Table of Contents Important Information ..................................................................................................................5 Special Plan Provisions ..................................................................................................................7 Important Notices...........................................................................................................................8 How To File Your Claim .............................................................................................................12 Eligibility - Effective Date............................................................................................................13 Employee Insurance.............................................................................................................................................. 13 Waiting Period ...................................................................................................................................................... 13 Dependent Insurance............................................................................................................................................. 13 Important Information About Your Medical Plan ...................................................................14 Open Access Plus Medical Benefits ............................................................................................15 The Schedule ........................................................................................................................................................ 15 Certification Requirements - Out-of-Network ...................................................................................................... 35 Prior Authorization/Pre-Authorized...................................................................................................................... 35 Covered Expenses................................................................................................................................................. 36 Prescription Drug Benefits ..........................................................................................................49 The Schedule ........................................................................................................................................................ 49 Covered Expenses................................................................................................................................................. 52 Limitations ............................................................................................................................................................ 52 Your Payments...................................................................................................................................................... 54 Exclusions............................................................................................................................................................. 54 Reimbursement/Filing a Claim ............................................................................................................................. 55 Exclusions, Expenses Not Covered and General Limitations ..................................................56 Coordination of Benefits. .............................................................................................................59 Expenses For Which A Third Party May Be Responsible........................................................61 Payment of Benefits......................................................................................................................62 Termination of Insurance. ...........................................................................................................63 Employees............................................................................................................................................................. 63 Dependents ........................................................................................................................................................... 63 Rescissions............................................................................................................................................................ 63 Federal Requirements .................................................................................................................. 63 Notice of Provider Directory/Networks ................................................................................................................ 63 Qualified Medical Child Support Order (QMCSO).............................................................................................. 63 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA)................... 64 Coverage for Maternity Hospital Stay .................................................................................................................. 66 Women’s Health and Cancer Rights Act (WHCRA) ............................................................................................ 66 Group Plan Coverage Instead of Medicaid ........................................................................................................... 67 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) ............................................... 67
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