(1) Every subscriber shall be issued an evidence of coverage which shall contain a clear and complete statement of:

(a) The services to which each enrollee is entitled;

(b) Any limitation of the services, kind of services, or benefits to be provided and exclusions, including any deductible, copayment, or other charges;

(c) Where and in what manner information is available as to where and how services may be obtained; and

(d) The method for resolving complaints.

(2) Any amendment to the evidence of coverage may be provided to the subscriber in a separate document.