Schedule of Medical Benefits for Cliff Berry, Inc. - High Plan (PPO)
Comprehensive medical and prescription drug benefits guide for Cliff Berry, Inc. High Plan PPO (Group #006R2563), effective September 1, 2025. Features $1,500/$3,000 in-network deductibles, $5,000/$10,000 out-of-pocket maximums, 80% in-network coinsurance, and prescription drug coverage through TrueScripts with no deductible. Includes preventive care at 100%, mental health benefits, and No Surprises Act protections.
Cliff Berry, Inc. - High Plan PPO Medical Benefits Schedule
Group #: 006R2563
Effective Date: September 1, 2025
Status: NGF
Managed Care Type: PPO
PPO Network: United Choice (47/3)
Plan Administration
- Utilization Management (UM): MedWatch
- Case Management (CM): MedWatch
- Disease Management (DM): N/A
- Customer Service: Karias Care Concierge
- MCC Creditable: Yes
Network Coverage
- Primary network for subscribers in 3 New England states: HPHC
- Primary network for subscribers in other 47 states: UnitedHealthcare
Note: Other networks may apply. Covered Persons should refer to their ID Cards for the applicable network.
Ancillary Programs
HPI Sponsored Specialty Programs
- ☒ SCM+ Dialysis Program: Full dialysis carve-out
Prescription Drug Benefits
Administered by: TrueScripts
Key Information
- Do Prescription Drug Costs count toward Medical OOP Max? COMBINED
- Are scripts subject to Deductibles? NO
- Non-Participating Pharmacy Coverage: NO
- Mandatory Mail Order: NO
- Maintenance Medication Program: NO
- Out-of-Network Pharmacy Coverage: NOT COVERED
Coverage Details
Note: Prescription drug Co-payments and Coinsurance accumulate toward the Out-of-Pocket Maximum. Once the Out-of-Pocket Maximums have been met, prescription drugs are covered at 100% for the balance of the Plan Year.
Contraceptive Coverage:
- Generic FDA-approved contraceptive medications and devices are covered at 100%
- Preferred brand name and non-preferred brand name contraceptive medications are subject to Co-payments and Coinsurance as shown, unless the generic form is not available
- If generic is not available, the available preferred brand name drug (or non-preferred brand name if preferred brand name is not available) will be covered at 100%
Tobacco Cessation Products: Covered at 100%
Step Therapy
Certain prescription drug products are subject to step therapy requirements. Covered Persons may be required to use a different prescription drug product(s) or pharmaceutical product(s) first.
To determine whether a particular prescription drug product is subject to step therapy requirements:
- Visit: www.truescripts.com
- Call: Member Customer Care at the telephone number on your ID card
Retail Card Program - You Pay:
Up to a 30 day supply:
- $10 Co-payment per generic drug
- $40 Co-payment per preferred brand name drug
- $75 Co-payment per non-preferred brand name drug
Up to a 90 day supply:
- $30 Co-payment per generic drug
- $120 Co-payment per preferred brand name drug
- $225 Co-payment per non-preferred brand name drug
Mail Order Pharmacy - You Pay:
Up to a 90 day supply:
- $20 Co-payment per generic drug
- $80 Co-payment per preferred brand name drug
- $150 Co-payment per non-preferred brand name drug
Specialty Drugs (Retail and Mail Order) - You Pay:
Up to a 30 day supply:
- 20% Coinsurance up to $250 per prescription per Specialty drugs
Medical Plan Year Deductible
In-Network Providers
Single Plan (Employee only): $1,500
Family Plan (Employee & family): $1,500 per person, up to $3,000 per family
Individual Deductible Included in Family Coverage: YES
Out-of-Network Providers
Single Plan (Employee only): $3,000
Family Plan (Employee & family): $3,000 per person, up to $6,000 per family
Individual Deductible Included in Family Coverage: YES
Important Note on Family Plan Deductible
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
80% of the Contracted Rate (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximums has been reached, then 100% thereafter for the balance of the Plan Year
Out-of-Network Providers
60% of the Allowed Amount* (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximums has been reached, then 100% thereafter for the balance of the Plan Year
Plan Year Out-of-Pocket Maximums
Including all applicable Co-payments, Plan Year Deductible and Coinsurance, including those for prescription drugs
In-Network Providers
Single Plan (Employee only): $5,000
Family Plan (Employee & family): $5,000 per person, up to $10,000 per family
Individual OOPM Included in Family Coverage: YES
Out-of-Network Providers
Single Plan (Employee only): $10,000
Family Plan (Employee & family): $10,000 per person, up to $20,000 per family
Individual OOPM Included in Family Coverage: YES
Important Note on Family Plan Out-of-Pocket Maximum
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.
Deductible and Out-of-Pocket Maximum Structure
- In/Out-of-Network Deductibles are: SEPARATE
- In/Out-of-Network Out-of-Pocket Maximums are: SEPARATE
Important: The In-Network Provider and Out-of-Network Deductible and Out-of-Pocket Maximums are separate and do not accumulate. Eligible expenses which track toward the In-Network Provider Deductible and Out-of-Pocket Maximums will not be credited toward the satisfaction of the Out-of-Network Deductible and Out-of-Pocket Maximums and vice versa.
Expenses Excluded from Out-of-Pocket Maximum
- Precertification penalties
Medical Co-Payments
In-Network Providers
- Inpatient Hospital Co-payment: NONE
- Outpatient Hospital Surgery Co-payment:
- Hospital Based: $800
- Freestanding Facility: $400 (Effective 9/1/25)
- Primary Care Physician Co-payment: $25
- Specialty Care Physician Co-payment: $50
- Co-payment Maximums: NONE
Out-of-Network Providers
- Inpatient Hospital Co-payment: NONE
- Outpatient Hospital Surgery Co-payment: NONE
- Primary Care Physician Co-payment: NONE
- Specialty Care Physician Co-payment: NONE
- Co-payment Maximums: NONE
Precertification Requirements
Inpatient Hospitalization
Precertification is required for inpatient hospitalization and outpatient surgical procedures.
Timeline:
- Schedule admission: Precertify 7 business days prior to date of admission
- Emergency admissions: Precertify within 2 business days of admission
Failure to Precertify:
- In-Network Provider: May result in a reduction in benefits
- Out-of-Network Provider: Will result in a reduction in benefits of $400 per admission
Other Services Requiring Precertification
Other services, including those deemed cosmetic or Experimental/Investigational, may also require precertification regardless of whether the service is rendered inpatient, outpatient or in an office setting. See individual benefits for services requiring precertification.
Important: If precertification is required but is 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 that may not require precertification but is determined in advance not to be medically necessary. Any penalty incurred due to failure to obtain precertification or preauthorization for services may be the responsibility of the Covered Person.
No Surprises Act (NSA) Protections
Important Note on Balance Billing Protection
The following services are paid at In-Network Provider Deductible, Co-payment and Coinsurance levels, subject to the Qualifying Payment Amount:
- Emergency services rendered by Out-of-Network Providers for "Emergency Care" as defined in the Definitions section
- Air ambulance services rendered by Out-of-Network Providers of air ambulance services
- Non-emergency services rendered by Out-of-Network Providers on an inpatient or outpatient basis at an In-Network Hospital or facility for:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory
- Neonatology
- Assistant surgeon
- Hospitalist
- Intensivist services
Provided the Covered Person has not validly waived the applicability of the No Surprises Act of the Consolidated Appropriations Act of 2021 (NSA)
Balance Billing Protections
- When emergency services are rendered by an Out-of-Network Provider for Emergency Care, or air ambulance services are rendered by an Out-of-Network Provider of air ambulance services, the Out-of-Network Provider cannot balance bill the Covered Person
- When non-emergency services listed above are rendered by an Out-of-Network Provider at an In-Network facility, the Out-of-Network Provider cannot balance bill the Covered Person unless the Covered Person gives written consent and gives up their protections in accordance with the NSA
- If a Covered Person waives their protections and agrees to balance billing per the NSA, Out-of-Network Providers will be paid according to the Plan's Out-of-Network level of benefits, subject to the Allowed Amount
When services are rendered by an Out-of-Network Provider in any instance other than the reasons listed above, Covered Persons may be responsible for any amount above the Allowed Amount.
