Schedule of Medical Benefits for Cliff Berry, Inc. - Mid Plan (PPO)

Cliff Berry, Inc. - Mid Plan Health Benefits Schedule

Effective Date: September 1, 2025
Group Number: 006R2563
Plan Type: PPO (Preferred Provider Organization)
Status: NGF
Managed Care Type: PPO

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Plan Overview

Network Information

• PPO Network: United Choice (47/3)
• Primary Network (3 New England States): HPHC (Harvard Pilgrim Health Care)
• Primary Network (Other 47 States): UnitedHealthcare
• Note: Other networks may apply. Please refer to your ID card for the network that applies to you.

Plan Administration

• Utilization Management (UM): MedWatch
• Case Management (CM): MedWatch
• Disease Management (DM): N/A
• Customer Service: Karias Care Concierge

Specialty Programs

HPI Sponsored Specialty Programs:

• ☒ SCM+ Dialysis Program: Full dialysis carve-out

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Prescription Drug Benefits

Administered by: TrueScripts

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 and non-preferred brand contraceptives: Subject to co-payments/coinsurance unless generic form is not available
• Tobacco cessation products: Covered at 100%

Step Therapy

Certain prescription drugs are subject to step therapy requirements. You may be required to use a different prescription drug product first. To determine if step therapy applies, 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

Retail Card Program (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 (Retail and Mail Order, Up to 30-Day Supply)

• Coinsurance: 20% up to $250 per prescription

Additional Prescription Drug Information

• Out-of-Network Pharmacy Coverage: NOT COVERED
• Prescription Drug Costs: Count toward COMBINED Medical OOP Max
• Deductible Requirement: NO (Scripts not subject to deductibles)
• Non-Participating Pharmacy Coverage: NO
• Mandatory Mail Order: NO
• Maintenance Medication Program: NO

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Medical Plan Deductibles

In-Network Deductibles

Single Plan (Employee Only): $3,500
Family Plan (Employee & Family):

• $3,500 per person
• Up to $7,000 per family

Out-of-Network Deductibles

Single Plan (Employee Only): $7,000
Family Plan (Employee & Family):

• $7,000 per person
• Up to $14,000 per family

Important Deductible Information

• Individual Deductible Included in Family Coverage: YES
• Deductible Carryover: NO
• In/Out-of-Network Deductibles: SEPARATE (do not accumulate together)
• Family deductible may be met by any combination of family members
• Once an individual family member satisfies the individual deductible, claims will be paid for that individual

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Coinsurance (Reimbursement Percentage)

In-Network Providers

80% of the Contracted Rate (after deductible, unless otherwise stated) until Out-of-Pocket Maximum is reached, then 100% for the balance of the Plan Year

Out-of-Network Providers

60% of the Allowed Amount (after deductible, unless otherwise stated) until Out-of-Pocket Maximum is reached, then 100% for the balance of the Plan Year

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Out-of-Pocket Maximums

In-Network Out-of-Pocket Maximums

Single Plan (Employee Only): $6,600
Family Plan (Employee & Family):

• $6,600 per person
• Up to $13,200 per family

Out-of-Network Out-of-Pocket Maximums

Single Plan (Employee Only): $13,200
Family Plan (Employee & Family):

• $13,200 per person
• Up to $26,400 per family

Out-of-Pocket Maximum Information

• Individual OOPM Included in Family Coverage: YES
• In/Out-of-Network OOPMs: SEPARATE (do not accumulate together)
• Includes all applicable co-payments, deductibles, and coinsurance (including prescription drugs)
• Excluded from OOPM: Precertification penalties
• Once individual OOPM is satisfied, claims are paid at 100% for that individual
• Family OOPM may be met by any combination of family members

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Medical Co-Payments

In-Network Co-Payments

• Primary Care Physician Visit: $25
• Specialty Care Physician Visit: $65
• Inpatient Hospital: NONE
• Outpatient Hospital Surgery: NONE

Out-of-Network Co-Payments

• All Services: NONE (subject to deductible and coinsurance instead)

Co-Payment Maximums

• In-Network: NONE
• Out-of-Network: NONE

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Precertification Requirements

Precertification Required For:

