10 Transplant Services...................................................................................................................................60 Urgent Care Services ................................................................................................................................60 Virtual Visits (Telemedicine / Telehealth Visits) ........................................................................................60 Vision Services ..........................................................................................................................................60 Prescription Drugs Administered by a Medical Provider......................................................................62 Important Details About Prescription Drug Coverage ...............................................................................62 What’s Not Covered ..................................................................................................................................64 Claims Payment.........................................................................................................................................71 Maximum Allowed Amount........................................................................................................................71 General ..................................................................................................................................................71 Federal/State Taxes/Surcharges/Fees......................................................................................................74 Claims Review...........................................................................................................................................74 Notice of Claim / Claims Forms / Proof of Loss.........................................................................................74 Time Benefits Payable...............................................................................................................................75 Member’s Cooperation ..............................................................................................................................75 Payment of Benefits ..................................................................................................................................75 Inter-Plan Arrangements ...........................................................................................................................76 Out-of-Area Services .............................................................................................................................76 Coordination of Benefits When Members Are Covered Under More Than One Plan.........................79 Subrogation and Reimbursement ...........................................................................................................84 Your Right To Appeal................................................................................................................................88 Notice of Adverse Benefit Determination ..................................................................................................88 Appeals......................................................................................................................................................88 How Your Appeal will be Decided..........................................................................................................89 Notification of the Outcome of the Appeal .............................................................................................90 Appeal Denial.........................................................................................................................................90 Voluntary Second Level Appeals...........................................................................................................90 External Review.....................................................................................................................................90 Requirement to file an Appeal before filing a lawsuit.............................................................................91 Eligibility and Enrollment – Adding Members........................................................................................92 Who is Eligible for Coverage .....................................................................................................................92 The Subscriber.......................................................................................................................................92 Dependents............................................................................................................................................92 Types of Coverage.................................................................................................................................93 When You Can Enroll................................................................................................................................93 Initial Enrollment ....................................................................................................................................93 Open Enrollment....................................................................................................................................93 Special Enrollment Periods....................................................................................................................93 Medicaid and Children’s Health Insurance Program Special Enrollment ..............................................94 Late Enrollees ........................................................................................................................................94 Members Covered Under the Employer’s Prior Plan.............................................................................94 Enrolling Dependent Children ...................................................................................................................94 Newborn Children ..................................................................................................................................94 Adopted Children ...................................................................................................................................95 Adding a Child due to Award of Legal Custody or Guardianship ..........................................................95 Qualified Medical Child Support Order ..................................................................................................95 Updating Coverage and/or Removing Dependents ..................................................................................95 Nondiscrimination ......................................................................................................................................95 Statements and Forms ..............................................................................................................................96 Termination and Continuation of Coverage ...........................................................................................97 Termination................................................................................................................................................97 Removal of Members ................................................................................................................................97