Healthdrive Corporation HDHP Plan (QHDHP) - 2026 Benefits Guide
This benefits schedule outlines the medical and prescription drug coverage for Healthdrive Corporation employees enrolled in the HDHP Plan (QHDHP) through CIGNA PPO network, effective January 1, 2026. The plan features separate in-network and out-of-network deductibles and out-of-pocket maximums, 90% in-network coinsurance (70% out-of-network), and comprehensive coverage for preventive care, medical services, mental health, and specialty treatments.
Plan Administration Information
| Detail | Information |
|---|---|
| Group Number | 001D2617 |
| Effective Date | January 1, 2026 |
| Status | NGF |
| Plan Type | HDHP Plan (QHDHP) |
| Managed Care Type | PPO |
Approvals
| Role | Name | Date |
|---|---|---|
| TRU Department | TRU | (Date to be entered) |
| Account Manager | Julie Elwell/Kate Gilpatrick | December 19, 2025 |
| Compliance | Patrick Moore | December 19, 2025 |
Internal Use Only
| Function | Provider/Details |
|---|---|
| PPO Network | CIGNA |
| Out-of-Network Claims Pricing | Phia |
| UM (Utilization Management) | Cigna Payer Solutions |
| CM (Case Management) | MedWatch |
| DM (Disease Management) | Choose an item |
| Customer Service | Karias Care Concierge |
| MCC Creditable | Yes |
Document Version History
Draft as of: 11-17-2025 PM, 11-18-2025 PM, 11-24-2025 PM, 11-26-25 PM, 12-3-25 PM, 12-10-25 PM
Annual Deductibles and Out-of-Pocket Maximums
Medical Calendar Year Deductible
| Coverage Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee Only) | $2,250 | $4,500 |
| Family Plan | $4,500 per family | $9,000 per family |
Important Notes:
- Individual Deductible Included in Family Coverage: NO
- Family Plan Members: The entire family deductible must be satisfied before claims are paid for any covered family member. It may be satisfied by any combination of one or more family members.
- Deductible Carryover: NO
Reimbursement Percentage (Coinsurance)
| Network | Coinsurance | Applies |
|---|---|---|
| In-Network | 90% of the Contracted Rate | After Deductible; unless otherwise stated |
| Out-of-Network | 70% of the Allowed Amount* | After Deductible; unless otherwise stated |
After Out-of-Pocket Maximum is reached: 100% for the balance of the Calendar Year
Calendar Year Out-of-Pocket Maximums
Including all applicable Co-payments, Calendar Year Deductible and Coinsurance, including those for prescription drugs
| Coverage Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee Only) | $8,000 | $16,000 |
| Family Plan - Per Person | $8,000 per person | $16,000 per person |
| Family Plan - Family Total | Up to $16,000 per family | Up to $32,000 per family |
Important Notes:
- Individual OOPM Included in Family Coverage: YES
- The Family Plan contains both an individual Out-of-Pocket Maximum and a family Out-of-Pocket Maximum. Once an individual family member satisfies the individual Out-of-Pocket Maximum, claims will be paid for that individual at 100%. Otherwise, once the entire family Out-of-Pocket Maximum is satisfied, claims will be paid at 100% for all covered family members. The family Out-of-Pocket Maximum may be met by any combination of family members.
Network Separation Rules
The In-Network Provider and Out-of-Network Provider Deductible and Out-of-Pocket Maximums are separate and do not accumulate.
- Eligible expenses which track toward the In-Network Provider Deductible and Out-of-Pocket Maximums will NOT be credited toward the satisfaction of the Out-of-Network Deductible and Out-of-Pocket Maximums and vice versa.
In addition: Covered Services that contain dollar, frequency or visit limits are combined In-Network and Out-of-Network maximums.
| Tracking | Status |
|---|---|
| In/Out-of-Network Deductibles are: | SEPARATE |
| In/Out-of-Network Out-of-Pocket Maximums are: | SEPARATE |
Expenses Excluded from Out-of-Pocket Maximum
The following expenses are excluded from the Out-of-Pocket Maximum:
- Precertification penalties
No Surprises Act (NSA) Protection Details
Emergency Services and Balance Billing Protection
Emergency services rendered by Out-of-Network Providers for "Emergency Care" as defined in the section titled "Definitions"; air ambulance services rendered by Out-of-Network Providers of air ambulance services; and non-emergency services rendered by Out-of-Network Providers on an inpatient or outpatient basis at an In-Network Hospital or facility for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services, provided the Covered Person has not validly waived the applicability of the No Surprises Act of the Consolidated Appropriations Act of 2021 (NSA), will be paid at the In-Network Provider Deductible, Co-payment and Coinsurance levels, subject to the Qualifying Payment Amount.
Balance Billing Rules
When Out-of-Network Providers CANNOT Balance Bill:
- When emergency services are rendered by an Out-of-Network Provider for Emergency Care
- When air ambulance services are rendered by an Out-of-Network Provider of air ambulance services
When Balance Billing May Apply with Written Consent:
- When non-emergency services are rendered by an Out-of-Network Provider on an inpatient or outpatient basis at an In-Network Hospital or facility for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services, the Out-of-Network Provider cannot balance bill the Covered Person unless the Covered Person gives written consent and gives up their protections in accordance with the NSA.
