Cliff Berry Inc | Summary of Benefits and Coverage: High Plan PPO
Summary of Benefits and Coverage: High Plan PPO
Coverage Period: September 1, 2025 – August 31, 2026
Plan Provider: Cliff Berry, Inc.
Plan Type: PPO (Preferred Provider Organization)
Coverage For: Employee & Dependents
Important Plan Information
This Summary of Benefits and Coverage (SBC) document helps you understand what this health plan covers and what you'll pay for covered services. For complete terms of coverage or to get more information, call 1-888-832-0354.
For general definitions of common insurance terms like allowed amount, balance billing, coinsurance, copayment, deductible, provider, and other underlined terms, visit healthcare.gov/sbc-glossary or call 1-888-832-0354.
Key Questions About Your Coverage
What is the Overall Deductible?
In-Network:
- Single Plan: $1,500 per employee
- Family Plan: $1,500 per person / $3,000 family
Out-of-Network:
- Single Plan: $3,000 per employee
- Family Plan: $3,000 per person / $6,000 family
What This Means: Generally, you must pay all costs from providers up to the deductible amount before this plan begins to pay. For family plans, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
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. This plan covers certain preventive services without cost sharing and before you meet your deductible. See the list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits.
Are There Other Deductibles for Specific Services?
No. You don't have to meet separate deductibles for specific services.
What is the Out-of-Pocket Limit?
In-Network:
- Single Plan: $5,000 per employee
- Family Plan: $5,000 per person / $10,000 family
Out-of-Network:
- Single Plan: $10,000 per employee
- Family Plan: $10,000 per person / $20,000 family
What This Means: The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members on this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit is met.
What is NOT Included in the Out-of-Pocket Limit?
The following expenses do NOT count toward your out-of-pocket limit:
- Preauthorization penalties
- Premiums
- Balance billing charges
- Healthcare services 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 you use in-network providers. You pay the most when you use out-of-network providers, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware that your network provider might use an out-of-network provider for some services (such as lab work). Always check with your provider before you get services.
Do You Need a Referral to See a Specialist?
No. You can see any specialist you choose without a referral.
Common Medical Events: What You'll Pay
Note: All copayment and coinsurance costs shown below are AFTER your deductible has been met, if a deductible applies.
If You Visit a Healthcare Provider's Office or Clinic
| Service | In-Network Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Primary Care Visit (injury/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 | $50 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 | Covered services listed at healthcare.gov |
If You Have a Test
| Service | In-Network Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Diagnostic Tests (X-rays, blood work) | $40 copay/visit; deductible waived | 40% coinsurance | None |
| All Other Diagnostic Tests | No charge; deductible waived | 40% coinsurance | None |
| Lab Work | 20% coinsurance | 40% coinsurance | None |
| Imaging (CT/PET scan, MRI) | $300 copay/visit; deductible waived | 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
Deductible waived for all prescription drugs. Out-of-network drugs NOT covered.
Certain prescription drugs are subject to Step Therapy. You may be required to use different prescription drugs or pharmaceutical products first.
| Drug Type | Retail (30 days) | Retail (90 days) | Mail Order (90 days) |
|---|---|---|---|
| Generic Drugs | $10 copay | $30 copay | $20 copay |
| Preferred Brand Drugs | $40 copay | $120 copay | $80 copay |
| Non-Preferred Brand Drugs | $75 copay | $225 copay | $150 copay |
| Specialty Drugs | 20% coinsurance ($250 max) | — | 20% coinsurance ($250 max) |
More prescription drug coverage information is available at hpiTPA.com.
