Schedule of Medical Benefits for Cliff Berry, Inc. - Base Plan (PPO)
This is the official Schedule of Medical Benefits for Cliff Berry, Inc. Base Plan (Group #006R2563), a PPO managed care plan effective September 1, 2025. The schedule outlines complete benefit coverage including dual network structure (HPHC for 3 New England states, UnitedHealthcare for 47 other states), In-Network deductibles of $5,000 individual/$10,000 family, Out-of-Pocket Maximums of $7,350 individual/$14,700 family, and 70% In-Network/50% Out-of-Network coinsurance. Prescription drug benefits are administered by TrueScripts with retail and mail order options featuring co-payments from $10-$75 and specialty drugs at 20% coinsurance up to $250. The plan includes 100% coverage for preventive care (no deductible), precertification requirements for inpatient and select outpatient services with $400 Out-of-Network penalty, and special programs including SCM+ dialysis carve-out and No Surprises Act protections. Complete details provided for all covered services: physician visits, hospital care (inpatient/outpatient), mental health/substance use treatment, vision care, and extensive other services with specific co-payments, coinsurance, visit limits, and exclusions.
Schedule of Medical Benefits for Cliff Berry, Inc. - Base Plan (PPO)
Plan Overview
Group Number: 006R2563
Effective Date: September 1, 2025
Status: NGF
Plan Type: PPO (Preferred Provider Organization)
Network Information
PPO Network: United Choice (47/3)
- Primary network for 3 New England states: HPHC (Harvard Pilgrim Health Care)
- Primary network for other 47 states: UnitedHealthcare
Note: Covered Persons should refer to their ID Cards for the network that applies to them.
Administrative Services
- Utilization Management (UM): MedWatch
- Case Management (CM): MedWatch
- Disease Management (DM): N/A
- Customer Service: Karias Care Concierge
- Prescription Drug Administrator: TrueScripts
Specialty Programs
HPI Sponsored Specialty Programs:
- SCM+ Dialysis Program: Full dialysis carve-out
Prescription Drug Benefits
Coverage Notes
- Prescription drug co-payments and coinsurance accumulate toward the Out-of-Pocket Maximum
- Once Out-of-Pocket Maximums are met, prescription drugs are covered at 100% for the balance of the Plan Year
- Generic FDA-approved contraceptive medications and devices: Covered at 100%
- Preferred/Non-preferred brand contraceptives: Subject to co-payments unless generic is unavailable
- Tobacco cessation products: Covered at 100%
Step Therapy
Certain prescription drugs are subject to step therapy requirements. Covered Persons may be required to use a different prescription drug product first. To determine if a drug requires step therapy, visit www.truescripts.com or call Member Customer Care.
Retail Card Program
Up to 30-day supply:
- Generic: $10 co-payment
- Preferred Brand: $40 co-payment
- Non-Preferred Brand: $75 co-payment
Up to 90-day supply:
- Generic: $30 co-payment
- Preferred Brand: $120 co-payment
- Non-Preferred Brand: $225 co-payment
Mail Order Pharmacy
Up to 90-day supply:
- Generic: $20 co-payment
- Preferred Brand: $80 co-payment
- Non-Preferred Brand: $150 co-payment
Specialty Drugs
Up to 30-day supply (Retail and Mail Order):
- 20% coinsurance up to $250 per prescription
Important Information
- Out-of-Network Pharmacy Coverage: NOT COVERED
- Prescription Drug Costs: Count toward COMBINED Medical Out-of-Pocket Maximum
- Scripts subject to Deductibles: NO
- Non-Participating Pharmacy Coverage: NO
- Mandatory Mail Order: NO
- Maintenance Medication Program: NO
Medical Plan Year Deductibles
In-Network Providers
Single Plan (Employee only):
- $5,000 deductible
Family Plan (Employee & family):
- $5,000 per person, up to $10,000 per family
- Individual deductible included in family coverage: YES
Out-of-Network Providers
Single Plan (Employee only):
- $10,000 deductible
Family Plan (Employee & family):
- $10,000 per person, up to $20,000 per family
- Individual deductible included in family coverage: YES
Family Deductible Structure
The Family Plan contains both an individual deductible and a family deductible. Once an individual family member satisfies the individual deductible, claims will be paid for that individual. Otherwise, the entire family deductible must be satisfied before claims will be paid for any family members. The family deductible may be met by any combination of family members.
