SUMMARY PLAN DESCRIPTION

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SUMMARY PLAN DESCRIPTIONFort Bend Independent School DistrictNexus OA PlanEffective: January 1, 2020Group Number: 902915

FORT BEND INDEPENDENT SCHOOL DISTRICT MEDICAL NEXUS OA PLANTABLE OF CONTENTSSECTION 1 - WELCOME . 1SECTION 2 - INTRODUCTION. 3Eligibility . 3Cost of Coverage . 3How to Enroll . 4When Coverage Begins . 4Changing Your Coverage. 5SECTION 3 - HOW THE PLAN WORKS . 7Selecting a Network Primary Physician . 7Accessing Benefits . 7Eligible Expenses . 10Annual Deductible . 11Copayment . 11Coinsurance . 12Out-of-Pocket Maximum . 12SECTION 4 - PERSONAL HEALTH SUPPORT and PRIOR AUTHORIZATION . 13Care Management . 13Prior Authorization. 14Special Note Regarding Medicare. 14SECTION 5 - PLAN HIGHLIGHTS . 16Payment Terms and Features . 16Schedule of Benefits . 18SECTION 6 - ADDITIONAL COVERAGE DETAILS . 27Diabetes Services . 33Lab, X-Ray and Diagnostics - Outpatient . 38Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine- Outpatient. 39Pregnancy - Maternity Services . 43Reconstructive Procedures . 46Urgent Care Center Services . 54SECTION 7 - CLINICAL PROGRAMS AND RESOURCES . 56iTABLE OF CONTENTS

FORT BEND INDEPENDENT SCHOOL DISTRICT MEDICAL NEXUS OA PLANConsumer Solutions and Self-Service Tools . 56Disease and Condition Management Services . 59Complex Medical Conditions Programs and Services . 61Wellness Programs. 63SECTION 8 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOTCOVER . 64Alternative Treatments. 64Dental . 64Devices, Appliances and Prosthetics . 65Drugs . 66Experimental or Investigational or Unproven Services . 67Foot Care . 67Medical Supplies. 68Mental Health, Neurobiological Disorders - Autism Spectrum Disorder Services andSubstance-Related and Addictive Disorders Services. 68Nutrition . 69Personal Care, Comfort or Convenience . 70Physical Appearance . 71Procedures and Treatments . 71Providers . 73Reproduction . 73Services Provided under Another Plan . 74Transplants. 75Travel . 75Types of Care . 75Vision and Hearing . 76All Other Exclusions . 76SECTION 9 - CLAIMS PROCEDURES . 79Network Benefits . 79Non-Network Benefits . 79If Your Provider Does Not File Your Claim. 79Health Statements . 81Explanation of Benefits (EOB) . 81iiTABLE OF CONTENTS

FORT BEND INDEPENDENT SCHOOL DISTRICT MEDICAL NEXUS OA PLANClaim Denials and Appeals . 81Federal External Review Program . 83Limitation of Action . 89SECTION 10 - COORDINATION OF BENEFITS (COB) . 90Determining Which Plan is Primary . 90When This Plan is Secondary . 92When a Covered Person Qualifies for Medicare . 92Medicare Crossover Program. 93Right to Receive and Release Needed Information . 94Overpayment and Underpayment of Benefits. 94SECTION 11 - SUBROGATION AND REIMBURSEMENT . 96Right of Recovery . 99SECTION 12 - WHEN COVERAGE ENDS . 101Coverage for a Disabled Dependent Child . 102Continuing Coverage Through COBRA . 102When COBRA Ends . 106Uniformed Services Employment and Reemployment Rights Act . 107SECTION 13 - OTHER IMPORTANT INFORMATION . 108Amendments to the Plan . 108Qualified Medical Child Support Orders (QMCSOs) . 108Your Relationship with UnitedHealthcare and Fort Bend Independent School District. 109Relationship with Providers . 109Your Relationship with Providers . 110Interpretation of Benefits . 110Review and Determine Benefits in Accordance with UnitedHealthcare ReimbursementPolicies . 111Information and Records. 112Incentives to Providers . 112Incentives to You . 113Rebates and Other Payments . 113Workers' Compensation Not Affected . 113Future of the Plan . 113iiiTABLE OF CONTENTS

FORT BEND INDEPENDENT SCHOOL DISTRICT MEDICAL NEXUS OA PLANPlan Document . 114Medicare Eligibility . 114SECTION 14 - GLOSSARY . 115SECTION 15 - IMPORTANT ADMINISTRATIVE INFORMATION . 130ATTACHMENT I - HEALTH CARE REFORM NOTICES . 131Patient Protection and Affordable Care Act ("PPACA") . 131ATTACHMENT II - LEGAL NOTICES . 132Women's Health and Cancer Rights Act of 1998 . 132Statement of Rights under the Newborns' and Mothers' Health Protection Act . 132ATTACHMENT III – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS . 133ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS .