Matrix Sciences International Inc. - HSA Base Plan Benefits Guide
This DRAFT benefits schedule (as of 11/18/25) outlines the HSA Base Plan (Qualified High-Deductible Health Plan) for Matrix Sciences International Inc. employees and their families. The plan features a PPO network (CIGNA), with separate in-network and out-of-network deductibles and out-of-pocket maximums. Preventive care is covered at 100% in-network with no deductible. The plan includes comprehensive medical, prescription drug, mental health, and wellness benefits. Group #: 001R2613 | Effective Date: 1/1/2026 | Status: NGF | Document Version: 26.0
Document Approval Status
| Role | Name | Date |
|---|---|---|
| TRU Department | [To be entered] | Click here to enter a date |
| Account Manager | Julie Elwell / Kate Kilpatrick | Click here to enter a date |
| Compliance | Margaret Sargent | Click here to enter a date |
Note: This is a DRAFT document with pending approval signatures.
Plan Administration Details
| Component | Provider/Details |
|---|---|
| Plan Name | Matrix Sciences International Inc. - HSA Base Plan (QHDHP) |
| Group Number | 001R2613 |
| Effective Date | 1/1/2026 |
| Status | NGF (New Group Formation) |
| Managed Care Type | PPO |
| PPO Network | CIGNA |
| Out-of-Network Claims Pricing | Phia |
| Utilization Management (UM) | Cigna Payer Solutions |
| Case Management (CM) | MedWatch |
| Disease Management (DM) | None |
| Customer Service | Karias Care Concierge |
| MCC Creditable | Yes |
| Prescription Drug Administrator | TrueScripts |
Standardly Covered Services
The following services are covered under this plan (subject to the terms and conditions outlined in the Plan Document):
- Breast Reduction Surgery - When medically necessary; precertification required
- Orthoptics - Unless otherwise listed as excluded in the Plan Document
- Breastfeeding Support, Supplies and Counseling - If there are no in-network lactation providers, then out-of-network providers should be covered at the in-network 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
- Child/Adolescent Mental Health/Substance Use 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
- 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, as well as transplants for permanent artificial heart when Medically Necessary and Covered Person is already on the transplant list
Standardly Excluded Services
The following services are specifically excluded from coverage:
- Sex therapy
- Xenotransplants (cross-species) transplants
Prescription Drug Benefits (Administered by TrueScripts)
Coverage 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 pay Co-payments and Coinsurance, if applicable, which accumulate toward the Out-of-Pocket Maximums
- Once the Out-of-Pocket Maximums have been met, prescription drugs will be covered at 100% for the balance of the Calendar Year
- U.S. Food and Drug Administration (FDA) approved contraceptive medications and devices: Covered at 100% (Deductible waived)
- Tobacco cessation products: Covered at 100% (Deductible waived)
- Preventive Care medications: Not subject to the Deductible
Important Prescription Drug Plan Settings
| Setting | Value |
|---|---|
| Do Prescription Drug Costs count to a Separate Rx OOP Max or count toward Medical OOP Max? | COMBINED |
| Are scripts subject to Deductibles? | NO |
| Other | [None specified] |
Editorial Note: #INCLUDE FOR PLANS USING SPECIALTY DRUG PROGRAMS# - See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs
Retail Card Program (Up to 30-day supply)
After Deductible, You Pay:
- Generic drugs: 0% Coinsurance per generic drug
- Preferred brand name drugs: 0% Coinsurance per preferred brand name drug
- Non-preferred brand name drugs: 0% Coinsurance per non-preferred brand name drug
Mail Order Pharmacy (Up to 90-day supply)
After Deductible, You Pay:
- Generic drugs: 0% Coinsurance per generic drug
- Preferred brand name drugs: 0% Coinsurance per preferred brand name drug
- Non-preferred brand name drugs: 0% Coinsurance per non-preferred brand name drug
Specialty Drugs (Retail only - 30-day supply)
After Deductible, You Pay:
- Specialty drugs: $0 Coinsurance per prescription per Specialty drug
Out-of-Network Pharmacy Coverage (Retail only - Up to 30-day supply)
After Deductible, You Pay:
- All medications: 50% Coinsurance, subject to Allowed Amount
Medical Benefits Summary
Calendar Year Deductible
| Coverage Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee only) | $3,400 | $10,200 |
| Family Plan (Employee & family) | $3,400 per person, up to $6,800 per family | $10,200 per person, up to $20,400 per family |
| Individual Deductible Included in Family Coverage | YES | YES |
| Medical Calendar Year Deductible Carryover | NO | NO |
Important Note About Family Deductible: The Family Plan contains both an individual Deductible and a family Deductible. Once an individual family member satisfies the individual Deductible, claims will be paid for that individual. Otherwise, the entire family Deductible must be satisfied before claims will be paid for any family members. The family Deductible may be met by any combination of family members.
