HDHP Plan 2026 - Summary of Benefits and Coverage
This article provides comprehensive information about the HDHP Plan (Qualified High Deductible Health Plan - PPO) effective January 1, 2026 through December 31, 2026. The plan covers employees and dependents across multiple provider organizations. This guide includes detailed cost-sharing information, coverage limits, excluded services, preauthorization requirements, and example scenarios to help understand out-of-pocket costs. This is only a summary. For complete terms of coverage, contact 1-888-832-0354.
HDHP Plan 2026 - Summary of Benefits and Coverage
Plan Overview
Plan Type: QHDHP-PPO (Qualified High Deductible Health Plan - Preferred Provider Organization)
Coverage Period: 01/01/2026 – 12/31/2026
Coverage For: Employee & Dependents
Contact Number: 1-888-832-0354
Provider Search: provider-search.kariashealth.com
Karias Care Concierge: 1-888-832-0354
Applicable Provider Organizations
This plan applies to the following provider organizations:
- HealthDrive Medical Services, PC (Document: 001D2623_D2623CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf)
- Jeffrey Morer OD (Document: 001D2622_D2622CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf)
- Alex H Jaret, DMD (Document: 001D2621_D2621CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf)
- HealthDrive Podiatry Group, PC (Document: 001D2620_D2620CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf)
- HealthDrive Podiatry Group, PA (Document: 001D2619_D2619CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf)
- Mobile Audiology Associates (Document: 001D2618_D2618CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf)
- HealthDrive Corporation (Document: 001D2617_D2617CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf)
Important Questions About This Plan
What is the overall deductible?
| Plan Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan | $2,250 (employee) | $4,500 (employee) |
| Family Plan | $4,500 (family) | $9,000 (family) |
Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.
Are there services covered before you meet your deductible?
Yes. In-network preventive services are some of the services covered before you meet your deductible.
Why This Matters: This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits.
Are there other deductibles for specific services?
No. You don't have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?
| Plan Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan | $8,000 (employee) | $16,000 (employee) |
| Family Plan | $8,000 per person / $16,000 family | $16,000 per person / $32,000 family |
Why This Matters: The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to 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?
The following expenses do NOT count toward the out-of-pocket limit:
- Preauthorization penalties
- Premiums
- Balance billing charges
- Health care this plan doesn't cover
Why This Matters: 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. Please visit provider-search.kariashealth.com to search for service providers or call the Karias Care Concierge at 1-888-832-0354 for additional assistance.
Why This Matters: This plan uses a provider network. You pay less if you use a provider in the plan's network. You pay the most if you use an out-of-network provider and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?
No. You may see a specialist you choose without a referral.
Cost Sharing by Service Type
IMPORTANT: All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
If you visit a health care provider's office or clinic
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Primary care visit to treat an injury or illness | 10% coinsurance | 30% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if services are preventive. Then check what your plan will pay. |
| Specialist visit | 10% coinsurance | 30% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if services are preventive. Then check what your plan will pay. |
| Preventive care/screening/immunization | No charge; deductible waived | 30% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if services are preventive. Then check what your plan will pay. |
If you have a test
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Diagnostic test (x-ray, blood work) | 10% coinsurance | 30% coinsurance | None |
| Imaging (CT/PET scan, MRI) | 10% coinsurance | 30% coinsurance | None |
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at hpiTPA.com
| Drug Type & Supply | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Generic drugs - Retail (30-day supply) | 10% coinsurance | Not covered | Deductible applies except to preventative care medications. See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs |
| Generic drugs - Retail/Mail Order (90-day supply) | 10% coinsurance | Not covered | Deductible applies except to preventative care medications. See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs |
| Preferred brand drugs - Retail (30-day supply) | 10% coinsurance | Not covered | Deductible applies except to preventative care medications. See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs |
| Preferred brand drugs - Retail/Mail Order (90-day supply) | 10% coinsurance | Not covered | Deductible applies except to preventative care medications. See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs |
| Non-preferred brand drugs - Retail (30-day supply) | 10% coinsurance | Not covered | Deductible applies except to preventative care medications. See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs |
| Non-preferred brand drugs - Retail/Mail Order (90-day supply) | 10% coinsurance | Not covered | Deductible applies except to preventative care medications. See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs |
| Specialty drugs - Retail/Mail Order (30-day supply) | 10% coinsurance | Not covered | Deductible applies except to preventative care medications. See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs |
If you have outpatient surgery
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Facility fee (e.g., ambulatory surgical center) | 10% coinsurance | 30% coinsurance | None |
| Physician/surgeon fees | 10% coinsurance | 30% coinsurance | None |
If you need immediate medical attention
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Emergency room care | In-network deductible; then 10% coinsurance | In-network deductible; then 10% coinsurance | None |
| Emergency medical transportation | Deductible only | Deductible only | None |
| Urgent care | 10% coinsurance | 30% coinsurance | None |
If you have a hospital stay
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Facility fee (e.g., hospital room) | 10% coinsurance | 30% coinsurance | Preauthorization required or you pay $500 more |
| Physician/surgeon fees | 10% coinsurance | 30% coinsurance | Preauthorization required or you pay $500 more |
If you need mental health, behavioral health or substance abuse services
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Outpatient services | 10% coinsurance | 30% coinsurance | Preauthorization required for Inpatient services or you pay $500 more |
| Inpatient services | 10% coinsurance | 30% coinsurance | Preauthorization required for Inpatient services or you pay $500 more |
If you are pregnant
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Office visits - Prenatal Care | No charge; deductible waived | 30% coinsurance | Maternity care may include tests and services described elsewhere in SBC. Requires preauthorization for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) or you pay $500 more |
| Office visits - Postnatal Care | Deductible only | 30% coinsurance | Maternity care may include tests and services described elsewhere in SBC. Requires preauthorization for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) or you pay $500 more |
| Childbirth/delivery professional services | Deductible only | 30% coinsurance | Maternity care may include tests and services described elsewhere in SBC. Requires preauthorization for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) or you pay $500 more |
| Childbirth/delivery facility services | Deductible only | 30% coinsurance | Maternity care may include tests and services described elsewhere in SBC. Requires preauthorization for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) or you pay $500 more |
If you need help recovering or have other special health needs
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Home health care | 10% coinsurance | 30% coinsurance | None |
| Rehabilitation services - Inpatient | 10% coinsurance | 30% coinsurance | 60 days/yr Preauthorization required for Inpatient or you pay $500 more. 60 visits/yr combined for Occupational & Physical therapies. |
| Rehabilitation services - Outpatient | 10% coinsurance | 30% coinsurance | 60 days/yr Preauthorization required for Inpatient or you pay $500 more. 60 visits/yr combined for Occupational & Physical therapies. |
| Habilitation services | 10% coinsurance | 30% coinsurance | Early Intervention to age 3. Preauthorization requirements and visit limits are based on services provided for Learning Deficiencies & Behavioral problems |
| Skilled nursing care | 10% coinsurance | 30% coinsurance | 100 days/yr. Preauthorization required or you pay $500 more |
| Durable medical equipment | 10% coinsurance | 30% coinsurance | Please refer to plan document for items requiring preauthorization |
| Hospice services | 10% coinsurance | 30% coinsurance | Preauthorization required for Inpatient services |
If your child needs dental or eye care
| Service | In-Network Provider (You pay the least) | Out-of-Network Provider (You pay the most) | Limitations, Exceptions, & Other Important Information |
|---|---|---|---|
| Children's eye exam | No charge; deductible waived | 30% coinsurance | 1 exam/24 months up to age 18 |
| Children's glasses | Not covered | Not covered | n/a |
| Children's dental check-up | Not covered | Not covered | n/a |
Excluded Services & 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.
The following services are generally NOT covered:
- Dental care (routine child & adult)
- Private Duty Nursing
- Weight loss programs
- Long term care
- Routine eye care (adult age 18 and older)
- Non-emergency care when traveling outside U.S.
- Routine foot care
Other Covered Services
Limitations may apply to these services. This isn't a complete list. Please see your plan document.
| Service | Limitation/Benefit |
|---|---|
| Acupuncture | 12 visits/yr |
| Hearing aids | $2,000/ear/36 months up to age 21 or younger |
| Bariatric Surgery | (See plan document) |
| Infertility Treatment | $20,000/lifetime |
| Chiropractic care | (See plan document) |
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. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
The plan would be responsible for the other costs of these EXAMPLE covered services.
