Cliff Berry Inc | Summary of Benefits and Coverage: Base Plan PPO
Summary of Benefits and Coverage: Base Plan PPO
Coverage Period: September 1, 2025 – August 31, 2026
Coverage For: Employee & Dependents
Plan Type: PPO
Important Information
This Summary of Benefits and Coverage (SBC) document helps you understand your health plan coverage and cost-sharing for covered health care services.
Note: Information about the cost of this plan (premiums) will be provided separately.
For complete terms of coverage or additional information:
- Call: 1-888-832-0354
- Website: provider-search.kariashealth.com
- Glossary of terms: healthcare.gov/sbc-glossary
Plan Overview: Important Questions
What is the overall deductible?
In-Network:
- Single Plan: $5,000 per employee
- Family Plan: $5,000 per person / $10,000 per family
Out-of-Network:
- Single Plan: $10,000 per employee
- Family Plan: $10,000 per person / $20,000 per family
Why this matters: Generally, you must 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. However, a copayment or coinsurance may apply.
The plan covers certain preventive services without cost sharing 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 for this plan?
In-Network:
- Single Plan: $7,350 per employee
- Family Plan: $7,350 per person / $14,700 per family
Out-of-Network:
- Single Plan: $14,700 per employee
- Family Plan: $14,700 per person / $29,400 per family
Why this matters: The out-of-pocket limit is the most you could pay in a year for covered services. Each family member must meet their own out-of-pocket limit until the overall family 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. You pay less when using in-network providers. You pay the most when using out-of-network providers, and you might receive a bill for the difference between the provider's charge and what your plan pays (balance billing).
Provider Search:
- Visit: provider-search.kariashealth.com
- Call Karias Care Concierge: 888-832-0354
Important: Your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?
No. You may see any specialist you choose without a referral.
Common Medical Events: What You Pay
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 & Notes |
|---|---|---|---|
| Primary care visit | $30 copay/visit; deductible waived | 50% 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 | $75 copay/visit; deductible waived | 50% 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 | 50% 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. |
If you have a test
| Service | In-Network | Out-of-Network | Limitations & Notes |
|---|---|---|---|
| Diagnostic test (x-rays, blood work) | 30% coinsurance | 50% coinsurance | None |
| Imaging (CT/PET scan, MRI) | 30% coinsurance | 50% coinsurance | Preauthorization required. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
If you need drugs to treat your illness or condition
Prescription drug coverage available at hpiTPA.com
Certain prescription drugs are subject to Step Therapy. You may be required to use different prescription drugs or pharmaceutical products first.
Deductible waived for all prescription drugs.
| Drug Type | In-Network | Out-of-Network |
|---|---|---|
| Generic drugs |
Retail (30 days): $10 copay Retail (90 days): $30 copay Mail Order (90 days): $20 copay |
Not covered |
| Preferred brand drugs |
Retail (30 days): $40 copay Retail (90 days): $120 copay Mail Order (90 days): $80 copay |
Not covered |
| Non-preferred brand drugs |
Retail (30 days): $75 copay Retail (90 days): $225 copay Mail Order (90 days): $150 copay |
Not covered |
| Specialty drugs |
20% coinsurance ($250 max) Retail & Mail Order (30 days) |
Not covered |
If you have outpatient surgery
| Service | In-Network | Out-of-Network | Limitations & Notes |
|---|---|---|---|
| Facility fee (e.g., ambulatory surgery center) | 30% coinsurance | 50% coinsurance | Preauthorization required. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
| Physician/surgeon fees | 30% coinsurance | 50% coinsurance | Preauthorization required. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
If you need immediate medical attention
| Service | In-Network | Out-of-Network | Limitations & Notes |
|---|---|---|---|
| Emergency room care | $500 copay/visit; deductible waived | $500 copay/visit; deductible waived | Copay waived if admitted |
| Emergency medical transportation | In-network deductible only | In-network deductible only | None |
| Urgent care | Deductible only | 50% coinsurance | None |
If you have a hospital stay
| Service | In-Network | Out-of-Network | Limitations & Notes |
|---|---|---|---|
| Facility fee (e.g., hospital room) | 30% coinsurance | 50% coinsurance | Preauthorization required. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
| Physician/surgeon fees | 30% coinsurance | 50% coinsurance | Preauthorization required. Penalty of $400 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 & Notes |
|---|---|---|---|
| Outpatient services - Office Visit | $30 copay/visit; deductible waived | 50% coinsurance | Preauthorization required for intensive outpatient treatment. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
