GreatWater 360 Auto Care – HSA Plan

1. Plan Identification & General Setup

Field	Detail
Document Type	2 Tier Install Plan Document
TPA	90 Degree Benefits
TPA Hours of Operation	8:00–5:00pm CST
Document Status	Initial
Group Name	Dykstras Auto LLC dba Great Water 360 Auto
Legal Name	Dykstras Auto LLC dba Great Water 360 Auto
Effective Date	7-1-2026
Master Group Number	64670
Subgroup(s)	64680
Benefit Plan(s)	HSA
ERISA Plan	Yes
Dental/Vision Benefits	Excepted (unbundled)
Fiscal Year Date (Plan Funding)	Not specified
Benefits Applied Per	Calendar Year
Does Plan Have Grandfather Status?	No
Is Plan considered a Qualified High Deductible Health Plan?	Yes

2. Summary of Benefits — Deductibles, Coinsurance & Out-of-Pocket Maximums

Item	Tier 1 Network Providers	Tier 2 Out-of-Network
Annual Deductible – Per Person	$6,500	$13,000
Annual Deductible – Per Family	$13,000	$26,000
Do in/out-of-network deductibles cross-apply?	No (Accumulates separately)	No (Accumulates separately)
Does deductible apply to out-of-pocket max?	Yes	Yes
Does last-3-months deductible carry over to following year?	No	No
Carry-over applies to	N/A	N/A
Does deductible carry-over apply to OOP?	Not applicable (no carry-over)	Not applicable (no carry-over)
Coinsurance Rate (paid by plan after deductible, unless otherwise stated)	100%	100%
Annual Out-of-Pocket Maximum – Per Person	$6,500	$13,000
Annual Out-of-Pocket Maximum – Per Family	$13,000	$26,000
Do in/out-of-network OOP maximums cross-apply?	No (Accumulates separately)	No (Accumulates separately)
Does 3-month Carry-Over OOP benefit apply?	No	No
Is OOP integrated with pharmacy?	Yes	Yes
Do copays apply to the OOP maximum?	Yes	Yes
Are all benefit maximums combined across in/out-of-network?	Yes	Yes
Are Mental/Nervous Services covered?	Yes	Yes
Are Substance Abuse Services covered?	Yes	Yes
Specialty Drugs – New-to-Market Waiting Period	6 months	6 months
How many levels of appeals before IRO?	2 levels	2 levels

Comment: When covered, all Mental/Nervous and Substance Abuse benefits are paid as any other illness.

3. Additional Programs Available

Program	Detail
Teladoc	Subject to deductible

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4. Reference-Based Pricing (RBP) & Network Details

Item	Tier 1 Network Providers	Tier 2 Out-of-Network
RBP?	No	Yes — % of Medicare: 130/150%

Benefit Level	Plan Number	PPO Code	Notes (For 90 Degree Benefits Use Only)
Tier 1 Network Providers	64680	5100–5129	AETNA
Tier 1 Network Providers	64680	11111	Override to pay Tier 1 Network Providers
Tier 2 Out-of-Network	64681	0	130% for professional / 150% for facility

Additional Network Programs	Status
A&G	Yes — If yes: NSA only
Patient Defender	No
Pace	No
CareConnect	Yes — Benchmark State: Utah

5. Eligibility

Item	Detail
Number of Employees	730 (Note: special COB rules may apply for Medicare-eligible employees if employer has fewer than 100 EEs)
Standard FMLA	Yes
Continuation of coverage for disability outside of FMLA?	No
Continuation of coverage for layoff?	No
Leave of absence that doesn't meet FMLA requirements allowed?	No
Are benefits limited to full-time employees only?	Yes

Coverage Available For	Eligible?
Domestic Partners	No
Common Law Spouse	No
Dependents	Yes
Adopted Children	Yes
Foster Children	Yes
Children under legal guardianship	Yes
Grandchildren	No
Can spouse be covered if eligible for other coverage?	Yes

Reinstatement of Coverage: Employee is treated as a new hire (no waiting period for new hires).

6. Stop Loss, Continuity of Care & Precertification (General)

Item	Detail
Stop Loss – Specific	Tracks to Specific MED/RX
Stop Loss – Aggregate	Tracks to Aggregate MED/RX
Does the plan offer Continuity of Care benefits?	Yes
Continuity of Care 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.
Continuity of Care Comment	Standard 90 days
Precertification/Notification Provider	American Health Holdings (AHH)
Precertification Phone Number	833-462-0103
Applicable Services Requiring Precertification	See Precertification Pages (Section 36)
Allow retroactive precertification?	No — services requiring precertification will be denied if not on file
Will a penalty apply for obtaining Post-Service Precertification?	Yes — Amount: $250
Precert required for Medicare Primary?	No
Precert required if Other Coverage Primary?	No

7. Medical Office Visit Benefits

Coverage Codes: AOV, AOVS, OV, OVS, POV, SMV, SOV, TELM, TELS, ZPOV, ZSMV, ZSOV

Item	Tier 1 Network Providers	Tier 2 Out-of-Network
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Different copay for Specialists?	No	No

8. Office-Based Services (Surgery, Injections, Testing)

Office Surgery (Includes related anesthesia services)

Coverage Codes: AF, AFQ, AFS, OPM, OPMS, SF, SFS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Different copay for specialists?	No	No

Therapeutic Injections (Office)

Coverage Codes: INJ, INJS, MINJ, ZMIN

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Different copay for specialists?	No	No

Allergy Injections and Serum

Coverage Codes: ALI, ALIS, ALS, ALSS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Different copay for specialists?	No	No

Allergy Testing

Coverage Codes: ALT, ALTS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Different copay for specialists?	No	No

