Carolina Orthopaedic and Neurosurgical Associates - HSA Plan Benefits Guide
This is a Qualified High Deductible Health Plan (HDHP) with separate in-network (Tier 1) and out-of-network (Tier 2) benefits. The plan features higher deductibles and out-of-pocket maximums for Tier 2 services. TPA: 90 Degree Benefits. Network: CIGNA (Tier 1). Emergency services and ambulance services receive Tier 1 benefits regardless of network status. Dental and Vision benefits are Excepted (unbundled). Benefits applied per Calendar Year.
Plan Identification & Administrative Details
| Field | Details |
|---|---|
| Document Type | Install Plan Document |
| Group Name | Carolina Orthopaedic and Neurosurgical Associates |
| Legal Name | Carolina Orthopaedic and Neurosurgical Associates |
| Master Group Number | 65100 |
| Subgroup | 65101 |
| Benefit Plan(s) | HSA Plan |
| Effective Date | 01/01/2026 |
| Plan Type | Qualified High Deductible Health Plan (QHDHP) |
| Grandfather Status | No |
| ERISA Plan | Yes |
| Dental/Vision Benefits | Excepted (unbundled) |
| Fiscal Year Date (Plan Funding) | 1/1 - 12/31 |
| Benefits Applied Per | Calendar Year |
| TPA | 90 Degree Benefits |
| TPA Hours of Operation | 8:00 AM - 5:00 PM CST |
Network & Payment Structure
Benefit Level Plan Configuration
| Tier | Subgroup | PPO Code | Network/Payment Method |
|---|---|---|---|
| Tier 1 | 65101 | 3002 | CIGNA |
| Tier 1 | 65101 | 11111 | OVERRIDE TO PAY TIER 1 |
| Tier 2 | 65100 | 0 | 130% OF MEDICARE FOR PROFESSIONAL; 150% OF MEDICARE FOR FACILITIES |
Reference-Based Pricing (RBP)
| Tier | RBP | % of Medicare |
|---|---|---|
| Tier 1 | No | N/A |
| Tier 2 | Yes | 130% (Professional) / 150% (Facilities) |
Note: For 90 Degree Benefits Use Only
Annual Deductibles & Out-of-Pocket Maximums
Deductibles (Per Calendar Year)
| Coverage Level | Tier 1 (In-Network) | Tier 2 (Out-of-Network) |
|---|---|---|
| Per Person | $2,500 | $10,000 |
| Per Family | $5,000 | $20,000 |
Important Notes:
- In and out of network deductibles DO NOT cross-apply (SEPARATE)
- Deductible DOES apply to out-of-pocket maximum
- Last 3 months carryover: NO
- If yes, carryover deductible apply to OOP: N/A
Out-of-Pocket Maximums (Per Calendar Year)
| Coverage Level | Tier 1 (In-Network) | Tier 2 (Out-of-Network) |
|---|---|---|
| Per Person | $5,000 | $15,000 |
| Per Family | $10,000 | $30,000 |
Important Notes:
- In and out of network OOP maximums DO NOT cross-apply (SEPARATE)
- 3-month Carry Over Out-of-Pocket benefit: NO
- Out-of-pocket IS integrated with pharmacy (Tier 1: Yes, Tier 2: Yes)
- Copays DO apply to out-of-pocket maximum (Tier 1: Yes, Tier 2: Yes)
Coinsurance
| Tier | Plan Pays | Patient Pays |
|---|---|---|
| Tier 1 | 80% | 20% |
| Tier 2 | 50% | 50% |
After deductible is satisfied
Mental Health & Substance Abuse Coverage
| Service Type | Tier 1 | Tier 2 |
|---|---|---|
| Mental/Nervous Services Covered | Yes | Yes |
| Substance Abuse Services Covered | Yes | Yes |
Comments: When covered, all Mental Nervous and Substance Abuse benefits are paid as any other illness.
Specialty Drugs & Appeals
| Item | Details |
|---|---|
| Specialty Drugs - New to Market Waiting Period | 6 months (both tiers) |
| Levels of Appeals Before IRO | 1 |
Additional Programs Available
| Program | Status | Details |
|---|---|---|
| Teladoc | Active | $0 Consult fee |
| RBP (Reference-Based Pricing) | Tier 2 Only | 130% Medicare (Professional), 150% Medicare (Facilities) |
| A&G Editing/Bill Review | Yes | - |
| Patient Defender | Yes | - |
| Pace | Yes | - |
| CareConnect | Yes | Benchmark State: Utah |
Eligibility
Employee Information
| Item | Details |
|---|---|
| Number of Employees | 174 |
| Medicare COB Note | Special COB rules may apply for employees with Medicare if employer has less than 100 EEs |
| Standard FMLA | Yes |
| Continuation for Disability (outside FMLA) | NO |
| Continuation for Layoff | NO |
| Leave of Absence (non-FMLA) | NO |
| Benefits Limited to Full-Time Employees Only | Yes |
Dependent Eligibility
| Dependent Type | Eligible |
|---|---|
| Dependents | Yes |
| Adopted Children | Yes |
| Domestic Partners | No |
| Common Law Spouse | No |
| Foster Children | No |
| Children Under Legal Guardianship | No |
| Grandchildren | No |
| Dependent Age Limit | 26 |
Spouse Eligibility
Is Spouse eligible for coverage if able to obtain coverage elsewhere: Yes
Reinstatement of Coverage
- Employee is treated as a new hire: Yes
- If No, waiting period is waived if rehired within: 30 days
Stop Loss
| Type | Tracks To |
|---|---|
| Stop Loss - Specific | MED/RX |
| Stop Loss - Aggregate | MED/RX |
Continuity of Care
| Feature | Details |
|---|---|
| Does the plan offer continuity of care benefits? | Yes |
| Duration | Standard 90 days |
| Notes | For persons under care for a serious illness or pregnancy, network benefits are available for a limited period if the primary care physician leaves the network. |
Pre-Certification / Notification
| Item | Details |
|---|---|
| Pre-certification Provided By | CIGNA |
| Pre-certification Phone Number | 888-832-4354 |
| Applicable Services | See CIGNA Pre-Certification Listing (attached to plan document) |
| Allow Retroactive Pre-certification | NO - Services requiring pre-certification will be denied if not on file |
| Post-Service Pre-certification Penalty | NO - No penalty amount |
| Pre-cert Required for Medicare Primary | NO |
| Pre-cert Required if Other Coverage Primary | NO |
IMPORTANT: Refer to the separate CIGNA PRE-CERTIFICATION LISTING included with this plan document for specific services requiring pre-certification.