Preventive Care
Services marked with ** are provided according to the terms prescribed by the regulations issued under the Patient Protection and Affordable Care Act of 2010 (PPACA). The majority of the PPACA preventive care services recommendations are issued by the U.S. Preventive Service Task Force (USPSTF). These may be amended from time to time. New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance of the revised recommendation.
Preventive Care Services
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Routine Physical Exams (Including routine immunizations and flu shots) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Well Child Care (Including screenings, routine immunizations and flu shots) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Fluoride Varnish (Up to age 6) - Up to 4 varnish treatments per person, per Plan Year* | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Breastfeeding Support, Supplies and Counseling (During pregnancy and/or in the postpartum period and rental or purchase of breastfeeding equipment) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Gynecological/Obstetrical Care (Including preconception and prenatal services) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Pap Smears | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Breast Cancer Screening including Routine Mammograms and BRCA testing | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Immunizations (If not billed with an office visit; includes flu shots) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Lab, X-rays, and Clinical Tests (Including those related to maternity care) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Colorectal Cancer Screening including sigmoidoscopies and colonoscopies (As recommended by the US Preventive Service Task Force; precertification required) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Lung Cancer Screening, including Low-Dose Computed Tomography (LDCT) (As recommended by the US Preventive Service Task Force) - Up to 1 per person, per Plan Year* | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Nutritional Counseling | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Smoking Cessation Counseling and Intervention (Including smoking cessation clinics and programs) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Hearing Exams | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Prostate Exams and Prostate-Specific Antigen (PSA) Screenings | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Abdominal Aortic Aneurysm Screening (As recommended by the US Preventive Service Task Force) - Up to 1 per person, per lifetime* | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Bone Density Screening - Women (as recommended by the US Preventive Service Task Force for Osteoporosis Screening) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Bone Density Screening - All other Covered Persons | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
*These maximums are combined In-Network and Out-of-Network maximums.
Breast Pump 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 INN lactation providers, then OON providers should be covered at the INN level of benefits with no cost sharing. If the only reason for the visit with the provider is lactation, it should be with no cost-sharing.
NSA Protections for Preventive Care
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
Vision Care
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Routine Vision Exam (Excludes contact lens fitting) - Up to 1 exam per person, every 24 consecutive months* | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Eyewear (Lenses, frames, and contact lenses) | NOT COVERED | NOT COVERED |
| Eyewear for Special Conditions (Initial purchase of non-routine eyewear following surgery; contact lenses needed to treat keratoconus (including the fitting of these contact lenses); intraocular lenses implanted after corneal transplant, cataract surgery or other covered eye surgery when the natural eye lens is replaced) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
*These maximums are combined In-Network and Out-of-Network maximums.
Physician Services
Physician Office Visits and Services
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Allergy Testing | $25 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Allergy Treatment | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Anesthesia (Inpatient/Outpatient) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Chiropractic Services - Up to 20 visits per person, per Plan Year* | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Maternity (Includes Physician delivery charges, prenatal and postpartum care) - Prenatal care | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Maternity - Physician delivery charges | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Maternity - Postnatal care | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Physician Hospital Visits | 80% (after Deductible) | 60% 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) | $25 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Physician Office Visits - Specialist (Includes all related charges billed at time of visit; precertification required for on-going wound care) | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Second Surgical Opinion | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Surgery (Inpatient) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Surgery (Outpatient) - Hospital based | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Surgery (Outpatient) - Freestanding facility | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Surgery (Physician's office) | $25 Primary Care or $50 Specialist Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
*These maximums are combined In-Network and Out-of-Network maximums.
Hospital Services - Inpatient
Precertification is always required for inpatient hospitalization.
- In-Network Provider: Failure to obtain precertification may result in a reduction in benefits
- Out-of-Network Provider: Failure to obtain precertification will result in a reduction in benefits in the amount of $400 per admission
The reduction in benefits cannot be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan. Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Note: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Hospital Room & Board (Precertification for Medical Necessity required) - Semi-private room or special care unit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Maternity Services (Precertification required for stays in excess of 48 hours [vaginal]; 96 hours [cesarean]) - Semi-private room or special care unit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Birthing Center | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Newborn Care (Includes Physician visits & circumcision) - Semi-private room or special care unit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Organ, Bone Marrow and Stem Cell Transplants (Precertification for Medical Necessity required; see Medical Benefits section for other limitations) - Semi-private room or special care unit; Includes transportation, food and lodging expenses - Transportation/food/lodging limits: $8,000 per Transplant | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Surgical Facility & Supplies | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Miscellaneous Hospital Charges | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
Hospital Services - Outpatient
Outpatient Hospital Co-payment: A separate $800 Hospital Co-payment will apply to each outpatient/surgical procedure performed in an In-Network Hospital based facility and a separate $400 Co-payment will apply to each outpatient/surgical procedure performed in an In-Network Freestanding facility (Effective 9/1/25). The Co-payment will not apply to office surgery.
