Jr. Davis Construction Company Health Benefit Plan (Buy Up Plan) — Summary of Benefits and Coverage
This Summary of Benefits and Coverage (SBC) describes the Jr. Davis Construction Company Health Benefit Plan (Buy Up Plan), a PPO plan for individuals and families with a coverage period of 04/01/2026 through 03/31/2027. The plan uses the Cigna provider network and is administered by Preferred Benefit Administrators, Inc. It outlines how costs are shared between the plan and the member for covered health care services, including deductibles, copayments, coinsurance, out-of-pocket maximums, prescription drug coverage, and exclusions. Premium information is provided separately. This document is only a summary; complete terms of coverage are available from Preferred Benefit Administrators, Inc.
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Table of Contents
- Important Questions and Answers
- Cost-Sharing Details by Medical Event
- Prescription Drug Coverage
- Mental Health, Behavioral Health, and Substance Abuse Services
- Pregnancy and Maternity Care
- Recovery and Special Health Needs
- Children's Dental and Vision
- Excluded Services
- Other Covered Services
- Coverage Examples
- Your Rights and Additional Information
- Language Access Services
1. Important Questions and Answers
| Important Question | Answer | Why This Matters |
|---|---|---|
| What is the overall deductible? | In-network: $1,500 individual / $4,500 family. Out-of-network: $5,000 individual / $10,000 family. | 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 plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. In-network preventive services and physician office visits are some of the services covered before you meet your deductible. | This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? | Yes. $300 individual / $300 family for prescription drugs. There are no other specific deductibles. | You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. |
| What is the out-of-pocket limit for this plan? | In-network: $5,000 individual / $10,000 family. Out-of-network: $10,000 individual / $20,000 family. | 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 has been met. |
| What is not included in the out-of-pocket limit? | Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services, and health care this plan doesn't cover. | Even though you pay these expenses, they don't count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. Visit Cigna.com or call Preferred Benefit Administrators at 1-888-524-2777 for a list of network providers. | This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? | No. | You can see the specialist you choose without a referral. |
2. Cost-Sharing Details by Medical Event
Note: All coinsurance costs shown are after your deductible has been met, if a deductible applies.
If You Visit a Health Care Provider's Office or Clinic
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Primary care visit to treat an injury or illness | Teladoc virtual visit: no cost. PCP office visit: $25 copay. | 50% coinsurance after deductible | None |
| Specialist visit | $50 copay | 50% coinsurance after deductible | None |
| Preventive care/screening/immunization | No cost | 50% coinsurance after deductible | You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. |
If You Have a Test
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Diagnostic test (x-ray, blood work) | Blood work: No cost. X-Rays/Diagnostic Tests: $100 copay. | 50% coinsurance after deductible | Preauthorization is required for imaging. If you don't get preauthorization, benefits will be reduced by $750. |
| Imaging (CT/PET scans, MRIs) | No cost if scheduled through Karias Health. $500 copay if not scheduled through Karias Health. | 50% coinsurance after deductible | Preauthorization is required for imaging. If you don't get preauthorization, benefits will be reduced by $750. |
If You Have Outpatient Surgery
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Facility fee (e.g., ambulatory surgery center) | 30% coinsurance after deductible | 50% coinsurance after deductible | Preauthorization is required. If you don't get preauthorization, benefits will be reduced by $750. |
| Physician/surgeon fees | 30% coinsurance after deductible | 50% coinsurance after deductible | Preauthorization is required. If you don't get preauthorization, benefits will be reduced by $750. |
If You Need Immediate Medical Attention
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Emergency room care | 30% coinsurance after deductible | Emergency: 30% coinsurance after in-network deductible. Non-Emergency: 50% coinsurance after deductible. | None |
| Emergency medical transportation | 30% coinsurance after in-network deductible | 30% coinsurance after in-network deductible | None |
| Urgent care | $55 copay | 50% coinsurance after deductible | None |
If You Have a Hospital Stay
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Facility fee (e.g., hospital room) | 30% coinsurance after deductible | 50% coinsurance after deductible | Preauthorization is required. If you don't get preauthorization, benefits will be reduced by $750. |
| Physician/surgeon fees | 30% coinsurance after deductible | 50% coinsurance after deductible | None |
3. Prescription Drug Coverage
Prescription drug specific deductible: $300 per individual / $300 per family. This deductible applies to all drugs except generic and preventive care drugs.