Medical Office Visits
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | AOV, AOVS, OV, OVS, POV, SMV, SOV, TELM, TELS, ZPOV, ZSMV, ZSOV | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Co-pay Amount | N/A | N/A |
| Plan Pays | 80% | 50% |
| Different Co-pay for Specialists | No | No |
Office Surgery
Includes related anesthesia services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | AF, AFQ, AFS, OPM, OPMS, SF, SFS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Therapeutic Injections (Office)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | INJ, INJS, MINJ, ZMIN | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Allergy Services
Allergy Injections and Serum
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | ALI, ALIS, ALS, ALSS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Allergy Testing
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | ALT, ALTS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Diagnostic Services - Office Setting
Office Charges for X-ray & Professional Component
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | XRDR, XRDS | |
| Covered Service | Yes | Yes |
| Includes High Cost Imaging (MRI, CT, PET, etc.) | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Office Charges for Laboratory & Professional Component
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | LBDR, LBDS, MOXL, SMOX, SOXL, ZMOX, ZSMX, ZSOXX | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Office Charges Diagnostic Testing
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | ODX, ODXS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
All Other Office Related Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HBOO, HBOS, HBPO, HBPS, OIV, OIVS, OMS, OMSS, OWCT | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Diagnostic Services - Outpatient/Independent
Independent Laboratory & Professional Component
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | LAB | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Lab/X-ray/Diagnostic Imaging (Including Ultrasound) - Outpatient Physician
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | PRF | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Lab/X-ray/Diagnostic Imaging (Including Ultrasound) - Outpatient Testing and/or Facility Fee
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | CUS, HLAB, HXL, HXR, MXL, OPDX, OUSS, SMXL, SXL, US, XRAY | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Major Diagnostic Procedures - Physician
Including, but not limited to: MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans, facility/professional expenses, all Outpatient and office places of service
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | PRF | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Major Diagnostic Procedures - Testing and/or Facility Fee
Including, but not limited to: MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans, facility/professional expenses, all Outpatient and office places of service
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | BONE, CAT, CST, HCAT, MRIO, MRIS, MYEL, NUC, NUCO, NUCS, OBON, OBOS, OCAT, OCSS, OCST, OCUS, OMRI, OMYE, OMYS, OPES, OPET, OSPC, OSPS, PET, SCAT, SPCT | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Sleep Studies
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | OSLP, SLPS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Acupuncture Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | AP, APS | |
| Covered Service | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
| Maximum Visits | N/A | N/A |
| Maximum Benefit | N/A | N/A |
Ambulance and Medically Appropriate Transport
Ground and Air
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | AMB, AMBR, AR | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 80% |
| Include Facility to Facility When Medically Necessary | Yes | Yes |
Comments: Tier 2 applies Tier 1 deductible/OOP
Chiropractic Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | CH, CHX | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Benefit | $500 per calendar year | $500 per calendar year |
Durable Medical Equipment
Includes DME supplies
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | BRA, DIEQ, DME, DMS, DTE, MMS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Insulin Pumps Considered DME | Yes | |
| Includes Insulin Pump Supplies | Yes | |
| Cover Cost of Repairs (not due to misuse) | Yes | |
| Cover Replacements (outside warranty, unable to repair) | Yes | |
| Cover Batteries | Yes | |
| Cover Sales Tax and Shipping Charges | Yes | |
| Rental Maximum up to Purchase Price | Yes |
Extended Care Facility Benefits
Skilled nursing, subacute facility
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | SNF | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Days | 60 days per calendar year | 60 days per calendar year |
Home Health Care Benefits
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HHC, HHS, PHC, PHS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Visits | 60 visits per calendar year | 60 visits per calendar year |
Hospice Care Benefits
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HO, OHO | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Days/Visits | No day maximum | No day maximum |
| Allow Custodial / Respite Care | No | |
| Include in Hospice Benefit | N/A |
Bereavement Counseling
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HBC, HFC | |
| Covered Service | Yes | Yes |
| Include in Hospice Benefit | Yes | Yes |
| Maximum Visits | No day maximum | No day maximum |
| Timeframe | Services must be furnished within 6 months of death | |
| Plan Pays | 80% | 50% |
Emergency Services
Emergency Room Hospital Facility Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | ER, MNO, NER, SMOF, SNO | |
| Covered Service | Yes | Yes |
| All Emergency Services Paid In-Network | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Co-pay Amount | N/A | N/A |
| If Admitted Within 24 Hours, Waive Co-pay | Yes | Yes |
| Plan Pays | 80% | 80% |
Comments: Tier 2 applies Tier 1 deductible/OOP
Emergency Room Hospital Professional Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | ERD, MERD, NERD, SAER, SMER | |
| Covered Service | Yes | Yes |
| All Emergency Services Paid In-Network | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Co-pay Amount | N/A | N/A |
| Plan Pays | 80% | 80% |
Comments: Tier 2 applies Tier 1 deductible/OOP
Hospital Services
Inpatient Facility Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | BC, HM, HNS, ICU, IMC, MHM, MRB, RB, SHM, SMHM, SMRB, SRB | |
