePlan: Regence PPO health planPlan Sponsor: Your Employer - The City of TacomaYou and Your: The Participant and DependentsEMPLOYER PAID BENEFITSYour Plan is an employer-paid benefits plan administered by Regence BlueShield (usually referred to asthe "Claims Administrator" in this Booklet). This means that Your employer, not Regence BlueShield,pays for Your covered medical services and supplies. Your claims will be paid only after Your employerprovides Regence BlueShield with the funds to pay Your benefits and pay all other charges due under thePlan. The Claims Administrator provides administrative claims payment services only and does notassume any financial risk or obligation with respect to claims.Because of their extensive experience and reputation of service, Regence BlueShield has been chosenas the Claims Administrator of Your Plan.The following pages are the Booklet, the written description of the terms and benefits of coverageavailable under the Plan. This Booklet is effective January 1, 2022, or the date after that on which Yourcoverage became effective. This Booklet replaces any plan description, Booklet or certificate previouslyissued by Regence BlueShield and makes it void.WW0122IHSHSABK1CITY OF TACOMA, 10010327, EFF 01012022

Using Your BookletYOU SELECT YOUR PROVIDER AND CONTROL YOUR OUT-OF-POCKET EXPENSESYou control Your out-of-pocket expenses by choosing Your Provider under three choices called:"Category 1," "Category 2" and "Category 3." Category 1. You see a preferred Provider. Your out-of-pocket expenses will be lower when choosinga preferred Provider and You will not be billed for balances beyond any Deductible and/orCoinsurance for Covered Services.Category 2. You see a participating Provider. Choosing this category means Your out-of-pocketexpenses will generally be higher than for Category 1 because larger discounts with preferredProviders may be negotiated. You will not be billed for balances beyond any Deductible and/orCoinsurance for Covered Services.Category 3. You see a Provider that does not have a participating contract with the ClaimsAdministrator. Choosing this category means You may be billed for balances beyond any Deductibleand/or Coinsurance. This is referred to as balance billing.For each benefit, this Booklet indicates the Provider You may choose and Your payment amount.Definitions of each Provider type are in the Definitions section. You can go regence.com for furtherProvider network information.ADDITIONAL ADVANTAGES OF PARTICIPATIONThe Claims Administrator provides access to discounts on select items and services, personalized healthcare planning information, health-related events and innovative health-decision tools, as well as a teamdedicated to Your personal health care needs. You also have access to the Claims Administrator's Website and mobile application to help You navigate Your way through health care decisions. For access, Youjust set up Your free account once and it is always up to You whether to participate. THESE SERVICESARE VOLUNTARY, NOT INSURANCE AND ARE OFFERED IN ADDITION TO THE BENEFITS INYOUR BOOKLET. Additional information about some programs and services can be found in the ValueAdded Services Appendix at the end of the Booklet. Go to regence.com or the Claims Administrator's mobile application. You can use the ClaimsAdministrator's secure applications to: view recent claims, benefits and coverage;find a contracting Provider or identify Participating Pharmacies;use tools to estimate upcoming health care costs and otherwise help You manage health careexpenses;get suggestions to improve or maintain wellness and participate in self-guided motivational onlinewellness programs;learn about prescriptions for various Illnesses; andaccess information about Regence Advantages. Regence Advantages is a discount program thatgives You access to savings on a variety of health-related products and services. The ClaimsAdministrator has contracted with several program partners, listed on the secure applications, tooffer discounts on their products and services, such as hearing care, health and wellnessproducts and vision care.**Note that if You choose to access these discounts, You may receive savings on an item or service that iscovered by Your health plan, that also may create savings or administrative fees for the ClaimsAdministrator. Any such discounts or coupons are complements to the group health plan, but are notinsurance.ENHANCED SERVICES, SUPPORT, AND ACCESSYour Plan Sponsor has chosen to include enhanced services, support, and access. These enhancementswill allow You to take increased advantage of Your health plan and better control over Your and YourFamily's health. Such services may include, but are not limited to:WW0122IHSHSABK1CITY OF TACOMA, 10010327, EFF 01012022

Enhanced convenience and options for access to medical care. These may include additionalresources for You to receive covered medical care, such as enhanced virtual care options that areintegrated with Your store and forward services, telehealth and telemedicine, durable medicalequipment, preventive, behavioral health, and/or other benefits. You may also be offered increasedease in accessing non-Covered Services, such as cosmetic services or in integrating care forcomplex and multi-Provider conditions.Healthcare and vitality assistance tools. You may have tools that enable You to make and trackmedical appointments; manage health care expenses; receive support in caring for others; rememberto timely refill prescriptions and perform regular self-care; track weight, food, and exercise statistics;and more.Non-medical lifestyle enhancements. These may include access or assistance with non-medicalservices, such as resilience, mindfulness, yoga or stress reduction programs, and pet wellness andinsurances services.Your Plan Sponsor's enhancements can be accessed through a single-sign on by visiting the ClaimsAdministrator's Web site, or by contacting Customer Service. These services are specialized and maychange over time. Your use of these additional services selected by Your Plan is voluntary. In somecases, the Claims Administrator may have an affiliation with the entity that performs the servicespurchased by Your Plan. The use of these services may result in savings or value to You, Your PlanSponsor, and the Claims Administrator. ANY SUCH ENHANCED SERVICES, SUPPORT, AND ACCESSARE COMPLEMENTS TO THE GROUP HEALTH PLAN, BUT ARE NOT INSURANCE.CONTACT INFORMATIONCustomer Service: 1 (855) 877-0047(TTY: 711)Phone lines are open Monday-Friday 5 a.m. - 8 p.m. and Saturday 8 a.m. – 4:30 p.m., Pacific Time.Contact Customer Service: if You have questions;if would like to learn more about Your coverage;to request a copy of Your identification card or print a copy via the Claims Administrator's Web site ifYou have not received or have lost Your Plan identification card;if You would like to request written or electronic information regarding any other plan that the ClaimsAdministrator offers;to talk with one of the Claims Administrator's Customer Service representatives;via the Claims Administrator's Web site, regence.com, to submit a claim online or chat live with aCustomer Service representative, or to access a list of contracted health care benefit managersacting on the Claims Administrator's behalf in the utilization of health care services; orfor assistance in a language other than English.Case Management: Case managers assess Your needs, develop plans, coordinate resources andnegotiate with Providers. For additional information refer to the Medical Benefits Section or call CaseManagement at 1 (866) 543-5765.BlueCard Program: This unique program enables You to access Hospitals and Physicians whentraveling outside the four-state area Regence serves (Idaho, Oregon, Utah and Washington), as well asreceive care in 200 countries around the world. Call Customer Service to learn how to have access tocare through the BlueCard Program.Health Saving Account (HSA) Administrator: HealthEquity, the Plan’s HSA administrator, is availableto take your questions and assist you with managing your HSA account. They are available 24/7, 365days a year 1-866-346-5800 or visit their robust website at www.healthequity.com/HSAlearn.WW0122IHSHSABK1CITY OF TACOMA, 10010327, EFF 01012022

