ii T a 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