9. Diagnostic Testing, Lab & Imaging

Office Charges for X-Ray & Professional Component

Coverage Codes: XRDR, XRDS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Includes High Cost Imaging (MRI/CT/PET)?	No	No
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Office Charges for Laboratory & Professional Component

Coverage Codes: LBDR, LBDS, MOXL, SMOX, SOXL, ZMOX, ZSMX, ZSOX

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Office Charges Diagnostic Testing

Coverage Codes: ODX, ODXS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

All Other Office Related Services

Coverage Codes: HBOO, HBOS, HBPO, HBPS, OIV, OIVS, OMS, OMSS, OWCT

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Independent Laboratory & Professional Component

Coverage Code: LAB

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Diagnostic Testing, Lab & X-Ray (Freestanding) — Facility/professional expenses

Coverage Codes: FSDX, XRFS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Diagnostic Testing, Lab & X-Ray (Outpatient) — Facility/professional expenses

Coverage Codes: HLAB, HXL, HXR, MXL, OPDX, SMXL, SXL, US, XRAY, PRF

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Advanced Imaging (Freestanding) — Includes MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans

Coverage Codes: MDXF, PRF

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Advanced Imaging (Outpatient) — All Outpatient and Office Places of Service

Coverage Codes: BONE, CAT, CST, HCAT, MRIO, MRIS, MYEL, NUC, NUCO, NUCS, OBON, OBOS, OCAT, OCSS, OCST, OMRI, OMYE, OMYS, OPES, OPET, OSPC, OSPS, PET, PRF, SCAT, SPCT

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Sleep Studies

Coverage Codes: OSLP, SLPS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

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10. Other Outpatient & Ancillary Services

Acupuncture Services

Coverage Codes: AP, APS

Item	Tier 1	Tier 2
Covered service?	No	No

Comment: Not a covered benefit.

Ambulance and Other Medically Appropriate Transport (Ground and Air)

Coverage Codes: AMB, AMBR, AR

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Include facility-to-facility when medically necessary?	Yes	Yes

Comment: Tier 2 Out-of-Network cost-sharing applies to Tier 1 Network Providers' deductible and OOP.

Chiropractic Services

Coverage Codes: CH, CHX

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Maximum visits	30 visits (Other)	30 visits (Other)

Durable Medical Equipment (includes DME supplies)

Coverage Codes: BRA, DIEQ, DME, DMS, DTE, MMS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

DME Rules	Answer
Are insulin pumps considered DME?	Yes
Does this include insulin pump supplies?	Yes
Cover cost of repairs not due to misuse?	Yes
Cover cost of replacements if no longer functioning, out of warranty, unable to be repaired?	Yes
Cover batteries for covered equipment?	Yes
Cover sales tax and shipping charges?	Yes
Is there a rental maximum up to purchase price of equipment?	Yes

11. Facility & Care Benefits (SNF, Home Health, Hospice)

Extended Care Facility Benefits (Skilled Nursing, Subacute Facility)

Coverage Code: SNF

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Maximum days/visits	45 days (Other)	45 days (Other)

Home Health Care Benefits

Coverage Codes: HHC, HHS, PHC, PHS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Maximum days/visits	No day maximum	No day maximum

Hospice Care Benefits

Coverage Codes: HO, OHO

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Maximum days/visits	No day maximum	No day maximum
Allow Custodial/Respite Care?	No	No

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12. Bereavement Counseling

Coverage Codes: HBC, HFC

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Included in Hospice benefit?	Yes	Yes
Maximum visits	No day maximum	No day maximum
Paid by plan	100%	100%

Note: Services must be furnished within 6 months of death.

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13. Emergency & Inpatient Services

Emergency Room Hospital Facility Services

Coverage Codes: ER, MNO, NER, SMOF, SNO

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Want all emergency services paid in-network?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
If admitted within 24 hours, copay waived?	No	No
Paid by plan	100%	100%

Comment: Tier 2 Out-of-Network cost-sharing applies to Tier 1 Network Providers' deductible and OOP.

Emergency Room Hospital Professional Services

Coverage Codes: ERD, MERD, NERD, SAER, SMER

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Want all emergency services paid in-network?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Comment: Tier 2 Out-of-Network cost-sharing applies to Tier 1 Network Providers' deductible and OOP.

Inpatient Facility Services

Coverage Codes: BC, HM, HNS, ICU, IMC, MHM, MRB, RB, SHM, SMHM, SMRB, SRB

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Precert penalty waived for Emergency inpatient admissions?	Yes	Yes
If admitted through ER, is ER copay waived?	Yes	Yes
Reduce to semi-private room rate if available?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Ancillary (All Other Inpatient) Services

Coverage Codes: DX, HV, MID, MNI, PAT, RAD, SID, SIP, SMID, SMNI, WC

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Infusion Therapy

Coverage Code: IVIN

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

14. Surgery-Related Expenses

Second Surgical Opinion

Coverage Codes: SV, SVS — Comment: Subject to deductible and co-insurance.