Medical Plan Year Deductible Carryover: NO
Reimbursement Percentage (Coinsurance)
In-Network Providers
- 70% of the Contracted Rate (after deductible; unless otherwise stated)
- 100% after Out-of-Pocket Maximum is reached
Out-of-Network Providers
- 50% of the Allowed Amount (after deductible; unless otherwise stated)
- 100% after Out-of-Pocket Maximum is reached
Plan Year Out-of-Pocket Maximums
Includes all applicable co-payments, plan year deductible, coinsurance, and prescription drug costs.
In-Network Providers
Single Plan (Employee only):
- $7,350 Out-of-Pocket Maximum
Family Plan (Employee & family):
- $7,350 per person, up to $14,700 per family
- Individual OOPM included in family coverage: YES
Out-of-Network Providers
Single Plan (Employee only):
- $14,700 Out-of-Pocket Maximum
Family Plan (Employee & family):
- $14,700 per person, up to $29,400 per family
- Individual OOPM included in family coverage: YES
Family Out-of-Pocket Maximum Structure
The Family Plan contains both an individual Out-of-Pocket Maximum and a family Out-of-Pocket Maximum. Once an individual family member satisfies the individual Out-of-Pocket Maximum, claims will be paid for that individual at 100%. Otherwise, once the entire family Out-of-Pocket Maximum is satisfied, claims will be paid at 100% for all covered family members. The family Out-of-Pocket Maximum may be met by any combination of family members.
Important Notes
- In/Out-of-Network Deductibles: SEPARATE (do not accumulate together)
- In/Out-of-Network Out-of-Pocket Maximums: SEPARATE (do not accumulate together)
- Eligible expenses that track toward In-Network deductible and Out-of-Pocket Maximum will NOT be credited toward Out-of-Network deductible and Out-of-Pocket Maximum (and vice versa)
Expenses Excluded from Out-of-Pocket Maximum
- Precertification penalties
No Surprises Act Protection
Emergency services rendered by Out-of-Network Providers for "Emergency Care," air ambulance services, and non-emergency services rendered by Out-of-Network Providers at In-Network facilities for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services will be paid at In-Network levels (provided the Covered Person has not validly waived NSA protections).
Balance Billing Protection:
- Out-of-Network Providers cannot balance bill Covered Persons for emergency services or air ambulance services
- For non-emergency services at In-Network facilities, Out-of-Network Providers cannot balance bill unless the Covered Person gives written consent and waives NSA protections
- If NSA protections are waived, Out-of-Network benefits apply
Medical Co-Payments
In-Network Providers
Primary Care Physician: $30 co-payment
Specialty Care Physician: $75 co-payment
Inpatient Hospital: NONE
Outpatient Hospital Surgery: NONE
Out-of-Network Providers
All Services: NONE (standard coinsurance applies)
Co-payment Maximums
In-Network: NONE
Out-of-Network: NONE
Precertification Requirements
Inpatient Hospitalization
Precertification is REQUIRED for all inpatient hospitalizations:
- Scheduled admissions: Must be precertified 7 business days prior to admission
- Emergency admissions: Must be precertified within 2 business days of admission
Failure to Obtain Precertification
In-Network Provider: May result in a reduction in benefits
Out-of-Network Provider: Will result in a $400 reduction in benefits per admission
The reduction in benefits cannot be used to satisfy any applicable co-payments, deductibles, or Out-of-Pocket Maximums. Any penalty incurred is the responsibility of the Covered Person.
Other Services Requiring Precertification
Services deemed cosmetic, experimental/investigational, or other specific services may also require precertification regardless of setting. See individual benefits for specific requirements.
Important: If precertification is required but not obtained, coverage may not be available for services not determined to be Medically Necessary. The Plan reserves the right to deny coverage prospectively for any service determined in advance not to be medically necessary.
