10 Other Therapy Services.......................................................................................................................64 Transplant Services.................................................................................................................................64 Urgent Care Services ..............................................................................................................................64 Virtual Visits (Telemedicine / Telehealth Visits) ......................................................................................65 Vision Services ........................................................................................................................................65 Prescription Drugs Administered by a Medical Provider .....................................................................66 Important Details About Prescription Drug Coverage..........................................................................66 What’s Not Covered ..................................................................................................................................68 EXPERIMENTAL OR INVESTIGATIONAL SERVICES EXCLUSION ................................................74 Claims Payment ........................................................................................................................................76 Maximum Allowed Amount......................................................................................................................76 General ................................................................................................................................................76 Claims Review.........................................................................................................................................79 Notice of Claim / Claims Forms / Proof of Loss.......................................................................................80 Time Benefits Payable.............................................................................................................................80 Member’s Cooperation ............................................................................................................................81 Payment of Benefits ................................................................................................................................81 Inter-Plan Arrangements .........................................................................................................................81 Out-of-Area Services ...........................................................................................................................81 Coordination of Benefits When Members Are Covered Under More Than One Plan ........................84 Subrogation and Reimbursement ...........................................................................................................89 Your Right To Appeal ...............................................................................................................................93 Notice of Adverse Benefit Determination ................................................................................................93 Appeals....................................................................................................................................................93 How Your Appeal will be Decided........................................................................................................94 Notification of the Outcome of the Appeal ...........................................................................................95 Appeal Denial.......................................................................................................................................95 Voluntary Second Level Appeals.........................................................................................................95 External Review...................................................................................................................................95 Requirement to file an Appeal before filing a lawsuit...........................................................................96 Eligibility and Enrollment – Adding Members........................................................................................97 Who is Eligible for Coverage ...................................................................................................................97 The Subscriber.....................................................................................................................................97 Dependents..........................................................................................................................................97 Types of Coverage...............................................................................................................................98 When You Can Enroll..............................................................................................................................98 Initial Enrollment ..................................................................................................................................98 Open Enrollment..................................................................................................................................98 Special Enrollment Periods..................................................................................................................99 Medicaid and Children’s Health Insurance Program Special Enrollment ............................................99 Late Enrollees ......................................................................................................................................99 Members Covered Under the Employer’s Prior Plan...........................................................................99 Enrolling Dependent Children .................................................................................................................99 Newborn Children ................................................................................................................................99 Adopted Children ...............................................................................................................................100 Adding a Child due to Award of Legal Custody or Guardianship ......................................................100 Qualified Medical Child Support Order ..............................................................................................100 Updating Coverage and/or Removing Dependents ..............................................................................100 Nondiscrimination ..................................................................................................................................101 Statements and Forms ..........................................................................................................................101 Termination and Continuation of Coverage .........................................................................................102 Termination............................................................................................................................................102