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Clinic Services (At a Hospital) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Emergency Room Expenses (Includes Facility, Lab, X-ray & Physician services) - Co-payment is waived if admitted on an inpatient basis to a Hospital | $500 Co-payment per visit, then 100% (Deductible waived) | $500 Co-payment per visit, then 100% (Deductible waived) |
| Outpatient Department | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. (Precertification required) - Hospital Based | $800 Co-payment per visit, then 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. (Precertification required) - Freestanding Facility (Effective 9/1/25) | $400 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Preadmission Testing | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Urgent Care Facility/Walk-In Clinic | $80 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
Mental Health/Substance Use
Precertification is always required for inpatient hospitalization.
- In-Network Provider: Failure to obtain precertification may result in a reduction in benefits
- Out-of-Network Provider: Failure to obtain precertification will result in a reduction in benefits in the amount of $400 per admission
The reduction in benefits cannot be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan. Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Note: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Inpatient Hospitalization (Precertification for Medical Necessity required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Partial Hospitalization/Intensive Outpatient Treatment (Precertification for Medical Necessity required) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Inpatient Physician Visit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Hospital Clinic Visit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Office Visit | $25 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Methadone Maintenance/Treatment | $25 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
Other Services & Supplies
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Acupuncture - Up to 10 visits per person, per Plan Year* | $25 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Alternative/Complementary Care Benefit | NOT COVERED | NOT COVERED |
| Ambulance Services (See Medical Benefits section for limitations) | $200 Co-payment per trip, then 100% (Deductible waived) | $200 Co-payment per trip, then 100% Allowed Amount (Deductible waived) |
| Autism Spectrum Disorders Treatment (Includes Applied Behavioral Analysis (ABA); benefit limits apply to occupational, physical and speech therapies; precertification is required for ABA; see Medical Benefits section for limitations) - Note: Screenings are covered under Preventive Care | Benefits are based on services provided | Benefits are based on services provided |
| Bariatric Surgery | NOT COVERED | NOT COVERED |
| Cardiac Rehabilitation (Phase 1 and 2 only; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Chemotherapy & Radiation Therapy (Precertification for Medical Necessity required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Clinical Trials – Routine Services during Approved Clinical Trials (Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services; see Medical Benefits section for other limitations) | Benefits are based on services provided | Benefits are based on services provided |
| Cochlear Implants (Precertification for Medical Necessity required) - For Covered Persons up to age 19, once every 5 years | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Dental/Oral Services (Excludes excision of impacted wisdom teeth; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Diabetes Self-Management Training and Education | $25 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Diagnostic Imaging (MRI, CT Scan, PET Scan) - Precertification required | $300 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) - X-ray | $40 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) - Labs | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) - All other diagnostic tests | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Inpatient Dialysis/Hemodialysis and Related Professional Services (Precertification for Medical Necessity required; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Outpatient Dialysis/Hemodialysis Professional Services (Precertification for Medical Necessity required; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
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, which is 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 above.