• Inpatient hospitalization: Must be precertified 7 business days prior to admission (or within 2 business days for emergency admissions)
• Outpatient surgical procedures
• Services deemed cosmetic or Experimental/Investigational
• Other services as specified (see individual benefit descriptions)

Failure to Obtain Precertification:

• In-Network Provider: May result in a reduction in benefits
• Out-of-Network Provider: WILL result in a $400 reduction per admission
• Penalties cannot be used to satisfy co-payments, deductibles, or Out-of-Pocket Maximums
• Penalty responsibility: Covered Person

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No Surprises Act (NSA) Protection

Emergency services and certain out-of-network services at in-network facilities will be paid at in-network levels when:

• Emergency services rendered by Out-of-Network Providers
• Air ambulance services by Out-of-Network Providers
• Non-emergency services by Out-of-Network Providers at In-Network facilities for: emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services
• Condition: Covered Person has not validly waived NSA applicability

Balance Billing Protection

Out-of-Network Providers CANNOT balance bill the Covered Person for:

• Emergency Care services
• Air ambulance services
• Covered non-emergency services at in-network facilities (unless written consent is provided per NSA)

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Preventive Care Services

All preventive services marked with ** are provided according to PPACA (Patient Protection and Affordable Care Act) regulations.

In-Network Coverage: 100% (Deductible Waived)

Out-of-Network Coverage: 60% Allowed Amount (After Deductible)

Covered Preventive Services

General Preventive Care

• **Routine Physical Exams (including routine immunizations and flu shots)
• **Routine Well Child Care (including screenings, routine immunizations, and flu shots)
• **Routine Immunizations (if not billed with office visit; includes flu shots)
• **Routine Lab, X-rays, and Clinical Tests (including maternity-related)

Women's Health

• **Routine Gynecological/Obstetrical Care (including preconception and prenatal services)
• **Routine Pap Smears
• **Breast Cancer Screening (including routine mammograms and BRCA testing)
• **Breastfeeding Support, Supplies and Counseling (during pregnancy and/or postpartum period)
  • Hospital Grade Breast Pumps: rental covered up to 3 months
  • Electric Breast Pumps: rent or purchase (whichever is less)
  • Manual Breast Pumps: purchase
  • Note: If no in-network lactation providers available, out-of-network providers covered at in-network level with no cost sharing
• **Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling)

Pediatric Care

• *Fluoride Varnish (up to age 6): Up to 4 varnish treatments per person, per Plan Year

Cancer Screenings

• **Routine Colorectal Cancer Screening (including sigmoidoscopies and colonoscopies per USPSTF recommendations; precertification required)
• *Lung Cancer Screening (including Low-Dose Computed Tomography/LDCT per USPSTF recommendations): Up to 1 per person, per Plan Year
• Routine Prostate Exams and PSA Screenings

Health Counseling

• **Nutritional Counseling
• **Smoking Cessation Counseling and Intervention (including smoking cessation clinics and programs)

Diagnostic Screenings

• *Abdominal Aortic Aneurysm Screening (per USPSTF recommendations): Up to 1 per person, per lifetime
• **Bone Density Screening
  • Women (per USPSTF recommendations for osteoporosis): 100% (Deductible waived)
  • All other Covered Persons: 80% (after Deductible) In-Network; 60% Out-of-Network

Other Preventive Services

• Routine Hearing Exams: $65 co-payment per visit, then 100% (Deductible waived) In-Network; 60% Out-of-Network

*Combined In-Network and Out-of-Network maximums

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Vision Care

Routine Vision Exam

• Frequency: Up to 1 exam per person every 24 consecutive months*
• In-Network: 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• Excludes: Contact lens fitting

Routine Eyewear

• Lenses, frames, and contact lenses: NOT COVERED

Eyewear for Special Conditions

• Covered: Initial purchase of non-routine eyewear following surgery; contact lenses for keratoconus (including fitting); intraocular lenses after corneal transplant, cataract surgery, or other covered eye surgery
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

*Combined In-Network and Out-of-Network maximum

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Physician Services

Primary Care Physician Office Visits

• In-Network: $25 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• Includes all related charges billed at time of visit
• Precertification required for on-going wound care