Anesthesia

Coverage Codes: AI, AIQ, AO, AOQ, MNA, SMA

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Surgeon / Assistant Surgeon / Co-Surgeon

Coverage Codes: CIRC, SI, SO, STER, TI, TO

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Assistant Surgeon bills limited to 25% of U&C fee for procedure?	Yes	Yes

Outpatient Hospital Surgery and Ambulatory Surgical Center

Coverage Codes: ASF, OHS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan (after copay/deductible)	100%	100%

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15. Maternity Care

Maternity Care (Physician)

Coverage Codes: CIRC, MAT, MATD, MATO

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Maternity Care (Inpatient Facility/Birthing Center)

Coverage Codes: HNS, WC, MATF

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

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16. Outpatient Hospital & Physician Services / Dialysis / Urgent Care

Outpatient Hospital Services – Unless Otherwise Specified

Coverage Codes: CO, HBO, HMIS, HOBS, HWCT, MNOP, PA, PADR, SAOP, SMPH

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Outpatient Physician Services – Unless Otherwise Specified

Coverage Codes: DIED, HBP, PM

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Dialysis

Coverage Codes: DI, HDI

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Urgent Care Services

Coverage Code: URG

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Include all related services?	Yes	Yes
Paid by plan	100%	100%

17. Ologist (Hospital-Based Specialist) Benefits — Hospitalists, Radiology, ER Physician, Anesthesiology & Pathology (REAP)

Question	Answer
Are services for Hospitalists, Radiology, Pathology, and Anesthesiology providers paid as in-network when performed at a participating facility?	Yes
Are services for ER Physicians paid as In-Network?	Yes
Are charges paid in-network if referred by a participating physician?	No
Are services performed outside the service area paid as In-Network?	No
Are services unable to be provided by a network provider paid as In-Network?	Yes
Is the network level of benefits payable when a participant receives emergency care out of area or at non-network hospital for accidental injury/emergency?	Yes

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18. Infertility Treatment Services

Coverage Codes: INF, INFS, INFT, INHT, INIT, IVF, IVSF, SINT

Item	Tier 1	Tier 2
Covered service?	Yes	Yes

Type of Service	Covered?
Diagnostic only (to determine diagnosis)	Yes
Genetic testing to diagnose infertility	Yes
Diagnostic & other services	Yes
Fertility Test	Yes
Tests/exams to prepare for induced conception	Yes
Surgical reversal of sterilized state (result of prior surgery)	No
Manipulation of Sperm (must have infertility diagnosis)	Yes
Direct attempts to cause pregnancy	Yes
Hormone or therapy drugs	No
Artificial Insemination	Yes
Invitro Fertilization (IVF)	No
Gamete Intrafallopian Transfer (GIT)	No
Zygote Intrafallopian Transfer (ZIFT)	No
Embryo Transfer (for members diagnosed with cancer)	Yes
Freezing or storage of embryo, eggs, or semen (only for cancer diagnosis)	Yes

Comments: Must have infertility diagnosis for treatment. Covers diagnosis, counseling, and artificial insemination when medically necessary to treat infertility. All other services, including IVF, are excluded. Fertility preservation is only covered for members diagnosed with cancer.

19. Weight Reduction, Chemotherapy, Hearing Aids, Orthotics, Prosthetics

Weight Reduction Procedures

Coverage Codes: BAR, BARS, OBE

Item	Tier 1	Tier 2
Covered service?	Yes	No
Does deductible apply?	Yes	—
Does co-pay apply?	No	—
Paid by plan	50%	N/A

Comments: Includes all fees associated with facility, professional, and related services for all weight reduction procedures. Surgical treatment of obesity limited to once per lifetime unless medically necessary.

Chemotherapy / Radiation Therapy

Coverage Codes: CT, HCT, HRT, RT

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Hearing Aids

Coverage Codes: HA, HA2, HARC

Item	Tier 1	Tier 2
Covered service?	No	No

Comment: Not covered.

Orthotics

Coverage Codes: DS, OR, ORH, ORI, ORS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Allow custom-molded foot orthotics?	Yes	Yes
Allow non-custom molded shoe inserts?	Yes	Yes
Allow diabetic shoes?	Yes	Yes

Diabetic Shoe Limit: Limited to 1 pair per calendar year, up to $500.

Prosthetics

Coverage Code: PRO

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Initial purchase, fitting, repair, and replacement covered?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

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20. Pregnancy/Maternity Miscellaneous Rules

Coverage Code: See appropriate benefit section

Question	Answer
Are services in a Physician's office paid per the Medical Office Visit section?	Yes
Are services in a Hospital paid per the Hospital section?	Yes
Allow dependent daughter pregnancies?	No — only PPACA required services are covered (would cover medically necessary hospital services related to complications other than delivery)
Allow outpatient birthing centers?	Yes
Allow home deliveries?	No
Allow all elective abortions?	Based on applicable state law
Cover elective abortions when pregnancy results from rape or incest?	Based on applicable state law
Cover elective abortions when life of mother is in danger?	Based on applicable state law
Abortions covered for	All females covered under the plan

Newborns: Apply normal plan benefits — process under mother. Newborn dependents must be enrolled on the plan; automatic 31-day coverage applies only if the employee already has dependent coverage, and the newborn must be enrolled thereafter.

21. Preventive Care & Wellness Benefits

Preventive Care Services for ACA Covered Services

Coverage Codes: AB, AB1, AB2, AB3, AB4, AB5, AB6, AB7, ABCV, ABH, ABNC, ABR, ABX

For a Non-Grandfathered Plan, the plan follows the US Preventive Services Task Force recommendations. Preventive services are covered without cost sharing (generally applies only when rendered by a network provider).

Item	Tier 1	Tier 2
Does deductible apply?	No	No
Does co-pay apply?	No	No
Paid by plan	100%	100%

Additional Wellness Services (outside ACA list): Yes — includes all services identified and billed as routine.