| Outpatient services - Intensive outpatient treatment | No charge; deductible waived | 50% coinsurance | Preauthorization required for intensive outpatient treatment. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
| Inpatient services | 30% coinsurance | 50% coinsurance | Preauthorization required. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
If you are pregnant
| Service | In-Network | Out-of-Network | Limitations & Notes |
|---|---|---|---|
| Office visits - Prenatal | No charge; deductible waived | 50% coinsurance | Maternity care may include tests and services described elsewhere in SBC. |
| Office visits - Postnatal | 30% coinsurance | 50% coinsurance | Maternity care may include tests and services described elsewhere in SBC. |
| Childbirth/delivery professional services | 30% coinsurance | 50% coinsurance | Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) |
| Childbirth/delivery facility services | 30% coinsurance | 50% coinsurance | 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 & Notes |
|---|---|---|---|
| Home health care | $75 copay/visit; deductible waived | 50% coinsurance | 60 visits/yr. Preauthorization required. Penalty of $400 for failure to obtain preauthorization for out-of-network care. |
| Rehabilitation services - Inpatient | 30% coinsurance | 50% coinsurance | 60 days/yr with Skilled nursing care. Preauthorization required. Penalty of $400 for out-of-network. |
| Rehabilitation services - Outpatient | $75 copay/visit; deductible waived | 50% coinsurance | 30 visits/yr combined for Speech, Occupational & Physical therapies (preauthorization required after 13 visits each). Penalty of $400 for out-of-network. |
| Habilitation services - Early Intervention | No charge; deductible waived | 50% coinsurance | To age 3. Preauthorization & visit limits based on services provided. Penalty of $400 for out-of-network. |
| Habilitation services - Developmental Delay | No charge; deductible waived | 50% coinsurance | To age 3. Preauthorization & visit limits based on services provided. Penalty of $400 for out-of-network. |
| Skilled nursing care | 30% coinsurance | 50% coinsurance | 60 days/yr with Inpatient rehab. Preauthorization required. Penalty of $400 for out-of-network. |
| Durable medical equipment | 30% coinsurance | 50% coinsurance | Preauthorization required for insulin pumps/supplies, equipment over $2,500, and out-of-network providers. |
| Hospice services - Inpatient | 30% coinsurance | 50% coinsurance | Preauthorization required. Penalty of $400 for out-of-network. |
| Hospice services - Outpatient | $75 copay/visit; deductible waived | 50% coinsurance | Preauthorization required. Penalty of $400 for out-of-network. |
If your child needs dental or eye care
| Service | In-Network | Out-of-Network | Limitations & Notes |
|---|---|---|---|
| Children's eye exam | No charge; deductible waived | 50% coinsurance | 1 exam per 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
- 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 - see plan document for details)
- Acupuncture - 10 visits/yr
- Chiropractic care - 20 visits/yr
- Routine eye care (adult) - 1 exam per 24 months
Your Rights & Resources
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)
- Website: www.dol.gov/ebsa/healthreform
You may also explore coverage through the Health Insurance Marketplace:
- Website: www.HealthCare.gov
- Phone: 1-800-318-2596
Your Grievance and Appeals Rights
If you have a complaint or need to appeal a claim denial:
- Contact the plan: 1-888-832-0354
- U.S. Department of Labor: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
Review your explanation of benefits and plan documents for complete claim, appeal, and grievance procedures.
Minimum Essential Coverage & Minimum Value Standards
Does this plan provide Minimum Essential Coverage? Yes.
Does this plan meet Minimum Value Standards? Yes.
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 the plan might cover costs for sample medical situations.
Example 1: Having a Baby (Normal Delivery)
Plan Details:
- Overall deductible: $5,000
- Specialist copayment: $75
- Hospital (facility) coinsurance: 30%
- Other coinsurance: 30%
Services included: Specialist office visits (prenatal care), childbirth/delivery professional services, childbirth/delivery facility services, diagnostic tests (ultrasounds and blood work), specialist visit (anesthesia)
Total Example Cost: $12,700
Example 2: Managing Type 2 Diabetes (Routine Maintenance)
Plan Details:
- Overall deductible: $5,000
- Specialist copayment: $75
- Hospital (facility) coinsurance: 30%
- Other coinsurance: 30%
Services included: Primary care physician office visits (including disease education), diagnostic tests (blood work), prescription drugs, durable medical equipment (glucose meter)
Total Example Cost: $5,600
Example 3: Simple Fracture (Emergency Room Visit)
Plan Details:
- Overall deductible: $5,000
- Specialist copayment: $75
- Hospital (facility) coinsurance: 30%
- Other copayment: $75
Services included: Emergency room care (including medical supplies), diagnostic test (x-ray), durable medical equipment (crutches), rehabilitation services (physical therapy)
Total Example Cost: $2,800
For questions or assistance, contact Karias Care Concierge at 1-888-832-0354