10 Other Therapy Services ................................ ................................ ................................ ....................... 61 Transplant Services ................................ ................................ ................................ ................................ . 61 Urgent Care Services ................................ ................................ ................................ .............................. 61 Virtual Visits (Telemedicine / Telehealth Visits) ................................ ................................ ...................... 62 Vision Services ................................ ................................ ................................ ................................ ........ 62 Prescription Drugs Administered by a Medical Provider ................................ ................................ ..... 63 Important Details About Prescription Drug Coverage ................................ ................................ .......... 63 What’s Not Covered ................................ ................................ ................................ ................................ .. 65 EXPERIMENTAL OR INVESTIGATIONAL SERVICES EXCLUSION ................................ ................ 71 Claims Payment ................................ ................................ ................................ ................................ ........ 73 Maximum Allowed Amount ................................ ................................ ................................ ...................... 73 General ................................ ................................ ................................ ................................ ................ 73 Claims Review ................................ ................................ ................................ ................................ ......... 76 Notice of Claim / Claims Forms / Proof of Loss ................................ ................................ ....................... 77 Time Benefits Payable ................................ ................................ ................................ ............................. 77 Member’s Cooperation ................................ ................................ ................................ ............................ 78 Payment of Benefits ................................ ................................ ................................ ................................ 78 Inter - Plan Arrangements ................................ ................................ ................................ ......................... 78 Out - of - Area Services ................................ ................................ ................................ ........................... 78 Coordination of Benefits When Members Are Covered Under More Than One Plan ........................ 81 Subrogation and Reimbursement ................................ ................................ ................................ ........... 86 Your Right To Appeal ................................ ................................ ................................ ............................... 90 Notice of Adverse Benefit Determination ................................ ................................ ................................ 90 Appeals ................................ ................................ ................................ ................................ .................... 90 How Your Appeal will be Decided ................................ ................................ ................................ ........ 91 Notification of the Outcome of the Appeal ................................ ................................ ........................... 92 Appeal Denial ................................ ................................ ................................ ................................ ....... 92 Voluntary Second Level Appeals ................................ ................................ ................................ ......... 92 External Review ................................ ................................ ................................ ................................ ... 92 Requirement to file an Appeal before filing a lawsuit ................................ ................................ ........... 93 Eligibility and Enrollment – Adding Members ................................ ................................ ........................ 94 Who is Eligible for Coverage ................................ ................................ ................................ ................... 94 The Subscriber ................................ ................................ ................................ ................................ ..... 94 Dependents ................................ ................................ ................................ ................................ .......... 94 Types of Coverage ................................ ................................ ................................ ............................... 95 When You Can Enroll ................................ ................................ ................................ .............................. 95 Initial Enrollment ................................ ................................ ................................ ................................ .. 95 Open Enrollment ................................ ................................ ................................ ................................ .. 95 Special Enrollment Periods ................................ ................................ ................................ .................. 96 Medicaid and Children’s Health Insurance Program Special Enrollment ................................ ............ 96 Late Enrollees ................................ ................................ ................................ ................................ ...... 96 Members Covered Under the Employer’s Prior Plan ................................ ................................ ........... 96 Enrolling Dependent Children ................................ ................................ ................................ ................. 96 Newborn Children ................................ ................................ ................................ ................................ 96 Adopted Children ................................ ................................ ................................ ................................ . 97 Adding a Child due to Award of Legal Custody or Guardianship ................................ ........................ 97 Qualified Medical Child Support Order ................................ ................................ ................................ 97 Updating Coverage and/or Removing Dependents ................................ ................................ ................ 97 Nondiscrimination ................................ ................................ ................................ ................................ .... 98 Statements and Forms ................................ ................................ ................................ ............................ 98 Termination and Continuation of Coverage ................................ ................................ ........................... 99 Termination ................................ ................................ ................................ ................................ .............. 99