| Service | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Durable Medical Equipment (Precertification for Medical Necessity required for insulin pumps and supplies, and equipment in excess of $2,500 or for Out-of-Network providers; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Early Intervention Services (See Medical Benefits section for limitations) - Up to age 3 | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Erectile Dysfunction Treatment | NOT COVERED | NOT COVERED |
| Family Planning (Including but not limited to consultations and diagnostic tests) - For Women (See also Prescription Drug Benefit and Preventive Care Section) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Family Planning - For Men | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Gender Dysphoria Treatment and Related Services | NOT COVERED | NOT COVERED |
| Genetic Counseling, Testing and Related Services (Precertification for Medical Necessity required for genetic testing) - Note: Coverage is provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services; precertification is not required | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Gene Therapy (Precertification for Medical Necessity required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Growth Hormones | NOT COVERED | NOT COVERED |
| Hearing Aids | NOT COVERED | NOT COVERED |
| Home Health Care (Precertification for Medical Necessity required; see Medical Benefits section for other limitations) - Up to 60 visits per person, per Plan Year* | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Hospice Care (Inpatient/Outpatient) (Precertification for Medical Necessity required; see Medical Benefits section for other limitations) - Inpatient | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Hospice Care (Inpatient/Outpatient) - Outpatient | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Infertility Treatment | NOT COVERED | NOT COVERED |
| Injectables (Precertification for Medical Necessity required for injectables in excess of $1,500) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Learning Deficiencies, Behavioral Problems/Developmental Delays (Precertification and visit limits are based on services provided) | 100% (Deductible waived) | 60% 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 the Durable Medical Equipment benefit) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Occupational Therapy (For treatment due to Illness or Injury; precertification for Medical Necessity required after 13 visits) - Up to 30 visits per person, per Plan Year, combined with Physical Therapy and Speech Therapy* | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Orthotics (Includes foot orthotics; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Pain Clinics (Precertification for Medical Necessity required for inpatient services) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Physical Therapy (For treatment due to Illness or Injury; precertification for Medical Necessity required after 13 visits) - Up to 30 visits per person, per Plan Year, combined with Occupational Therapy and Speech Therapy* | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Podiatry Care (See Medical Benefits section for limitations) | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Private Duty Nursing | NOT COVERED | NOT COVERED |
| Prosthetics (Precertification required as noted under the Durable Medical Equipment benefit; see Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Rehabilitation Hospital (Precertification for Medical Necessity required; see Medical Benefits section for other limitations) - Up to 60 days per person, per Plan Year, combined with Skilled Nursing Facility* | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Respiratory Therapy | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Skilled Nursing Facility/Extended Care Facility (Precertification for Medical Necessity required; see Medical Benefits section for other limitations) - Up to 60 days per person, per Plan Year, combined with Rehabilitation Hospital* | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Sleep Studies (Precertification for Medical Necessity required for inpatient sleep studies; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Speech Therapy (For treatment due to Illness or Injury; precertification for Medical Necessity required after 13 visits) - Up to 30 visits per person, per Plan Year, combined with Occupational Therapy and Physical Therapy* | $50 Co-payment per visit, then 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Telemedicine (Applies to medical and behavioral health services; see Medical Benefits section for additional information) | $25 Co-payment per visit, then 100% (Deductible waived) - Paid based on services provided | 60% Allowed Amount (after Deductible) - Paid based on services provided |
| Telemedicine - All other virtual visits with a Provider with whom a Covered Person has established relationship, including, but not limited to Occupational Therapy, Physical Therapy and Speech Therapy | Paid based on services provided | Paid based on services provided |
| Temporomandibular Joint Disorders (TMJ) Treatment (Precertification required; see Medical Benefits section for other limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Termination of Pregnancy | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Travel Immunizations | NOT COVERED | NOT COVERED |
| Voluntary Sterilization - For Women | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Voluntary Sterilization - For Men | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Wigs (When hair loss is due to the treatment of cancer; see Medical Benefits section for other limitations) - Up to $500 per Covered Person, every 5 years* | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
*These maximums are combined In-Network and Out-of-Network maximums.