Specialist Physician Office Visits

• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• Includes all related charges billed at time of visit
• Precertification required for on-going wound care

Allergy Services

• Allergy Testing: $25 co-payment per visit, then 100% (Deductible waived) In-Network; 60% Out-of-Network
• Allergy Treatment: 80% (after Deductible) In-Network; 60% Out-of-Network

Anesthesia (Inpatient/Outpatient)

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Chiropractic Services

• Limit: Up to 20 visits per person, per Plan Year*
• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Maternity Services

• Prenatal Care:
  • In-Network: 100% (Deductible waived)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
• Physician Delivery Charges:
  • In-Network: 80% (after Deductible)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
• Postnatal Care:
  • In-Network: 80% (after Deductible)
  • Out-of-Network: 60% Allowed Amount (after Deductible)

Physician Hospital Visits

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Second Surgical Opinion

• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Surgery

• Inpatient Surgery:
  • In-Network: 80% (after Deductible)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
• Outpatient Surgery:
  • In-Network: 80% (after Deductible)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
• Surgery in Physician's Office:
  • In-Network: $25 Primary Care or $65 Specialist co-payment per visit, then 100% (Deductible waived)
  • Out-of-Network: 60% Allowed Amount (after Deductible)

*Combined In-Network and Out-of-Network maximum

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Hospital Services - Inpatient

⚠️ PRECERTIFICATION ALWAYS REQUIRED FOR INPATIENT HOSPITALIZATION

Failure to Obtain Precertification:

• In-Network: May result in reduction in benefits
• Out-of-Network: WILL result in $400 reduction per admission
• Penalties cannot satisfy co-payments, deductibles, or OOPMs
• Penalty responsibility: Covered Person

Hospital Room & Board

• Coverage: Semi-private room or special care unit
• Private Room: Only when Medically Necessary or when facility doesn't provide semi-private rooms
• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Maternity Services (Inpatient)

• Coverage: Semi-private room or special care unit
• Precertification Required: For stays exceeding 48 hours (vaginal) or 96 hours (cesarean)
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Birthing Center

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Newborn Care

• Coverage: Includes Physician visits & circumcision
• Room: Semi-private room or special care unit
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Organ, Bone Marrow and Stem Cell Transplants

• Coverage: Semi-private room or special care unit
• Includes: Transportation, food and lodging expenses
• Transportation/Food/Lodging Limit: $8,000 per Transplant
• Precertification: Required for Medical Necessity (see Medical Benefits section for other limitations)
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Surgical Facility & Supplies

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Miscellaneous Hospital Charges

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

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Hospital Services - Outpatient

Clinic Services (At a Hospital)

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Emergency Room Expenses

• Includes: Facility, Lab, X-ray & Physician services
• In-Network: $500 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: $500 co-payment per visit, then 100% (Deductible waived)
• Note: Co-payment is waived if admitted on an inpatient basis to a Hospital

Outpatient Department

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Outpatient Surgery in Hospital/Ambulatory Surgical Center

• Precertification: Required
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Preadmission Testing

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Urgent Care Facility/Walk-In Clinic

• In-Network: $80 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

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Mental Health/Substance Use Services

⚠️ PRECERTIFICATION ALWAYS REQUIRED FOR INPATIENT HOSPITALIZATION

Failure to Obtain Precertification:

• In-Network: May result in reduction in benefits
• Out-of-Network: WILL result in $400 reduction per admission
• Penalties cannot satisfy co-payments, deductibles, or OOPMs
• Penalty responsibility: Covered Person
• Private Room: Only when Medically Necessary or when facility doesn't provide semi-private rooms

Inpatient Hospitalization

• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Partial Hospitalization/Intensive Outpatient Treatment

• Precertification: Required for Medical Necessity
• In-Network: 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Inpatient Physician Visit

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Hospital Clinic Visit

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Office Visit

• In-Network: $25 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Methadone Maintenance/Treatment

• In-Network: $25 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

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Other Services & Supplies

Acupuncture

• Limit: Up to 10 visits per person, per Plan Year*
• In-Network: $25 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Alternative/Complementary Care Benefit

