Table of Contents INTRODUCTION ........................................................................................................................................... 1 PLAN INFORMATION .................................................................................................................................. 2 MEDICAL SCHEDULE OF BENEFITS ........................................................................................................ 4 MEDICAL SCHEDULE OF BENEFITS ...................................................................................................... 10 MEDICAL SCHEDULE OF BENEFITS ...................................................................................................... 16 MEDICAL SCHEDULE OF BENEFITS ...................................................................................................... 22 TRANSPLANT SCHEDULE OF BENEFITS .............................................................................................. 29 TRANSPLANT SCHEDULE OF BENEFITS .............................................................................................. 30 OUT-OF-POCKET EXPENSES AND MAXIMUMS .................................................................................... 31 OUT-OF-POCKET EXPENSES AND MAXIMUMS .................................................................................... 33 ELIGIBILITY AND ENROLLMENT ............................................................................................................ 35 SPECIAL ENROLLMENT PROVISION ..................................................................................................... 39 TERMINATION ........................................................................................................................................... 41 COBRA CONTINUATION OF COVERAGE ............................................................................................... 43 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 .................. 51 PROTECTION FROM BALANCE BILLING ............................................................................................... 52 PROVIDER NETWORK .............................................................................................................................. 55 COVERED MEDICAL BENEFITS .............................................................................................................. 57 TELADOC SERVICES ................................................................................................................................ 68 HOME HEALTH CARE BENEFITS ............................................................................................................ 71 TRANSPLANT BENEFITS ......................................................................................................................... 72 PRESCRIPTION DRUG BENEFITS ........................................................................................................... 75 HEARING AID BENEFITS .......................................................................................................................... 76 MENTAL HEALTH BENEFITS ................................................................................................................... 77 SUBSTANCE USE DISORDER AND CHEMICAL DEPENDENCY BENEFITS ....................................... 78 UMR CARE: CLINICAL ADVOCACY RELATIONSHIPS TO EMPOWER .............................................. 79 CENTERS OF EXCELLENCE .................................................................................................................... 83