- If a Covered Person waives their protections and agrees to balance billing per the NSA, Out-of-Network Providers will be paid according to the Plan's In-Network level of benefits, subject to the Allowed Amount.
General Balance Billing Rule
When services are rendered by an Out-of-Network Provider in any instance other than the reasons listed above, Covered Persons may be responsible for any amount above the Allowed Amount when services are rendered by an Out-of-Network Provider.
Prescription Drug Benefits
Administrator: TRUESCRIPTS
General Coverage Rules
Cost Structure:
- Covered Persons pay 100% until the satisfaction of the applicable Calendar Year Deductible
- Once the Calendar Year Deductible has been met, the Covered Persons pays Co-payments and Coinsurance, if applicable, which accumulate toward the Out-of-Pocket Maximums
- Once the Out-of-Pocket Maximums has been met, prescription drugs will be covered at 100% for the balance of the Calendar Year
Special Coverage Rules (Deductible Waived)
Contraceptive Coverage:
- Generic U.S. Food and Drug Administration (FDA) approved contraceptive medications and devices are covered at 100% (Deductible waived)
- Preferred brand name and non-preferred brand name contraceptive medications are subject to Coinsurance as shown, unless the generic form is not available
- In that case, the available preferred brand name drug (or non-preferred brand name if preferred brand name is not available) will be covered at 100% (Deductible waived)
Other Deductible-Waived Coverage:
- Tobacco cessations products are covered at 100% (Deductible waived)
- Preventive Care medications are not subject to the Deductible
Retail Card Program (After Deductible, You Pay)
Up to a 30 day supply:
- 10% Coinsurance per generic drug
- 10% Coinsurance per preferred brand name drug
- 10% Coinsurance per non-preferred brand name drug
Up to a 90 day supply:
- 10% Coinsurance per generic drug
- 10% Coinsurance per preferred brand name drug
- 10% Coinsurance per non-preferred brand name drug
Mail Order Pharmacy (After Deductible, You Pay)
Up to a 90 day supply:
- 10% Coinsurance per generic drug
- 10% Coinsurance per preferred brand name drug
- 10% Coinsurance per non-preferred brand name drug
Specialty Drugs - Retail and Mail Order (After Deductible, You Pay)
Up to a 30 day supply:
- 10% Coinsurance per prescription per Specialty drug
Note: See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs
Out-of-Network Pharmacy Coverage
NOT COVERED
Key Prescription Drug Tracking
| Question | Answer |
|---|---|
| Do Prescription Drug Costs count to a Separate Rx OOP Max or count toward Medical OOP Max? | COMBINED |
| Are scripts subject to Deductibles? | YES, MEDICAL DEDUCTIBLE |
Preventive Care Services
Important Information About Preventive Care
The preventive care services marked below with ** are provided according to the terms prescribed by the regulations issued under the Patient Protection and Affordable Care Act of 2010 (PPACA). The majority of the PPACA preventive care services recommendations are issued by the U.S. Preventive Service Task Force (USPSTF). These may be amended from time to time. Please see the Medical Benefits section for additional details about the preventive coverage provided, or a complete listing can be found here. New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance of the revised recommendation.
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
Routine Exams and Screenings
| Service | In-Network | Out-of-Network |
|---|---|---|
| **Routine Physical Exams (Including routine and travel immunizations and flu shots) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Routine Well Child Care (Including screenings, routine and travel immunizations and flu shots) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Fluoride Varnish (Up to age 6) - Up to four (4) varnish treatments per person, per Calendar Year | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Routine Pap Smears | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Breast Cancer Screening including Routine Mammograms and BRCA testing | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Routine Immunizations (If not billed with an office visit; includes flu shots and travel immunization) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Routine Lab, X-rays, and Clinical Tests (Including those related to maternity care) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Routine Colorectal Cancer Screening, including sigmoidoscopies and colonoscopies (As recommended by the US Preventive Service Task Force) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Lung Cancer Screening, including Low-Dose Computed Tomography (LDCT) (As recommended by the US Preventive Service Task Force) - Up to one (1) per person, per Calendar Year | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Nutritional Counseling | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Smoking Cessation Counseling and Intervention (Including smoking cessation clinics and programs) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| Routine Hearing Exams | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| Routine Prostate Exams and Prostate-Specific Antigen (PSA) Screenings | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Abdominal Aortic Aneurysm Screening (As recommended by the US Preventive Service Task Force) - Up to one (1) per person, per lifetime | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
Women's Health Services
| Service | Details/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| **Breastfeeding Support, Supplies and Counseling (During pregnancy and/or in the postpartum period and rental or purchase of breastfeeding equipment) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| Breast Pump Limits: | |||
| - Hospital Grade Breast Pumps | rental covered up to 3 months; precertification required for rental in excess of 3 months | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| - Electric Breast Pumps | rent or purchase, whichever is less | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| - Manual Breast Pumps | purchase | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| **Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| **Routine Gynecological/Obstetrical Care (Including preconception and prenatal services) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
Special Breastfeeding Coverage Note:
- For Breastfeeding Support, Supplies and Counseling: If there are no INN lactation providers, then OON providers should be covered at the INN level of benefits with no cost sharing. If the only reason for the visit with the provider is lactation, it should be with no cost-sharing.