• Coverage: NOT COVERED

Ambulance Services

• In-Network: $200 co-payment per trip, then 100% (Deductible waived)
• Out-of-Network: $200 co-payment per trip, then 100% Allowed Amount (Deductible waived)
• See Medical Benefits section for limitations

Autism Spectrum Disorders Treatment

• Includes: Applied Behavioral Analysis (ABA)
• Benefit Limits: Apply to occupational, physical, and speech therapies
• Precertification: Required for ABA
• Coverage: Benefits based on services provided (both In-Network and Out-of-Network)
• Note: Screenings covered under Preventive Care

Bariatric Surgery

• Coverage: NOT COVERED

Cardiac Rehabilitation

• Coverage: Phase 1 and 2 only
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Chemotherapy & Radiation Therapy

• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Clinical Trials - Routine Services

• Coverage: Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services
• Coverage: Benefits based on services provided (both In-Network and Out-of-Network)
• See Medical Benefits section for other limitations

Cochlear Implants

• Eligibility: Covered Persons up to age 19
• Frequency: Once every 5 years
• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Dental/Oral Services

• Excludes: Excision of impacted wisdom teeth
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Diabetes Self-Management Training and Education

• In-Network: $25 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Diagnostic Imaging (MRI, CT Scan, PET Scan)

• Precertification: Required
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Diagnostic X-ray and Laboratory (Outpatient)

• X-rays (In-Network): 80% (after Deductible)
• Labs (In-Network): 100% (Deductible waived)
• All Other Diagnostic Tests (In-Network): 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Dialysis/Hemodialysis Services

Inpatient Dialysis/Hemodialysis and Related Professional Services

• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Outpatient Dialysis/Hemodialysis Professional Services

• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Outpatient Dialysis/Hemodialysis Facility Services

• Coverage: Covered under separate administrative carve-out program
• Program: Outpatient Dialysis Health Reimbursement Arrangement plan
• Administrator: Specialty Care Management (SCM)
• Contact: Phone number on back of ID card
• Note: Professional Services covered under Plan as shown above

Durable Medical Equipment

• Precertification Required For:
  • Insulin pumps and supplies
  • Equipment in excess of $2,500
  • Out-of-Network providers
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Early Intervention Services

• Eligibility: Up to age 3
• In-Network: 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for limitations

Erectile Dysfunction Treatment

• Coverage: NOT COVERED

Family Planning

• For Women:
  • In-Network: 100% (Deductible waived)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
  • See also Prescription Drug Benefit and Preventive Care Section
• For Men:
  • In-Network: 100% (Deductible waived)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
• Includes consultations and diagnostic tests

Gender Dysphoria Treatment and Related Services

• Coverage: NOT COVERED

Genetic Counseling, Testing and Related Services

• Precertification: Required for Medical Necessity for genetic testing
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• Note: BRCA Testing covered under Breast Cancer Screening in Preventive Care (precertification not required)

Gene Therapy

• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Growth Hormones

• Coverage: NOT COVERED

Hearing Aids

• Coverage: NOT COVERED

Home Health Care

• Limit: Up to 60 visits per person, per Plan Year*
• Precertification: Required for Medical Necessity
• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Hospice Care (Inpatient/Outpatient)

• Precertification: Required for Medical Necessity
• Inpatient (In-Network): 80% (after Deductible)
• Outpatient (In-Network): $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Infertility Treatment

• Coverage: NOT COVERED

Injectables

• Precertification: Required for Medical Necessity for injectables in excess of $1,500
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Learning Deficiencies, Behavioral Problems/Developmental Delays

• Precertification and Visit Limits: Based on services provided
• In-Network: 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Marital Counseling

• Coverage: NOT COVERED

Massage Therapy

• Coverage: NOT COVERED

Medical and Enteral Formula

• Coverage: NOT COVERED

Modified Low Protein Food Products

• Coverage: NOT COVERED

Neuromuscular Stimulator Equipment including TENS

• Precertification: Required as noted under Durable Medical Equipment benefit
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Occupational Therapy

• Coverage: For treatment due to Illness or Injury
• Limit: Up to 30 visits per person, per Plan Year*, combined with Physical Therapy and Speech Therapy
• Precertification: Required for Medical Necessity after 13 visits
• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Orthotics

• Includes: Foot orthotics
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Pain Clinics

