(1) The requirements for utilization review, prior authorization or step therapy for each category of prescription drug covered under a health plan;

(2) The cost-sharing requirements for prescription drug coverage, including a description of how the costs of prescription drugs will specifically be applied or not applied to any deductible or out-of-pocket maximum required under a health plan;

(3) The exclusions from coverage under a health plan and any restrictions on use or quantity of covered health care services in each category of benefits; and

(4) The amount of coverage provided under a health plan for out-of-network providers or noncovered health care services and any right of appeal available to an enrollee when out-of-network providers or noncovered health care services are medically necessary.