Retail prescriptions: 30-day supply maximum. 90-day supply maximum for maintenance drugs.
Mail Order prescriptions: 90-day supply maximum.
More information about prescription drug coverage is available at PreferredTPA.com.
| Drug Tier | Network Provider — Retail | Network Provider — Maintenance and Mail Order | Out-of-Network Provider |
|---|---|---|---|
| Generic drugs | $10 copay | $25 copay | Not covered |
| Preferred Brand | $60 copay | $150 copay | Not covered |
| Non-Preferred Brand | $100 copay | $250 copay | Not covered |
| Specialty drugs — Generic | $25 copay | N/A | Not covered |
| Specialty drugs — Preferred | $150 copay | N/A | Not covered |
| Specialty drugs — Non-Preferred | $250 copay | N/A | Not covered |
4. Mental Health, Behavioral Health, and Substance Abuse Services
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Outpatient services | Office visit: $25 copay. Intensive outpatient treatment: No cost. | 50% coinsurance after deductible | Preauthorization is required for inpatient admissions. If you don't get preauthorization, benefits will be reduced by $750. |
| Inpatient services | 30% coinsurance after deductible | 50% coinsurance after deductible | Preauthorization is required for inpatient admissions. If you don't get preauthorization, benefits will be reduced by $750. |
5. Pregnancy and Maternity Care
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Office visits | No cost | 50% coinsurance after deductible | Maternity care may include tests and services described elsewhere in the SBC. Preauthorization required for stays over 48 hours (normal delivery) or 96 hours (caesarean). If you don't get preauthorization, benefits will be reduced by $750. |
| Childbirth/delivery professional services | No cost | 50% coinsurance after deductible | See above. |
| Childbirth/delivery facility services | 30% coinsurance after deductible | 50% coinsurance after deductible | See above. |
6. Recovery and Special Health Needs
| Service | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Home health care | 30% coinsurance after deductible | 50% coinsurance after deductible | Limited to 20 visits. |
| Rehabilitation services — Inpatient | 30% coinsurance after deductible | 50% coinsurance after deductible | Inpatient Rehab is limited to 60 days/yr (combined with Skilled Nursing facility). Preauthorization required for Inpatient Rehab. If you don't get preauthorization, benefits will be reduced by $750. |
| Rehabilitation services — Outpatient | $50 copay | 50% coinsurance after deductible | Combined maximum of 25 visits/yr for Occupational, Physical, and Speech therapy. |
| Habilitation services — Early intervention | $25 copay | 50% coinsurance after deductible | Covered when Medically Necessary to treat a mental health condition (i.e., autism). Limits do not apply to mental health conditions for Physical, Speech, and Occupational therapies. Early intervention: to age 3. |
| Habilitation services — Developmental delay | $25 copay | 50% coinsurance after deductible | Preauthorization and visit limits based on services provided. |
| Skilled nursing care | 30% coinsurance after deductible | 50% coinsurance after deductible | Skilled nursing care limited to 60 days. Preauthorization is required for Skilled nursing, insulin pumps/supplies, and equipment over $2,500 and Inpatient Hospice. If you don't get preauthorization, benefits will be reduced by $750. |
| Durable medical equipment | 30% coinsurance after deductible | 50% coinsurance after deductible | Preauthorization is required for equipment over $2,500. If you don't get preauthorization, benefits will be reduced by $750. |
| Hospice services | 30% coinsurance after deductible | 50% coinsurance after deductible | Preauthorization is required for Inpatient Hospice. If you don't get preauthorization, benefits will be reduced by $750. |
7. Children's Dental and Vision
| Service | Network Provider | Out-of-Network Provider | Limitations, Exceptions, and Other Important Information |
|---|---|---|---|
| Children's eye exam | Not covered | Not covered | None |
| Children's glasses | Not covered | Not covered | None |
| Children's dental check-up | Not covered | Not covered | None |
8. Excluded Services
The plan generally does NOT cover the following services (check your policy or plan document for more information and a list of any other excluded services):
- Acupuncture
- Bariatric Surgery
- Cosmetic Surgery
- Dental Care (routine adult and child)
- Hearing Aids
- Infertility Treatment
- Long Term Care
- Non-emergency care when traveling outside the U.S.
