JR Davis Construction Health Benefit Plan – Choose Orlando: Medical Schedule of Benefits
This document is the Medical Schedule of Benefits for the JR Davis Construction Health Benefit Plan under the Choose Orlando option, effective April 1, 2026. It outlines covered medical services, associated cost-sharing (copayments, coinsurance, and deductibles), and coverage levels for both Employers Health Network (EHN) PPO providers and Non-PPO providers. The plan is administered by Preferred Benefit Administrators, with member concierge care provided by Karias Health. Members should refer to the Medical Plan Document and Summary Plan Description for full coverage details.
Effective April 1, 2026
Document Link : Visit the document hereTable of Contents
- Deductibles and Cost-Sharing Overview
- Plan Coinsurance and Out-of-Pocket Maximums
- Lifetime Maximum Benefit
- Alcohol and Substance Abuse Treatment
- Allergy Injections and Testing
- Ambulance Services
- Autism Spectrum Disorders Treatment
- Birthing Center
- Cardiac Rehabilitation
- Chemotherapy and Radiation Therapy
- Chiropractic Services / Spinal Manipulation
- Clinical Trials
- Dental / Oral Services
- Diabetes Self-Management Training and Education
- Dialysis / Hemodialysis
- Durable Medical Equipment
- Early Intervention Services
- Emergency Room Services
- Family Planning
- Genetic Counseling, Testing and Related Services
- Home Health Care
- Hospice Care
- Hospital Services (Inpatient)
- Hospital Services (Outpatient)
- Injectables
- Learning Deficiencies, Behavioral Problems and Developmental Delays
- Maternity Care
- Medical and Enteral Formula
- Mental Health Services
- Newborn Care
- Orthotics
- Outpatient Imaging
- Outpatient X-Ray and Laboratory Services
- Outpatient Therapy Services
- Physician Hospital Visits
- Physician Office Visits
- Podiatry Care
- Precertification Requirements
- Prescription Drug Benefits
- Prosthetic Appliances
- Respiratory Therapy
- Routine Colonoscopy
- Routine Mammogram
- Routine Well Adult Care
- Routine Well Child Care
- Second Surgical Opinion
- Skilled Nursing Facility, Extended Care Facility and Rehabilitation Hospital
- Surgical Procedures
- Temporomandibular Joint Disorders (TMJ) Treatment
- Transplant Benefits
- Urgent Care Facility and Walk-in Clinic
- All Other Covered Medical Expenses
- Contact Information
1. Deductibles and Cost-Sharing Overview
| Detail | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Medical Plan Deductible – Individual | $1,000 | $10,000 |
| Medical Plan Deductible – Family | $2,000 | $30,000 |
| Prescription Drug Deductible – Individual | $300 | N/A |
| Prescription Drug Deductible – Family | $300 | N/A |
Notes:
- PPO and Non-PPO deductibles do not combine.
- The Calendar Year deductible does NOT include precertification penalties, non-covered expenses, or charges in excess of Reasonable & Allowed charges.
- If enrolled for family coverage, each family member must meet their own individual deductible until the overall family deductible has been met.
2. Plan Coinsurance and Out-of-Pocket Maximums
| Detail | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Plan Coinsurance | Plan pays 80% of covered expenses | Plan pays 50% of Reasonable & Allowed Amount |
| Out-of-Pocket Maximum – Individual | $3,000 | $20,000 |
| Out-of-Pocket Maximum – Family | $6,000 | $40,000 |
Notes:
- PPO and Non-PPO Out-of-Pocket maximums do not combine.
- The Out-of-Pocket Maximum includes Medical & Prescription Drug Calendar Year deductibles, Member Coinsurance, Medical & Prescription Drug Co-payments.
- Precertification penalties, non-covered expenses, and charges in excess of Reasonable & Customary charges do not accumulate towards the Out-of-Pocket Maximum.
- If enrolled for family coverage, each family member must meet their own individual Out-of-Pocket maximum until the overall family Out-of-Pocket maximum has been met.