Wellness Benefits
| Service | Coverage Status |
|---|---|
| Childbirth Classes | NOT COVERED |
| Fitness Reimbursement Benefit | NOT COVERED |
| Weight Loss Reimbursement Benefit | NOT COVERED |
Additional Benefits Summary
EXCLUDED Benefits
The following services are NOT COVERED under this plan:
- Alternative/Complementary Care:
- Biofeedback
- Chelation Therapy
- Homeopathic Treatment
- Hypnosis/Hypnotherapy
- Rolfing/Reiki
- Bariatric Surgery
- Erectile Dysfunction Treatment
- Gender Dysphoria Treatment and Related Services
- Growth Hormones
- Hearing Aids
- Infertility Treatment
- Marital Counseling
- Massage Therapy
- Medical and Enteral Formula
- Modified Low Protein Food Products
- Private Duty Nursing
- Routine Eyewear (Lenses, frames, and contact lenses)
- Travel Immunizations
- Wellness Benefits:
- Childbirth Classes
- Fitness Reimbursement Benefit
- Weight Loss Reimbursement Benefit
COVERED Benefits (Additional Details)
| Service | Coverage Details |
|---|---|
| Applied Behavior Analysis (ABA) | Covered under Autism Spectrum Disorders treatment; Pays as a MH/SA OP OV |
| Breast Reduction Surgery | Covered when Medically Necessary; precertification required |
| Cardiac Rehab Phase III (Outpatient maintenance) | NOT COVERED (Only Phase I and II are covered) |
| Home Visit by Visiting Nurse after early maternity discharge | Covered |
| Planned Home Births | Covered |
| Orthoptics | Covered; Pays as Specialist OP OV |
| Sex Therapy | NOT COVERED |
Important Definitions and Notes
Combined Visit Limits
The following services share combined visit limits:
-
Occupational Therapy, Physical Therapy, and Speech Therapy: Combined maximum of 30 visits per person, per Plan Year
- Precertification for Medical Necessity required after 13 visits
-
Rehabilitation Hospital and Skilled Nursing Facility: Combined maximum of 60 days per person, per Plan Year
Precertification Summary
Services Requiring Precertification:
- All inpatient hospitalizations (7 business days prior for scheduled admissions; 2 business days for emergency admissions)
- Outpatient surgical procedures
- Routine colorectal cancer screening
- Organ, bone marrow and stem cell transplants
- Chemotherapy & radiation therapy
- Cochlear implants
- Diagnostic imaging (MRI, CT Scan, PET Scan)
- Inpatient and outpatient dialysis/hemodialysis
- Durable medical equipment (insulin pumps and supplies, and equipment in excess of $2,500 or for Out-of-Network providers)
- Genetic testing
- Gene therapy
- Injectables in excess of $1,500
- Breast reduction surgery
- Cardiac rehabilitation
- Home health care
- Hospice care
- Pain clinics (inpatient services)
- Rehabilitation hospital
- Skilled nursing facility
- Inpatient sleep studies
- Temporomandibular joint disorders (TMJ) treatment
- Mental health/substance use inpatient hospitalization and partial hospitalization/intensive outpatient treatment
- Applied Behavioral Analysis (ABA) for Autism Spectrum Disorders
- On-going wound care
- Maternity services for stays in excess of 48 hours (vaginal) or 96 hours (cesarean)
Important Plan Provisions
-
Private Room Coverage: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms
-
Emergency Room Co-payment Waiver: The $500 Emergency Room Co-payment is waived if the Covered Person is admitted on an inpatient basis to a Hospital
-
Outpatient Surgery Co-payments:
- Hospital Based Facility: $800 Co-payment
- Freestanding Facility: $400 Co-payment (Effective 9/1/25)
- Office Surgery: No separate Co-payment applies
-
Network Determination: Covered Persons should refer to their ID Cards for the network that applies to them
-
Allowed Amount: When services are rendered by an Out-of-Network Provider (except in cases protected by the No Surprises Act), Covered Persons may be responsible for any amount above the Allowed Amount
Contact Information
For Prescription Drug Benefits:
- Website: www.truescripts.com
- Phone: Call Member Customer Care at the telephone number on your ID card
For Outpatient Dialysis Facility Services:
- Contact: Specialty Care Management (SCM)
- Phone: Call the phone number listed on the back of your ID card
For General Benefits and Claims:
- Customer Service: Karias Care Concierge
- Phone: See ID card for contact information
Compliance and Legal Information
This Schedule of Medical Benefits is subject to the terms, conditions, limitations, and exclusions set forth in the Plan Document/Summary Plan Description. 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.
Plan Version: 25.1
Document Status: DRAFT as of 7-23-2025 PM, 7-24-25 PM, 7-25-25 PM, 8-1-25 PM, 8-12-2025 PM
Corrections Noted:
- Correction made 8-12-25, Effective 9-1-25: Freestanding Facility Outpatient Surgery Co-payment updated to $400
This document contains proprietary information for internal and member use only. For complete plan details, exclusions, and limitations, please refer to the full Plan Document/Summary Plan Description.