| Covered Service | Yes | Yes |
| Notification Penalty Waived for Emergency Admissions | Yes | Yes |
| If Admitted Through ER, is ER Copay Waived | Yes | Yes |
| Reduce to Semi-Private Room Rate if Available | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Ancillary (All Other Inpatient) Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | DX, HV, MID, MNI, PAT, RAD, SID, SIP, SMID, SMNI, WC | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Infusion Therapy
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | IVIN | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Surgery Services
Second Surgical Opinion
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | SV, SVS | |
| Covered Service | Yes | Yes |
Comments: Paid same as any other illness
Anesthesia
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | AI, AIQ, AO, AOQ, MNA, SMA | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Surgeon / Assistant Surgeon / Co-Surgeon
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | CIRC, SI, SO, STER, TI, TO | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Assistant Surgeon Bill Limitation | Yes (25% of U&C fee) | Yes (25% of U&C fee) |
Outpatient Hospital Surgery and Ambulatory Surgical Center
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | ASF, OHS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Maternity & Newborn Services
Maternity Surgery (Includes Physician Attendance)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | MAT, MATD, MATO | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Routine Newborn Care
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | CIRC, HNS, WC | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Pregnancy / Maternity Benefits - Miscellaneous
| Question | Answer |
|---|---|
| Services in Physician's Office Paid Per Medical Office Visit Section | Yes |
| Services in Hospital Paid Per Hospital Section | Yes |
| Allow Dependent Daughter Pregnancies | Yes (If no, PPACA required services covered) |
| Allow Outpatient Birthing Centers | Yes |
| Allow Home Deliveries | Yes |
| Allow All Elective Abortions | No |
| Cover Elective Abortions - Rape/Incest | Yes (Must be compliant with applicable state law) |
| Cover Elective Abortions - Mother's Life in Danger | Yes (Must be compliant with applicable state law) |
| Abortions Covered For | All females covered under the plan |
| Allow Sterilization | Yes |
Newborn Enrollment Rules
| Option | Selected |
|---|---|
| Apply Normal Plan Benefits | |
| Process Under Mother | |
| Must Be Enrolled Within | 31 days |
| Automatic 31-Day Coverage, Must Enroll Thereafter | ✓ |
| Automatic 31-Day Coverage Only if EE Has Dependent Coverage |
Outpatient Services
Outpatient Hospital Services (Unless Otherwise Specified)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | CO, HBO, HMIS, HOBS, HWCT, MNOP, PA, PADR, SAOP, SMPH | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Outpatient Physician Services (Unless Otherwise Specified)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | DIED, HBP, PM | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Dialysis
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | DI, HDI | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Urgent Care Services
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | URG | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Include All Related Services | Yes | Yes |
| Plan Pays | 80% | 50% |
"Ologist" Benefits (REAP)
REAP = Radiology, Emergency Room Physicians, Anesthesiology, Pathology, Hospitalists
| Scenario | In-Network Benefits Apply? |
|---|---|
| Hospitalists, Radiology, Pathology, Anesthesiology at Participating Facility | Yes |
| Emergency Room Physicians | Yes |
| Services Referred by Participating Physician | Yes |
| Services Outside Service Area (>100 miles from residence) | Yes |
| Services Unable to be Provided by Network Provider | Yes |
| Emergency Care Out of Area or at Non-Network Hospital | Yes |
Infertility Treatment Services
Coverage Overview
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | INF, INFS, INFT, INHT, INIT, IVF, IVSF, SINT | |
| Covered Service | No | No |
Specific Infertility Services
| Service Type | Tier 1 | Tier 2 |
|---|---|---|
| Diagnostic Only (to determine diagnosis) | No | No |
| Genetic Testing to Diagnose Infertility | No | No |
| Diagnostic & Other Services | No | No |
| Fertility Test | No | No |
| Tests/Exams for Induced Conception | No | No |
| Surgical Reversal of Sterilization | No | No |
| Sperm Enhancement Procedures | No | No |
| Direct Attempts to Cause Pregnancy | No | No |
| Hormone or Therapy Drugs | No | No |
| Artificial Insemination | No | No |
| Invitro Fertilization | No | No |
| Gamete Intrafallopian Transfer (GIT) | No | No |
| Zygote Intrafallopian Transfer (ZIFT) | No | No |
| Embryo Transfer | No | No |
| Freezing or Storage of Embryo, Eggs, or Semen | No | No |
List of Covered Drugs: None
Cancer Treatment
Chemotherapy / Radiation Therapy - Professional
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | CT, HCT, HRT, RT | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Chemotherapy / Radiation Therapy - Facility
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | CT, HCT, HRT, RT | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Hearing Aids
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HA, HA2, HARC | |
| Covered Service | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
| Maximum Benefit | No benefit maximum |
Orthotics
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | DS, OR, ORH, ORI, ORS | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Allow Custom-Molded Foot Orthotics | Yes | Yes |
| Allow Non-Custom Molded Shoe Inserts | Yes | Yes |
| Allow Diabetic Shoes | Yes | Yes |
| Diabetic Shoes Limits | 1 pair per calendar year up to $500 |
Prosthetics
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | PRO | |
| Covered Service | Yes | Yes |
| Initial Purchase, Fitting, Repair, Replacement Covered | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Preventive Care Services (ACA Covered Services)
Non-Grandfathered Plan
Coverage Code: AB, AB1, AB2, AB3, AB4, AB5, AB6, AB7, ABCV, ABH, ABNC, ABR, ABX
Plan follows US Preventive Services Task Force recommendations: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Preventive services covered without cost sharing. This generally applies only when services rendered by network provider.