If You Have Outpatient Surgery
| Service | In-Network Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Facility Fee - Hospital Based | Deductible then $800 copay/visit | 40% coinsurance | Preauthorization required. $400 penalty for failure to obtain preauthorization for out-of-network care. |
| Facility Fee - Freestanding Facility | $400 copay/visit; deductible waived | 40% coinsurance | Preauthorization required. $400 penalty for failure to obtain preauthorization for out-of-network care. |
| Physician/Surgeon Fees - Hospital Based | Deductible only | 40% coinsurance | Preauthorization required. $400 penalty for failure to obtain preauthorization for out-of-network care. |
| Physician/Surgeon Fees - Freestanding | No charge; deductible waived | 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 Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| 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 Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Facility Fee (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 Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Outpatient Services - Office Visit | $25 copay/visit; deductible waived | 40% coinsurance | Preauthorization required for intensive outpatient treatment. $400 penalty for out-of-network failure to preauthorize. |
| Outpatient Services - Intensive Treatment | No charge; deductible waived | 40% coinsurance | Preauthorization required for intensive outpatient treatment. $400 penalty for out-of-network failure to preauthorize. |
| Inpatient Services | 20% coinsurance | 40% coinsurance | Preauthorization required. $400 penalty for out-of-network failure to preauthorize. |
If You Are Pregnant
| Service | In-Network Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Office Visits - Prenatal | No charge; deductible waived | 40% coinsurance | Maternity care may include tests and services described elsewhere in SBC. |
| Office Visits - Postnatal | 20% coinsurance | 40% coinsurance | Maternity care may include tests and services described elsewhere in SBC. |
| Childbirth/Delivery Professional Services | 20% coinsurance | 40% coinsurance | Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) |
| Childbirth/Delivery Facility Services | 20% coinsurance | 40% 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 Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Home Health Care | $50 copay/visit; deductible waived | 40% coinsurance | 60 visits/year. Preauthorization required. $400 penalty for out-of-network failure to preauthorize. |
| Rehabilitation Services - Inpatient | 20% coinsurance | 40% coinsurance | 60 days/year with skilled nursing care. Preauthorization required. $400 penalty for out-of-network failure to preauthorize. |
| Rehabilitation Services - Outpatient | $50 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 failure to preauthorize. |
| 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 failure to preauthorize. |
| 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 failure to preauthorize. |
| Skilled Nursing Care | 20% coinsurance | 40% coinsurance | 60 days/year with inpatient rehab. Preauthorization required. $400 penalty for out-of-network failure to preauthorize. |
| Durable Medical Equipment | 20% coinsurance | 40% coinsurance | Preauthorization required for insulin pumps/supplies, equipment over $2,500, and out-of-network providers |
| Hospice Services - Inpatient | 20% coinsurance | 40% coinsurance | Preauthorization required. $400 penalty for out-of-network failure to preauthorize. |
| Hospice Services - Outpatient | $50 copay/visit; deductible waived | 40% coinsurance | Preauthorization required. $400 penalty for out-of-network failure to preauthorize. |
If Your Child Needs Dental or Eye Care
| Service | In-Network Provider | Out-of-Network Provider | Limitations & Notes |
|---|---|---|---|
| Children's Eye Exam | No charge; deductible waived | 40% 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
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 per year
- Chiropractic Care: 20 visits per year
- Routine Eye Care (Adult): 1 exam per 24 months
Your Rights and Resources
Your Rights to Continue Coverage
If you want to continue your 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
If you have a complaint against your plan for a denial of a claim (called a grievance or appeal):
- Contact the plan at 1-888-832-0354
- Contact the U.S. Department of Labor's Employee Benefits Security Administration at 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 medical costs in common situations. The actual costs may vary depending on the care you receive, the prices your providers charge, and other factors.
Example 1: Having a Baby (Normal Delivery)
Plan Assumptions:
- Overall deductible: $1,500
- Specialist copayment: $50
- Hospital facility coinsurance: 20%
- Other copayment: $25
Services Include: 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
What Peg Would Pay:
- Cost sharing: $2,900
- Deductibles: $1,500
- Copayments: $200
- Coinsurance: $1,200
Example 2: Managing Type 2 Diabetes (Routine Maintenance)
Plan Assumptions:
- Overall deductible: $1,500
- Specialist copayment: $50
- Hospital facility coinsurance: 20%
- Other coinsurance: 20%
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
What Joe Would Pay:
- Cost sharing: $2,200
- Deductibles: $1,500
- Copayments: $500
- Coinsurance: $200
Example 3: Simple Fracture (Emergency Room Visit)
Plan Assumptions:
- Overall deductible: $1,500
- Specialist copayment: $50
- Hospital facility coinsurance: 20%
- Other copayment: $50
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
What Mia Would Pay:
- Cost sharing: $900
- Deductibles: $0
- Copayments: $700
- Coinsurance: $200
Contact Information
For Questions or Assistance:
- Phone: 1-888-832-0354
- Provider Search: provider-search.kariashealth.com
- Prescription Drug Information: hpiTPA.com
- Plan Glossary: healthcare.gov/sbc-glossary