• Precertification: Required for Medical Necessity for inpatient services
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Physical Therapy

• Coverage: For treatment due to Illness or Injury
• Limit: Up to 30 visits per person, per Plan Year*, combined with Occupational Therapy and Speech Therapy
• Precertification: Required for Medical Necessity after 13 visits
• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Podiatry Care

• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for limitations

Private Duty Nursing

• Coverage: NOT COVERED

Prosthetics

• Precertification: Required as noted under Durable Medical Equipment benefit
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for limitations

Rehabilitation Hospital

• Limit: Up to 60 days per person, per Plan Year*, combined with Skilled Nursing Facility
• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Respiratory Therapy

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Skilled Nursing Facility/Extended Care Facility

• Limit: Up to 60 days per person, per Plan Year*, combined with Rehabilitation Hospital
• Precertification: Required for Medical Necessity
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Sleep Studies

• Precertification: Required for Medical Necessity for inpatient sleep studies
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Speech Therapy

• Coverage: For treatment due to Illness or Injury
• Limit: Up to 30 visits per person, per Plan Year*, combined with Occupational Therapy and Physical Therapy
• Precertification: Required for Medical Necessity after 13 visits
• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Speech Therapy

• Coverage: For treatment due to Illness or Injury
• Limit: Up to 30 visits per person, per Plan Year*, combined with Occupational Therapy and Physical Therapy
• Precertification: Required for Medical Necessity after 13 visits
• In-Network: $65 co-payment per visit, then 100% (Deductible waived)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Telemedicine

• Applies to: Medical and behavioral health services
• Medical/Behavioral Health Services:
  • In-Network: $25 co-payment per visit, then 100% (Deductible waived)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
• All Other Virtual Visits: With a Provider with whom Covered Person has established relationship (including Occupational Therapy, Physical Therapy, and Speech Therapy)
  • In-Network: Paid based on services provided
  • Out-of-Network: Paid based on services provided
• See Medical Benefits section for additional information

Temporomandibular Joint Disorders (TMJ) Treatment

• Precertification: Required
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

Termination of Pregnancy

• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)

Travel Immunizations

• Coverage: NOT COVERED

Voluntary Sterilization

• For Women:
  • In-Network: 100% (Deductible waived)
  • Out-of-Network: 60% Allowed Amount (after Deductible)
• For Men:
  • In-Network: 100% (Deductible waived)
  • Out-of-Network: 60% Allowed Amount (after Deductible)

Wigs

• Eligibility: When hair loss is due to the treatment of cancer
• Limit: Up to $500* per Covered Person every 5 years
• In-Network: 80% (after Deductible)
• Out-of-Network: 60% Allowed Amount (after Deductible)
• See Medical Benefits section for other limitations

*Combined In-Network and Out-of-Network maximums

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Wellness Benefits

All Providers

• Childbirth Classes: NOT COVERED
• Fitness Reimbursement Benefit: NOT COVERED
• Weight Loss Reimbursement Benefit: NOT COVERED

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Additional Benefits - Detailed Coverage Table

EXCLUDED Benefits

The following services are NOT COVERED under this Plan:

• Alternative/Complementary Care Benefit:
  • Biofeedback
  • Chelation Therapy
  • Homeopathic Treatment
  • Hypnosis/Hypnotherapy
  • Rolfing/Reiki
• Cardiac Rehab Phase III (Outpatient maintenance)
• Planned Home Births
• Sex Therapy

COVERED Additional Benefits

Applied Behavior Analysis (ABA)

• Coverage: Covered under Autism Spectrum Disorders treatment
• Payment: Pays as a Mental Health/Substance Abuse Outpatient Office Visit

Breast Reduction Surgery

• Coverage: When Medically Necessary
• Precertification: Required

Home Visit by Visiting Nurse After Early Maternity Discharge

• Coverage: COVERED

Orthoptics

• Coverage: COVERED
• Payment: Pays as Specialist Outpatient Office Visit

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Important Plan Notes and Reminders

Balance Billing and Allowed Amounts

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.