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Covered Service | Yes | Yes |
| Deductible Applies | No | No |
| Co-pay Applies | No | No |
| Plan Pays | 100% | Not covered if out of network |
Are there additional services covered under separate Wellness Benefit not included in USPSTF recommendations: No
Routine/Wellness Services (Outside of ACA)
Routine Physical Exam
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HWC, WCB, WCBS, WLB, WLBS | |
| Additional Routine Physical Exams Not Required by ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Immunizations
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | IMAS, IMM, IMMA, IMMB, IMMG, IMMS, IMSH | |
| Additional Immunizations Not Required by ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
List of Non-Covered Immunizations: (None specified)
Routine Diagnostic Tests, Labs, X-rays
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HWL, WLAB, WXL, WXR | |
| Additional Tests Not Required by ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Routine Mammogram
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | MAM, MAM2, OMAM, OMAS, OMA2, OM2S | |
| Additional Routine Mammograms Not Required by ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Routine Pap Smear / Test and Pelvic Exam
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | PAP, PAPR, PAPS | |
| Additional Circumstances Beyond ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Routine Fecal Blood Culture
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | WLB | |
| Additional Circumstances Beyond ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Routine PSA Test and Prostate Exam
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | PS, PSS | |
| Cover Routine PSA Test and Prostate Exam | Yes | No |
| Deductible Applies | No | N/A |
| Co-pay Applies | No | N/A |
| Plan Pays | 100% | N/A |
Details: Out of network is not covered
Routine Colonoscopy, Sigmoidoscopy and Similar Preventative Procedures
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | OCOL, OCOS, WLAB, WLB, WXL, WXLS | |
| Additional Circumstances Beyond ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Contraceptive Management
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | BCI, BCIS, BCR, BCRS, BINJ, BINS, CONS, CONT | |
| Additional Circumstances Beyond ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Routine Hearing Exam
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | RHE | |
| Additional Circumstances Beyond ACA | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Nutritional Counseling
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | WCBS | |
| Additional Circumstances for Behavioral/Nutritional Counseling | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
Vision Care Benefits
Vision Plan Information
| Item | Details |
|---|---|
| Separate Benefit for Vision Care | No |
| Other Vendor | Yes - VSP |
| Medical Related Eye Exams and Glaucoma Testing | Yes (covered under medical) |
| Glaucoma and Cataracts | Yes (covered under medical) |
| Routine Eye Exams | No (not covered under medical) |
| Routine Eye Exams Included In | Vision care benefit (VSP) |
| Benefit for Routine Eye Refractions | No (Tier 1), No (Tier 2) |
Coverage Code: REE, VEX
Other Vision Care Services
Are any of these covered under Medical Plan?
