Cliff Berry Inc | Mid Plan PPO - Summary of Benefits and Coverage
Mid Plan PPO - Summary of Benefits and Coverage
Coverage Period: September 1, 2025 – August 31, 2026
Plan Sponsor: Cliff Berry, Inc.
Coverage For: Employee & Dependents
Plan Type: PPO
About This Summary
The Summary of Benefits and Coverage (SBC) helps you understand your health plan options. This document shows how you and the plan share costs for covered health care services.
Important: This is only a summary. For complete coverage details, call 1-888-832-0354 or visit the provider search at provider-search.kariashealth.com.
For general definitions of terms like allowed amount, balance billing, coinsurance, copayment, deductible, and provider, visit healthcare.gov/sbc-glossary.
Important Questions at a Glance
What is the Overall Deductible?
In-Network:
- Single Plan: $3,500 per employee
- Family Plan: $3,500 per person / $7,000 family
Out-of-Network:
- Single Plan: $7,000 per employee
- Family Plan: $7,000 per person / $14,000 family
You must generally pay all costs from providers up to the deductible amount before the plan begins to pay. Each family member must meet their own individual deductible until the total family deductible is met.
Are There Services Covered Before You Meet Your Deductible?
Yes. In-network preventive services and physician office visits are covered before you meet your deductible. The plan covers certain preventive services without cost sharing and before you meet your deductible. See covered preventive services at healthcare.gov/coverage/preventive-care-benefits.
Are There Other Deductibles for Specific Services?
No. You don't have to meet deductibles for specific services.
What is the Out-of-Pocket Limit?
In-Network:
- Single Plan: $6,600 per employee
- Family Plan: $6,600 per person / $13,200 family
Out-of-Network:
- Single Plan: $13,200 per employee
- Family Plan: $13,200 per person / $26,400 family
The out-of-pocket limit is the most you could pay in a year for covered services. Family members must meet their own limits until the overall family out-of-pocket limit is met.
What is NOT Included in the Out-of-Pocket Limit?
- Preauthorization penalties
- Premiums
- Balance billing charges
- Health care this plan doesn't cover
Will You Pay Less if You Use a Network Provider?
Yes. Visit provider-search.kariashealth.com to search for service providers or call the Karias Care Concierge at 888-832-0354 for assistance.
You pay less when using in-network providers. You pay the most for out-of-network providers and might receive a bill for the difference between the provider's charge and what your plan pays (balance billing). Be aware that network providers might use out-of-network providers for some services (such as lab work). Always check with your provider before getting services.
Do You Need a Referral to See a Specialist?
No. You may see a specialist you choose without a referral.
Common Medical Events - What You Will Pay
Important: All copayment and coinsurance costs shown are after your deductible has been met, if a deductible applies.
If You Visit a Health Care Provider's Office or Clinic
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Primary care visit to treat injury or illness | $25 copay/visit; deductible waived | 40% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if services are preventive, then check what your plan will pay. |
| Specialist visit | $65 copay/visit; deductible waived | 40% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if services are preventive, then check what your plan will pay. |
| Preventive care/Screening/Immunization | No charge; deductible waived | 40% coinsurance |
You may have to pay for services that aren’t preventive. Ask your provider if the services are preventive. Then check what your plan will pay. |
If You Have a Test
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Diagnostic tests (blood work, X-rays, all other diagnostic tests) | No charge; deductible waived / 20% coinsurance | 40% coinsurance / 40% coinsurance | None |
| Imaging (CT/PET scan, MRI) | 20% coinsurance | 40% coinsurance | Preauthorization required; $400 penalty for failure to obtain preauthorization for out-of-network care |
If You Need Drugs to Treat Your Illness or Condition
All prescription drug copays have the deductible waived. Out-of-network prescriptions are not covered.