Preventive Care Services
Services marked with ** are provided according to PPACA (Affordable Care Act) regulations and USPSTF recommendations. New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance.
In-Network Benefits (Deductible Waived)
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Routine Physical Exams (including routine immunizations and flu shots) | 100% | 50% Allowed Amount (after deductible) |
| Routine Well Child Care (including screenings, routine immunizations and flu shots) | 100% | 50% Allowed Amount (after deductible) |
| Fluoride Varnish (up to age 6, up to 4 varnish treatments per person per plan year)* | 100% | 50% Allowed Amount (after deductible) |
| Breastfeeding Support, Supplies and Counseling | 100% | 50% Allowed Amount (after deductible) |
| Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling) | 100% | 50% Allowed Amount (after deductible) |
| Routine Gynecological/Obstetrical Care (including preconception and prenatal services) | 100% | 50% Allowed Amount (after deductible) |
| Routine Pap Smears | 100% | 50% Allowed Amount (after deductible) |
| Breast Cancer Screening (including routine mammograms and BRCA testing) | 100% | 50% Allowed Amount (after deductible) |
| Routine Immunizations (if not billed with office visit; includes flu shots) | 100% | 50% Allowed Amount (after deductible) |
| Routine Lab, X-rays, and Clinical Tests (including those related to maternity care) | 100% | 50% Allowed Amount (after deductible) |
| Routine Colorectal Cancer Screening (including sigmoidoscopies and colonoscopies; precertification required) | 100% | 50% Allowed Amount (after deductible) |
| Lung Cancer Screening (including Low-Dose CT; up to 1 per person per plan year)* | 100% | 50% Allowed Amount (after deductible) |
| Nutritional Counseling | 100% | 50% Allowed Amount (after deductible) |
| Smoking Cessation Counseling and Intervention (including smoking cessation clinics and programs) | 100% | 50% Allowed Amount (after deductible) |
| Abdominal Aortic Aneurysm Screening (up to 1 per person per lifetime)* | 100% | 50% Allowed Amount (after deductible) |
| Bone Density Screening - Women (as recommended by USPSTF for Osteoporosis Screening) | 100% | 50% Allowed Amount (after deductible) |
| Bone Density Screening - All other Covered Persons | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Routine Prostate Exams and PSA Screenings | 100% | 50% Allowed Amount (after deductible) |
| Routine Hearing Exams | $75 co-payment per visit, then 100% | 50% Allowed Amount (after deductible) |
*Combined In-Network and Out-of-Network maximums
Breast Pump Coverage Limits
- Hospital Grade Breast Pumps: Rental covered up to 3 months
- Electric Breast Pumps: Rent or purchase, whichever is less
- Manual Breast Pumps: Purchase
Internal Note: If there are no In-Network lactation providers, Out-of-Network providers should be covered at In-Network level with no cost sharing. If the only reason for the visit is lactation, it should be with no cost-sharing.
Important Balance Billing Information
When services are rendered by an Out-of-Network Provider in any instance other than emergency services, air ambulance services, or covered non-emergency services at In-Network facilities under NSA protections, Covered Persons may be responsible for any amount above the Allowed Amount (balance billing).
Vision Care
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Routine Vision Exam (excludes contact lens fitting; up to 1 exam per person every 24 consecutive months)* | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Routine Eyewear (lenses, frames, and contact lenses) | NOT COVERED | NOT COVERED |
| Eyewear for Special Conditions (initial purchase post-surgery; contact lenses for keratoconus; intraocular lenses after transplant/cataract/eye surgery) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
*Combined In-Network and Out-of-Network maximum
Physician Services
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Allergy Testing | $30 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Allergy Treatment | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Anesthesia (Inpatient/Outpatient) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Chiropractic Services (up to 20 visits per person per plan year)* | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Physician Hospital Visits | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Physician Office Visits - Primary Care (includes all related charges billed at time of visit; precertification required for on-going wound care) | $30 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Physician Office Visits - Specialist (includes all related charges billed at time of visit; precertification required for on-going wound care) | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Second Surgical Opinion | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Surgery (Inpatient) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Surgery (Outpatient) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Surgery (Physician's office) | $30 Primary Care or $75 Specialist co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
*Combined In-Network and Out-of-Network maximum
Maternity
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Prenatal care | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Physician delivery charges | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Postnatal care | 70% (after deductible) | 50% Allowed Amount (after deductible) |
Hospital Services - Inpatient
Precertification is ALWAYS required for inpatient hospitalization.