Reimbursement Percentage (Coinsurance)
| In-Network | Out-of-Network |
|---|---|
| 100% of the Contracted Rate (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximums has been reached, then 100% thereafter for the balance of the Calendar Year | 60% of the Allowed Amount* (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximums has been reached, then 100% thereafter for the balance of the Calendar Year |
*See No Surprises Act (NSA) provisions below for exceptions
Calendar Year Out-of-Pocket Maximums
Includes: Calendar Year Deductible and Coinsurance, including those for prescription drugs
| Coverage Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee only) | $3,400 | $20,400 |
| Family Plan (Employee & family) | $3,400 per person, up to $6,800 per family | $20,400 per person, up to $40,800 per family |
| Individual OOPM Included in Family Coverage | YES | YES |
Important Note About Family Out-of-Pocket Maximum: 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.
No Surprises Act (NSA) Provisions and Balance Billing Protection
Emergency Services: 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 Prohibitions:
- When emergency services are rendered by an Out-of-Network Provider for Emergency Care, or air ambulance services are rendered by an Out-of-Network Provider of air ambulance services, the Out-of-Network Provider cannot balance bill the Covered Person
- 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
Standard Out-of-Network Services: 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.
Critical Rules About Deductibles and Out-of-Pocket Maximums
The In-Network Provider and Out-of-Network Provider Deductible and Out-of-Pocket Maximums are separate and do not accumulate.
| Setting | Status |
|---|---|
| In/Out-of-Network Deductibles are | SEPARATE |
| In/Out-of-Network Out-of-Pocket Maximums are | SEPARATE |
Important: 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.
Combined Limits: In addition, Covered Services that contain dollar, frequency or visit limits are combined In-Network and Out-of-Network maximums.
Expenses Excluded from Medical Out-of-Pocket Maximum
The following expenses are excluded from the Medical Out-of-Pocket Maximum:
- Precertification penalties
Preventive Care Services
IMPORTANT PPACA INFORMATION: 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 NSA Coverage: 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.
Preventive Care Benefits Table
| Service | In-Network | Out-of-Network | Limits/Notes |
|---|---|---|---|
| **Routine Physical Exams (Including routine and travel immunizations and flu shots) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Routine Well Child Care (Including screenings, routine and travel immunizations and flu shots) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Fluoride Varnish (Up to age 6) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | Up to four (4) varnish treatments per person, per Calendar Year |
| **Breastfeeding Support, Supplies and Counseling (During pregnancy and/or in the postpartum period and rental or purchase of breastfeeding equipment) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | Breast Pump Limits:<br>• Hospital Grade Breast Pumps: rental covered up to 3 months; precertification required for rental in excess of 3 months<br>• Electric Breast Pumps: rent or purchase, whichever is less<br>• Manual Breast Pumps: purchase |
| **Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Routine Gynecological/Obstetrical Care (Including preconception and prenatal services) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Routine Pap Smears | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Breast Cancer Screening (including Routine Mammograms and BRCA testing) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Routine Immunizations (If not billed with an office visit; includes flu shots and travel immunization) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Routine Lab, X-rays, and Clinical Tests (Including those related to maternity care) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Routine Colorectal Cancer Screening (including sigmoidoscopies and colonoscopies) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | As recommended by the US Preventive Service Task Force |
| **Lung Cancer Screening (including Low-Dose Computed Tomography [LDCT]) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | Up to one (1) per person, per Calendar Year; As recommended by the US Preventive Service Task Force |
| **Nutritional Counseling | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Smoking Cessation Counseling and Intervention (Including smoking cessation clinics and programs) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| Routine Hearing Exams | 100% | 60% Allowed Amount (after Deductible) | Limits: [See Plan Document] |
| Routine Prostate Exams and Prostate-Specific Antigen (PSA) Screenings | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Abdominal Aortic Aneurysm Screening | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | Up to one (1) per person, per lifetime; As recommended by the US Preventive Service Task Force |