Bone Density & Chronic Condition Support
| Service | Details | In-Network | Out-of-Network |
|---|---|---|---|
| **Bone Density Screening | |||
| - Women (as recommended by the US Preventive Service Task Force for Osteoporosis Screening) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - All other Covered Persons | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| Equipment for those with Chronic Conditions | |||
| Limited to the following services: | |||
| - Blood pressure monitor (hypertension) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - Peak flow meter (asthma) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - Glucometer and selected insulin products (such as vial, pump or inhaler) (diabetes) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| Tests/Screenings for those with Chronic Conditions | |||
| Limited to the following services: | |||
| - Hemoglobin A1c (diabetes) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - Retinopathy screening (diabetes) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - INR (liver disease or bleeding disorders) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - LDL (heart disease) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
Vision Care
| Service | Frequency/Age Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Routine Vision Exam (Excludes contact lens fitting) | Up to one (1) exam per person every 24 months | ||
| - Up to age 18 | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - Age 18 and older | NOT COVERED | NOT COVERED | |
| Routine Eyewear (Lenses, frames, and contact lenses) | NOT COVERED | NOT COVERED | |
| Eyewear for Special Conditions (Initial purchase of non-routine eyewear following surgery; contact lenses needed to treat keratoconus (including the fitting of these contact lenses); intraocular lenses implanted after corneal transplant, cataract surgery or other covered eye surgery when the natural eye lens is replaced) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Physician Services
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Allergy Testing | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Allergy Treatment | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Anesthesia (Inpatient/Outpatient) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Chiropractic Services (Charges for lab and x-ray are paid based on services provided and are not subject to any office visit or dollar limits) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Maternity: | ||
| - Prenatal care | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) |
| - Physician delivery charges (Excluding home births) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| - Postnatal care (Includes home visit with a Visiting Nurse following early discharge) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Physician Hospital Visits | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Physician Office Visits (Includes all related charges billed at time of visit) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Second Surgical Opinion | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Surgery (Inpatient) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Surgery (Outpatient) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Surgery (Physician's office) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Hospital Services - Inpatient
CRITICAL PRECERTIFICATION REQUIREMENT
Precertification is always required for inpatient hospitalization. Failure to obtain precertification will result in a reduction in benefits in the amount of $500 per admission. The reduction in benefits cannot be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan.
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Note: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | Room Type | In-Network | Out-of-Network |
|---|---|---|---|
| Hospital Room & Board (Precertification required) | Semi-private room or special care unit | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Maternity Services (Precertification required for stays in excess of 48 hours[vaginal]; 96 hours [cesarean]) | Semi-private room or special care unit | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Birthing Center | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Newborn Care (Includes Physician visits & circumcision) | Semi-private room or special care unit | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Organ, Bone Marrow and Stem Cell Transplants (Precertification required; Managed through Cigna's LifeSOURCE Transplant Network®; see Medical Benefits section for other limitations) | Semi-private room or special care unit - Includes transportation, food and lodging expenses | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Surgical Facility & Supplies | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Miscellaneous Hospital Charges | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Hospital Services - Outpatient
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency services rendered for "Emergency Care" as defined in the section titled "Definitions"; and Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Clinic Services (At a Hospital) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Emergency Room Expenses (Includes Facility, Lab, X-ray & Physician services) | 90% (after Deductible) | 90% (after In-Network Deductible) |
| Outpatient Department | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Preadmission Testing | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Urgent Care Facility/Walk-In Clinic | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Mental Health & Substance Use Services
CRITICAL PRECERTIFICATION REQUIREMENT
Precertification is always required for inpatient hospitalization. Failure to obtain precertification will result in a reduction in benefits in the amount of $500 per admission. The reduction in benefits cannot be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan.
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Note: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
Coverage Details
Coverage for Child/Adolescent MH/SU services includes, but is not limited to, CBAT and ICBAT, Intensive care coordination, in-home behavioral services and therapies as well as therapeutic monitoring services – coverage/cost varies based on where the services are rendered
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospitalization (Precertification required) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Partial Hospitalization/Intensive Outpatient Treatment | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Inpatient Physician Visit | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Hospital Clinic Visit | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Office Visit | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Methadone Maintenance/Treatment: | ||
| - Office Visit | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| - Medication Administration (When administered by either a Provider or self-administered in a home setting) | 100% (after Deductible) | 70% Allowed Amount (after Deductible) |
Other Services & Supplies
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for air ambulance services rendered by an Out-of-Network Provider of air ambulance services; and Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
Therapy & Rehabilitation Services
| Service | Limits/Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Acupuncture | Up to 12 visits per person per Calendar Year | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Alternative/Complementary Care Benefit (Chelation Therapy, Homeopathic treatment, Hypnosis/Hypnotherapy, Rolfing/Reiki) | NOT COVERED | NOT COVERED | |
| Aural Therapy | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Biofeedback Therapy | NOT COVERED | NOT COVERED | |
| Cardiac Rehabilitation (Phase 1 and 2 only (Phase 3 is excluded); see Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Occupational Therapy (For treatment due to Illness or Injury; see Medical Benefits section for other limitations) | Up to 60 visits per person, per Calendar Year, combined with Physical Therapy | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Physical Therapy (For treatment due to Illness or Injury; see Medical Benefits section for other limitation) | Up to 60 visits per person, per Calendar Year, combined with Occupational Therapy | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Speech Therapy (For treatment due to Illness or Injury; see Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Respiratory Therapy | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Transportation Services
