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Western Montana Providence Health & Services - SPD Group #2000204 - January 1, 2011
Page 8 and 9: PPO BENEFITThis Plan provides benef
Page 10 and 11: Schedule of Medical Benefits - Prov
Page 12 and 13: Schedule of Medical Benefits - Prov
Page 14: Schedule of Medical Benefits - Prov
Page 17 and 18: PHARMACY BENEFITPrescription drug c
Page 19 and 20: Pharmacy BenefitSERVICE OPTIONSThe
Page 21 and 22: Pharmacy Benefit8. Legend vitamins
Page 23 and 24: Medical Benefit Determination Requi
Page 25 and 26: MEDICAL BENEFITSThe following Medic
Page 27 and 28: Medical Benefits10. Charges for Sur
Page 29 and 30: Medical BenefitsPre-authorization o
Page 31 and 32: Medical Benefits4. Transportation s
Page 33 and 34: Medical BenefitsRECONSTRUCTIVE BREA
Page 35 and 36: Medical BenefitsServices for donors
Page 37 and 38: PRE-AUTHORIZATIONTHE BENEFITS QUOTE
Page 39 and 40: HOSPITAL ADMISSION CERTIFICATIONPre
Page 41 and 42: MEDICAL BENEFIT EXCLUSIONSThe Gener
Page 43 and 44: Medical Benefit Exclusions29. Charg
Page 45 and 46: General Plan Exclusions and Limitat
Page 47 and 48: COORDINATION OF BENEFITSThe Coordin
Page 49 and 50: Coordination of BenefitsB. The star
Page 51 and 52: PROCEDURES FOR CLAIMING BENEFITSCla
Page 53 and 54:
Procedures for Claiming BenefitsIf
Page 55 and 56:
ELIGIBILITY PROVISIONSIf both the h
Page 57 and 58:
Eligibility ProvisionsRETIREE ELIGI
Page 59 and 60:
Effective Date of CoverageOPEN ENRO
Page 61 and 62:
Effective Date of CoverageA loss of
Page 63 and 64:
Qualified Medical Child Support Ord
Page 65 and 66:
Family and Medical Leave ActEMPLOYE
Page 67 and 68:
TERMINATION OF COVERAGEPARTICIPANT
Page 69 and 70:
Termination of Coverage5. The date
Page 71 and 72:
Continued Coverage After Terminatio
Page 73 and 74:
Continued Coverage After Terminatio
Page 76 and 77:
Continuation Coverage For Adult Ben
Page 78:
FRAUD AND ABUSETHIS PLAN IS SUBJECT
Page 81 and 82:
Recovery/Reimbursement/SubrogationR
Page 83 and 84:
Plan AdministrationCONTRIBUTIONS TO
Page 85 and 86:
GENERAL PROVISIONSEXAMINATIONThe Pl
Page 87 and 88:
GENERAL DEFINITIONSCertain words an
Page 89 and 90:
General DefinitionsCONVALESCENT PER
Page 91 and 92:
General DefinitionsEMPLOYEE“Emplo
Page 93 and 94:
General Definitions6. It is not, ot
Page 95 and 96:
General DefinitionsC. The billed ch
Page 97 and 98:
General DefinitionsPARTIAL HOSPITAL
Page 99 and 100:
General DefinitionsQUALIFIED BENEFI
Page 101 and 102:
ERISA STATEMENT OF RIGHTSAs a Parti
Page 103 and 104:
HIPAA PRIVACY AND SECURITY STANDARD
Page 105 and 106:
WESTERN MONTANA PROVIDENCE HEALTH &
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