147
‘‘(i) the latest summary plan descrip-
tion, including the latest summary of ma-
terial modifications; and 
‘‘(ii) the actual plan provisions setting 
forth the benefits available under the plan, 
to the extent such information relates to the 
coverage options under the plan available to the 
participant or beneficiary. A reasonable charge 
may be made to cover the cost of providing 
such information in such generally recognized 
electronic format. The Secretary may by regula-
tion prescribe a maximum amount which will 
constitute a reasonable charge under the pre-
ceding sentence. 
‘‘(B) ALTERNATIVE ACCESS.—The require-
ments of this paragraph may be met by making 
such information generally available (rather 
than upon request) on the Internet or on a pro-
prietary computer network in a format which is 
readily accessible to participants and bene-
ficiaries. 
‘‘(2) ADDITIONAL
INFORMATION
TO
BE
PRO-
VIDED ON REQUEST.—
‘‘(A) INCLUSION IN SUMMARY PLAN DE-
SCRIPTION
OF
SUMMARY
OF
ADDITIONAL
IN-
148
FORMATION.—The information required under 
subsection (a) includes a summary description 
of the types of information required by this 
subsection to be made available to participants 
and beneficiaries on request. 
‘‘(B) 
INFORMATION
REQUIRED
FROM 
PLANS AND ISSUERS ON REQUEST.—In addition 
to information required to be included in sum-
mary plan descriptions under this subsection, a 
group health plan (and a health insurance 
issuer offering health insurance coverage in 
connection with a group health plan) shall pro-
vide the following information to a participant 
or beneficiary on request: 
‘‘(i) NETWORK CHARACTERISTICS.—If 
the plan (or issuer) utilizes a defined set of 
providers under contract with the plan (or 
issuer), a detailed list of the names of such 
providers and their geographic location, set 
forth separately with respect to primary 
care providers and with respect to special-
ists. 
‘‘(ii) CARE
MANAGEMENT
INFORMA-
TION.—A description of the circumstances 
under which, and the extent to which, the
149
plan has special disease management pro-
grams or programs for persons with dis-
abilities, indicating whether these pro-
grams are voluntary or mandatory and 
whether a significant benefit differential 
results from participation in such pro-
grams. 
‘‘(iii) INCLUSION
OF
DRUGS
AND 
BIOLOGICALS IN FORMULARIES.—A state-
ment of whether a specific drug or biologi-
cal is included in a formulary used to de-
termine benefits under the plan and a de-
scription of the procedures for considering 
requests for any patient-specific waivers.
‘‘(iv) PROCEDURES FOR DETERMINING 
EXCLUSIONS BASED ON MEDICAL NECES-
SITY OR EXPERIMENTAL TREATMENTS.—
Upon receipt by the participant or bene-
ficiary of any notification of an adverse 
coverage decision based on a determination 
relating to medical necessity or an experi-
mental treatment or technology, a descrip-
tion of the procedures and medically-based 
criteria used in such decision.
150
‘‘(v) PREAUTHORIZATION AND UTILI-
ZATION REVIEW PROCEDURES.—Upon re-
ceipt by the participant or beneficiary of 
any notification of an adverse coverage de-
cision, a description of the basis on which 
any preauthorization requirement or any 
utilization review requirement has resulted 
in such decision. 
‘‘(vi) ACCREDITATION
STATUS
OF 
HEALTH INSURANCE ISSUERS AND SERV-
ICE PROVIDERS.—A description of the ac-
creditation and licensing status (if any) of 
each health insurance issuer offering 
health insurance coverage in connection 
with the plan and of any utilization review 
organization utilized by the issuer or the 
plan, together with the name and address 
of the accrediting or licensing authority. 
‘‘(vii) MEASURES OF ENROLLEE SAT-
ISFACTION.—The latest information (if 
any) maintained by the plan, or by any 
health insurance issuer offering health in-
surance coverage in connection with the 
plan, relating to enrollee satisfaction.
151
‘‘(viii) QUALITY PERFORMANCE MEAS-
URES.—The latest information (if any) 
maintained by the plan, or by any health 
insurance issuer offering health insurance 
coverage in connection with the plan, relat-
ing to quality of performance of the deliv-
ery of medical care with respect to cov-
erage options offered under the plan and 
of health care professionals and facilities 
providing medical care under the plan. 
‘‘(C) 
INFORMATION
REQUIRED
FROM 
HEALTH CARE PROFESSIONALS ON REQUEST.—
Any health care professional treating a partici-
pant or beneficiary under a group health plan 
shall provide to the participant or beneficiary, 
on request, a description of his or her profes-
sional qualifications (including board certifi-
cation status, licensing status, and accreditation 
status, if any), privileges, and experience and a 
general description by category (including sal-
ary, fee-for-service, capitation, and such other 
categories as may be specified in regulations of 
the Secretary) of the applicable method by 
which such professional is compensated in con-
nection with the provision of such medical care.
152
‘‘(D) 
INFORMATION
REQUIRED
FROM 
HEALTH CARE FACILITIES ON REQUEST.—Any 
health care facility from which a participant or 
beneficiary has sought treatment under a group 
health plan shall provide to the participant or 
beneficiary, on request, a description of the fa-
cility’s corporate form or other organizational 
form and all forms of licensing and accredita-
tion status (if any) assigned to the facility by 
standard-setting organizations. 
‘‘(f) ACCESS TO INFORMATION RELEVANT TO THE 
COVERAGE OPTIONS UNDER WHICH THE PARTICIPANT 
OR BENEFICIARY IS ELIGIBLE TO ENROLL.—In addition 
to information otherwise required to be made available 
under this section, a group health plan (and a health in-
surance issuer offering health insurance coverage in con-
nection with a group health plan) shall, upon written re-
quest (made not more frequently than annually), make 
available to a participant (and an employee who, under 
the terms of the plan, is eligible for coverage but not en-
rolled) in connection with a period of enrollment the sum-
mary plan description for any coverage option under the 
plan under which the participant is eligible to enroll and 
any information described in clauses (i), (ii), (iii), (vi), 
(vii), and (viii) of subsection (e)(2)(B).