Table of Contents
Important Information..................................................................................................................5
Special Plan Provisions..................................................................................................................7
Important Notices ..........................................................................................................................8
How To File Your Claim .............................................................................................................10
Eligibility - Effective Date ...........................................................................................................11 Employee Insurance .............................................................................................................................................11 Waiting Period......................................................................................................................................................11 Dependent Insurance ............................................................................................................................................11
Important Information About Your Medical Plan...................................................................12
Open Access Plus Medical Benefits ............................................................................................13 The Schedule ........................................................................................................................................................13 Certification Requirements - Out-of-Network......................................................................................................28 Prior Authorization/Pre-Authorized .....................................................................................................................28 Covered Expenses ................................................................................................................................................29 Prescription Drug Benefits..........................................................................................................40 The Schedule ........................................................................................................................................................40 Covered Expenses ................................................................................................................................................43 Limitations............................................................................................................................................................43 Your Payments .....................................................................................................................................................45 Exclusions ............................................................................................................................................................45 Reimbursement/Filing a Claim.............................................................................................................................46
Exclusions, Expenses Not Covered and General Limitations ..................................................47
Coordination of Benefits..............................................................................................................49
Expenses For Which A Third Party May Be Responsible .......................................................51
Payment of Benefits .....................................................................................................................52
Termination of Insurance............................................................................................................53 Employees ............................................................................................................................................................53 Dependents ...........................................................................................................................................................53 Rescissions ...........................................................................................................................................................53 Federal Requirements .................................................................................................................54 Notice of Provider Directory/Networks................................................................................................................54 Qualified Medical Child Support Order (QMCSO) .............................................................................................54 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) ..................54 Effect of Section 125 Tax Regulations on This Plan ............................................................................................56 Eligibility for Coverage for Adopted Children.....................................................................................................56 Coverage for Maternity Hospital Stay ..................................................................................................................57 Women’s Health and Cancer Rights Act (WHCRA) ...........................................................................................57 Group Plan Coverage Instead of Medicaid...........................................................................................................57 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) ...............................................57
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