| Service | Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Ambulance Services (See Medical Benefits section for limitations) | 90% (after Deductible) | 90% Allowed Amount (after Deductible) |
Specialized Medical Services
| Service | Limits/Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Autism Spectrum Disorders Treatment (Includes Applied Behavioral Analysis (ABA); any benefit limits under the Plan for occupational, physical and speech therapies do not apply; precertification is required for ABA; precertification is required for ABA; see Medical Benefits section for limitations) Note: Screenings are covered under Preventive Care | Benefits are based on services provided | Benefits are based on services provided | |
| Bariatric Surgery (See Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Chemotherapy & Radiation Therapy | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Clinical Trials – Routine Services during Approved Clinical Trials (Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services; see Medical Benefits section for other limitations) | Benefits are based on services provided | Benefits are based on services provided | |
| Cochlear Implants | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Dialysis/Hemodialysis (See Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Telemedicine (Applies to medical and behavioral health services; see Medical Benefits section for additional information) INCLUDES DOCTOR ON DEMAND | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Diagnostic Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Dental & Oral Services
| Service | Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Dental/Oral Services (Excludes excision of impacted wisdom teeth; see Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Oral Pharynx Procedures | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Temporomandibular Joint Disorders (TMJ) Treatment | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Diabetes Management
| Service | In-Network | Out-of-Network |
|---|---|---|
| Diabetes Self-Management Training and Education | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Durable Medical Equipment & Orthotics/Prosthetics
| Service | Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Durable Medical Equipment (See Medical Benefits section for limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Neuromuscular Stimulator Equipment including TENS | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Orthotics (Includes foot orthotics; see Medical Benefits section for limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Prosthetics (See Medical Benefits section for limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Home & Extended Care Services
| Service | Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Early Intervention Services (See Medical Benefits section for limitations) (Up to age 3) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Home Health Care (See Medical Benefits section for limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Hospice Care (Inpatient/Outpatient) (Precertification required for inpatient services; see Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Private Duty Nursing | NOT COVERED | NOT COVERED | |
| Rehabilitation Hospital (Precertification required; see Medical Benefits section for other limitations) | Up to 60 days per person, per Calendar Year | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Skilled Nursing Facility/Extended Care Facility (Precertification required; see Medical Benefits section for other limitations) | Up to 100 days per person, per Calendar Year | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Specialized Treatments & Genetic Services
| Service | Limits/Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Erectile Dysfunction Treatment (see Medical Benefits section for limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Gender Dysphoria Treatment and Related Services (Includes gender identity counseling, gender reassignment surgery and hormone replacement therapy; precertification required for gender reassignment surgery; see Medical Benefits section for other limitations) | Benefits are based on services provided | Benefits are based on services provided | |
| Gene Therapy | NOT COVERED | NOT COVERED | |
| Genetic Counseling, Testing and Related Services (Note: Coverage is provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services; precertification is not required) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Growth Hormones (See Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Hearing & Audiology
| Service | Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Hearing Aids | Up to $2,000 per ear every 36 months for Covered Persons age 21 or younger | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Fertility & Family Planning Services
| Service | Limits/Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Family Planning (Including but not limited to consultations and diagnostic tests) | |||
| - For Women (See also Prescription Drug Benefit and Preventive Care Section) | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - For Men | 100% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Infertility Treatment (See Medical Benefits section for other limitations) | Up to $20,000 per Covered Person per lifetime for all covered medical and prescription drug expenses combined | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
| Voluntary Sterilization: | |||
| - For Women | 100% (Deductible waived) | 70% Allowed Amount (after Deductible) | |
| - For Men | 100% (after Deductible) | 70% Allowed Amount (after Deductible) |
Injections & Medications
| Service | In-Network | Out-of-Network |
|---|---|---|
| Injectables | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Nutritional Support
| Service | Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Medical and Enteral Formula (Including metabolic formula; precertification required; see Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) | |
| Modified Low Protein Food Products (See Medical Benefits section for limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Developmental & Learning Services
| Service | Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Learning Deficiencies, Behavioral Problems/Developmental Delays (Precertification and visit limits are based on services provided) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Counseling Services
| Service | Coverage |
|---|---|
| Marital Counseling | NOT COVERED |
| Massage Therapy | NOT COVERED |
Foot Care
| Service | Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Podiatry Care (See Medical Benefits section for limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Sleep Disorders
| Service | Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Sleep Studies (Limited to the testing and treatment of Obstructive Sleep Apnea; see Medical Benefits section for other limitations) | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Pregnancy-Related Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Termination of Pregnancy | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Wigs & Cosmetic Aids
| Service | Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Wigs (When hair loss is due to the treatment of cancer, other serious medical condition, trauma, Injury or alopecia; see Medical Benefits section for other limitations) | Up to one wig and $350 per person per Calendar Year | 90% (after Deductible) | 70% Allowed Amount (after Deductible) |
Travel Benefit for Covered Services Restricted by State Law
For Covered Persons seeking Covered Services when access to the services is restricted or prohibited in the Covered Person's state of residence as a result of state law (e.g., termination of pregnancy, gender affirming surgery for minors), the Plan will cover the transportation and lodging expenses listed below that are "primarily for and essential to" receiving such medical care, in accordance with Internal Revenue Code (IRC) guidelines for qualified expenses. IRC § 213(d).