Routine/Wellness Outside of ACA — Detail by Service

Service	Coverage Code	Covered as wellness?	Deductible Applies?	Co-pay?	Paid by Plan (Tier 1)	Paid by Plan (Tier 2)
Routine Physical Exam	HWC, WCB, WCBS, WLB, WLBS	Yes	No	No	100%	100%
Immunization	IMAS, IMM, IMMA, IMMB, IMMG, IMMS, IMSH	Yes	No	No	100%	100%
Routine Diagnostic Tests, Labs, X-rays	HWL, WLAB, WXL, WXR	Yes	No	No	100%	100%
Routine Mammogram	MAM, MAM2, OMAM, OMAS, OMA2, OM2S	Yes	No	No	100%	100%
Routine Pap Smear/Test & Pelvic Exam	PAP, PAPR, PAPS	Yes	No	No	100%	100%
Routine Fecal Blood Culture	WLB	Yes	No	No	100%	100%
Routine PSA Test and Prostate Exam	PS, PSS	Yes	No	No	100%	100%
Routine Colonoscopy, Sigmoidoscopy & similar	OCOL, OCOS, WLAB, WLB, WXL, WXLS	Yes	No	No	100%	100%
Contraceptive Management	BCI, BCIS, BCR, BCRS, BINJ, BINS, CONS, CONT	Yes	No	No	100%	100%
Routine Hearing Exam	RHE	Yes	No	No	100%	100%
Nutritional Counseling	WCBS	Yes	No	No	100%	100%

List of non-covered immunizations: None listed.

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22. Vision Care Benefits

Coverage Codes: REE, VEX

Question	Answer
Separate benefit allowed for Vision care under this medical plan?	No
Is there another vendor?	Yes — Vendor Name: Guardian, Phone: (888) 482-7342
Medical-related eye exams and glaucoma testing covered under medical?	Yes
Glaucoma and cataracts covered under Medical?	Yes
Routine eye exams covered (under this plan)?	No
Is there a benefit for routine eye refractions?	No (both tiers)

Other Vision Care Services (Coverage under Medical Plan)

Coverage Codes: HW, PHW, VANA, VBL, VCD, VCL, VFR, VINE, VLB, VLS, VLT, VSL, VTL, VTNT

Item	Covered?	Maximum
Single Vision Lenses	No	$ —
Bifocal	No	$ —
Trifocal	No	$ —
Lenticular	No	$ —
Progressive Lens	No	$ —
Lens Coating	No	$ —
Frames	No	$ —
Contacts	No	$ —
Safety Lenses and Frames	No	$ —
Sunglasses or subnormal vision aids	No	$ —
Eye Surgeries to improve/correct eyesight (e.g., LASIK, radial keratotomy)	No	—
Fitting/dispensing of non-prescription glasses or vision devices	No	—
Vision therapy services (including orthoptics)	No	—
Correction of visual acuity or refractive errors	No	—
Aniseikonia (each eye sees object differently)	No	—
Does deductible apply?	No	—
Does co-pay apply?	No	—
Paid by plan	0% / 0%	—

23. Dental/Oral Surgery & TMJ Benefits

Oral Surgery Benefits — Paid Under Medical

Coverage Code: See applicable benefit section

Item	Tier 1	Tier 2
Covered service?	Yes	Yes

Coverage Condition	Allowed?
Excision of partially/completely impacted teeth (incl. all related services under medical)	No (See comments)
Excision of tumors/cysts of jaw, cheeks, lips, tongue, roof/floor of mouth requiring pathological exam	Yes
Surgical procedures to correct accidental injuries of jaws, cheeks, lips, tongue, roof/floor of mouth	Yes
Reduction of fractures & dislocations of the 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 (cutting tissue in midline of tongue)	Yes
Gingival mucosal surgery (gingivectomy, osseous, periodontal surgery and grafting) for gingivitis/periodontitis	Yes
Apicoectomy (excision of tooth root without extracting entire tooth)	Yes
Root canal therapy if performed with an Apicoectomy	Yes
Alveolectomy (leveling structures supporting teeth for dentures) — not payable if with routine extraction of natural teeth	Yes

Other Dental Services

Coverage Code: See applicable benefit section

Item	Tier 1	Tier 2
Allow Dental Implants?	No	No
Allow Anesthesia, X-ray, and Lab for medically appropriate hospital services?	Yes	Yes
Allow coverage for any other dental services under medical plan?	No	No

Temporomandibular Joint Disorder (TMJ) Benefits

Coverage Codes: TMJ, TMJO, TMJS

Item	Tier 1	Tier 2
Covered service?	Yes	Yes

Comments: Includes primary care physicians and specialty office visits for evaluation and treatment, X-rays including contrast studies, and surgery. Excludes dental services such as orthodontic services, dental X-rays, and dental appliances.

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24. Rehabilitative & Habilitative Services

Physical Therapy (Outpatient Treatment)

Coverage Codes: DPT, HPT, PT

Item	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Maximum benefit	60 visits combined (Other)	60 visits combined (Other)

Comments: PT/OT/ST combined 60 visits per calendar year.

Occupational Therapy (Outpatient Treatment)

Coverage Codes: HOT, OT

Item	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Maximum benefit	60 visits combined (Other)	60 visits combined (Other)

Comments: PT/OT/ST combined 60 visits per calendar year.

Speech Therapy

Coverage Codes: HST, ST

Item	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%
Maximum benefit	60 visits combined (Other)	60 visits combined (Other)

Comments: PT/OT/ST combined 60 visits per calendar year.

Other Outpatient Rehabilitative and Habilitative Services (ABA Therapy, Cognitive Rehab, Cardiac Rehab, Pulmonary Rehab)

Coverage Codes: ABA, ABAH, COGR, CR, PRHB

Item	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

25. Wigs

Coverage Code: WIG (for cancer treatment or a medically appropriate condition)

Item	Tier 1	Tier 2
Covered service?	No	No

Comments: Not covered.

