iv TA B L E O F C O N T E N T S Welcome! ........................................................................................................................ iii Schedule of Benefits ........................................................................................................ 1 Eligibility Provisions .......................................................................................................... 6 Termination and Continuation of Health Coverage ........................................................ 14 Continuation Coverage (Self-Pay) ................................................................................. 18 Comprehensive Medical Coverage ................................................................................ 27 No Surprises Act ............................................................................................................ 30 Preferred Provider Organization .................................................................................... 34 Quantum Health Care Coordination Program ................................................................ 37 Case Management ......................................................................................................... 42 Personal Care Guide Management ................................................................................ 43 Covered Medical Charges List ....................................................................................... 45 Areas of Limited Coverage ............................................................................................. 48 Exclusions ...................................................................................................................... 69 Prescription Drug Coverage—CVS Caremark / Virta ..................................................... 73 Coordination of Benefits ................................................................................................. 81 Third-Party Liability and Right of Recovery .................................................................... 87 Claims Filing and Appeal Procedures ............................................................................ 91 Miscellaneous Provisions and Cost Savings Advice .................................................... 108 General Benefit Provisions ........................................................................................... 118 General Information ..................................................................................................... 119 Glossary ....................................................................................................................... 125 Statement of ERISA Rights .......................................................................................... 135