ii TA B L E O F C O N T E N T S Welcome! ................................................................................................................ i Schedule of Benefits ............................................................................................... 1 Eligibility Provisions ................................................................................................. 7 Termination and Continuation of Health Coverage ................................................. 15 Continuation Coverage (Self-Pay) .......................................................................... 19 Comprehensive Medical Coverage ......................................................................... 28 No Surprises Act ..................................................................................................... 31 Preferred Provider Organization ............................................................................. 35 Quantum Health Care Coordination Program ......................................................... 38 Case Management .................................................................................................. 43 Personal Care Guide Management ......................................................................... 44 Covered Medical Charges List ................................................................................ 46 Areas of Limited Coverage ...................................................................................... 49 Exclusions ............................................................................................................... 70 Prescription Drug Coverage—CVS Caremark / Virta .............................................. 74 Coordination of Benefits .......................................................................................... 82 Third-Party Liability and Right of Recovery ............................................................. 88 Claims Filing and Appeal Procedures ..................................................................... 92 Miscellaneous Provisions and Cost Savings Advice ............................................... 109 General Benefit Provisions ...................................................................................... 119 General Information ................................................................................................ 120 Glossary .................................................................................................................. 126 Statement of ERISA Rights ..................................................................................... 136