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26. Transplant Services

Question	Answer
Is there a separate transplant policy in place?	No
Covered when donor is covered under the plan but recipient is not?	No

Transplant Facility Benefits — Recipient

Coverage Code: TRN

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Facility – Travel and Housing — Recipient

Coverage Codes: TRL, TRNT

Item	Covered?
Covered Service?	Yes
Airfare	Yes
Meals	Yes
Tolls	Yes
Parking Fees	Yes
Apartment Rental	Yes
Hotel/Motel	Yes
Relocation Fees	No
Taxes	No

Comments: $5,000 per transplant covered at 100%.

Facility Benefits — Living Donor

Coverage Code: TRN

Item	Tier 1	Tier 2
Covered service?	Yes	Yes

27. Mental Health / Substance Abuse Facility Benefits

Mental Nervous/Substance Abuse Residential Treatment Center

Coverage Codes: MRES, SRES

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

Mental Nervous/Substance Abuse Outpatient Facility Treatment – All (PHP, DT, IOP, etc.)

Coverage Codes: DT, SDT, SMDT

Item	Tier 1	Tier 2
Covered service?	Yes	Yes
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

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28. All Other Covered Services (Not Otherwise Specified)

Item	Tier 1	Tier 2
Does deductible apply?	Yes	Yes
Does co-pay apply?	No	No
Paid by plan	100%	100%

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29. Prescription Drug Benefits

Coverage Code: PCS (Invoice only)

Item	Detail
Are Prescription Drugs covered under	Drug Plan
6-month waiting period for new-to-market specialty drugs?	Yes
RX Vendor Name	TrueScripts
Does deductible apply?	Yes (Tier 1) / Yes (Tier 2)
Does co-pay apply?	No (Tier 1) / No (Tier 2)
Apply deductible after copay?	N/A (Tier 1) / N/A (Tier 2)

Drug Type	1–30 Days Supply Amount	31–90 Days Supply Amount
Generic	Subject to deductible/coinsurance ($Ded/Coins)	Subject to deductible/coinsurance ($Ded/Coins)
Brand Preferred	Subject to deductible/coinsurance ($Ded/Coins)	Subject to deductible/coinsurance ($Ded/Coins)
Brand Non-Preferred	Subject to deductible/coinsurance ($Ded/Coins)	Subject to deductible/coinsurance ($Ded/Coins)
Specialty	Subject to deductible/coinsurance ($Ded/Coins)	N/A

Note: Unlike the PPO plan, this HSA plan does not use flat-dollar drug copays. All drug tiers are paid based on deductible/coinsurance ("$Ded/Coins"), consistent with IRS rules for HSA-qualified plans (no benefits paid before the deductible is met, except ACA-required preventive drugs).

30. Specialty Pharmacy Injectable Drugs

Coverage Code: SPD

Question	Answer
Are injectable drug benefits covered under the medical plan, paid same as other medical office services?	Yes

Comments: Medications and supplies related to administration of injectable prescription medication may be covered under the Medical or Pharmacy benefits, but not both.

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31. Diabetic Supplies, Insulin, Growth Hormones & Contraceptive Products

Item	Medical Plan (Tier 1/Tier 2)
Diabetic Supplies	Yes
Insulin	Yes
Growth Hormones	Yes
Take Home Medications	No

Contraceptive Products	Medical Plan (Tier 1/Tier 2)
Contraceptive patches, oral tablets, or self-insertable vaginal devices containing contraceptive hormones (e.g., Nuvaring)	Yes
Contraceptive Injections (such as Depo-Provera)	Yes
Contraceptives administered in the Dr. Office (e.g., IUDs, implants)	Yes

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32. Miscellaneous Excluded/Covered Services List

Service	Status	Coverage Code
Abortion – elective	Excluded	ABO
Alternative/Complimentary Treatment (Holistic/homeopathic medicine, Hypnosis, other non-accepted medical practice)	Excluded	INEL
Biofeedback	Excluded	BFF
Blood Pressure Cuffs/Monitors	Excluded	INEL
Botox	Excluded	BOT
— If covered, covered through	Medical and PBM (Both)	—
Breast Reductions	See appropriate benefit section	—
Counseling – Marriage	Excluded	INEL
Treatment of bunions, corns, calluses, toenails (unless medically necessary)	Excluded	INEL
Gender Affirming Care (excludes anything considered cosmetic)	See appropriate benefit section	—
Genetic Counseling or Testing based on Medical Appropriateness or family history (ACA-mandated genetic testing covered for Non-GF plans)	Excluded	GEN
Gene Therapy – Medical and/or Prescription drug charges	Excluded	GENE
Orphan drugs – Medical and/or Prescription drug charges	Excluded	ORPH
Implantable hearing devices (e.g., cochlear, soundtec)	Excluded	CIRH, COCH
Panniculectomy/Abdominoplasty	See appropriate benefit section	—
Sales Tax, shipping and handling	Excluded	INEL
Complications from a non-covered service	Excluded	INEL
Sexual Function (medications/devices to increase sexual function/satisfaction, penile pumps, erectaid devices) — Diagnostic, Non-Surgical, Surgical, Prescription Drugs	See appropriate benefit section	—
Telemedicine (Patient to Physician)	Covered	TELM, TELS
Telemedicine (Physician to Physician)	Excluded	INEL
Teladoc (separate benefit from medical)	Covered	TELA, TELB
Smoking cessation drugs	Excluded	SMK

Note: This Miscellaneous list is identical to the PPO plan's list, with one difference: "Gender Affirming Care" is marked "See appropriate benefit section" in this HSA document (rather than listed as a flat exclusion as in the PPO version).