| **Bone Density Screening - Women (as recommended by the US Preventive Service Task Force for Osteoporosis Screening) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| **Bone Density Screening - All other Covered Persons | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| Equipment for those with Chronic Conditions | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | Limited to the following services:<br>• Blood pressure monitor (hypertension)<br>• Peak flow meter (asthma)<br>• Glucometer and selected insulin products (such as vial, pump or inhaler) (diabetes) |
| Tests/Screenings for those with Chronic Conditions | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | Limited to the following services:<br>• Hemoglobin A1c (diabetes)<br>• Retinopathy screening (diabetes)<br>• INR (liver disease or bleeding disorders)<br>• LDL (heart disease) |
Vision Care
| Service | In-Network | Out-of-Network | Notes |
|---|---|---|---|
| Routine Vision Exam | 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) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
Physician Services
Out-of-Network NSA Coverage: 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 | Notes |
|---|---|---|---|
| Allergy Testing | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Allergy Treatment | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Anesthesia (Inpatient/Outpatient) | 100% (after Deductible) | 60% 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) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Up to 30 visits per person, per Calendar Year |
| Maternity - Prenatal care | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | [Choose an item.] |
| Maternity - Physician delivery charges | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Maternity - Postnatal care (Includes home visit with a Visiting Nurse following early discharge) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Physician Hospital Visits | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Physician Office Visits - Primary Care (Includes all related charges billed at time of visit) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Physician Office Visits - Specialist (Includes all related charges billed at time of visit) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Second Surgical Opinion | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Surgery - Inpatient | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Surgery - Outpatient | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Surgery - Physician's office | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
Hospital Services - Inpatient
CRITICAL PRECERTIFICATION REQUIREMENTS
Precertification is always required for inpatient hospitalization. Failure to obtain precertification may result in a reduction in benefits. 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 NSA Coverage: 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.
Inpatient Hospital Benefits
| Service | In-Network | Out-of-Network | Notes |
|---|---|---|---|
| Hospital Room & Board (Semi-private room or special care unit) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required |
| Maternity Services (Semi-private room or special care unit) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required for stays in excess of 48 hours [vaginal]; 96 hours [cesarean] |
| Birthing Center | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Newborn Care (Includes Physician visits & circumcision; Semi-private room or special care unit) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Organ, Bone Marrow and Stem Cell Transplants (Semi-private room or special care unit) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required; Managed through Cigna's LifeSOURCE Transplant Network®; see Medical Benefits section for other limitations<br>Transportation/food/lodging limits: $10,000 per Transplant |
| Surgical Facility & Supplies | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Miscellaneous Hospital Charges | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
Hospital Services - Outpatient
CRITICAL PRECERTIFICATION REQUIREMENTS
Precertification for outpatient surgical procedures is required. Failure to obtain precertification for outpatient surgical procedures may result in a reduction in benefits. (The penalty will not apply to outpatient surgical procedures performed in a Physician's office)
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Out-of-Network NSA Coverage: 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.
Outpatient Hospital Benefits
| Service | In-Network | Out-of-Network |
|---|---|---|
| Clinic Services (At a Hospital) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Emergency Room Expenses (Includes Facility, Lab, X-ray & Physician services) | 100% (after Deductible) | 100% (after In-Network Deductible) |
| Outpatient Department | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Preadmission Testing | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Urgent Care Facility/Walk-In Clinic | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
Mental Health / Substance Use Services
CRITICAL PRECERTIFICATION REQUIREMENTS
Precertification is always required for inpatient hospitalization. Failure to obtain precertification may result in a reduction in benefits. 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 NSA Coverage: 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.
