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 Claims Payment ........................................................................................................................................ 72 Maximum Allowed Amount ...................................................................................................................... 72 General ................................................................................................................................................ 72 Claims Review ......................................................................................................................................... 75 Notice of Claim / Claims Forms / Proof of Loss....................................................................................... 76 Time Benefits Payable ............................................................................................................................. 76 Member’s Cooperation ............................................................................................................................ 77 Payment of Benefits ................................................................................................................................ 77 Inter-Plan Arrangements ......................................................................................................................... 77 Out-of-Area Services ........................................................................................................................... 77 Coordination of Benefits When Members Are Covered Under More Than One Plan ........................ 80 Subrogation and Reimbursement ........................................................................................................... 85 Your Right To Appeal ............................................................................................................................... 89 Notice of Adverse Benefit Determination ................................................................................................ 89 Appeals .................................................................................................................................................... 89 How Your Appeal will be Decided ........................................................................................................ 90 Notification of the Outcome of the Appeal ........................................................................................... 91 Appeal Denial ....................................................................................................................................... 91 Voluntary Second Level Appeals ......................................................................................................... 91 External Review ................................................................................................................................... 91 Requirement to file an Appeal before filing a lawsuit ........................................................................... 92 Eligibility and Enrollment – Adding Members........................................................................................ 93 Who is Eligible for Coverage ................................................................................................................... 93 The Subscriber ..................................................................................................................................... 93 Dependents .......................................................................................................................................... 93 Types of Coverage ............................................................................................................................... 94 When You Can Enroll .............................................................................................................................. 94 Initial Enrollment .................................................................................................................................. 94 Open Enrollment .................................................................................................................................. 94 Special Enrollment Periods .................................................................................................................. 95 Medicaid and Children’s Health Insurance Program Special Enrollment ............................................ 95 Late Enrollees ...................................................................................................................................... 95 Members Covered Under the Employer’s Prior Plan ........................................................................... 95 Enrolling Dependent Children ................................................................................................................. 95 Newborn Children ................................................................................................................................ 95 Adopted Children ................................................................................................................................. 96 Adding a Child due to Award of Legal Custody or Guardianship ........................................................ 96 Qualified Medical Child Support Order ................................................................................................ 96 Updating Coverage and/or Removing Dependents ................................................................................ 96 Nondiscrimination .................................................................................................................................... 97 Statements and Forms ............................................................................................................................ 97 Termination and Continuation of Coverage ........................................................................................... 98 Termination .............................................................................................................................................. 98 Removal of Members .............................................................................................................................. 98 10