33. Weight Control (Morbid Obesity) & Injury Exclusions

Weight Control (Morbid Obesity)

Item	Detail
Covered Service?	Limited to once per lifetime
Definition used	Body mass index (or) 100 pounds over body weight

Covered components, if covered (Coverage Codes BAR, BARS, OBE):

• Bariatric Therapy
• Gastric or intestinal bypass
• Gastric sleeve
• Prescription medication needed for weight loss
• Physician supervised weight loss programs
• Diet Supplements

Injuries — Excluded

• Incurred while legally intoxicated
• Illegal Drugs or Medicines (illness or injury resulting from voluntary taking of or being under the influence of any controlled substance, drug, hallucinogen, or narcotic not administered on the advice of a physician)

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34. General Items

Item	Detail
Dependent Age Limitation	26
Percentile of Usual & Customary used (Out-of-Network)	80th (Standard)
Percent of Medicare	130/150%
Timely Filing Period	12 Months

Note: This section uses the same checkbox-style format flagged earlier in this conversation (see the PPO plan's General Items correction). I was not provided a screenshot of this specific page for the HSA document, so please verify the "Percentile of Usual & Customary" and "% of Medicare" checkbox selections against the source PDF before publishing, the same way we corrected the PPO version.

Are these provider types normally covered under the medical plan?

Medical	Covered?
CNM – Certified Nurse Midwife (when acting within license scope, performing a service payable under the plan when performed by an MD)	Yes
Chiropractor	Yes
Massage Therapist	No
Licensed Professional Counselor	No

Mental Health Treatment Providers	Covered?
PSY.D. – Therapist with PhD or master's degree in psychiatry or related field	Yes
State licensed psychologist	Yes
State licensed or certified Social Worker	Yes
Certified addiction counselor (for substance abuse)	Yes
MSW – Masters in Social Work	Yes

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35. Coordination of Benefits (COB)

Question	Answer
Is COB the same for Medicare-eligible employees?	Yes
If plan is not primary and a covered person has Part A but has not elected Part B, will the plan reduce benefits as if Part B was elected?	No
Birthday Rule or Gender Rule	Birthday
Do you question primary carrier for their Rule?	Yes

Coordination of Benefits Savings (Plan Designation):

Code	Description
0	Accumulated COB savings are applied toward satisfying the deductible and reducing the copayment on claims (both current and future) until accumulated savings are used up. COB savings accumulate for each plan participant in a "COB bank" in the claimant's name.
1	COB savings are applied toward satisfying the claimant's deductible and reducing the copayment portion of only the current claim.
2	Carve Out COB – COB savings are not used to satisfy a member's deductible or reduce copayment on current or future claims. Savings accumulate in the plan's name and reduce the plan's liability only.

COB Payment Code Definitions (for reference):

Code	Description
0	COB Savings applied to entire claimant's incurred charges, even if not eligible under the plan (e.g., used to pay for services denied as cosmetic).
1	COB savings applied only to charges eligible under the plan.
2	COB savings applied only to charges eligible under the plan, BUT savings not applied toward annual accumulators.
3	COB Savings code not considered; savings will not be generated.
9	COB processing ignored for the group, regardless of any COB amounts entered on the claim.

36. AHH Precertification List (Full Detail)

Administered by: American Health Holdings (AHH)

American Health's precertification is a determination of medical necessity only and does not involve matters of claim payment, eligibility, coverage, or the type/availability of benefits. The establishment and construct of a precertification list is solely the responsibility of the customer and/or applicable plan sponsor (not American Health). Design and implementation of a precertification list should be made only after obtaining advice of the customer's legal and benefit professionals, including full review of applicable health and welfare benefit plan terms/conditions and applicable laws (e.g., ERISA, and the Health Parity and Addiction Equity Act of 2008, as amended). American Health has no responsibility for reviewing plan documents, advising on the precertification list, or compliance with applicable laws. No representation or warranty is given; document offered as-is.

Precertification requirements should be implemented only for services listed within the Summary Plan Description as requiring prenotification or precertification and not defined as excluded.

AHH completes medical necessity review only for surgery/procedure. AHH does not review for hardware or implantable devices related to surgeries/procedures.

All Inpatient Admissions (Precertification Required)

• Acute
• Long-Term Acute Care
• Mental Health / Substance Use Disorder
• Obstetric — Prenotification only (precertification only required if days exceed Federal mandate)
• Rehabilitation
• Residential Treatment Facility
• Skilled Nursing Facility
• Transplant

Outpatient and Physician – Surgery

Prenotification required for:

• Biopsies (excluding skin)
• Creation and Revision of Arteriovenous Fistula (AV Fistula) or Vessel to Vessel Cannula for Dialysis
• Oophorectomy, unilateral and bilateral
• Open Prostatectomy
• Thyroidectomy, Partial or Complete
• Vascular Access Devices for the Infusion of Chemotherapy (e.g. PICC and Central Lines)

Precertification required for:

• Abdominoplasty
• Autologous chondrocyte implantation, Carticel
• Back Surgeries
• Balloon sinuplasty
• Blepharoplasty
• Cervicoplasty (neck lift)
• Facial skin lesions (Photo therapy, laser therapy – excluding MOHS)
• Hernia repair, abdominal and incisional (only when associated with a cosmetic procedure)
• Hysterectomy (including prophylactic)
• IDET (thermal intradiscal procedures)
• Liposuction/lipectomy
• Mammoplasty, augmentation, and reduction (including removal of implant)
• Mastectomy (including gynecomastia and prophylactic)
• Morbid obesity procedures
• Orthognathic procedures (e.g., Genioplasty, LeFort osteotomy, Mandibular ORIF, TMJ)
• Osteochondral Allograft, knee
• Otoplasty
• Panniculectomy
• Rhinoplasty
• Rhytidectomy
• Scar revisions
• Septoplasty
• Sleep apnea related surgeries, limited to: Radiofrequency ablation (Coblation, Somnoplasty); Uvulopalatopharyngoplasty (UPPP) (including laser-assisted procedures)
• Transplant (excluding cornea)
• Varicose vein surgery/sclerotherapy