3. Lifetime Maximum Benefit
| Detail | Coverage |
|---|---|
| Lifetime Maximum Benefit | Unlimited |
4. Alcohol and Substance Abuse Treatment
Precertification is required for Inpatient admissions and Partial Hospitalization / Intensive Outpatient Treatment.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Office Visit | $20 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Hospital Clinic Visit | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Partial Hospitalization / Intensive Outpatient Treatment | 100% of covered expenses; not subject to Calendar Year deductible. Includes Physician visits. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Inpatient Hospitalization | 100% of covered expenses following a $750 per admission Hospital Co-payment; not subject to Calendar Year deductible. Includes Physician visits. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5. Allergy Injections and Testing
Includes office visits and serum.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Allergy Injections & Testing | $20 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
6. Ambulance Services
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Ambulance Services | 80% Coinsurance; subject to In-Network Calendar Year deductible | 80% Coinsurance; subject to In-Network Calendar Year deductible |
Note: Limitations apply; refer to Plan for details.
7. Autism Spectrum Disorders Treatment
Precertification is required for ABA; limitations apply.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Autism Spectrum Disorders Treatment | Benefits are based on services provided | Benefits are based on services provided |
Notes:
- Benefit limits do not apply to occupational, physical, and speech therapies for treatment of autism spectrum disorders.
- Includes habilitative and rehabilitative care, Applied Behavior Analysis (ABA), pharmacy care, psychiatric care, psychological care, therapeutic care, and social work services.
8. Birthing Center
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Birthing Center | 100% of covered expenses following a $750 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
9. Cardiac Rehabilitation
Phase 1 and 2 only.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Cardiac Rehabilitation | $40 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
10. Chemotherapy and Radiation Therapy
Requires Precertification.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Chemotherapy & Radiation Therapy | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
11. Chiropractic Services / Spinal Manipulation
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Chiropractic Services / Spinal Manipulation | $40 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Limited to 26 visits per Calendar Year.
12. Clinical Trials
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Clinical Trials | Benefits are based on services provided | Benefits are based on services provided |
Note: Includes routine services during Approved Clinical Trials. Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services.
13. Dental / Oral Services
Excludes excision of impacted wisdom teeth.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Dental / Oral Services | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
14. Diabetes Self-Management Training and Education
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Diabetes Self-Management Training & Education | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
15. Dialysis / Hemodialysis
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Dialysis / Hemodialysis | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
16. Durable Medical Equipment
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Durable Medical Equipment | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Precertification is required for insulin pumps and supplies, and equipment in excess of $2,500 and for Out-of-Network providers.
17. Early Intervention Services
Up to age 3.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Early Intervention Services | $20 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
18. Emergency Room Services
Includes Facility, Lab, X-ray & Physician services.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Emergency Care | 100% of covered expenses following a $250 Co-payment; subject to In-Network Calendar Year deductible | 100% of covered expenses following a $250 Co-payment; subject to In-Network Calendar Year deductible |
| Non-Emergency Care | 80% Coinsurance; subject to In-Network Calendar Year deductible | 80% Coinsurance; subject to In-Network Calendar Year deductible |
Note: The Emergency Care Co-payment will be waived if admitted on an inpatient basis to a Hospital.
19. Family Planning
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| For Women | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| For Men | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
20. Genetic Counseling, Testing and Related Services
Precertification is required.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Genetic Counseling, Testing & Related Services | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Precertification is not required for BRCA Testing.
21. Home Health Care
Precertification is required.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Home Health Care | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Limited to 20 visits per Calendar Year.