Failure to precertify:
- In-Network: May result in benefit reduction
- Out-of-Network: Will result in $400 benefit reduction per admission
The reduction cannot be used to satisfy co-payments, deductibles, or Out-of-Pocket Maximums. Any penalty is the responsibility of the Covered Person.
Note: Private room covered only when Medically Necessary or when facility does not provide semi-private rooms.
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Hospital Room & Board (semi-private or special care unit; precertification for Medical Necessity required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Maternity Services (precertification required for stays exceeding 48 hours [vaginal]; 96 hours [cesarean]; semi-private or special care unit) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Birthing Center | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Newborn Care (includes physician visits & circumcision; semi-private or special care unit) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Organ, Bone Marrow and Stem Cell Transplants (precertification required; semi-private or special care unit; includes transportation, food and lodging expenses up to $8,000 per transplant) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Surgical Facility & Supplies | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Miscellaneous Hospital Charges | 70% (after deductible) | 50% Allowed Amount (after deductible) |
Hospital Services - Outpatient
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Clinic Services (at a Hospital) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Emergency Room Expenses (includes facility, lab, x-ray & physician services; co-payment waived if admitted inpatient) | $500 co-payment per visit, then 100% (Deductible waived) | $500 co-payment per visit, then 100% (Deductible waived) |
| Outpatient Department | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. (precertification required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Preadmission Testing | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Urgent Care Facility/Walk-In Clinic | 100% (after deductible) | 50% Allowed Amount (after deductible) |
Mental Health/Substance Use
Precertification is ALWAYS required for inpatient hospitalization.
Failure to precertify:
- In-Network: May result in benefit reduction
- Out-of-Network: Will result in $400 benefit reduction per admission
The reduction cannot be used to satisfy co-payments, deductibles, or Out-of-Pocket Maximums. Any penalty is the responsibility of the Covered Person.
Note: Private room covered only when Medically Necessary or when facility does not provide semi-private rooms.
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Inpatient Hospitalization (precertification for Medical Necessity required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Partial Hospitalization/Intensive Outpatient Treatment (precertification for Medical Necessity required) | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Inpatient Physician Visit | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Hospital Clinic Visit | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Office Visit | $30 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Methadone Maintenance/Treatment | $30 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
Other Services & Supplies
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Acupuncture (up to 10 visits per person per plan year)* | $30 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Alternative/Complementary Care Benefit | NOT COVERED | NOT COVERED |
| Ambulance Services | 100% (after deductible) | 100% Allowed Amount (after In-Network deductible) |
| Autism Spectrum Disorders Treatment (includes ABA; benefit limits apply to occupational, physical and speech therapies; precertification required for ABA; screenings covered under Preventive Care) | Benefits based on services provided | Benefits based on services provided |
| Bariatric Surgery | NOT COVERED | NOT COVERED |
| Cardiac Rehabilitation (Phase 1 and 2 only) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Chemotherapy & Radiation Therapy (precertification for Medical Necessity required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Clinical Trials - Routine Services during Approved Clinical Trials (limited to routine covered services including hospital visits, laboratory, and imaging services) | Benefits based on services provided | Benefits based on services provided |
| Cochlear Implants (precertification for Medical Necessity required; for Covered Persons up to age 19, once every 5 years) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Dental/Oral Services (excludes excision of impacted wisdom teeth) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Diabetes Self-Management Training and Education | $30 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Diagnostic Imaging (MRI, CT Scan, PET Scan; precertification required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Inpatient Dialysis/Hemodialysis and Related Professional Services (precertification for Medical Necessity required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Outpatient Dialysis/Hemodialysis Professional Services (precertification for Medical Necessity required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Durable Medical Equipment (precertification required for insulin pumps and supplies, and equipment exceeding $2,500 or for Out-of-Network providers) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Early Intervention Services (up to age 3) | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Erectile Dysfunction Treatment | NOT COVERED | NOT COVERED |