Excluded Expenses
This benefit does not include reimbursement for items or services that are not considered expenses for medical care under IRC 213(d), such as:
- Alcohol/tobacco/entertainment
- Childcare expenses
- Lost wages
- Meals
- Personal care/hygiene items
- Telephone calls
- Taxes
Companion Coverage
This coverage for transportation and lodging costs is available for the Covered Person who is receiving the Covered Service and one companion if the companion's presence is necessary to enable the Covered Person to receive the Covered Services.
Covered Transportation & Lodging Expenses
Lodging
Lodging expenses will be reimbursed up to $50.00 per person per night (up to $100.00 total if travel is with an eligible companion) when the Covered Services are provided by a Physician in a licensed Hospital (or in a medical care facility which is related to, or the equivalent of, a licensed Hospital).
Ground Transportation
If the Covered Person is traveling by automobile to a covered facility for Covered Services, costs the Covered Person pays for a rental car, mileage, parking, and/or tolls are eligible for reimbursement. Reimbursement for mileage costs will be calculated based on the standard mileage rates for the use of a car for medical purposes that are issued by the Internal Revenue Service and that are in effect for the time period in which the Covered Service is received. Costs paid for train, bus, taxi and/or rideshare services are also eligible for reimbursement.
Air Transportation
If a Covered Person is traveling by airplane to a covered facility for Covered Services, airfare is eligible for reimbursement for a regularly scheduled commercial flight (coach class only).
Distance Requirement
Coverage is available when the Covered Person must travel at least 100 miles in each direction from their residence to a qualified, licensed provider that can furnish the Covered Services.
Annual Limit
This coverage is provided up to a total reimbursement of $2,500 per Person, per Calendar Year, after satisfaction of the Calendar Year Deductible
Reimbursement Process
Covered Persons must submit a Travel Benefit Reimbursement Form with attestation that eligibility criteria have been met, along with all supporting documentation (travel receipts, bills, etc.), to the Claim Administrator for reimbursement for qualified transportation and lodging expenses.
Wellness Benefits
| Service | Coverage |
|---|---|
| Childbirth Classes | 100% reimbursement up to a maximum of $90 for one childbirth class and up to $45 for each refresher class for each covered expectant mother. |
| Fitness Reimbursement Benefit | NOT COVERED |
| Weight Loss Reimbursement Benefit | NOT COVERED |
Standardly Covered Services
The following services are covered when medically necessary:
Breast Reduction Surgery
- When Medically Necessary
- Precertification required
Orthoptics
- Covered unless otherwise listed as excluded in the Plan Document
Breastfeeding Support - Special Coverage Rules
- For Breastfeeding Support, Supplies and Counseling: If there are no INN lactation providers, then OON providers should be covered at the INN level of benefits with no cost sharing
- If the only reason for the visit with the provider is lactation, it should be with no cost-sharing
Mental Health/Substance Use Services - Special Coverage
- Coverage for Child/Adolescent MH/SU services includes, but is not limited to:
- CBAT and ICBAT
- Intensive care coordination
- In-home behavioral services and therapies
- Therapeutic monitoring services
- Coverage/cost varies based on where the services are rendered
Transplant Services
Transplant services include non-experimental human organ transplant of an organ or tissue from one person to another or grafting living tissue from its normal position to another site. Transplant procedures can include:
- Human tissue or human cartilage transplants
- Transplants for permanent artificial heart when Medically Necessary and Covered Person is already on the transplant list
Standardly Excluded Services
The following services are excluded from coverage:
- Sex therapy
- Xenotransplants (cross-species) transplants
Quick Reference Summary Tables
Key Plan Numbers at a Glance
| Plan Feature | In-Network Single | In-Network Family | Out-of-Network Single | Out-of-Network Family |
|---|---|---|---|---|
| Annual Deductible | $2,250 | $4,500 | $4,500 | $9,000 |
| Coinsurance | 90% | 90% | 70% | 70% |
| Out-of-Pocket Max (Individual) | $8,000 | $8,000 per person | $16,000 | $16,000 per person |
| Out-of-Pocket Max (Family) | N/A | $16,000 | N/A | $32,000 |
Precertification Always Required For:
| Service Type | Precertification Required | Penalty for Non-Compliance |
|---|---|---|
| All Inpatient Hospitalizations | YES | $500 per admission |
| Maternity stays exceeding: | ||
| - 48 hours (vaginal delivery) | YES | $500 per admission |
| - 96 hours (cesarean delivery) | YES | $500 per admission |
| Applied Behavioral Analysis (ABA) for Autism | YES | Varies |
| Gender Reassignment Surgery | YES | Varies |
| Breast Reduction Surgery | YES | Varies |
| Medical and Enteral Formula | YES | Varies |
| Hospital Grade Breast Pump rental exceeding 3 months | YES | Varies |
| Hospice Care (Inpatient only) | YES | Varies |
| Rehabilitation Hospital | YES | Varies |
| Skilled Nursing Facility/Extended Care Facility | YES | Varies |
| Organ, Bone Marrow, and Stem Cell Transplants | YES (Managed through Cigna's LifeSOURCE) | Varies |
Common Visit Limits
| Service | Limit | Time Period |
|---|---|---|
| Acupuncture | 12 visits | Per Calendar Year |
| Physical Therapy + Occupational Therapy (Combined) | 60 visits | Per Calendar Year |
| Routine Vision Exam (under age 18) | 1 exam | Every 24 months |
| Fluoride Varnish (up to age 6) | 4 treatments | Per Calendar Year |
| Lung Cancer Screening (LDCT) | 1 screening | Per Calendar Year |
| Abdominal Aortic Aneurysm Screening | 1 screening | Per Lifetime |
