10 Surgery ....................................................................................................................................................55 Oral Surgery.........................................................................................................................................55 Reconstructive Surgery........................................................................................................................56 Temporomandibular Joint (TMJ) and Craniomandibular Joint Services .................................................56 Therapy Services.....................................................................................................................................56 Physical Medicine Therapy Services ...................................................................................................56 Other Therapy Services.......................................................................................................................57 Transplant Services.................................................................................................................................57 Urgent Care Services ..............................................................................................................................57 Virtual Visits (Telemedicine / Telehealth Visits) ......................................................................................58 If you have any questions about this coverage, please contact Member Services at the number on the back of your Identification Card...............................................................................................................58 Routine Eye Exam ...............................................................................................................................58 Frames.................................................................................................................................................59 Contact Lenses ....................................................................................................................................59 Vision Services for Members Age 19 and Older .....................................................................................59 Routine Eye Exam ...............................................................................................................................59 Vision Services (All Members / All Ages) ................................................................................................59 Prescription Drugs Administered by a Medical Provider .....................................................................60 Important Details About Prescription Drug Coverage..........................................................................60 What’s Not Covered ..................................................................................................................................62 EXPERIMENTAL OR INVESTIGATIONAL SERVICES EXCLUSION ................................................68 Claims Payment ........................................................................................................................................70 Maximum Allowed Amount......................................................................................................................70 General ................................................................................................................................................70 Claims Review.........................................................................................................................................72 Time Benefits Payable.............................................................................................................................73 Member’s Cooperation ............................................................................................................................73 Payment of Benefits ................................................................................................................................74 Inter-Plan Arrangements .........................................................................................................................74 Out-of-Area Services ...........................................................................................................................74 Coordination of Benefits When Members Are Covered Under More Than One Plan ........................77 Subrogation and Reimbursement ...........................................................................................................82 Your Right To Appeal ...............................................................................................................................86 Notice of Adverse Benefit Determination ................................................................................................86 Appeals....................................................................................................................................................87 How Your Appeal will be Decided........................................................................................................88 Notification of the Outcome of the Appeal ...........................................................................................88 Appeal Denial.......................................................................................................................................88 Voluntary Second Level Appeals.........................................................................................................88 External Review...................................................................................................................................89 Requirement to file an Appeal before filing a lawsuit...........................................................................89 Prescription Drug List Exceptions........................................................................................................90 Eligibility and Enrollment – Adding Members........................................................................................91 Who is Eligible for Coverage ...................................................................................................................91 The Subscriber.....................................................................................................................................91 Dependents..........................................................................................................................................91 Types of Coverage...............................................................................................................................92 When You Can Enroll..............................................................................................................................92 Initial Enrollment ..................................................................................................................................92 Special Enrollment Periods..................................................................................................................92 Medicaid and Children’s Health Insurance Program Special Enrollment ............................................93 Late Enrollees ......................................................................................................................................93