- Routine Eye Care (adult and child)
- Private Duty Nursing
- Routine Foot Care
- Weight Loss Programs
9. Other Covered Services
Limitations may apply to these services. This is not a complete list. Please see your plan document.
- Chiropractic Care (26 visits / yr)
10. Coverage Examples
Note: These are not cost estimators. 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. These coverage examples are based on self-only coverage.
Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)
| Plan Parameter | Value |
|---|---|
| The plan's overall deductible | $1,500 |
| Specialist copayment | $50 |
| Hospital (facility) coinsurance | 30% |
| Other coinsurance | 0 |
This example event includes services like: Specialist office visits (prenatal care), Childbirth/Delivery Professional Services, Childbirth/Delivery Facility Services, Diagnostic tests (ultrasounds and blood work), Specialist visit (anesthesia).
| Cost Category | Amount |
|---|---|
| Total Example Cost | $12,700 |
| Deductibles | $1,500 |
| Copayments | $10 |
| Coinsurance | $2,100 |
| Limits or exclusions | $60 |
| The total Peg would pay | $3,860 |
Managing Joe's Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)
| Plan Parameter | Value |
|---|---|
| The plan's overall deductible | $1,500 |
| Specialist copayment | $50 |
| Hospital (facility) coinsurance | 30% |
| Other coinsurance | 30% |
This example event includes services like: Primary care physician office visits (including disease education), Diagnostic tests (blood work), Prescription drugs, Durable medical equipment (glucose meter).
| Cost Category | Amount |
|---|---|
| Total Example Cost | $5,600 |
| Deductibles | $800 |
| Copayments | $600 |
| Coinsurance | $0 |
| Limits or exclusions | $20 |
| The total Joe would pay | $1,420 |
Mia's Simple Fracture (in-network emergency room visit and follow up care)
| Plan Parameter | Value |
|---|---|
| The plan's overall deductible | $1,500 |
| Specialist copayment | $50 |
| Hospital (facility) coinsurance | 30% |
| Other copayment | $50 |
This example event includes services like: Emergency room care (including medical supplies), Diagnostic test (x-ray), Durable medical equipment (crutches), Rehabilitation services (physical therapy).
| Cost Category | Amount |
|---|---|
| Total Example Cost | $2,800 |
| Deductibles | $1,500 |
| Copayments | $500 |
| Coinsurance | $100 |
| Limits or exclusions | $0 |
| The total Mia would pay | $2,100 |
The plan would be responsible for the other costs of these example covered services.
11. Your Rights and Additional Information
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-444-3272 (EBSA) or dol.gov/ebsa/healthreform. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how 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 Preferred Benefit Administrators at 1-888-524-2777.
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 the 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.
For more information about your coverage, or to get a copy of the complete terms of coverage: Contact Preferred Benefit Administrators, Inc. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at PreferredTPA.com or call 1-888-524-2777 to request a copy.
For more information about limitations and exceptions: See the plan or policy document at PreferredTPA.com.
12. Language Access Services
- Spanish (Español): Para obtener asistencia en Español, llame al 1-888-524-2777
- Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-524-2777
- Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 1-888-524-2777
- Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-524-2777
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OMB Control Numbers: DT - 1545-0047 / Expiration Date: 12/31/2019. DOL - 1210-0147 / Expiration Date: 5/31/2022. HHS - 0938-1146 / Expiration Date: 10/31/2022.