Coverage Code: HW, PHW, VANA, VBL, VCD, VCL, VFR, VINE, VLB, VLS, VLT, VSL, VTL, VTNT
| Service | Tier 1 | Tier 2 | Maximum |
|---|---|---|---|
| Lenses - Single Vision | No | No | N/A |
| Lenses - Bifocal | No | No | N/A |
| Lenses - Trifocal | No | No | N/A |
| Lenses - Lenticular | No | No | N/A |
| Lenses - Progressive | No | No | N/A |
| Lens Coating | No | No | N/A |
| Frames | No | No | N/A |
| Contacts | No | No | N/A |
| Safety Lenses and Frames | No | No | N/A |
| Sunglasses or Subnormal Vision Aids | No | No | N/A |
| Eye Surgeries for Refractive Disorders (LASIK, Radial Keratotomy, etc.) | No | No | N/A |
| Fitting/Dispensing Non-Prescription Glasses | No | No | N/A |
| Vision Therapy Services (including orthoptics) | No | No | N/A |
| Correction of Visual Acuity or Refractive Errors | No | No | N/A |
| Aniseikonia (Each eye sees object differently) | No | No | N/A |
Oral Surgery Benefits (Paid Under Medical)
Coverage Code: See applicable benefit section
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Covered Service | Yes | Yes |
Covered Oral Surgery Services
| Service | Coverage | Conditions |
|---|---|---|
| Excision of Partially or Completely Impacted Teeth | Yes | See comments |
| Excision of Tumors and Cysts | Yes | When conditions require pathological exams (jaw, cheeks, lips, tongue, roof and floor of mouth) |
| Surgical Procedures for Accidental Injuries | Yes | Jaws, cheeks, lips, tongue, roof and floor of mouth |
| Reduction of Fractures & Dislocations of Jaw | Yes | |
| External Incision and Drainage of Cellulitis | Yes | |
| Incision of Accessory Sinuses, Salivary Glands or Ducts | Yes | |
| Excision of Exostosis of Jaws and Hard Palate | Yes | |
| Frenectomy | Yes | Cutting of tissue in midline of tongue |
| Gingival Mucosal Surgery | Yes | Gingivectomy, osseous, periodontal surgery and grafting to treat gingivitis or periodontitis |
| Apicoectomy | Yes | Excision of tooth root without extraction of entire tooth |
| Root Canal Therapy | Yes | If performed in conjunction with Apicoectomy |
| Alveolectomy | Yes | Leveling of structures supporting teeth for dentures. NOT payable if performed with routine extraction |
Other Dental Services
Coverage Code: See applicable benefit section
| Service | Tier 1 | Tier 2 |
|---|---|---|
| Dental Implants | No | No |
| Anesthesia, X-ray, Lab for Medically Appropriate Hospital Services | Yes | Yes |
| Any Other Dental Services Under Medical Plan | No | No |
Temporomandibular Joint Disorder (TMJ) Benefits
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | TMJ, TMJO, TMJS | |
| Covered Service | No | No |
Covered Services (if applicable)
| Service Type | Coverage |
|---|---|
| All (surgery, appliances, adjustments) | No |
| Diagnostic Only | No |
| Non-Surgical Treatment | No |
| Surgery Only | No |
Maximum Lifetime Amount: N/A Services Maximum Applies To: N/A
Therapy & Rehabilitation Services
Physical Therapy (Outpatient Treatment)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | DPT, HPT, PT | |
| Covered Service | Yes | Yes |
| PT and OT Combined Benefit | Yes | |
| Aquatic Therapy with PT | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Benefit | 36 VISITS per calendar year | 36 VISITS per calendar year |
Comments: Includes massage therapy performed by a covered provider.
Occupational Therapy (Outpatient Treatment)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HOT, OT | |
| Covered Service | Yes | Yes |
| PT and OT Combined Benefit | Yes | |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Benefit | 36 VISITS per calendar year | 36 VISITS per calendar year |
Comments: Includes massage therapy performed by a covered provider.
Speech Therapy
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | HST, ST | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Benefit | 20 VISITS per calendar year | 20 VISITS per calendar year |
Other Outpatient Rehabilitative and Habilitative Services
ABA therapy, Cognitive Rehab, Cardiac rehab, Pulmonary rehab
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | ABA, ABAH, COGR, CR, PRHB | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
| Maximum Benefit | No benefit maximum | No benefit maximum |
Massage Therapy (Performed by Massage Therapist)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | MT | |
| Covered Service | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
| Maximum Benefit | No benefit maximum |
Comments: Massage therapy services are covered when a medical diagnosis exists and services are provided by a Physical Therapist, Occupational Therapist, or Physician.
Wigs (For Cancer Treatment or Medically Appropriate Condition)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | WIG | |
| Covered Service | No | No |
| Deductible Applies | N/A | N/A |
| Co-pay Applies | N/A | N/A |
| Plan Pays | N/A | N/A |
| Maximum Benefit | No maximum |
Transplant Services
| Item | Details |
|---|---|
| Separate Transplant Policy | No (Tier 1), No (Tier 2) |
| Transplant Services Provided By | (Phone number blank) |
| Covered When Donor Under Plan but Recipient Not | Yes (Tier 1), Yes (Tier 2) |
Transplant Facility Benefits - Recipient
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | TRN | |
| Covered Service | Yes | No |
| Deductible Applies | Yes | N/A |
| Co-pay Applies | No | N/A |
| Plan Pays | 80% | N/A |
Facility - Travel and Housing - Recipient
| Benefit | Coverage |
|---|---|
| Coverage Code | TRL, TRNT |
| Covered Service | No |
| Airfare | No (Tier 1), No (Tier 2) |
| Meals | No (Tier 1), No (Tier 2) |
| Tolls | No (Tier 1), No (Tier 2) |