Mental Health/Substance Use Benefits
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospitalization | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Partial Hospitalization/Intensive Outpatient Treatment | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Inpatient Physician Visit | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Hospital Clinic Visit | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Office Visit | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Methadone Maintenance/Treatment | [See Plan Document for coverage details] | [See Plan Document for coverage details] |
Other Services & Supplies
Out-of-Network NSA Coverage: 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.
| Service | In-Network | Out-of-Network | Limits/Notes |
|---|---|---|---|
| Acupuncture | NOT COVERED | NOT COVERED | - |
| Alternative/Complementary Care Benefit (Chelation Therapy, Homeopathic treatment, Hypnosis/Hypnotherapy, Rolfing/Reiki) | NOT COVERED | NOT COVERED | - |
| Ambulance Services | 100% (after Deductible) | 100% Allowed Amount (after In-Network Deductible) | See Medical Benefits section for limitations |
| Autism Spectrum Disorders Treatment (Includes Applied Behavioral Analysis [ABA]) | Benefits are based on services provided | Benefits are based on services provided | Any benefit limits under the Plan for occupational, physical and speech therapies do not apply; Precertification is required for ABA; see Medical Benefits section for limitations<br>Note: Screenings are covered under Preventive Care |
| Bariatric Surgery | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Biofeedback Therapy | NOT COVERED | NOT COVERED | - |
| Cardiac Rehabilitation (Phase 1 and 2 only; Phase 3 is excluded) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Chemotherapy & Radiation Therapy | 100% (after Deductible) | 60% 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) | Benefits are based on services provided | Benefits are based on services provided | See Medical Benefits section for other limitations |
| Cochlear Implants | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Dental/Oral Services (Includes excision of impacted wisdom teeth) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Diabetes Self-Management Training and Education | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Diagnostic X-ray and Laboratory (Outpatient) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Dialysis/Hemodialysis | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Durable Medical Equipment | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Early Intervention Services (Up to age 3) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
| Erectile Dysfunction Treatment | Not Covered, except for medication covered through the Prescription Drug Program | Not Covered, except for medication covered through the Prescription Drug Program | Editorial Note: #USE IF NOT COVERED UNDER MEDICAL PLAN, BUT COVERED UNDER RX PLAN; REMOVE BENEFIT FROM PD SCHEDULE IF NOT COVERED UNDER EITHER#<br>Precertification required for implants; see Medical Benefits section for limitations<br>Limits: [See Plan Document] |
| Family Planning - For Women (Including but not limited to consultations and diagnostic tests) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | See also Prescription Drug Benefit and Preventive Care Section |
| Family Planning - For Men | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Gender Dysphoria Treatment and Related Services (Includes gender identity counseling, gender reassignment surgery and hormone replacement therapy) | Benefits are based on services provided | Benefits are based on services provided | Precertification required for gender reassignment surgery; see Medical Benefits section for other limitations |
| Gene Therapy | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required for inpatient hospitalization |
| Genetic Counseling, Testing and Related Services | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Note: Coverage is provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services; precertification is not required |
| Growth Hormones | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Hearing Aids - Under age 18 | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Up to one (1) hearing aid per hearing impaired ear, every 24 months |
| Hearing Aids - Age 18 and over | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Up to $2,500 per hearing aid, per hearing impaired ear, every 24 months |
| Home Health Care | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Hospice Care (Inpatient/Outpatient) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required for inpatient services; see Medical Benefits section for other limitations |
| Infertility Treatment | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Up to four (4) cycles per person, per Calendar Year<br>See Medical Benefits section for other limitations |
| Injectables | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Learning Deficiencies, Behavioral Problems/Developmental Delays | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification and visit limits are based on services provided |
| Marital Counseling | [Coverage details not specified in schedule] | [Coverage details not specified in schedule] | Limits: [To be determined - see Plan Document] |
| Massage Therapy | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Medical and Enteral Formula (Including metabolic formula) | [Coverage details not specified in schedule] | [Coverage details not specified in schedule] | Precertification required; see Medical Benefits section for other limitations |
| Modified Low Protein Food Products | [Coverage details not specified in schedule] | [Coverage details not specified in schedule] | Up to $ [amount not specified] per person, per <Calendar><Plan> Year [to be determined]<br>See Medical Benefits section for limitations |
| Neuromuscular Stimulator Equipment including TENS | [Coverage details not specified in schedule] | [Coverage details not specified in schedule] | Precertification required |