| Hearing Aids (age 21 or younger) | $2,000 per ear | Every 36 months |
| Rehabilitation Hospital | 60 days | Per Calendar Year |
| Skilled Nursing Facility | 100 days | Per Calendar Year |
| Wigs | 1 wig, up to $350 | Per Calendar Year |
| Infertility Treatment | $20,000 | Per Person, Per Lifetime (medical and Rx combined) |
| Travel Benefit for State-Restricted Services | $2,500 | Per Person, Per Calendar Year |
Prescription Drug Coinsurance (After Deductible)
| Drug Type | Retail (30-day) | Retail (90-day) | Mail Order (90-day) | Specialty (30-day) |
|---|---|---|---|---|
| Generic | 10% | 10% | 10% | 10% |
| Preferred Brand | 10% | 10% | 10% | 10% |
| Non-Preferred Brand | 10% | 10% | 10% | 10% |
| Specialty Drugs | N/A | N/A | N/A | 10% |
Services NOT Covered (Complete List)
| Excluded Service |
|---|
| Alternative/Complementary Care Benefit (Chelation Therapy, Homeopathic treatment, Hypnosis/Hypnotherapy, Rolfing/Reiki) |
| Biofeedback Therapy |
| Cardiac Rehabilitation - Phase 3 |
| Fitness Reimbursement Benefit |
| Gene Therapy |
| Marital Counseling |
| Massage Therapy |
| Private Duty Nursing |
| Routine Eyewear for age 18 and older (lenses, frames, contact lenses) |
| Routine Vision Exam for age 18 and older |
| Sex Therapy |
| Weight Loss Reimbursement Benefit |
| Xenotransplants (cross-species transplants) |
| Out-of-Network Pharmacy |
| Excision of impacted wisdom teeth |
| Home births (for physician delivery charges) |
Maternity Care Details
Prenatal Care
- Coverage: 100% In-Network (Deductible waived)
- Coverage: 70% Out-of-Network (After Deductible)
- Includes routine gynecological/obstetrical care and preconception services covered under Preventive Care
Delivery
- Physician Delivery Charges (excluding home births): 90% In-Network / 70% Out-of-Network (After Deductible)
- Birthing Center: 90% In-Network / 70% Out-of-Network (After Deductible)
Hospital Stay
- Precertification Required For:
- Vaginal delivery: Stays exceeding 48 hours
- Cesarean delivery: Stays exceeding 96 hours
- Coverage: 90% In-Network / 70% Out-of-Network (After Deductible)
Postnatal Care
- Coverage: 90% In-Network / 70% Out-of-Network (After Deductible)
- Includes home visit with a Visiting Nurse following early discharge
Newborn Care
- Includes: Physician visits & circumcision
- Coverage: 90% In-Network / 70% Out-of-Network (After Deductible)
Breastfeeding Support
- Coverage: 100% In-Network (Deductible waived)
- Special Coverage Rule: If no in-network lactation providers available, out-of-network providers covered at in-network level with no cost sharing
- If sole purpose of visit is lactation: no cost-sharing
- Breast Pumps: See Preventive Care section for detailed limits
Childbirth Education
- Covered under Wellness Benefits:
- 100% reimbursement up to $90 for one childbirth class
- Up to $45 for each refresher class
Important Age-Specific Coverage
Coverage for Children/Minors
| Service | Age Limit | Coverage Details |
|---|---|---|
| Routine Vision Exam | Up to age 18 | 100% In-Network (Deductible waived) |
| Hearing Aids | Age 21 or younger | Up to $2,000 per ear every 36 months |
| Fluoride Varnish | Up to age 6 | Up to 4 treatments per Calendar Year |
| Early Intervention Services | Up to age 3 | 90% In-Network / 70% Out-of-Network (After Deductible) |
| Child/Adolescent MH/SU Services | All ages | Includes CBAT, ICBAT, intensive care coordination, in-home behavioral services |
Adult-Specific Services
| Service | Age Requirement | Coverage Details |
|---|---|---|
| Routine Vision Exam | Age 18 and older | NOT COVERED |
| Bone Density Screening - Women | Per USPSTF guidelines | 100% In-Network (Deductible waived) |
| Prostate Exams and PSA Screenings | As recommended | 100% In-Network (Deductible waived) |
Penalty and Fee Structure
Precertification Penalty
- Amount: $500 per admission
- Applies to: Failure to obtain precertification for inpatient hospitalization
- Important: This penalty CANNOT be used to satisfy any applicable Co-payments, Deductibles, or Out-of-Pocket Maximums
- Responsibility: Covered Person is responsible for this penalty
General Responsibility Statement
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Network & Payment Terms
Allowed Amount Definition
Referenced throughout document for Out-of-Network payments
Contracted Rate
Referenced for In-Network payments at 90% coinsurance
Qualifying Payment Amount
Referenced in context of No Surprises Act protections
Balance Billing
Applies when services rendered by Out-of-Network Provider outside NSA protections - Covered Persons may be responsible for amounts above Allowed Amount
Critical Reminders for Members
Always Contact for Precertification
- Before ANY inpatient hospital admission
- Before Applied Behavioral Analysis (ABA) therapy
- Before gender reassignment surgery
- Before breast reduction surgery
- When renting hospital-grade breast pump beyond 3 months
- Before inpatient hospice care
- Before rehabilitation hospital admission
- Before skilled nursing facility admission
- Before organ, bone marrow, or stem cell transplants
- Before medical and enteral formula
Separate Tracking Systems
- In-Network and Out-of-Network deductibles do NOT combine
- In-Network and Out-of-Network out-of-pocket maximums do NOT combine
- Must satisfy each separately
Combined Tracking
- All prescription drug costs count toward COMBINED Medical Out-of-Pocket Maximum
- Services with dollar, frequency, or visit limits ARE combined between In-Network and Out-of-Network
Documentation Required for Reimbursement
- Travel Benefit: Must submit Travel Benefit Reimbursement Form with attestation and all receipts/bills
- Wellness Benefits: Follow submission requirements for childbirth class reimbursement
Additional Reference Information
For Complete Coverage Details
This schedule is an overview. For comprehensive information about:
- Specific definitions (Emergency Care, Medically Necessary, etc.)