| Parking Fees | No (Tier 1), No (Tier 2) |
| Apartment Rental | No (Tier 1), No (Tier 2) |
| Hotel / Motel | No (Tier 1), No (Tier 2) |
| Relocation Fees | No (Tier 1), No (Tier 2) |
| Taxes | No (Tier 1), No (Tier 2) |
| Allow Travel Expenses | No (Tier 1), No (Tier 2) |
Facility Benefits - Living Donor
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | TRN | |
| Covered Service | Yes | No |
Mental Health & Substance Abuse Services
Mental Nervous/Substance Abuse Residential Treatment Center
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | MRES, SRES | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Mental Nervous/Substance Abuse Outpatient Facility Treatment
All (PHP, DT, IOP, etc.)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | DT, SDT, SMDT | |
| Covered Service | Yes | Yes |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
All Other Covered Services (Not Otherwise Specified)
| Benefit | Tier 1 | Tier 2 |
|---|---|---|
| Coverage Code | (Not specified) | |
| Deductible Applies | Yes | Yes |
| Co-pay Applies | No | No |
| Plan Pays | 80% | 50% |
Prescription Drug Benefits
Plan Overview
| Item | Details |
|---|---|
| Coverage Code | PCS (Invoice only) |
| Prescription Drugs Covered Under Medical Plan | Drug plan |
| 6-Month Waiting Period for New to Market Specialty Drugs | Yes |
| Name of RX Vendor | TrueScripts |
| Deductible Applies | Yes (Tier 1), Yes (Tier 2) |
| Co-pay Applies | No (Tier 1), N/A (Tier 2) |
| Apply Deductible After Co-pay | N/A (Tier 1), N/A (Tier 2) |
Drug Tiers & Cost Sharing Structure
| Drug Type | Days Supply | Copay Structure |
|---|---|---|
| TIER 1 | 1-30 | 100% until deductible met / 20% after deductible met |
| TIER 1 | 31-90 | 100% until deductible met / 20% after deductible met |
| TIER 2 | 1-30 | 100% until deductible met / 20% after deductible met |
| TIER 2 | 31-90 | 100% until deductible met / 20% after deductible met |
| TIER 3 | 1-30 | 100% until deductible met / 20% after deductible met |
| TIER 3 | 31-90 | 100% until deductible met / 20% after deductible met |
| SPECIALTY TIER 1 | 1-30 | 100% until deductible met / 20% after deductible met |
| SPECIALTY TIER 2 | 1-30 | 20% TO $550 MAXIMUM |
| SPECIALTY TIER 3 | 1-30 | 20% TO $2000 MAXIMUM |
| SPECIALTY TIER 4 | 1-30 | 20% |
| SPECIALTY TIER 5 | 1-30 | 50% |
Specialty Pharmacy Injectable Drugs
| Item | Details |
|---|---|
| Coverage Code | SPD |
| Injectable Drugs Covered Under Medical Plan | Yes |
| Paid Same as Other Medical Office Services | Yes |
Comments: Medications and supplies related to the administration of injectable prescription medication may be covered under the Medical or Pharmacy benefits but not both.
Specific Item Coverage
How are the following items covered?
| Item | Medical Plan | Tier 1 | Tier 2 | Drug Plan | Not Covered |
|---|---|---|---|---|---|
| Diabetic Supplies | ✓ | Yes | Yes | ||
| Insulin | ✓ | Yes | Yes | ||
| Growth Hormones | ✓ | Yes | Yes | ||
| Take Home Medications | ✓ | Yes | Yes |
Contraceptive Products
How are the following items covered?
| Product | Medical Plan | Tier 1 | Tier 2 | Drug Plan | Not Covered |
|---|---|---|---|---|---|
| Contraceptive Patches, Oral Tablets, Self-Insertable Vaginal Devices (Nuva Ring) | ✓ | Yes | Yes | ||
| Contraceptive Injections (Depo-Provera) | ✓ | Yes | Yes | ||
| Contraceptives Administered in Dr. Office (IUDs, Implants) | ✓ | Yes | Yes |
Miscellaneous Services - Excluded/Covered Status
Complete Service List
| Service | Excluded | Covered | Coverage Code |
|---|---|---|---|
| Abortion - Elective | ✓ | ABO | |
| Alternative/Complementary Treatment (Holistic, Homeopathic, Hypnosis, Other) | ✓ | INEL | |
| Treatment for Acquired Brain Injury | ✓ | See appropriate benefit section | |
| Autism Services (Required per MHPAEA) | ✓ | DEVD | |
| Applied Behavior Analysis (ABA) | ✓ | ABA, ABAH | |
| Biofeedback | ✓ | BFF | |
| Blood Pressure Cuffs/Monitors | ✓ | INEL | |
| Botox (Medically Necessary) | ✓ | BOT | |
| Botox Coverage Through | Medical | ||
| Breast Reductions (If Medically Appropriate) | ✓ | See appropriate benefit section | |
| Counseling - Marriage | ✓ | INEL | |
| Developmental Delays (OT, PT, Speech, Medical) | ✓ | DEVD | |
| Treatment of Bunions, Corns, Calluses, Toenails | ✓ | INEL (unless medically necessary) | |
| Gender Affirming Care | ✓ | INEL | |
| Genetic Counseling/Testing (Medical Appropriateness or Family History) | ✓ | GEN | |
| Gene Therapy - Medical and/or Prescription Drug Charges | ✓ | GENE | |
| Orphan Drugs - Medical and/or Prescription Drug Charges | ✓ | ORPH | |
| Implantable Hearing Devices (Cochlear, Soundtec) | ✓ | CIRH, COCH | |
| Learning Disability | ✓ | DEVD | |
| Enteral and Parenteral Support | ✓ | MMS | |
| Oral Nutrition Therapy (If Medically Necessary) | ✓ | MMS | |
| Supplies - Feeding Tubes, Pumps, Bags, Products | ✓ | MMS | |
| Orthognathic, Prognathic, Maxillofacial Surgery | ✓ | See benefit section if covered (unless TMJ or Reconstructive) | |
| Panniculectomy/Abdominoplasty | ✓ | INEL | |
| Sales Tax, Shipping and Handling | ✓ | INEL | |
| Complications from Non-Covered Service | ✓ | INEL |
Sexual Function Services
| Service | Excluded | Covered | Coverage Code |
|---|---|---|---|
| Diagnostic | ✓ | See appropriate benefit section | |
| Non-Surgical | ✓ | See appropriate benefit section | |
| Surgical | ✓ | See appropriate benefit section | |
| Prescription Drugs | ✓ | See appropriate benefit section |
Note: Any medications (oral or other) used to increase sexual function or satisfaction, or penile pumps and erectaid devices are not covered.
