iv Table of Contents Schedule of Benefits ................................ ................................ ................................ ....... 1 Eligibility Provisions ................................ ................................ ................................ ......... 6 Termination and Continuation of Health Coverage ................................ ........................ 13 Co ntinuation Coverage (Self - Pay) ................................ ................................ ................. 16 Comprehensive Medical Coverage ................................ ................................ ................ 24 Preferred Provider Organization ................................ ................................ .................... 27 PHS+ Precertification Program ................................ ................................ ...................... 29 Case Management ................................ ................................ ................................ ........ 31 Disease Management Program ................................ ................................ ..................... 32 Employee Assistance Program ................................ ................................ ..................... 33 Covered Medical Charges List ................................ ................................ ...................... 34 Areas of Limited Coverage ................................ ................................ ............................ 37 Exclusions ................................ ................................ ................................ ..................... 54 Prescription Drug Coverage — CVS Caremark ................................ ............................... 57 Coordination of Benefits ................................ ................................ ................................ 63 Third - Party Liability and Right of Recovery ................................ ................................ .... 68 Claims Filing and Appeal Procedures ................................ ................................ ............ 72 Miscellaneous Provisions and Cost Savings Advice ................................ ...................... 87 General Benefit Provisions ................................ ................................ ............................ 96 Ge neral Information ................................ ................................ ................................ ....... 97 Glossary ................................ ................................ ................................ ...................... 102 Statement of ERISA Rights ................................ ................................ ......................... 109