Outpatient and Physician – Diagnostic Services

Prenotification required for:

• CT for non-orthopedic
• MRI for non-orthopedic

Precertification required for:

• Capsule endoscopy
• Genetic Testing (excludes tumor markers)
• PET
• Sleep Study

Outpatient and Physician – Continuing Care Services

Prenotification required for:

• Dialysis
• Transplant Evaluation (excluding cornea)

Precertification required for:

• Chemotherapy
• Durable Medical Equipment, limited to electric/motorized scooters or wheelchairs and pneumatic compression devices
• Hyperbaric Oxygen
• Home Health Care
• Oncology and transplant related injections, infusions and treatments (e.g. CAR-T, endocrine and immunotherapy), excluding supportive drugs (e.g. antiemetic and antihistamine)
• Radiation Therapy

Specialty Pharmacy Advocacy

Precertification for the following is available under Specialty Pharmacy Advocacy and not Utilization Management Outpatient:

All medications processed through the medical benefit which cost $2,000 or more per drug per month (excluding acute oncology or transplant treatments). When requested, this program can support precertification of medications processed through the PBM (e.g. maintenance chemotherapy).

Precertification List Revision Date: 2/10/2025

Note: This AHH Precertification List is identical in content to the PPO plan's precertification list — both plans share the same AHH-administered precertification rules.

37. Summary of Benefits and Coverage (SBC) — Official Federal Document

Field	Detail
Coverage Period	07/01/2026 – 06/30/2027
Plan Name	Dykstras Auto LLC dba GreatWater 360 Auto Care: HSA Plan #64680
Coverage For	Family
Plan Type	HSA
OMB Control Number	0938-1146
OMB Expiration Date	05/31/2026
More Info / Complete Terms	Call 1-888-267-4445 or visit https://portal.90degreebenefits.com
Glossary	http://www.healthcare.gov/sbc-glossary or call 1-888-267-4445

Note: Information about the cost of this plan (the premium) is provided separately. This is only a summary.

Important Questions

Question	Answer	Why This Matters
What is the overall deductible?	Network providers: $6,500 individual / $13,000 family; Out-of-network providers: $13,000 individual / $26,000 family	Generally, you must pay all costs from providers up to the deductible before the plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?	Yes. Preventive care and primary care services are covered before you meet your deductible.	This plan covers some items/services even before the deductible is met, though a copayment or coinsurance may apply. Certain preventive services are covered without cost sharing and before the deductible.
Are there other deductibles for specific services?	No.	You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
What is the out-of-pocket limit for this plan?	Network providers: $6,500 individual / $13,000 family; Out-of-network providers: $13,000 individual / $26,000 family	The out-of-pocket limit is the most you could pay in a year for covered services. Other family members must meet their own out-of-pocket limits until the overall family out-of-pocket limit is met.
What is not included in the out-of-pocket limit?	Premiums, balance-billing charges, and health care are not covered by this plan.	Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See www.aetna.com/asa for a list of network providers.	This plan uses a provider network. You pay less in-network. You pay the most out-of-network and may receive a balance bill. Your network provider might use an out-of-network provider for some services (e.g., lab work) — check with your provider first.
Do you need a referral to see a specialist?	No.	This plan will pay some or all of the costs to see a specialist for covered services.

Common Medical Events — Cost Sharing

All copayment and coinsurance costs shown below are after your deductible has been met, if a deductible applies.

If you visit a health care provider's office or clinic

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Primary care visit to treat an injury or illness	0% after deductible	0% after deductible
Specialist visit	0% after deductible	0% after deductible
Preventive care/screening/immunization	No charge	0% after deductible

Limitations/Notes: Primary care and specialist visits: None. Preventive care: You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive, then check what your plan will pay for.

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If you have a test

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Diagnostic test (x-ray, blood work)	0% after deductible	0% after deductible
Imaging (CT/PET scans, MRIs)	0% after deductible	0% after deductible

Limitations/Notes: None.

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If you need drugs to treat your illness or condition (see www.truescripts.com)

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Generic drugs	0% after deductible	Not Covered
Preferred brand drugs	0% after deductible	Not Covered
Non-preferred brand drugs	0% after deductible	Not Covered
Specialty drugs	0% after deductible	Not Covered

Limitations/Notes: Covers up to a 30-day supply (retail subscription); 31–90 day supply (mail order prescription).

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If you have outpatient surgery

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Facility fee (e.g., ambulatory surgery center)	0% after deductible	0% after deductible
Physician/surgeon fees	0% after deductible	0% after deductible

Limitations/Notes: Facility fee — Preauthorization is required. If you don't get preauthorization, a $250 penalty will apply. Physician/surgeon fees: None.

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If you need immediate medical attention

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Emergency room care	0% after deductible	0% after In-Network deductible
Emergency medical transportation	0% after deductible	0% after In-Network deductible
Urgent care	0% after deductible	0% after deductible

Limitations/Notes: None. Teladoc Virtual Visit: 0% after deductible.

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If you have a hospital stay

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Facility fee (e.g., hospital room)	0% after deductible	0% after deductible
Physician/surgeon fees	0% after deductible	0% after deductible

Limitations/Notes: Facility fee — Preauthorization is required. If you don't get preauthorization, a $250 penalty will apply. Physician/surgeon fees: None.

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If you need mental health, behavioral health, or substance abuse services

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Outpatient services	0% after deductible	0% after deductible
Inpatient services	0% after deductible	0% after deductible

Limitations/Notes: None.