- Complete exclusions list
- Coverage limitations
- Detailed billing procedures
- Appeals process
- Other plan provisions
Refer to: The complete Plan Document/Summary Plan Description (Medical Benefits Section and Medical Limitations and Exclusions Section)
Document Classification
This is an INTERNAL SCHEDULE for administrative use
Questions or Concerns
Contact Karias Care Concierge (Customer Service) for:
- Benefits verification
- Precertification requirements
- Claims questions
- Provider network information
- Coverage clarification
Glossary of Key Terms Used in This Document
| Term | Meaning in This Plan |
|---|---|
| Calendar Year | January 1 through December 31 |
| Coinsurance | The percentage of covered expenses you pay after meeting your deductible |
| Contracted Rate | The negotiated rate between the plan and in-network providers |
| Covered Person | An eligible individual enrolled in the plan |
| Deductible | The amount you must pay out-of-pocket before the plan begins to pay |
| FDA | U.S. Food and Drug Administration |
| HDHP | High Deductible Health Plan |
| INN | In-Network |
| IRC | Internal Revenue Code |
| Medically Necessary | Services required for diagnosis or treatment (see Plan Document for complete definition) |
| NSA | No Surprises Act of the Consolidated Appropriations Act of 2021 |
| OON | Out-of-Network |
| OOPM | Out-of-Pocket Maximum |
| PPACA | Patient Protection and Affordable Care Act of 2010 |
| PPO | Preferred Provider Organization |
| Precertification | Advance approval required for certain services |
| QHDHP | Qualified High Deductible Health Plan |
| USPSTF | U.S. Preventive Services Task Force |
Acronyms and Abbreviations
| Acronym | Full Form |
|---|---|
| ABA | Applied Behavioral Analysis |
| BRCA | Breast Cancer gene (genetic testing) |
| CBAT | Community-Based Acute Treatment |
| CT | Computed Tomography |
| ICBAT | Intensive Community-Based Acute Treatment |
| LDCT | Low-Dose Computed Tomography |
| LDL | Low-Density Lipoprotein |
| MH/SU | Mental Health/Substance Use |
| MRI | Magnetic Resonance Imaging |
| PET | Positron Emission Tomography |
| PSA | Prostate-Specific Antigen |
| TENS | Transcutaneous Electrical Nerve Stimulation |
| TMJ | Temporomandibular Joint |
Important Disclaimers & Notes
Document Completeness Notice
*This Internal Schedule is not a complete listing of all Plan benefits and exclusions. Please refer to the Medical Benefits Section and the Medical Limitations and Exclusions Section in the Plan Document/Summary Plan Description for a complete list of benefit and non-benefit type exclusions.
Document Version Reference
Version: 26.0
Key Contact & Administration Points
Customer Service
Karias Care Concierge
Prescription Drug Administration
TrueScripts
Utilization Management
Cigna Payer Solutions
Case Management
MedWatch
Transplant Services Management
Cigna's LifeSOURCE Transplant Network®
Claims Pricing (Out-of-Network)
Phia
How to Use This Guide
For Members
- Finding Your Benefits: Use the table of contents or search function to locate specific services
- Understanding Cost Sharing: Check if service is covered at deductible-waived, after-deductible, or not covered
- Precertification Requirements: Look for "precertification required" notation for each service
- Network Differences: Compare In-Network vs Out-of-Network costs before receiving care
- Annual Limits: Note any visit limits, dollar caps, or frequency restrictions
For Support Staff
- Quick Reference Tables: Use summary tables for fast verification of deductibles and limits
- Service-Specific Details: Navigate to detailed service sections for comprehensive coverage information
- NSA Protections: Refer to No Surprises Act section when addressing balance billing questions
- Precertification List: Use precertification table to verify which services require authorization
For Customer Service Representatives
- Member Inquiries: Cross-reference member questions with specific benefit sections
- Claims Questions: Direct members to appropriate claims administrator based on service type
- Coverage Verification: Confirm coverage levels and any applicable limitations
- Escalations: Direct complex cases to appropriate department (UM, Case Management, etc.)
Frequently Asked Questions
Deductibles & Out-of-Pocket Maximums
Q: Do my prescription drug costs count toward my medical deductible? A: Yes, prescription drug costs count toward the medical deductible and are combined with medical costs for the out-of-pocket maximum.