Sleep Disorders (If Medically Appropriate)
| Service | Excluded | Covered | Coverage Code |
|---|---|---|---|
| Sleep Studies | ✓ | OSLP, SLMS, SLDM, SLPS |
Telemedicine
| Service | Excluded | Covered | Coverage Code |
|---|---|---|---|
| Patient to Physician | ✓ | TELM, TELS | |
| Physician to Physician | ✓ | INEL | |
| Teladoc (Separate Benefit) | ✓ | TELA, TELB |
Smoking Cessation Drugs
| If Covered | Payment Method | Coverage Code |
|---|---|---|
| Paid Under Medical Benefit | SMK | |
| Paid Under Prescription Drug Benefit | ✓ |
Weight Control (Morbid Obesity)
| Service | Excluded | Covered | Coverage Code |
|---|---|---|---|
| All Weight Control Services | ✓ | BAR, BARS, OBE | |
| Bariatric Therapy | ✓ | ||
| Gastric or Intestinal Bypass | ✓ | ||
| Stomach Stapling | ✓ | ||
| Prescription Medication for Weight Loss | ✓ | ||
| Physician Supervised Weight Loss Programs | ✓ | ||
| Diet Supplements | ✓ |
Definition: Body mass index OR 100 pounds over body weight (not specified which applies)
Injuries
| Injury Type | Coverage Status |
|---|---|
| Injuries Incurred While Legally Intoxicated | Not covered |
| Illegal Drugs or Medicines | Not covered (illness or injury resulting from voluntary taking or being under influence of controlled substance, drug, hallucinogen, or narcotic not administered by Physician) |
General Items
Dependent Age Limitations
Age Limit: 26
Usual and Customary Percentile (Out of Network)
| Percentile | Selected |
|---|---|
| 80th (Standard) | ✓ |
| 85th | |
| 90th | |
| 95th | |
| % of Medicare | 130/150% |
| Other |
Provider Types Normally Covered
Medical Providers
| Provider Type | Covered | Requirements |
|---|---|---|
| CNM (Certified Nurse Midwife) | Yes | When acting within scope of license in state, performing service payable when done by MD |
| Chiropractor | Yes | Health care professional focusing on musculoskeletal and nervous system disorders |
| Massage Therapist | Conditional | Only when services provided by PT, OT, or Physician with medical diagnosis |
| Licensed Professional Counselor | Yes | For mental health |
| Certified Addiction Counselor | Yes | For substance abuse |
Mental Health Treatment Providers
| Provider Type | Covered |
|---|---|
| PSY.D. (Therapist with PhD or Master's in Psychiatry) | Yes |
| State Licensed Psychologist | Yes |
| State Licensed or Certified Social Worker | Yes |
| MSW (Masters in Social Work) | Yes |
Timely Filing Period
| Option | Selected |
|---|---|
| 12 Months | ✓ |
| 15 Months | |
| 18 Months | |
| 24 Months | |
| Other |
Coordination of Benefits (COB)
COB Rules
| Rule | Setting/Answer |
|---|---|
| Is COB Same for Medicare Eligible Employees | Yes |
| If No, COB Provision for Medicare Employees | N/A |
| Medicare - Plan Not Primary, Part A but Not Part B | Plan will NOT reduce benefits as if Part B elected |
| Birthday Rule or Gender Rule | Birthday |
| Question Primary Carrier for Their Rule | Yes |
COB Savings Code
Selected Code: 0
Definition: Accumulated COB savings are applied toward satisfying the deductible and reducing the copayment on claims (both the current COB claim and future claims) until accumulated savings are used up. COB savings accumulate for each plan participant in a "COB bank" in the claimant's name.
All COB Savings Options:
| Code | Description |
|---|---|
| 0 | ✓ SELECTED - Savings applied to deductible and copayment for current and future claims in "COB bank" |
| 1 | COB savings applied to deductible and copayment of current claim only |
| 2 | Carve Out COB - Savings not used for deductible or copayment, accumulate in plan's name only |
COB Payment Code
Selected Code: 0
Definition: COB savings are applied to the entire claimant's incurred charges, even if the charges are not eligible under the plan. For example, COB savings are used to pay for services denied as cosmetic.