Example 1: Peg is Having a Baby
(9 months of in-network prenatal care and a hospital delivery)
Plan Cost Sharing Details:
- The plan's overall deductible: $2,250
- Specialist coinsurance: 10%
- Hospital (facility) coinsurance: 10%
- Other coinsurance: 10%
This EXAMPLE event 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)
Total Example Cost: $12,700
| Cost Sharing Category | Amount Peg Would Pay |
|---|---|
| Deductibles | $2,250 |
| Copayments | $0 |
| Coinsurance | $800 |
| What isn't covered - Limits or exclusions | $60 |
| The total Peg would pay is | $3,110 |
Example 2: Mia's Simple Fracture
(in-network emergency room visit and follow up care)
Plan Cost Sharing Details:
- The plan's overall deductible: $2,250
- Specialist coinsurance: 10%
- Hospital (facility) coinsurance: 10%
- Other coinsurance: 10%
This EXAMPLE event includes services like:
- Emergency room care (including medical supplies)
- Diagnostic test (x-ray)
- Durable medical equipment (crutches)
- Rehabilitation services (physical therapy)
Total Example Cost: $2,800
| Cost Sharing Category | Amount Mia Would Pay |
|---|---|
| Deductibles | $2,250 |
| Copayments | $0 |
| Coinsurance | $20 |
| What isn't covered - Limits or exclusions | $400 |
| The total Mia would pay is | $2,670 |
Example 3: Managing Joe's type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)
Plan Cost Sharing Details:
- The plan's overall deductible: $2,250
- Specialist coinsurance: 10%
- Hospital (facility) coinsurance: 10%
- Other coinsurance: 10%
This EXAMPLE event includes services like:
- Primary care physician office visits (including disease education)
- Diagnostic tests (blood work)
- Prescription drugs
- Durable medical equipment (glucose meter)
Total Example Cost: $5,600
| Cost Sharing Category | Amount Joe Would Pay |
|---|---|
| Deductibles | $2,250 |
| Copayments | $0 |
| Coinsurance | $200 |
| What isn't covered - Limits or exclusions | $20 |
| The total Joe would pay is | $2,470 |
Your Rights and How to Get Help
Your Rights to Continue Coverage
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
Department of Labor's Employee Benefits Security Administration
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace:
- Website: www.HealthCare.gov
- Phone: 1-800-318-2596
Your Grievance and Appeals Rights
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
Plan Contact:
- Phone: 1-888-832-0354
U.S. Department of Labor's Employee Benefits Security Administration:
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform
Plan Compliance Information
Does this plan provide Minimum Essential Coverage?
Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards?
Yes.
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services
If you need assistance in another language, contact us at the numbers below:
| Language | Instructions | Phone Number |
|---|---|---|
| Spanish (Español) | Para obtener asistencia en Español, llame al | 1-888-832-0354 |
| Portuguese (Português) | De assistência em Português, ligue | 1-888-832-0354 |
| Chinese (中文) | 如果需要中文的帮助，请拨打这个号码 | 1-888-832-0354 |
Quick Reference Resources
Important Contact Information
- Plan Information & Assistance: 1-888-832-0354
- Karias Care Concierge: 1-888-832-0354
- Provider Search Website: provider-search.kariashealth.com
- Prescription Drug Information: hpiTPA.com
Important Websites
- Glossary of Common Terms: healthcare.gov/sbc-glossary
- Preventive Care Benefits List: healthcare.gov/coverage/preventive-care-benefits
- Health Insurance Marketplace: www.HealthCare.gov
- Department of Labor EBSA: www.dol.gov/ebsa/healthreform
How to Get Complete Plan Information
This Summary of Benefits and Coverage (SBC) document is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage:
- Call: 1-888-832-0354
- For general definitions of common terms such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary at healthcare.gov/sbc-glossary or call 1-888-832-0354 to request a copy.
Document Information
Document Version: v1.0
Effective Date: January 1, 2026
Expiration Date: December 31, 2026
Last Updated: January 2026
Source Documents
This knowledge base article consolidates information from the following official plan documents:
-
001D2623_D2623CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf
Provider: HealthDrive Medical Services, PC -
001D2622_D2622CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf
Provider: Jeffrey Morer OD -
001D2621_D2621CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf
Provider: Alex H Jaret, DMD -
001D2620_D2620CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf
Provider: HealthDrive Podiatry Group, PC -
001D2619_D2619CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf
Provider: HealthDrive Podiatry Group, PA -
001D2618_D2618CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf
Provider: Mobile Audiology Associates -
001D2617_D2617CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan.pdf
Provider: HealthDrive Corporation
Note: All seven provider organizations share identical plan benefits, cost-sharing structures, deductibles, out-of-pocket limits, and coverage terms. The only difference is the provider organization name on each document.
Preauthorization Requirements Summary
CRITICAL: Failure to obtain preauthorization when required will result in a $500 penalty that you must pay.
Services Requiring Preauthorization:
| Service Category | When Preauthorization is Required | Penalty for Not Getting Preauthorization |
|---|---|---|
| Hospital Stays | All hospital facility fees and physician/surgeon fees | You pay $500 more |
| Mental Health/Behavioral Health/Substance Abuse | Inpatient services only | You pay $500 more |
| Maternity Care | Hospital stays over 48 hours (normal delivery) or 96 hours (caesarean) | You pay $500 more |
| Rehabilitation Services | Inpatient rehabilitation only | You pay $500 more |
| Skilled Nursing Care | All skilled nursing care | You pay $500 more |
| Hospice Services | Inpatient hospice services only | (See plan document) |
| Durable Medical Equipment | Certain items (refer to plan document for specific items) | (See plan document) |
How to Get Preauthorization: Contact the plan at 1-888-832-0354 before receiving the service.
IMPORTANT DISCLAIMER: This knowledge base article is a summary of benefits and coverage. It is not a complete description of coverage. For complete details, refer to your official plan documents or contact the plan at 1-888-832-0354. Information about the cost of this plan (called the premium) is provided separately and is not included in this summary.