Retail (30 days) / Retail (90 days) / Mail Order (90 days):*
| Drug Type | In-Network Copay | Notes |
|---|---|---|
| Generic drugs | $10 / $30 / $20 |
Deductible waived. Certain prescription drugs are subject to Step Therapy. You may be required to use different prescription drug or pharmaceutical product(s) first |
| Preferred brand drugs | $40 / $120 / $80 |
Deductible waived. Certain prescription drugs are subject to Step Therapy. You may be required to use different prescription drug or pharmaceutical product(s) first |
| Non-preferred brand drugs | $75 / $225 / $150 |
Deductible waived. Certain prescription drugs are subject to Step Therapy. You may be required to use different prescription drug or pharmaceutical product(s) first |
| Specialty drugs (Retail & Mail Order 30 days) | 20% coinsurance ($250 max) |
Deductible waived. Certain prescription drugs are subject to Step Therapy. You may be required to use different prescription drug or pharmaceutical product(s) first |
More information about prescription drug coverage is available at hpiTPA.com
If You Have Outpatient Surgery
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Facility fee (e.g., ambulatory surgery center) | 20% coinsurance | 40% coinsurance | Preauthorization required; $400 penalty for failure to obtain preauthorization for out-of-network care |
| Physician/surgeon fees | 20% coinsurance | 40% coinsurance | Preauthorization required; $400 penalty for failure to obtain preauthorization for out-of-network care |
If You Need Immediate Medical Attention
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Emergency room care | $500 copay/visit; deductible waived | $500 copay/visit; deductible waived | Copay waived if admitted |
| Emergency medical transportation | $200 copay/visit; deductible waived | $200 copay/visit; deductible waived | None |
| Urgent care | $80 copay/visit; deductible waived | 40% coinsurance | None |
If You Have a Hospital Stay
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Facility fee (e.g., hospital room) | 20% coinsurance | 40% coinsurance | Preauthorization required; $400 penalty for failure to obtain preauthorization for out-of-network care |
| Physician/surgeon fees | 20% coinsurance | 40% coinsurance | Preauthorization required; $400 penalty for failure to obtain preauthorization for out-of-network care |
If You Need Mental Health, Behavioral Health, or Substance Abuse Services
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Outpatient services (Office Visit) | $25 copay/visit; deductible waived | 40% coinsurance | Preauthorization required for intensive outpatient treatment; $400 penalty for failure to obtain preauthorization for out-of-network care |
| Intensive outpatient treatment | No charge; deductible waived | 40% coinsurance | Preauthorization required for intensive outpatient treatment; $400 penalty for failure to obtain preauthorization for out-of-network care |
| Inpatient services | 20% coinsurance | 40% coinsurance | Preauthorization required; $400 penalty for failure to obtain preauthorization for out-of-network care |
If You Are Pregnant
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Office visits (Prenatal/Postnatal) | No charge; deductible waived / 20% coinsurance | 40% coinsurance | Maternity care may include tests and services described elsewhere in SBC. Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) |
| Childbirth/delivery professional services | 20% coinsurance | 40% coinsurance | Maternity care may include tests and services described elsewhere in SBC. Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) |
| Childbirth/delivery facility services | 20% coinsurance | 40% coinsurance | Maternity care may include tests and services described elsewhere in SBC. Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) |
If You Need Help Recovering or Have Other Special Health Needs
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Home health care | $65 copay/visit; deductible waived | 40% coinsurance | 60 visits/year; Preauthorization required; $400 penalty for out-of-network |
| Rehabilitation services - Inpatient | 20% coinsurance | 40% coinsurance | 60 days/year with skilled nursing care; Preauthorization required; $400 penalty for out-of-network |
| Rehabilitation services - Outpatient | $65 copay/visit; deductible waived | 40% coinsurance | 30 visits/year combined for Speech, Occupational & Physical therapies (preauthorization required after 13 visits each); $400 penalty for out-of-network |