| Family Planning - For Women | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Family Planning - For Men | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Gender Dysphoria Treatment and Related Services | NOT COVERED | NOT COVERED |
| Genetic Counseling, Testing and Related Services (precertification required for genetic testing; BRCA Testing covered under Preventive Care without precertification) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Gene Therapy (precertification for Medical Necessity required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Growth Hormones | NOT COVERED | NOT COVERED |
| Hearing Aids | NOT COVERED | NOT COVERED |
| Home Health Care (precertification for Medical Necessity required; up to 60 visits per person per plan year)* | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Hospice Care - Inpatient (precertification for Medical Necessity required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Hospice Care - Outpatient (precertification for Medical Necessity required) | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Infertility Treatment | NOT COVERED | NOT COVERED |
| Injectables (precertification for Medical Necessity required for injectables exceeding $1,500) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Learning Deficiencies, Behavioral Problems/Developmental Delays (precertification and visit limits based on services provided) | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Marital Counseling | NOT COVERED | NOT COVERED |
| Massage Therapy | NOT COVERED | NOT COVERED |
| Medical and Enteral Formula | NOT COVERED | NOT COVERED |
| Modified Low Protein Food Products | NOT COVERED | NOT COVERED |
| Neuromuscular Stimulator Equipment including TENS (precertification required as noted under DME) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Occupational Therapy (for treatment due to illness or injury; precertification required after 13 visits; up to 30 visits per person per plan year combined with Physical and Speech Therapy)* | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Orthotics (includes foot orthotics) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Pain Clinics (precertification for Medical Necessity required for inpatient services) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Physical Therapy (for treatment due to illness or injury; precertification required after 13 visits; up to 30 visits per person per plan year combined with Occupational and Speech Therapy)* | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Podiatry Care | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Private Duty Nursing | NOT COVERED | NOT COVERED |
| Prosthetics (precertification required as noted under DME) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Rehabilitation Hospital (precertification for Medical Necessity required; up to 60 days per person per plan year combined with Skilled Nursing Facility)* | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Respiratory Therapy | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Skilled Nursing Facility/Extended Care Facility (precertification for Medical Necessity required; up to 60 days per person per plan year combined with Rehabilitation Hospital)* | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Sleep Studies (precertification for Medical Necessity required for inpatient sleep studies) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Speech Therapy (for treatment due to illness or injury; precertification required after 13 visits; up to 30 visits per person per plan year combined with Occupational and Physical Therapy)* | $75 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Telemedicine - Medical and Behavioral Health Services | $30 co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Telemedicine - All Other Virtual Visits (including Occupational, Physical, and Speech Therapy) | Paid based on services provided | Paid based on services provided |
| Temporomandibular Joint Disorders (TMJ) Treatment (precertification required) | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Termination of Pregnancy | 70% (after deductible) | 50% Allowed Amount (after deductible) |
| Travel Immunizations | NOT COVERED | NOT COVERED |
| Voluntary Sterilization - For Women | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Voluntary Sterilization - For Men | 100% (Deductible waived) | 50% Allowed Amount (after deductible) |
| Wigs (when hair loss is due to cancer treatment; up to $500 per Covered Person every 5 years)* | 70% (after deductible) | 50% Allowed Amount (after deductible) |
*Combined In-Network and Out-of-Network maximums
Special Note: Outpatient Dialysis/Hemodialysis Facility Services
Outpatient dialysis facility charges are covered under a separate administrative carve-out program, the Outpatient Dialysis Health Reimbursement Arrangement plan, administered by Specialty Care Management (SCM). Covered Persons should contact SCM at the phone number listed on the back of their ID card for additional information.
Outpatient Dialysis/Hemodialysis Professional Services are covered under the Plan as shown in the table above.
