HealthDrive Corporation HDHP Plan - Benefits Summary 2026
This QHDHP-PPO plan covers employees and dependents from January 1, 2026 through December 31, 2026. It features in-network deductibles starting at $2,250 (single) and $4,500 (family), with 10% coinsurance for in-network services and 30% for out-of-network. Preventive care is covered at no charge before meeting the deductible.
Document Type: Summary of Benefits and Coverage (SBC)
About This Document
What is the Summary of Benefits and Coverage (SBC)?
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.
Important Notices
📋 This 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.
💰 Premium Information: Information about the cost of this plan (called the premium) will be provided separately.
📖 Glossary of Terms: For general definitions of common terms such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You may view the Glossary at healthcare.gov/sbc-glossary or call 1-888-832-0354 to request a copy.
Quick Reference Summary
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Annual Deductible (Single) | $2,250 | $4,500 |
| Annual Deductible (Family) | $4,500 | $9,000 |
| Out-of-Pocket Max (Single) | $8,000 | $16,000 |
| Out-of-Pocket Max (Family) | $16,000 | $32,000 |
| Primary Care Visits | 10% coinsurance | 30% coinsurance |
| Specialist Visits | 10% coinsurance | 30% coinsurance |
| Preventive Care | No charge | 30% coinsurance |
| Emergency Room | Deductible + 10% | Deductible + 10% |
| Prescription Drugs | 10% coinsurance | Not covered |
| Referral Required? | No | No |
| Preauth Penalty | $500 | $500 |
Plan Overview
| Plan Detail | Information |
|---|---|
| Plan Name | HealthDrive Corporation: HDHP Plan |
| Plan Type | QHDHP-PPO (Qualified High Deductible Health Plan - PPO) |
| Coverage Period | 01/01/2026 – 12/31/2026 |
| Coverage For | Employee & Dependents |
| Customer Service | 1-888-832-0354 |
| Provider Search | provider-search.kariashealth.com |
| Care Concierge | Karias Care Concierge at 1-888-832-0354 |
| Prescription Drug Info | hpiTPA.com |
Key Plan Features at a Glance
Deductibles
| Coverage Level | In-Network | Out-of-Network |
|---|---|---|
| Single Plan | $2,250 per employee | $4,500 per employee |
| Family Plan | $4,500 per family | $9,000 per family |
How Deductibles Work:
- 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.
Important: There are NO other deductibles for specific services. You don't have to meet separate deductibles for specific services.
Out-of-Pocket Limits
| Coverage Level | In-Network | Out-of-Network |
|---|---|---|
| Single Plan | $8,000 per employee | $16,000 per employee |
| Family Plan | $8,000 per person / $16,000 family | $16,000 per person / $32,000 family |
How Out-of-Pocket Limits Work:
- 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:
- Preauthorization penalties
- Premiums
- Balance billing charges
- Health care this plan doesn't cover
Important: Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Services Covered Before Deductible
- ✅ In-network preventive services are covered before you meet your deductible
- ✅ In-network preventive care/screening/immunization - No charge, deductible waived
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 the complete list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits
Specialist Referrals
Do you need a referral to see a specialist? No.
You may see a specialist you choose without a referral.
Specific Service Deductibles
Are there other deductibles for specific services? No.
You don't have to meet separate deductibles for specific services. The same overall deductible applies to all covered services (except those covered before the deductible).
Understanding Your Costs
What is Coinsurance?
Coinsurance is the percentage of costs you pay after meeting your deductible. For example:
- 10% coinsurance means you pay 10% and the plan pays 90%
- 30% coinsurance means you pay 30% and the plan pays 70%
Example: If a covered service costs $1,000 after you've met your deductible, you would pay $100 (10%) for in-network care or $300 (30%) for out-of-network care.
Cost Sharing by Service Type
⚠️ IMPORTANT: All copayment and coinsurance costs shown below are after your deductible has been met, if a deductible applies.