| Habilitation services - Early Intervention | No charge; deductible waived | 40% coinsurance | To age 3; Preauthorization & visit limits based on services provided; $400 penalty for out-of-network |
| Habilitation services - Developmental Delay | No charge; deductible waived | 40% coinsurance | To age 3; Preauthorization & visit limits based on services provided; $400 penalty for out-of-network |
| Skilled nursing care | 20% coinsurance | 40% coinsurance | 60 days/year with inpatient rehab; Preauthorization required for out-of-network or pay $400 more |
| Durable medical equipment | 20% coinsurance | 40% coinsurance | Preauthorization required for insulin pumps/supplies, equipment over $2,500, out-of-network providers |
| Hospice services - Inpatient | 20% coinsurance | 40% coinsurance | Preauthorization required; $400 penalty for out-of-network |
| Hospice services - Outpatient | $65 copay/visit; deductible waived | 40% coinsurance | Same as above |
If Your Child Needs Dental or Eye Care
| Service | In-Network | Out-of-Network | Limitations & Exceptions |
|---|---|---|---|
| Children's eye exam | No charge; deductible waived | 40% coinsurance | 1 exam/24 months |
| Children's glasses | Not covered | Not covered | n/a |
| Children's dental check-up | Not covered | Not covered | n/a |
Excluded Services & Other Covered Services
Services Your Plan Generally Does NOT Cover
Check your policy or plan document for more information and a complete list of excluded services.
- Bariatric surgery
- Cosmetic surgery
- Dental care (routine adult & child)
- Hearing aids
- Infertility treatment
- Long-term care
- Non-emergency care when traveling outside U.S.
- Private duty nursing
- Routine foot care
- Weight loss programs
Other Covered Services
Limitations may apply to these services. This isn't a complete list. Please see your plan document.
- Acupuncture (10 visits/year)
- Chiropractic care (20 visits/year)
- Routine eye care (adult - 1 exam/24 months)
Your Rights and Responsibilities
Your Rights to Continue Coverage
If you want to continue coverage after it ends, contact:
- Department of Labor's Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
- Health Insurance Marketplace: www.HealthCare.gov or 1-800-318-2596
Your Grievance and Appeals Rights
To file a complaint (grievance or appeal) for a denial of claim:
- Contact the plan at 1-888-832-0354
- U.S. Department of Labor's Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
Does This Plan Provide Minimum Essential Coverage?
Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.
Does This Plan Meet Minimum Value Standards?
Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services
- Spanish (Español): Para obtener asistencia en Español, llame al 1-888-832-0354
- Portuguese (Português): De assistência em Português, ligue 1-888-832-0354
- Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-888-832-0354
Coverage Examples
These examples show how this plan might cover costs for sample medical situations. Your actual costs will be different depending on the care you receive, the prices your providers charge, and other factors.
Plan Cost-Sharing:
- Overall deductible: $3,500
- Specialist copayment: $65
- Hospital (facility) coinsurance: 20%
- Other coinsurance: 20%
Example 1: Having a Baby (Normal Delivery)
Services include: Specialist office visits (prenatal care), childbirth/delivery professional and facility services, diagnostic tests (ultrasounds and blood work), specialist visit (anesthesia)
- Total Example Cost: $12,700
- In this example, Peg would pay: [Cost-sharing based on plan provisions]
Example 2: Managing Type 2 Diabetes (Routine Maintenance)
Services include: Primary care physician office visits (including disease education), diagnostic tests (blood work), prescription drugs, durable medical equipment (glucose meter)
- Total Example Cost: $5,600
- In this example, Joe would pay: [Cost-sharing based on plan provisions]
Example 3: Simple Fracture (Emergency Room Visit)
Services include: Emergency room care (including medical supplies), diagnostic test (x-ray), durable medical equipment (crutches), rehabilitation services (physical therapy)
- Total Example Cost: $2,800
- In this example, Mia would pay: [Cost-sharing based on plan provisions]
Contact Information
For Questions: Call 1-888-832-0354
Provider Search: provider-search.kariashealth.com
Prescription Coverage: hpiTPA.com
Karias Care Concierge: 888-832-0354