10 Other Therapy Services.........................................................................................................................58 Transplant Services...................................................................................................................................59 Urgent Care Services ................................................................................................................................59 Virtual Visits (Telemedicine / Telehealth Visits) ........................................................................................59 Vision Services ..........................................................................................................................................59 Prescription Drugs Administered by a Medical Provider......................................................................61 Important Details About Prescription Drug Coverage ...............................................................................61 What’s Not Covered ..................................................................................................................................63 Claims Payment.........................................................................................................................................70 Maximum Allowed Amount........................................................................................................................70 General ..................................................................................................................................................70 Federal/State Taxes/Surcharges/Fees......................................................................................................73 Claims Review...........................................................................................................................................73 Notice of Claim / Claims Forms / Proof of Loss.........................................................................................73 Time Benefits Payable...............................................................................................................................74 Member’s Cooperation ..............................................................................................................................74 Payment of Benefits ..................................................................................................................................74 Inter-Plan Arrangements ...........................................................................................................................75 Out-of-Area Services .............................................................................................................................75 Coordination of Benefits When Members Are Covered Under More Than One Plan.........................78 Subrogation and Reimbursement ...........................................................................................................83 Your Right To Appeal................................................................................................................................87 Notice of Adverse Benefit Determination ..................................................................................................87 Appeals......................................................................................................................................................87 How Your Appeal will be Decided..........................................................................................................88 Notification of the Outcome of the Appeal .............................................................................................89 Appeal Denial.........................................................................................................................................89 Voluntary Second Level Appeals...........................................................................................................89 External Review.....................................................................................................................................89 Requirement to file an Appeal before filing a lawsuit.............................................................................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 Open Enrollment....................................................................................................................................92 Special Enrollment Periods....................................................................................................................92 Medicaid and Children’s Health Insurance Program Special Enrollment ..............................................93 Late Enrollees ........................................................................................................................................93 Members Covered Under the Employer’s Prior Plan.............................................................................93 Enrolling Dependent Children ...................................................................................................................93 Newborn Children ..................................................................................................................................93 Adopted Children ...................................................................................................................................94 Adding a Child due to Award of Legal Custody or Guardianship ..........................................................94 Qualified Medical Child Support Order ..................................................................................................94 Updating Coverage and/or Removing Dependents ..................................................................................94 Nondiscrimination ......................................................................................................................................94 Statements and Forms ..............................................................................................................................95 Termination and Continuation of Coverage ...........................................................................................96 Termination................................................................................................................................................96