Office Visits
| Service | In-Network | Out-of-Network | Notes |
|---|---|---|---|
| Primary care visit (injury/illness) | 10% coinsurance | 30% coinsurance | You may have to pay for services that aren't preventive |
| Specialist visit | 10% coinsurance | 30% coinsurance | Ask your provider if services are preventive |
| Preventive care/screening/immunization | No charge; deductible waived | 30% coinsurance | - |
Diagnostic Services
| Service | In-Network | Out-of-Network | Limitations |
|---|---|---|---|
| Diagnostic test (x-ray, blood work) | 10% coinsurance | 30% coinsurance | None |
| Imaging (CT/PET scan, MRI) | 10% coinsurance | 30% coinsurance | None |
Prescription Drugs
For more information: Visit hpiTPA.com for prescription drug coverage details
| Drug Type | Supply Type | In-Network | Out-of-Network |
|---|---|---|---|
| Generic drugs | Retail (30-day supply) | 10% coinsurance | Not covered |
| Retail/Mail Order (90-day supply) | 10% coinsurance | Not covered | |
| Preferred brand drugs | Retail (30-day supply) | 10% coinsurance | Not covered |
| Retail/Mail Order (90-day supply) | 10% coinsurance | Not covered | |
| Non-preferred brand drugs | Retail (30-day supply) | 10% coinsurance | Not covered |
| Retail/Mail Order (90-day supply) | 10% coinsurance | Not covered | |
| Specialty drugs | Retail/Mail Order (30-day supply) | 10% coinsurance | Not covered |
Important Notes:
- Deductible applies to all prescription drugs except preventative care medications
- See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs
- Out-of-network prescriptions are NOT covered under this plan
Surgery
| Service | In-Network | Out-of-Network | Limitations |
|---|---|---|---|
| Outpatient facility fee (e.g., ambulatory surgical center) | 10% coinsurance | 30% coinsurance | None |
| Outpatient physician/surgeon fees | 10% coinsurance | 30% coinsurance | None |
Emergency and Urgent Care
| Service | In-Network | Out-of-Network | Notes |
|---|---|---|---|
| Emergency room care | In-network deductible; then 10% coinsurance | In-network deductible; then 10% coinsurance | Emergency room services are covered at in-network rates even when you go to an out-of-network facility |
| Emergency medical transportation | Deductible only | Deductible only | None |
| Urgent care | 10% coinsurance | 30% coinsurance | None |
Hospital Stay
| Service | In-Network | Out-of-Network | Preauthorization |
|---|---|---|---|
| Facility fee (hospital room) | 10% coinsurance | 30% coinsurance | Required or you pay $500 more |
| Physician/surgeon fees | 10% coinsurance | 30% coinsurance | - |
Mental Health & Substance Abuse Services
| Service | In-Network | Out-of-Network | Preauthorization |
|---|---|---|---|
| Outpatient services | 10% coinsurance | 30% coinsurance | - |
| Inpatient services | 10% coinsurance | 30% coinsurance | Required or you pay $500 more |
Maternity Care
| Service | In-Network | Out-of-Network | Notes |
|---|---|---|---|
| Office visits - Prenatal care | No charge; deductible waived | 30% coinsurance | May include tests and services described elsewhere in SBC |
| Office visits - Postnatal care | Deductible only | 30% coinsurance | - |
| Childbirth/delivery professional services | Deductible only | 30% coinsurance | Preauthorization required for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) or you pay $500 more |
| Childbirth/delivery facility services | Deductible only | 30% coinsurance | - |
Recovery & Special Health Needs
| Service | In-Network | Out-of-Network | Limitations |
|---|---|---|---|
| Home health care | 10% coinsurance | 30% coinsurance | None |
| Rehabilitation services - Inpatient | 10% coinsurance | 30% coinsurance | 60 days/year. Preauthorization required or you pay $500 more |
| Rehabilitation services - Outpatient | 10% coinsurance | 30% coinsurance | 60 visits/year 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/year. Preauthorization required or you pay $500 more |
| Durable medical equipment | 10% coinsurance | 30% coinsurance | Please to plan document for items requiring preauthorization |
| Hospice services | 10% coinsurance | 30% coinsurance | Preauthorization required for Inpatient services |
Children's Vision & Dental
| Service | In-Network | Out-of-Network | Limitations |
|---|---|---|---|
| Children's eye exam | No charge; deductible waived | 30% coinsurance | 1 exam per 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
Services Your Plan Generally Does NOT Cover
Check your policy or plan document for more information and a list of any other excluded services.