Wellness Benefits
| Benefit | Coverage |
|---|---|
| Childbirth Classes | NOT COVERED |
| Fitness Reimbursement Benefit | NOT COVERED |
| Weight Loss Reimbursement Benefit | NOT COVERED |
Additional Benefits - Covered and Excluded
Alternative/Complementary Care Benefit Details
| Service | Coverage | Additional Details |
|---|---|---|
| Biofeedback | EXCLUDED | |
| Chelation Therapy | EXCLUDED | |
| Homeopathic Treatment | EXCLUDED | |
| Hypnosis/Hypnotherapy | EXCLUDED | |
| Rolfing/Reiki | EXCLUDED | |
| Applied Behavior Analysis (ABA) | COVERED | Covered under Autism Spectrum Disorders treatment; pays as MH/SA OP OV |
| Breast Reduction Surgery | COVERED | When Medically Necessary; precertification required |
| Cardiac Rehab Phase III (Outpatient maintenance) | EXCLUDED | |
| Home Visit by Visiting Nurse after early maternity discharge | COVERED | |
| Planned Home Births | EXCLUDED | |
| Orthoptics | COVERED | Pays as Specialist OP OV |
| Sex Therapy | EXCLUDED |
Important Note: This is not a complete listing of all Plan exclusions. Please refer to the Medical Benefits Section and the Medical Limitations and Exclusions Section in the Plan Document/Summary Plan Description for a complete list of benefit and non-benefit type exclusions.
Important Contact Information
- TrueScripts (Prescription Drug Benefits): www.truescripts.com or call the number on your ID card
- Specialty Care Management (Dialysis Services): Call the phone number on the back of your ID card
- Customer Service: Karias Care Concierge
- Utilization Management/Case Management: MedWatch
Key Reminders
- Always check if your provider is In-Network to receive maximum benefits
- Obtain precertification when required to avoid penalties and benefit reductions
- In-Network and Out-of-Network deductibles and Out-of-Pocket Maximums are SEPARATE and do not accumulate toward each other
- Prescription drug costs count toward the COMBINED Medical Out-of-Pocket Maximum
- Prescription drugs are NOT subject to the medical deductible
- Emergency room co-payment is waived if you are admitted as an inpatient
- Private rooms are covered only when Medically Necessary or when the facility does not provide semi-private rooms
- Failure to obtain precertification for Out-of-Network inpatient admissions results in a $400 penalty per admission
- Review your ID card to determine which network applies to you (HPHC for 3 New England states, UnitedHealthcare for other 47 states)
- No Surprises Act protections apply to certain emergency and out-of-network services at in-network facilities
Commonly Asked Questions
Q: Do I need a referral to see a specialist?
A: The plan document does not indicate a referral requirement, but you should verify with your specific plan administrator.
Q: What happens if I don't precertify a hospital stay?
A: For In-Network providers, benefits may be reduced. For Out-of-Network providers, you will face a $400 penalty per admission that cannot count toward your deductible or Out-of-Pocket Maximum.
Q: Can I use mail order for my prescriptions?
A: Yes, mail order is available through TrueScripts for up to a 90-day supply with lower co-payments than retail.
Q: Are generic contraceptives covered?
A: Yes, generic FDA-approved contraceptive medications and devices are covered at 100% with no cost-sharing.
Q: What is the difference between the deductible and Out-of-Pocket Maximum?
A: The deductible is the amount you must pay before the plan begins to pay benefits (except for certain preventive services and services with co-payments). The Out-of-Pocket Maximum is the total amount you will pay in deductibles, co-payments, and coinsurance before the plan pays 100% of covered expenses.
Q: Do preventive services require a deductible?
A: Most preventive services marked with ** (PPACA preventive care) are covered at 100% In-Network with no deductible when received from In-Network providers.
Q: What if I receive care from an Out-of-Network provider at an In-Network hospital?
A: Under the No Surprises Act, certain Out-of-Network providers (emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist) rendering services at an In-Network facility will be paid at In-Network levels, provided you have not waived NSA protections.
Q: How do I know if a service requires precertification?
A: Contact MedWatch (Utilization Management) or refer to this benefits guide. Key services requiring precertification include: inpatient hospitalizations, outpatient surgeries, diagnostic imaging (MRI, CT, PET scans), and various other services as noted in the benefits descriptions.
Q: What is the therapy visit limit?