22. Hospice Care (Inpatient / Outpatient)
Precertification is required.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Hospice Care | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
23. Hospital Services (Inpatient)
All Inpatient Hospital admissions require Precertification.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Inpatient Hospital Services | 100% of covered expenses following a $750 per admission Hospital Co-payment; not subject to Calendar Year deductible. Includes surgical facility, supplies, and miscellaneous Hospital charges. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
24. Hospital Services (Outpatient)
Refer to Precertification requirements.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Clinic Services | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Outpatient Department | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Pre-admission Testing | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Outpatient Surgery in Hospital / Ambulatory Surgical Center | 100% of covered expenses following a $500 Co-payment per procedure; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
25. Injectables
Precertification is required for injectables in excess of $1,500.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Injectables | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
26. Learning Deficiencies, Behavioral Problems and Developmental Delays
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Learning Deficiencies, Behavioral Problems & Developmental Delays | $20 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
27. Maternity Care
Refer to Newborn Care for newborn benefits. Refer to Birthing Center for benefits, if applicable.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Physician delivery charges, prenatal/postpartum care, including planned home births | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Inpatient Hospital charges | $750 per admission Hospital Co-payment | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
28. Medical and Enteral Formula
Requires Precertification. Includes metabolic formula.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Medical & Enteral Formula | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
29. Mental Health Services
Precertification is required for Inpatient admissions and Partial Hospitalization / Intensive Outpatient Treatment.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Office Visit | $20 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Hospital Clinic Visit | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Partial Hospitalization / Intensive Outpatient Treatment | 100% of covered expenses; not subject to Calendar Year deductible. Includes Physician visits. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Inpatient Hospitalization | 100% of covered expenses following a $750 per admission Hospital Co-payment; not subject to Calendar Year deductible. Includes Physician visits. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
30. Newborn Care
Includes Physician visits and circumcision.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Newborn Care | 100% of covered expenses; not subject to Calendar Year deductible. Admission Co-payment is waived for Newborn Care. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
31. Orthotics
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Orthotics | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Notes:
- Includes foot orthotics.
- Precertification is required for helmets and knee braces.
32. Outpatient Imaging
Includes MRI, CT & PET Scans. Precertification is required.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Outpatient Imaging | $500 Co-payment per scan. Please contact Karias Health prior to imaging to determine if you are eligible for a $0 Co-payment. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
33. Outpatient X-Ray and Laboratory Services
Outpatient Hospital & Independent Facility.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Diagnostic X-Rays | $50 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Laboratory | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| All other diagnostic tests | $50 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
34. Outpatient Therapy Services
Requires Precertification after 13 visits.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Outpatient Therapy Services | $40 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Combined Outpatient Therapy maximum benefit of 25 visits for Physical Therapy, Speech Therapy, and Occupational Therapy due to Illness or Injury.
35. Physician Hospital Visits
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Physician Hospital Visits | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
36. Physician Office Visits
Includes all related charges billed at time of visit. Precertification is required for on-going wound care.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Teladoc Virtual Visit | $0 Co-payment | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Primary Care | $20 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Specialist | $40 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Urgent Care Facility / Walk-in Clinic | $40 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Virtual Provider visits | Paid based on services provided | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
37. Podiatry Care
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Podiatry Care | $40 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
38. Precertification Requirements
Failure to comply with the Precertification requirements of the Plan will result in a $750 reduction of benefits due to precertification non-compliance.
Pre-admission certification is mandatory for all inpatient and outpatient facility-based services. This includes all hospital admissions and all services at a hospital, surgical center, outpatient facility, or dialysis center. Emergency hospital admissions must be approved within 48 hours.
Services requiring Precertification:
| Service |
|---|
| All Inpatient Hospital Admissions |
| All Outpatient Hospital Based Services |
| Applied Behavior Analysis (ABA) Therapy |
| Medical & Enteral Formula |
| Chemotherapy & Radiation Therapy |
| DME in excess of $2,500 and DME from Out-of-Network Providers |
| Genetic Counseling, Testing & related Services |
| Helmets & Knee Braces (orthotics) |
| Home Health Care |
| Inpatient Hospice Care |
| Injectables in excess of $1,500 |
| Outpatient Imaging |
| Outpatient Therapy Services after 13 visits |
| On-going wound care |
39. Prescription Drug Benefits
Prescription Drug Calendar Year Deductible: $300 per Individual / $300 per Family
Notes:
- Tobacco cessation products are covered at 100%; Deductible waived.
- Preventive Care drugs are not subject to the Prescription Drug Deductible.
- Prescriptions purchased from Out-of-Network Pharmacies are not eligible for reimbursement by the Plan.
- See Covered Services section for coverage requirements related to specialty drugs.