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
Note: Limitations may apply to these services. This isn't a complete list. Please see your plan document for full details.
| Service | Coverage Details |
|---|---|
| Acupuncture | 12 visits per year |
| Hearing aids | $2,000 per ear per 36 months up to age 21 or younger |
| Bariatric surgery | Covered (see plan document for requirements) |
| Infertility treatment | $20,000 per lifetime |
| Chiropractic care | Covered (see plan document for limitations) |
Coverage Examples
⚠️ Important Information About These Examples:
These examples show how the plan might cover costs for sample medical situations. 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 hospital delivery
Plan Parameters for This Example:
- The plan's overall deductible: $2,250
- Specialist coinsurance: 10%
- Hospital (facility) coinsurance: 10%
- Other coinsurance: 10%
| Cost Component | Amount |
|---|---|
| Total Example Cost | $12,700 |
| Patient Pays: | |
| Deductibles | $2,250 |
| Copayments | $0 |
| Coinsurance | $800 |
| Limits or exclusions | $60 |
| Total Peg Would Pay | $3,110 |
Services included: Specialist office visits (prenatal care), childbirth/delivery professional services, childbirth/delivery facility services, diagnostic tests (ultrasounds and blood work), specialist visit (anesthesia)
Example 2: Mia's Simple Fracture
In-network emergency room visit and follow-up care
Plan Parameters for This Example:
- The plan's overall deductible: $2,250
- Specialist coinsurance: 10%
- Hospital (facility) coinsurance: 10%
- Other coinsurance: 10%
| Cost Component | Amount |
|---|---|
| Total Example Cost | $2,800 |
| Patient Pays: | |
| Deductibles | $2,250 |
| Copayments | $0 |
| Coinsurance | $20 |
| Limits or exclusions | $400 |
| Total Mia Would Pay | $2,670 |
Services included: Emergency room care (including medical supplies), diagnostic test (x-ray), durable medical equipment (crutches), rehabilitation services (physical therapy)
Example 3: Managing Joe's Type 2 Diabetes
A year of routine in-network care of a well-controlled condition
Plan Parameters for This Example:
- The plan's overall deductible: $2,250
- Specialist coinsurance: 10%
- Hospital (facility) coinsurance: 10%
- Other coinsurance: 10%
| Cost Component | Amount |
|---|---|
| Total Example Cost | $5,600 |
| Patient Pays: | |
| Deductibles | $2,250 |
| Copayments | $0 |
| Coinsurance | $200 |
| Limits or exclusions | $20 |
| Total Joe Would Pay | $2,470 |
Services included: Primary care physician office visits (including disease education), diagnostic tests (blood work), prescription drugs, durable medical equipment (glucose meter)
Important Plan Information
Network Providers
Will you pay less if you use a network provider? Yes.
To find network providers:
- Visit provider-search.kariashealth.com to search for service providers
- Call the Karias Care Concierge at 1-888-832-0354 for additional assistance
How the Network Works:
- This plan uses a provider network
- Using in-network providers: You pay the least
- Using out-of-network providers: You pay the most
- Balance Billing: You might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing)
- ⚠️ Important Warning: 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 to avoid unexpected out-of-network charges.
Preauthorization Requirements
Preauthorization is required for the following services, or you'll pay $500 more:
- Hospital facility stays
- Inpatient mental health/behavioral health/substance abuse services
- Inpatient rehabilitation services
- Skilled nursing care
- Maternity care stays over 48 hours (normal delivery) or 96 hours (caesarean)
- Inpatient hospice services
Minimum Coverage Standards
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.
Rights and Resources
Rights to Continue Coverage
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends.
Contact Information:
- Department of Labor's Employee Benefits Security Administration:
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform
Other Coverage Options: 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
Grievances and Appeals
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.
How to File:
- 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: 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
Language Access Services
- Spanish (Español): Para obtener asistencia en Español, llame al 1-888-832-0354
- Portuguese (Portuguès): De assistència em Portuguès, 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
Additional Resources
- Preventive care benefits list: healthcare.gov/coverage/preventive-care-benefits
- Glossary of terms: healthcare.gov/sbc-glossary
- Complete terms of coverage: Call 1-888-832-0354
Quick Reference Card
| What You Need | Action |
|---|---|
| Find a provider | Visit provider-search.kariashealth.com or call 1-888-832-0354 |
| Prescription drug information | Visit hpiTPA.com |
| Customer service | Call 1-888-832-0354 |
| Plan documents | Call 1-888-832-0354 |
| File a grievance/appeal | Call 1-888-832-0354 or contact Department of Labor |
Document Information:
- Document Version: v1.0
- Plan Year: 2026
- Coverage Period: 01/01/2026 – 12/31/2026
- Last Updated: January 1, 2026
- Document Reference: 001D2617_D2617CIGNASI1&FA1_SBC_Eff 01012026_v1.0_HDHP Plan-DRAFT