| Occupational Therapy (For treatment due to Injury or Illness) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Oral Pharynx Procedures | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Orthotics (Includes foot orthotics) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Physical Therapy (For treatment due to Injury or Illness) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitation |
| Podiatry Care | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
| Private Duty Nursing | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Prosthetics | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
| Rehabilitation Hospital | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required; see Medical Benefits section for other limitations |
| Respiratory Therapy | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Sleep Studies | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Skilled Nursing Facility/Extended Care Facility | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required; see Medical Benefits section for other limitations |
| Speech Therapy (For treatment due to Injury or Illness) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Telemedicine (Applies to medical and behavioral health services; INCLUDES DOCTOR ON DEMAND) | 100% (after Deductible)<br><br>Paid based on services provided | 60% Allowed Amount (after Deductible)<br><br>Paid based on services provided | All other virtual visits with a Provider with whom a Covered Person has established relationship, including, but not limited to Occupational Therapy, Physical Therapy and Speech Therapy<br>See Medical Benefits section for additional information |
| Temporomandibular Joint Disorders (TMJ) Treatment | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | Precertification required<br>Limits: [To be determined - see Plan Document] |
| Termination of Pregnancy | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Travel Immunizations | [Coverage details not specified in schedule] | [Coverage details not specified in schedule] | Editorial Note: #REMOVE IF COVERED UNDER PREVENTIVE CARE# [Include only if not covered at same level as routine immunizations under Preventive Care]<br>Limits: [To be determined - see Plan Document] |
| Voluntary Sterilization - For Women | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) | - |
| Voluntary Sterilization - For Men | 100% (after Deductible) | 60% Allowed Amount (after Deductible) | - |
| Wigs | NOT COVERED | NOT COVERED | - |
Wellness Benefits
IMPORTANT NOTE: The wellness benefits section contains placeholder values that need to be finalized. The document includes two different fitness reimbursement benefit options with editorial notes about which one to use.
| Benefit | Coverage | Details |
|---|---|---|
| Childbirth Classes | [Percentage not specified]% up to a maximum of $[amount not specified] | For childbirth classes for each covered expectant mother |
Fitness Reimbursement Benefit - Standard Option
Editorial Note from Document: #USE FOR STANDARD FITNESS REIMBURSEMENT BENEFIT#
| Element | Details |
|---|---|
| Reimbursement Amount | [Percentage not specified]% up to a total reimbursement of $[amount not specified] per [individual/family/person] [to be determined] per [Calendar/Plan] Year [to be determined] |
| Eligible Expenses | Health club membership fees |
| Membership Requirements | - Must be paid in the current [Calendar/Plan] Year for membership in that year<br>- The paid date must be within your dates of enrollment in this Plan |
| Proof Required | Reimbursement is available after providing proof of 4 months of membership in that year after enrollment into this Plan |
| Submission Process | Requests for reimbursement must be [submitted to and approved by COMPANY Human Resource Department] [submitted to the Claim Administrator] [approved by the COMPANY Human Resource Department and submitted to the Claim Administrator] for reimbursement [Selection to be determined] |
Fitness Reimbursement Benefit - Expanded Option
Editorial Note from Document: #USE FOR EXPANDED FITNESS REIMBURSEMENT BENEFIT#
| Element | Details |
|---|---|
| Reimbursement Amount | [Percentage not specified]% up to a total reimbursement of $[amount not specified] per [individual/family/person] [to be determined] per [Calendar/Plan] Year [to be determined] |
| Eligible Expenses | Monthly fees paid to a facility that provides cardiovascular and strength-training equipment for exercising and improving physical fitness |
| Qualifying Facilities Include | - Health clubs<br>- Fitness centers<br>- YMCA's<br>- YWCA's<br>- Jewish Community Centers<br>- Municipal fitness centers |
| Qualifying Fitness Studios/Facilities | Facilities that offer:<br>- Yoga<br>- Pilates®<br>- Zumba®<br>- Aerobic/group classes<br>- Indoor cycling/spinning classes<br>- Kickboxing<br>- CrossFit®<br>- Strength training<br>- Tennis<br>- Indoor rock climbing<br>- Personal training taught by a certified instructor |
| Definition of Qualified Health and Fitness Club | A facility with cardiovascular and strength-training equipment and facilities for exercising and improving physical fitness. Qualifying facilities include, but are not limited to, fitness studios/facilities that offer: Yoga, Pilates®, Zumba®, aerobic/group classes, indoor cycling/spinning classes, kickboxing, CrossFit®, strength training, tennis, indoor rock climbing, and personal training taught by a certified instructor. |
| Proof Required | Reimbursement is available after providing proof of 4 months of membership in that year after enrollment into this Plan |
| Submission Process | Requests for reimbursement must be [submitted to and approved by COMPANY Human Resource Department] [submitted to the Claim Administrator] [approved by the COMPANY Human Resource Department and submitted to the Claim Administrator] for reimbursement [Selection to be determined] |
Weight Loss Reimbursement Benefit
| Benefit | Coverage |
|---|---|
| Weight Loss Reimbursement Benefit | NOT COVERED |
Editorial Notes and Placeholder Text
The following items in the original document contain editorial notes or incomplete information that needs to be finalized:
- Maternity - Prenatal care: Contains "[Choose an item.]" placeholder
- Routine Hearing Exams: Limits section shows "Choose an item."