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If you are pregnant

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Office visits	0% after deductible	0% after deductible
Childbirth/delivery professional services	0% after deductible	0% after deductible
Childbirth/delivery facility services	0% after deductible	0% after deductible

Limitations/Notes: Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

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If you need help recovering or have other special health needs

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Home health care	0% after deductible	0% after deductible
Rehabilitation services	0% after deductible	0% after deductible
Habilitation services	0% after deductible	0% after deductible
Skilled nursing care	0% after deductible	0% after deductible
Durable medical equipment	0% after deductible	0% after deductible
Hospice services	0% after deductible	0% after deductible

Limitations/Notes:

• Home health care: None.
• Rehabilitation services: 60 visits/year maximum per therapy for PT/OT/ST. Chiropractic: 30 visits/year maximum.
• Habilitation services: (Same note as Rehabilitation services — 60 visits/year max per therapy for PT/OT/ST; Chiropractic: 30 visits/year maximum.)
• Skilled nursing care: 45 visits/calendar year.
• Durable medical equipment: Excludes vehicle modifications, home modifications, exercise, and bathroom equipment.
• Hospice services: Preauthorization is required. If you don't get preauthorization, a $250 penalty will apply.

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If your child needs dental or eye care

Service	Network Provider (You pay least)	Out-of-Network Provider (You pay most)
Children's eye exam	Not covered	Not covered
Children's glasses	Not covered	Not covered
Children's dental check-up	No charge	Not covered

Limitations/Notes: None.

Note: Unlike the PPO SBC, this HSA SBC lists "Children's dental check-up" as No charge for Network Provider (not "Not covered" as in the PPO plan), while Out-of-Network remains "Not covered."

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38. SBC Coverage Examples

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Actual costs will differ based on the actual care received, provider prices, and other factors. Focus on the cost-sharing amounts (deductibles, copayments, coinsurance) and excluded services under the plan to compare plans. Coverage examples are based on self-only coverage.

Shared example assumptions for all three scenarios:

Assumption	Value
Plan's overall deductible	$500
Specialist copayment	$50
Hospital (facility) coinsurance	20%
Other coinsurance	20%

Example 1: Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

Includes services like: Specialist office visits (prenatal care), Childbirth/Delivery Professional Services, Childbirth/Delivery Facility Services, Diagnostic tests (ultrasounds and blood work), Specialist visit (anesthesia)

Item	Amount
Total Example Cost	$12,700
Deductibles	$500
Copayments	$200
Coinsurance	$1,800
Limits or exclusions	$60
The total Peg would pay	$2,560

Example 2: Managing Joe's Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)

Includes services like: Primary care physician office visits (including disease education), Diagnostic tests (blood work), Prescription drugs, Durable medical equipment (glucose meter)

Item	Amount
Total Example Cost	$5,600
Deductibles*	$800
Copayments	$900
Coinsurance	$100
Limits or exclusions	$20
The total Joe would pay	$1,820

Example 3: Mia's Simple Fracture (in-network emergency room visit and follow-up care)

Includes services like: Emergency room care (including medical supplies), Diagnostic test (x-ray), Durable medical equipment (crutches), Rehabilitation services (physical therapy)

Item	Amount
Total Example Cost	$2,800
Deductibles*	$500
Copayments	$200
Coinsurance	$400
Limits or exclusions	$0
The total Mia would pay	$1,100

Notes:

• These numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to reduce your costs. For more information about the wellness program, contact: [insert].
• *This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?" row above.
• The plan would be responsible for the other costs of these example covered services.

Note: These Coverage Example figures and underlying assumptions ($500 deductible, $50 specialist copay, 20% coinsurance) are identical to those listed in the PPO plan's SBC. This is standard federal SBC template language — these illustrative figures do not represent this specific HSA plan's actual deductible or cost-sharing terms (which appear elsewhere in this document), per CMS's standardized example methodology.

39. SBC Excluded & Other Covered Services

Services Your Plan Generally Does NOT Cover

(Check your policy or plan document for more information and a list of any other excluded services.)

Excluded Service
Cosmetic surgery
Dental care (Adult)
Long-term care
Non-emergency care when traveling outside the U.S.
Private-duty nursing
Routine eye care (Adult)
Routine foot care

Other Covered Services

(Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

Other Covered Service
Bariatric surgery
Chiropractic care

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40. SBC Rights, Compliance & Language Access

Item	Detail
Your Rights to Continue Coverage	There are agencies that can help if you want to continue your coverage after it ends. Contact information for those agencies: [insert State, HHS, DOL, and/or other applicable agency contact information]. Other coverage options may be available, including individual insurance through the Health Insurance Marketplace (www.HealthCare.gov or 1-800-318-2596).
Your Grievance and Appeals Rights	Agencies can help with complaints against your plan for denial of a claim (a grievance or appeal). See the explanation of benefits for that medical claim for more information. Plan documents provide complete information on submitting a claim, appeal, or grievance for any reason. For more information, contact: [insert applicable contact information from instructions].
Does this plan provide Minimum Essential Coverage?	Yes. Minimum Essential Coverage generally includes plans, health insurance through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If eligible for certain Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards?	Yes. If the plan doesn't meet Minimum Value Standards, you may be eligible for a premium tax credit for a Marketplace plan.

Language Access Services

Language	Statement
Spanish (Español)	Para obtener asistencia en Español, llame al 1-888-267-4445.
Tagalog	Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-267-4445.
Chinese (中文)	如果需要中文的帮助, 请拨打这个号码 1-888-267-4445.
Navajo (Dine)	Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-267-4445.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.02 hours per response, including time to review instructions, search existing data resources, gather data needed, and complete/review the information collection. Comments on the accuracy of time estimates or suggestions for improving this form: write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Questions: Call 1-888-267-4445 if any underlined terms used in the SBC are unclear, to request a copy, or to view the Glossary at the member portal.