Table of ContentsUNDERSTANDING YOUR BENEFITS . 1MAXIMUM BENEFITS . 1DEDUCTIBLES . 1COINSURANCE . 1BALANCE BILLING . 1OUT-OF-POCKET MAXIMUM. 2HOW CALENDAR YEAR BENEFITS RENEW . 2MEDICAL BENEFITS . 3CASE MANAGEMENT . 4PREVENTIVE VERSUS DIAGNOSTIC SERVICES . 4CALENDAR YEAR DEDUCTIBLES . 4COINSURANCE . 4CALENDAR YEAR OUT-OF-POCKET MAXIMUM . 4PREVENTIVE CARE AND IMMUNIZATIONS . 4OFFICE OR URGENT CARE CENTER VISITS – ILLNESS OR INJURY . 6PROFESSIONAL SERVICES. 6ACUPUNCTURE . 8AMBULANCE SERVICES . 8AMBULATORY SURGICAL CENTER . 8APPROVED CLINICAL TRIALS . 8BARIATRIC SERVICES . 9BLOOD BANK. 10DENTAL HOSPITALIZATION. 10DETOXIFICATION . 10DIABETIC EDUCATION . 10DIALYSIS . 11DURABLE MEDICAL EQUIPMENT . 11EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES) . 11GENE THERAPY AND ADOPTIVE CELLULAR THERAPY . 12HOME HEALTH CARE . 13HOSPICE CARE . 13HOSPITAL CARE – INPATIENT AND OUTPATIENT. 13MATERNITY CARE . 14MEDICAL FOODS . 14MENTAL HEALTH SERVICES . 15NEURODEVELOPMENTAL THERAPY . 16NEWBORN CARE . 16NUTRITIONAL COUNSELING . 16ORTHOTIC DEVICES . 16PALLIATIVE CARE . 17PRESCRIPTION MEDICATIONS . 17PROSTHETIC DEVICES . 25RECONSTRUCTIVE SERVICES AND SUPPLIES . 25REHABILITATION SERVICES . 26REPAIR OF TEETH . 26REPRODUCTIVE HEALTH CARE SERVICES. 26RETAIL CLINIC OFFICE VISITS . 27SKILLED NURSING FACILITY. 27SPINAL MANIPULATIONS. 27SUBSTANCE USE DISORDER SERVICES . 28TEMPOROMANDIBULAR JOINT (TMJ) DISORDERS. 29WW0122IHSHSABK1CITY OF TACOMA, 10010327, EFF 01012022

TOBACCO USE CESSATION . 29TRANSGENDER SERVICES . 29TRANSPLANTS . 30VIRTUAL CARE . 31GENERAL EXCLUSIONS . 33PREEXISTING CONDITIONS . 33SPECIFIC EXCLUSIONS . 33CLAIMS ADMINISTRATION . 39SUBMISSION OF CLAIMS AND REIMBURSEMENT . 39OUT-OF-AREA SERVICES . 40BLUE CROSS BLUE SHIELD GLOBAL CORE . 42CLAIMS RECOVERY . 42SUBROGATION AND RIGHT OF RECOVERY . 42MAINTENANCE OF BENEFITS . 45APPEAL PROCESS . 49APPEALS. 49VOLUNTARY EXTERNAL APPEAL - IRO . 49EXPEDITED APPEALS . 50INFORMATION . 50DEFINITIONS SPECIFIC TO THE APPEAL PROCESS . 50WHO IS ELIGIBLE, HOW TO ENROLL AND WHEN COVERAGE BEGINS . 52INITIALLY ELIGIBLE, WHEN COVERAGE BEGINS . 52NEWLY ELIGIBLE DEPENDENTS . 53SPECIAL ENROLLMENT . 54ANNUAL OPEN ENROLLMENT PERIOD . 55DOCUMENTATION OF ELIGIBILITY . 55WHEN COVERAGE ENDS. 56AGREEMENT TERMINATION .

Regence BlueShield serves select counties in the state of Washington and is an Independent Licensee of the BlueCross and BlueShield Association . 2022 BOOKLET FOR: CITY OF TACOMA