A: Physical Therapy, Occupational Therapy, and Speech Therapy share a combined limit of 30 visits per person per plan year. Precertification is required after 13 visits.
Q: Is bariatric surgery covered?
A: No, bariatric surgery is not covered under this plan.
Q: Are hearing aids covered?
A: No, hearing aids are not covered. However, routine hearing exams are covered with a $75 co-payment.
Q: What dialysis services are covered?
A: Outpatient dialysis facility services are covered under a separate carve-out program administered by Specialty Care Management (SCM). Inpatient dialysis and outpatient dialysis professional services are covered under this plan at 70% In-Network (after deductible).
Summary of Annual Limits
| Service | Limit |
|---|---|
| Fluoride Varnish (up to age 6) | Up to 4 treatments per person per plan year |
| Lung Cancer Screening | Up to 1 per person per plan year |
| Abdominal Aortic Aneurysm Screening | Up to 1 per person per lifetime |
| Routine Vision Exam | Up to 1 exam per person every 24 consecutive months |
| Chiropractic Services | Up to 20 visits per person per plan year |
| Acupuncture | Up to 10 visits per person per plan year |
| Home Health Care | Up to 60 visits per person per plan year |
| Occupational/Physical/Speech Therapy (Combined) | Up to 30 visits per person per plan year |
| Rehabilitation Hospital & Skilled Nursing Facility (Combined) | Up to 60 days per person per plan year |
| Wigs (when due to cancer treatment) | Up to $500 per Covered Person every 5 years |
| Organ/Bone Marrow/Stem Cell Transplant Transportation/Lodging | Up to $8,000 per transplant |
| Cochlear Implants (up to age 19) | Once every 5 years |
Plan Document Reference
This summary is based on the Schedule of Medical Benefits for Cliff Berry, Inc. - Base Plan, effective September 1, 2025. This document provides a summary of benefits and is not intended to be a complete description of coverage.
For complete details, including all limitations and exclusions, please refer to:
- The complete Plan Document/Summary Plan Description
- The Medical Benefits Section
- The Medical Limitations and Exclusions Section
Document Version: Draft as of 7-23-2025 PM, 7-24-25 PM, 7-25-25 PM, 8-1-2025 PM
Approval Information
TRU Department: Pending approval
Account Manager: Julie Elwell - Pending approval
Compliance: Patrick Moore - Pending approval
Quick Reference Chart
Most Common Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Annual Deductible (Individual) | $5,000 | $10,000 |
| Annual Out-of-Pocket Max (Individual) | $7,350 | $14,700 |
| Primary Care Visit | $30 co-pay | 50% after deductible |
| Specialist Visit | $75 co-pay | 50% after deductible |
| Emergency Room | $500 co-pay, then 100% | $500 co-pay, then 100% |
| Urgent Care | 100% after deductible | 50% after deductible |
| Preventive Care | 100% (no deductible) | 50% after deductible |
| Inpatient Hospital | 70% after deductible | 50% after deductible |
| Outpatient Surgery | 70% after deductible | 50% after deductible |
| Lab/X-ray | 70% after deductible | 50% after deductible |
| MRI/CT/PET Scan | 70% after deductible (precert required) | 50% after deductible (precert required) |
| Mental Health Office Visit | $30 co-pay | 50% after deductible |
| Physical Therapy | $75 co-pay (30 visit max combined) | 50% after deductible |
| Telemedicine | $30 co-pay | 50% after deductible |
Prescription Drug Co-Payments
| Type | Retail 30-Day | Retail 90-Day | Mail Order 90-Day |
|---|---|---|---|
| Generic | $10 | $30 | $20 |
| Preferred Brand | $40 | $120 | $80 |
| Non-Preferred Brand | $75 | $225 | $150 |
| Specialty | 20% up to $250 max | N/A | 20% up to $250 max |
This knowledge base article is provided for informational purposes. Always refer to your official Plan Document and Summary Plan Description for complete coverage details, limitations, and exclusions. Contact your plan administrator if you have questions about your specific coverage.
Last Updated: Based on draft document dated August 1, 2025
Plan Effective Date: September 1, 2025