Your Medical Benefits

Participating in a Medical Plan

Eligibility

Qualified Medical Child Support Order

Enrolling

Coverage Levels

ID Cards

Pre-Existing Conditions

Cost of Coverage

When Coverage Begins

Changing Your Elections

Qualifying Change in Status

Special Enrollment Event

When Coverage Ends

Coverage for your Dependents ends on the last day of the month in which:

Certificate of Coverage

Coverage During a Leave

Short-Term Disability

Family Medical Leave

Leave of Absence

Long-Term Disability

Military Leave of Absence

How the Maroon Plan Works

Your Options

How It Works

Medically Necessary Care

Deductibles

Coinsurance

Eligible or Allowable Charges

Out-of-Pocket Maximum

Lifetime Maximum

Advantages of Using In-Network Providers

When You Must Pre-certify Care

If You Don’t Pre-certify

Information You Will Need When You Call

What Happens After You Call

What Is Covered

Hospice Care Benefits

Health Protection for Newborns and Mothers

Coverage for Breast Cancer

What Is Not Covered

How HMOs Work

Your Options

Choosing an HMO

Choosing a Coverage Level

How It Works

Your Primary Care Physician (PCP)

Referrals

In an Emergency

What Is Covered

Health Protection for Newborns and Mothers

Coverage for Breast Cancer

What Is Not Covered

Receiving Your Benefits

Filing a Claim

Maroon Plan

HMOs

Timeframe for Claim Review

Urgent Care Claims

Claim Requiring Advance Approval or Pre-Authorization

Approval of an Ongoing Course of Treatment

Post-Service Claim

If Your Claim Is Denied

Notification of Denial

Appealing Denied Claims

Review of Appeal

Urgent Care Claims

Claim Requiring Advance Approval or Pre-Authorization

Approval of an Ongoing Course of Treatment

Post-Service Claim

Notification of Appeal Denial

Coordination of Benefits

How Coordination of Benefits Works

Order of Coverage for You

Order of Coverage for Dependent Children

Payments

Coordination with Medicare

Benefit Overpayments

Right of Recovery

Administrative Information

Your ERISA Rights

Receive Information About Your Plans Benefits

Continue Group Plan Coverage

Prudent Actions by Plan Fiduciaries

Enforce Your Rights

Assistance with Your Questions

Discretionary Authority

Plan Amendment and Termination

Collective Bargaining

Privacy Information

Continuing Your Coverage Under COBRA – Very Important Notice for you and your spouse (if covered) or your Domestic Partner (if covered)

Qualified Beneficiaries

Qualifying Events

Benefits and Costs

When COBRA Coverage Ends

Disability Is a Special Case

Trade Act 2002

Additional Continuation Coverage Information

If You Have Questions

Other Plan Information

Glossary

A Final Note

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.