Q: Do in-network and out-of-network deductibles combine? A: No, in-network and out-of-network deductibles are separate and do not accumulate toward each other.
Q: How does the family deductible work? A: The entire family deductible must be satisfied before claims are paid for any covered family member. It may be satisfied by any combination of one or more family members.
Q: What happens when I reach my out-of-pocket maximum? A: Once you reach your out-of-pocket maximum, the plan pays 100% of covered services for the balance of the calendar year.
Preventive Care
Q: Do I pay anything for preventive care services? A: No, preventive care services marked with ** are covered at 100% in-network with no deductible or cost-sharing.
Q: What if there are no in-network lactation providers? A: Out-of-network lactation providers will be covered at in-network level with no cost sharing.
Precertification
Q: What happens if I don't get precertification for a hospital stay? A: You will be charged a $500 penalty per admission, which does not count toward your deductible or out-of-pocket maximum.
Q: Who is responsible for getting precertification? A: The covered person is responsible for obtaining precertification, though your provider may assist with this process.
Prescription Drugs
Q: Are contraceptives covered? A: Yes, generic FDA-approved contraceptives are covered at 100% with no deductible. Brand name contraceptives are also covered at 100% if no generic is available.
Q: Can I use an out-of-network pharmacy? A: No, out-of-network pharmacy services are not covered.
Q: What's the difference between retail and mail order? A: Both have the same 10% coinsurance. Mail order allows up to 90-day supplies while retail allows both 30-day and 90-day supplies.
Emergency Services
Q: What if I have an emergency and go to an out-of-network hospital? A: Emergency services are covered at in-network levels (90% coinsurance after deductible) even if provided by out-of-network providers, and you cannot be balance billed.
Q: Does urgent care count as emergency care? A: Urgent care is covered separately at 90% in-network and 70% out-of-network after deductible. True emergencies are covered at in-network levels regardless of provider.
Travel Benefits
Q: What is the travel benefit for state-restricted services? A: If you need to travel at least 100 miles each direction to receive covered services restricted in your state, the plan reimburses up to $2,500 per year for transportation and lodging.
Q: What expenses are covered under the travel benefit? A: Covered expenses include lodging (up to $50/night per person), ground transportation (rental car, mileage, parking, tolls, public transit), and airfare (coach class only).
Plan Compliance & Regulatory Information
ACA Compliance
This plan complies with the Patient Protection and Affordable Care Act of 2010 (PPACA) requirements including:
- Preventive care coverage at 100% in-network with no cost-sharing
- Coverage of essential health benefits
- No annual or lifetime dollar limits on essential health benefits
- Coverage for dependents up to age 26
No Surprises Act Compliance
This plan complies with the No Surprises Act of the Consolidated Appropriations Act of 2021, including:
- Protection from balance billing for emergency services
- Protection from balance billing for certain non-emergency services at in-network facilities
- Coverage of air ambulance services at in-network rates
- Required notice and consent procedures for waiving protections
Medicare Creditable Coverage
This plan is Medicare creditable coverage (MCC Creditable: Yes).
Coverage Transition Information
New Plan Year
- Effective Date: January 1, 2026
- Calendar Year: January 1, 2026 - December 31, 2026
- Deductible Reset: All deductibles reset to $0 on January 1, 2026
- Out-of-Pocket Maximum Reset: All out-of-pocket maximums reset to $0 on January 1, 2026
- Visit Limits Reset: All visit limits and dollar caps reset on January 1, 2026
Mid-Year Changes
For information about mid-year qualifying events and coverage changes, contact Karias Care Concierge.
Administrative Notes
Document Control
- Original Pages: 22 pages
- Group Number: 001D2617
- Effective Date: January 1, 2026
- Plan Status: NGF
- Version: 26.0
- Last Modified: December 19, 2025
Approval Status
- Account Manager Approval: ✓ Completed December 19, 2025 (Julie Elwell/Kate Gilpatrick)
- Compliance Approval: ✓ Completed December 19, 2025 (Patrick Moore)
- TRU Department Approval: Pending date entry
Draft History
This document has undergone multiple revisions:
- 11-17-2025 PM
- 11-18-2025 PM
- 11-24-2025 PM
- 11-26-25 PM
- 12-3-25 PM
- 12-10-25 PM
Legal Notices
Governing Document
In the event of any conflict between this Benefits Schedule and the official Plan Document/Summary Plan Description, the Plan Document/Summary Plan Description will govern.
Plan Amendment Rights
The employer reserves the right to amend, modify, or terminate the plan at any time in accordance with applicable law and the plan document provisions.
Non-Discrimination
This plan does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.
Privacy Rights
Your health information is protected under HIPAA (Health Insurance Portability and Accountability Act). Contact Customer Service for information about your privacy rights.
Appeals Process
You have the right to appeal coverage decisions. For information about the appeals process, refer to your Plan Document or contact Karias Care Concierge.
End of Document
This comprehensive knowledge base article contains all information from the original 22-page Healthdrive Corporation HDHP Plan Schedule document effective January 1, 2026. For official plan administration and legal interpretation, always refer to the complete Plan Document/Summary Plan Description.
For Additional Assistance:
- Customer Service: Karias Care Concierge
- Prescription Drug Questions: TrueScripts
- Precertification: Cigna Payer Solutions
- Complex Care Management: MedWatch
- Transplant Services: Cigna's LifeSOURCE Transplant Network®