Jr. Davis Construction Company Health Benefit Plan (Base Plan) — Summary of Benefits and Coverage

 

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Table of Contents

1. Important Questions & Answers
2. Office & Clinic Visits
3. Tests
4. Prescription Drugs
5. Outpatient Surgery
6. Immediate Medical Attention
7. Hospital Stay
8. Mental Health, Behavioral Health & Substance Abuse Services
9. Pregnancy
10. Recovery & Special Health Needs
11. Children's Dental & Eye Care
12. Excluded Services
13. Other Covered Services
14. Continuation of Coverage & Appeals Rights
15. Minimum Essential Coverage & Minimum Value
16. Language Access Services
17. Coverage Examples

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1. Important Questions & Answers

Important Question	Answer	Why This Matters
What is the overall deductible?	In-network: $4,000 individual / $8,000 family · Out-of-network: $10,000 individual / $30,000 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: $6,000 individual / $12,000 family · Out-of-network: $20,000 individual / $40,000 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 www.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.

Note: All coinsurance costs shown in the following sections are after your deductible has been met, if a deductible applies.

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2. Office & Clinic Visits

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & Other Important Information
Primary care visit to treat an injury or illness	Teladoc virtual visit: No cost · PCP office visit: $30 copay	50% coinsurance after deductible	None
Specialist visit	$55 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.

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3. Tests

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & Other Important Information
Diagnostic test (x-ray, blood work)	Independent Lab: No cost · Hospital based Lab: $50 copay · X-Rays/Diagnostic Tests: 30% coinsurance after deductible	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. 30% coinsurance after deductible 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.

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4. Prescription Drugs

Note: A prescription drug specific deductible of $300 per individual / $300 per family applies to all drugs except generic and preventive care drugs. More information about prescription drug coverage is available at www.PreferredTPA.com.

Drug Tier	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & Other Important Information
Generic drugs	Retail: $10 copay · Maintenance & Mail Order: $25 copay	Not covered	Retail prescriptions: 30-day supply maximum. 90-day supply maximum for maintenance drugs. Mail Order prescriptions: 90-day supply maximum.
Preferred Brand	Retail: $60 copay · Maintenance & Mail Order: $150 copay	Not covered	Same supply limits as above.
Non-Preferred Brand	Retail: $100 copay · Maintenance & Mail Order: $250 copay	Not covered	Same supply limits as above.
Specialty drugs	Generic: $25 copay · Preferred: $150 copay · Non-Preferred: $250 copay	Not covered	Same supply limits as above.

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5. Outpatient Surgery

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & 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.

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6. Immediate Medical Attention

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & 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	$60 copay	50% coinsurance after deductible	None

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7. Hospital Stay

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & 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

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8. Mental Health, Behavioral Health & Substance Abuse Services

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & Other Important Information
Outpatient services	Office visit: $30 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.

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9. Pregnancy

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & Other Important Information
Office visits	No cost	50% coinsurance after deductible	Maternity care may include tests and services described elsewhere in 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	Same as above.
Childbirth/delivery facility services	30% coinsurance after deductible	50% coinsurance after deductible	Same as above.

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10. Recovery & Special Health Needs

Service	In-Network (You Pay the Least)	Out-of-Network (You Pay the Most)	Limitations, Exceptions & 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 · Outpatient: $55 copay	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. Combined maximum of 25 visits/yr for Occupational, Physical & Speech therapy.
Habilitation services	Early intervention: $30 copay* · Developmental delay: $30 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. *To age 3. **Preauthorization & 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 & 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.

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11. Children's Dental & Eye Care

Service	In-Network	Out-of-Network	Limitations, Exceptions & 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

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12. Excluded Services

The following services are generally NOT covered by this plan. 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 & child)
• Hearing Aids
• Infertility Treatment
• Long Term Care
• Non-emergency care when traveling outside the U.S.
• Routine Eye Care (adult & child)
• Private Duty Nursing
• Routine Foot Care
• Weight Loss Programs

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13. Other Covered Services

Limitations may apply to these services. This isn't a complete list. Please see your plan document.

• Chiropractic Care (26 visits / yr)

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14. Continuation of Coverage & Appeals Rights

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. Contact the 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 www.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.

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15. Minimum Essential Coverage & Minimum Value

Question	Answer
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.

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16. Language Access Services

Language	Contact
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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17. Coverage Examples

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Plan parameters used in all examples: Overall deductible: $4,000 · Specialist copayment: $55 · Hospital (facility) coinsurance: 30% · Other coinsurance: 30%

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Example event includes: 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	$4,000
Copayments	$10
Coinsurance	$1,400
Limits or exclusions	$60
Total Peg would pay	$5,470

Managing Joe's Type 2 Diabetes

(A year of routine in-network care of a well-controlled condition)

Example event includes: 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
Total Joe would pay	$1,420

Mia's Simple Fracture

(In-network emergency room visit and follow up care)

Example event includes: 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	$2,100
Copayments	$400
Coinsurance	$50
Limits or exclusions	$0
Total Mia would pay	$2,500

The plan would be responsible for the other costs of these EXAMPLE covered services.

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For more information about limitations and exceptions, see the plan or policy document at www.PreferredTPA.com.