Separate Networks for In-Network and Out-of-Network

• In-Network Provider and Out-of-Network Deductibles are SEPARATE and do not accumulate
• In-Network Provider and Out-of-Network Out-of-Pocket Maximums are SEPARATE and do not accumulate
• Eligible expenses toward In-Network Deductible and OOPM will NOT be credited toward Out-of-Network Deductible and OOPM (and vice versa)

Medical Necessity

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. Coverage may not be available for services not determined to be Medically Necessary if precertification is required but not obtained.

Private Room Coverage

A private room is covered only when:

• Medically Necessary, OR
• When a facility does not provide semi-private rooms

Combined Visit/Service Limits

Many benefits have combined In-Network and Out-of-Network maximums (marked with * in the document). This means the total visits/services count toward one shared limit regardless of whether you use In-Network or Out-of-Network providers.

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Key Contact Information

Prescription Drug Benefits

• Website: www.truescripts.com
• Phone: Member Customer Care number on your ID card

Dialysis Services (Outpatient Facility)

• Program: Specialty Care Management (SCM)
• Phone: Number listed on back of ID card

General Plan Information

• Customer Service: Karias Care Concierge
• Utilization Management: MedWatch
• Case Management: MedWatch

Network Verification

• Always refer to your ID card for the specific network that applies to you
• Networks may vary based on your state of residence

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Exclusions and Limitations Summary

Services NOT COVERED:

• Alternative/Complementary Care (except ABA for Autism)
• Bariatric Surgery
• Childbirth Classes
• Erectile Dysfunction Treatment
• Fitness Reimbursement
• 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
• Planned Home Births
• Private Duty Nursing
• Routine Eyewear (lenses, frames, contact lenses)
• Sex Therapy
• Travel Immunizations
• Weight Loss Reimbursement

Services with Special Limitations:

• Acupuncture: 10 visits per year
• Chiropractic Services: 20 visits per year
• Cochlear Implants: Once every 5 years (up to age 19)
• Fluoride Varnish: 4 treatments per year (up to age 6)
• Home Health Care: 60 visits per year
• Lung Cancer Screening: 1 per year
• Occupational/Physical/Speech Therapy: 30 visits combined per year
• Rehabilitation Hospital/Skilled Nursing Facility: 60 days combined per year
• Routine Vision Exam: 1 every 24 months
• Wigs: $500 every 5 years (cancer-related)
• Abdominal Aortic Aneurysm Screening: 1 per lifetime

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Quick Reference Guide

Emergency Situations

• Emergency Room: $500 co-pay, then 100% (co-pay waived if admitted)
• Ambulance: $200 co-pay per trip, then 100%
• Emergency services from Out-of-Network Providers: Covered at In-Network levels (per NSA)

Office Visits

• Primary Care: $25 co-pay
• Specialist: $65 co-pay
• Urgent Care: $80 co-pay
• Mental Health Office Visit: $25 co-pay

Common Services

• Lab Work (Outpatient): 100% (no deductible) In-Network
• X-rays (Outpatient): 80% after deductible In-Network
• MRI/CT/PET Scan: 80% after deductible (precertification required)
• Outpatient Surgery: 80% after deductible (precertification required)
• Physical Therapy: $65 co-pay per visit (up to 30 visits/year combined with OT/ST)

Preventive Care

• Most Preventive Services: 100% (no deductible) In-Network
• Annual Physical: 100% (no deductible)
• Routine Mammogram: 100% (no deductible)
• Colonoscopy: 100% (no deductible, precertification required)

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Document Information

Plan Document Name: 006R2563_R2563U3&7M002_DRAFT SCHEDULE_Eff 09012025_Mid Plan PPO.pdf

Draft Dates: As of 7-23-2025 PM, 7-24-25 PM, 7-25-25 PM, 8-1-25 PM

Approval Signatures Required From:

• TRU Department
• Account Manager: Julie Elwell
• Compliance: Patrick Moore

Total Document Pages: 22

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Disclaimer

This is a summary of benefits based on the Schedule of Medical Benefits. This document 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:

• Complete list of benefit exclusions
• Complete list of non-benefit type exclusions
• Detailed definitions and limitations
• Full terms and conditions

For complete details about your coverage, always consult your official Plan Document/Summary Plan Description or contact Customer Service.

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Last Updated: Based on draft schedule effective 09/01/2025