- Erectile Dysfunction Treatment: Contains editorial note "#USE IF NOT COVERED UNDER MEDICAL PLAN, BUT COVERED UNDER RX PLAN; REMOVE BENEFIT FROM PD SCHEDULE IF NOT COVERED UNDER EITHER#"
- Travel Immunizations: Contains editorial note "#REMOVE IF COVERED UNDER PREVENTIVE CARE#"
- Wellness Benefits: Multiple placeholder values for percentages, dollar amounts, and selection options (individual/family/person, Calendar/Plan Year)
- Fitness Reimbursement: Two different benefit structures with editorial notes indicating which one to use
- Specialty Drug Programs: Document note "#INCLUDE FOR PLANS USING SPECIALTY DRUG PROGRAMS#"
Document Footer and Disclaimers
CRITICAL DISCLAIMER FROM ORIGINAL DOCUMENT:
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: 26.0
Document Status: DRAFT as of 11/18/25 MS
Approval Status: Pending (approval signatures not yet dated)
Summary of Key Plan Features
Quick Reference Table
| Feature | Details |
|---|---|
| Plan Type | HSA Base Plan (QHDHP - Qualified High-Deductible Health Plan) |
| Group Number | 001R2613 |
| Effective Date | January 1, 2026 |
| Network Type | PPO (CIGNA) |
| In-Network Deductible (Single) | $3,400 |
| In-Network Deductible (Family) | $6,800 total ($3,400 per person) |
| In-Network Out-of-Pocket Max (Single) | $3,400 |
| In-Network Out-of-Pocket Max (Family) | $6,800 total ($3,400 per person) |
| Out-of-Network Deductible (Single) | $10,200 |
| Out-of-Network Deductible (Family) | $20,400 total ($10,200 per person) |
| Out-of-Network Out-of-Pocket Max (Single) | $20,400 |
| Out-of-Network Out-of-Pocket Max (Family) | $40,800 total ($20,400 per person) |
| In-Network Coinsurance | 100% (after deductible) |
| Out-of-Network Coinsurance | 60% (after deductible) |
| Prescription Drugs Subject to Deductible? | NO |
| Prescription Drug Coinsurance (All tiers) | 0% after deductible |
| Preventive Care In-Network | 100% (No deductible) |
| Deductibles (In-Network vs Out-of-Network) | SEPARATE |
| Out-of-Pocket Maximums (In-Network vs Out-of-Network) | SEPARATE |
Important Reminders for Support Team
- This is a DRAFT document - Final approved version may differ
- All precertification requirements are strict - Penalties for non-compliance are the covered person's responsibility
- NSA protections apply to specific emergency and out-of-network services
- In-network and out-of-network costs do NOT cross-accumulate toward deductibles or out-of-pocket maximums
- Preventive care has special coverage rules under PPACA/USPSTF guidelines
- Multiple benefits have placeholders - refer to final Plan Document for complete details
- Customer service is handled by Karias Care Concierge
- Prescription drugs are administered by TrueScripts
- Calendar year basis - all limits and maximums reset January 1st
- HSA-compatible plan - Qualified High-Deductible Health Plan
Key Contacts
| Function | Contact |
|---|---|
| Account Manager | Julie Elwell / Kate Kilpatrick |
| Customer Service | Karias Care Concierge |
| Prescription Drug Administrator | TrueScripts |
| PPO Network | CIGNA |
| Utilization Management | Cigna Payer Solutions |
| Case Management | MedWatch |
| Out-of-Network Claims Pricing | Phia |
| Compliance | Margaret Sargent |
*For the most current and complete benefit information, always refer to the official Plan Document and Summary Plan Description (SPD). This knowledge base article is based on a DRAFT schedule dated 11/18/25 and is subject to change.