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.......................................................................................................36 Prior Authorization/Pre-Authorized.......................................................................................................................36 Covered Expenses..................................................................................................................................................37 Prescription Drug Benefits..........................................................................................................50 The Schedule..........................................................................................................................................................50 Covered Expenses..................................................................................................................................................53 Limitations .............................................................................................................................................................53 Your Payments.......................................................................................................................................................55 Exclusions ..............................................................................................................................................................55 Reimbursement/Filing a Claim..............................................................................................................................56 Exclusions, Expenses Not Covered and General Limitations..................................................57 Coordination of Benefits..............................................................................................................59 Expenses For Which A Third Party May Be Responsible.......................................................62 Payment of Benefits.....................................................................................................................63 Termination of Insurance............................................................................................................64 Employees..............................................................................................................................................................64 Dependents.............................................................................................................................................................64 Rescissions .............................................................................................................................................................64 Federal Requirements.................................................................................................................64 Notice of Provider Directory/Networks.................................................................................................................64 Qualified Medical Child Support Order (QMCSO)...............................................................................................64 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA)...................65 Coverage for Maternity Hospital Stay...................................................................................................................67 Women’s Health and Cancer Rights Act (WHCRA)............................................................................................67 Group Plan Coverage Instead of Medicaid............................................................................................................68 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA)................................................68
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