Retail Pharmacy Program (30-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $10 Co-pay | Deductible waived |
| Preferred Brand drugs | $60 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $100 Co-pay | After Prescription Drug Calendar Year deductible |
Retail Maintenance Pharmacy Program (90-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
Mail Order Pharmacy (90-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
Specialty Drugs – Retail & Mail Order (30-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
40. Prosthetic Appliances
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Prosthetic Appliances | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Refer to Durable Medical Equipment benefit for Precertification requirements.
41. Respiratory Therapy
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Respiratory Therapy | $40 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
42. Routine Colonoscopy
Age/frequency limitations apply.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Routine Colonoscopy | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
43. Routine Mammogram
Age/frequency limitations apply.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Routine Mammogram | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
44. Routine Well Adult Care
Age 18 and above.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Routine Well Adult Care | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
This routine benefit includes, but is not limited to, physician charges for an annual routine examination, routine x-rays and laboratory, immunizations and the routine services listed below:
| Covered Routine Services |
|---|
| Immunizations |
| Fasting lipoprotein profile (cholesterol screening) |
| Annual Prostate Specific Antigen (PSA) screening |
| Tobacco use screening and cessation interventions |
| Fasting blood sugar screening (for diabetes mellitus) |
| Blood pressure screening |
| Obesity screening and counseling |
| Annual colorectal screening |
| BRCA genetic counseling and testing |
| Statin preventive medication |
| Bone Mineral Density (BMD) screening (once every 24 months) |
| Women's Health Services: pelvic exam & Pap test; screening for gestational diabetes; DNA Testing; HPV (Human Papillomavirus); counseling for sexually transmitted infections; counseling & screening for human immunodeficiency virus; screening & counseling for interpersonal and domestic violence; breastfeeding support & supplies; sterilization; and contraceptive methods & counseling. Limitations may apply. |
Note: A complete list of covered ACA mandated routine services for women / adults is available at: healthcare.gov/coverage/preventive-care-benefits/
45. Routine Well Child Care
Birth through age 17.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Routine Well Child Care | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Includes: Office Visit charges, immunizations, laboratory blood tests, developmental screening, behavioral assessments, routine vision screening & hearing screening for newborns.
Note: A complete list of covered ACA mandated routine services for children is available at: healthcare.gov/coverage/preventive-care-benefits/
46. Second Surgical Opinion
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Primary Care | $20 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Specialist | $40 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
47. Skilled Nursing Facility, Extended Care Facility and Rehabilitation Hospital
Requires Precertification.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Skilled Nursing Facility / Extended Care Facility / Rehabilitation Hospital | $750 Co-payment per admission; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Combined Calendar Year maximum benefit of 60 days.
48. Surgical Procedures
Precertification is required for Outpatient surgery in a Hospital or Ambulatory Surgical Center.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Inpatient Hospital Surgery | 100% of covered expenses following a $750 Hospital Co-payment; not subject to Calendar Year deductible. Surgeon fees are payable at 100%; not subject to Calendar Year deductible. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Outpatient Hospital / Ambulatory Surgical Center | 100% of covered expenses following a $500 Co-payment per procedure; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| PCP Office | Included in $20 office visit Co-payment | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Specialist Office | Included in $40 office visit Co-payment | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
49. Temporomandibular Joint Disorders (TMJ) Treatment
Requires Precertification.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| TMJ Treatment | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
50. Transplant Benefits
Requires Precertification.
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Transplant Benefits | 100% of covered expenses following a $750 per admission Hospital Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Includes transportation, food and lodging expenses to a maximum benefit of $10,000 per transplant procedure.
51. Urgent Care Facility and Walk-in Clinic
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| Urgent Care Facility & Walk-in Clinic | $40 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
52. All Other Covered Medical Expenses
| Service | EHN PPO Providers | Non-PPO Providers |
|---|---|---|
| All Other Covered Medical Expenses | 80% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
53. Contact Information
Locate EHN Providers: Members.EHNconnects.com
Claims Administrator: Preferred Benefit Administrators PO Box 916188, Longwood, FL 32791-6188 Phone: 407-786-2777 or 888-524-2777 Website: PreferredTPA.com
Member Concierge Care: Karias Health Phone: 888-832-0354 Website: kariashealth.com