All COB Payment Options:
| Code | Description |
|---|---|
| 0 | ✓ SELECTED - COB savings applied to entire incurred charges, even if not eligible |
| 1 | COB savings applied only to charges eligible under the plan |
| 2 | COB savings applied only to eligible charges, BUT savings will not apply to annual accumulators |
| 3 | COB Savings code not considered, savings will not be generated |
| 9 | COB processing ignored for group, regardless of any COB amounts entered |
Document Completion & Approval
Form Completed By
| Field | Information |
|---|---|
| Completed By | Susan Green |
| Title | Plan Build |
| Date Completed | 12/26/2025 |
Customer Approval Section
IMPORTANT NOTE: Your approval of this installation document is of critical importance. This information is used to ensure we quote benefits correctly and must accurately reflect your plan document.
Any changes requested after you approve this document or after the effective date of your plan will need to be submitted to us so we do not quote benefits incorrectly.
Signature Fields:
- Customer Comments (if any): _______________
- Date: _______________
- Signature of Customer: _______________ (An electronic signature will be accepted)
Plan Modifications Section
For Future Use:
| Field | Information |
|---|---|
| Group Name | |
| Effective Date | |
| Group Number | |
| Modifications | The Install Plan Document is hereby modified as follows: |
Modification Completion
This Form Completed by: ________@ 90 Degree Benefits Date Completed: _______________
Customer Approval of Modifications
IMPORTANT NOTE: Your approval of these modifications is of critical importance. This information is used to ensure we quote benefits correctly and must accurately reflect your plan document.
Any further changes requested after you approve this document or after the effective date of your plan will need to be submitted to us so we do not quote benefits incorrectly.
Signature Fields:
- Customer Comments (if any): _______________
- Date: _______________
- Signature of Customer: _______________ (An electronic signature will be accepted)
CIGNA Pre-Certification Listing
IMPORTANT: A separate CIGNA PRE-CERTIFICATION LISTING is included with this plan document detailing specific services that require pre-certification. All support staff must refer to this listing when processing claims or answering member questions about pre-certification requirements.
Pre-Certification Contact:
- Provider: CIGNA
- Phone: 888-832-4354
- Retroactive Pre-cert: NOT ALLOWED - Services will be denied
Critical Reminders for Support Teams
Top Priority Items
- Emergency services and ambulance - ALWAYS paid at Tier 1 rates (80%) with Tier 1 ded/OOP, even if out-of-network provider
- Deductibles and OOP maximums are SEPARATE - Tier 1 and Tier 2 DO NOT cross-apply
- This is a Qualified HDHP - HSA eligible plan
- No copays on services - deductible + coinsurance structure (except specialty drugs have specific caps)
- Preventive care is 100% - In-network only, out-of-network NOT covered
- Pre-certification is REQUIRED - No retroactive approval, services denied if not on file
- Newborns - Must be enrolled within 31 days for continued coverage
Network & Payment Details
- Tier 1 Network: CIGNA (PPO Code 3002)
- Tier 2 Payment: 130% Medicare (professional), 150% Medicare (facilities)
- REAP providers - (Radiology, ER physicians, Anesthesiology, Pathology, Hospitalists) paid in-network when at network facility or medically necessary
Benefit Maximums to Remember
- Physical + Occupational Therapy COMBINED: 36 visits per calendar year
- Speech Therapy SEPARATE: 20 visits per calendar year
- Chiropractic: $500 maximum per calendar year
- Extended Care Facility: 60 days per calendar year
- Home Health Care: 60 visits per calendar year
- Diabetic Shoes: 1 pair per calendar year up to $500
Drug Benefits
- Specialty drugs - 6-month waiting period for new to market drugs
- Injectable drugs - Covered under medical (not pharmacy) when administered in office
- Diabetic supplies, insulin, growth hormones - All covered under medical plan at 80%/50%
- Prescription vendor: TrueScripts
Important Exclusions
- Infertility treatment - NOT covered (all services)
- Weight loss/bariatric surgery - NOT covered
- TMJ - NOT covered
- Hearing aids - NOT covered
- Vision services - Separate vendor (VSP), not covered under medical
- Gender affirming care - NOT covered
- Acupuncture - NOT covered
COB & Administrative
- Mental health & substance abuse - Paid same as any other illness
- Birthday rule - Used for COB determinations
- COB Savings Code 0 - Savings accumulate in member's "COB bank"
- Timely filing: 12 months
- Number of employees: 174 (may affect Medicare COB rules)
- Dependent age limit: 26
Important Contact Information
| Contact | Details |
|---|---|
| TPA | 90 Degree Benefits |
| TPA Hours | 8:00 AM - 5:00 PM CST |
| Pre-Certification | CIGNA: 888-832-4354 |
| Vision Benefits | VSP (see member card for phone) |
| Prescription Benefits | TrueScripts |
| Teladoc | $0 consult fee (see member card) |
Document Information
| Field | Details |
|---|---|
| Document Type | Install Plan Document - FINAL Approved |
| Last Updated | 1/30/2019 (Template) |
| Plan Build Date | 12/26/2025 |
| Plan Effective Date | 01/01/2026 |
| Total Pages | 29 pages |
| Master Group | 65100 |
| Subgroup | 65101 |
This knowledge base article contains all details from the Carolina Orthopaedic and Neurosurgical Associates HSA Plan Document. For questions or clarifications, contact 90 Degree Benefits during business hours (8:00 AM - 5:00 PM CST).
All information must match the signed plan document. Any discrepancies should be reported immediately to ensure accurate benefit adjudication.