| Cover Page | 12/21/2023 |
| Table of Contents | 12/21/2023 |
| Definitions | 12/21/2023 |
| How This Coverage Works (Introduction, Selecting a Primary Care Provider, Preauthorization, Medically Necessary) | 12/21/2023 |
| Access to Care and Transitional Care (Referrals, Specialty Care Provider as a PCP) | 12/21/2023 |
| Cost-Sharing Expenses and Allowed Amount | 12/21/2023 |
| Who Is Covered (Eligibility) | 12/21/2023 |
| Preventive Care (Well-Baby and Well-Child Care, Adult Annual Physical Examinations, Adult Immunizations, Well-Woman Examinations, Mammograms, Family Planning & Reproductive Health Services, Bone Mineral Density Measurements or Testing, Screening for Prostate Cancer) | 12/21/2023 |
| Ambulance and Pre-Hospital Emergency Medical Services | 12/21/2023 |
| Emergency Services and Urgent Care | 12/21/2023 |
| Outpatient and Professional Services (Acupuncture, Advanced Imaging Services, Allergy Testing and Treatment, Ambulatory Surgery Center, Chemotherapy, Chiropractic Services, Clinical Trials, Dialysis, Habilitation Services, Home Health Care, Infertility Treatment, Infusion Therapy, Interruption of Pregnancy, Laboratory Procedures, Diagnostic testing and Radiology Services, Maternity and Newborn Care, Medications for Use in the Office, Office Visits, Outpatient Hospital Services, Pre-admission Testing, Rehabilitation Services, Second Opinions, Surgical Services, Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive and Corrective Surgery, Transplants) | 04/03/2024 |
| Additional Benefits, Equipment and Devices (Autism Spectrum Disorder, Diabetic Equipment, Supplies and Self-Management Education, Durable Medical Equipment and Braces, Hearing Aids, Hospice, Prosthetics, Orthotics) | 12/21/2023 |
| Inpatient Services (Hospital Services, Observation Services, Inpatient Medical Services, Inpatient Stay for Maternity Care, Inpatient Stay for Mastectomy Care, Autologous Blood Banking Services, Rehabilitation Services, Skilled Nursing Facility, End of Life Care) | 12/21/2023 |
| Mental Health Care and Substance Use Services | 12/21/2023 |
| Prescription Drug Coverage | 12/21/2023 |
| Wellness Benefits | 12/21/2023 |
| Pediatric Vision Care | 12/21/2023 |
| Pediatric Dental Care | 12/21/2023 |
| Exclusions | 12/21/2023 |
| Claim Determinations | 12/21/2023 |
| Grievance | 12/21/2023 |
| Utilization Review | 12/21/2023 |
| External Appeal | 12/21/2023 |
| Termination | 12/21/2023 |
| Extension of Benefits | 12/21/2023 |
| Continuation | 12/21/2023 |
| Temporary Suspension Rights for Members of the Armed Forces | 12/21/2023 |
| General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification) | 12/21/2023 |
| Schedule of Benefits | 12/21/2023 |
| Age 29 Rider | 12/21/2023 |
| Travel and Lodging Rider | 12/21/2023 |