Matrix Sciences International Inc. - HSA Low Plan (QHDHP) Benefits Guide
This knowledge base article provides complete details of the Matrix Sciences International Inc. HSA Low Plan, a Qualified High Deductible Health Plan (QHDHP) administered through CIGNA's PPO network. The plan features separate in-network and out-of-network deductibles and out-of-pocket maximums, with 80% in-network and 60% out-of-network coinsurance after deductible. Prescription drugs are covered at 20% coinsurance after deductible, and preventive care services are covered at 100% with no deductible for in-network providers. The plan is HSA-compatible and effective January 1, 2026.
Effective Date: January 1, 2026
Group Number: 001R2613
Plan Type: PPO (Preferred Provider Organization)
Network: CIGNA
Status: NGF (New Group Filing)
Plan Administration
| Function | Administrator |
|---|---|
| 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 |
| Prescription Drug Benefit | TrueScripts |
| MCC Creditable | Yes |
Key Plan Features
Annual Deductibles
| Coverage Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee Only) | $3,500 | $7,000 |
| Family Plan - Per Person | $3,500 | $7,000 |
| Family Plan - Family Maximum | $7,000 | $14,000 |
Important Notes:
- Individual deductible is included in family coverage: YES
- Deductible carryover: NO
- In-Network and Out-of-Network deductibles are SEPARATE and do not accumulate toward each other
Family Plan Details: 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.
Coinsurance (Reimbursement Percentage)
| Network Type | Coinsurance Rate | Applied To |
|---|---|---|
| In-Network | 80% | Contracted Rate (after deductible) |
| Out-of-Network | 60% | Allowed Amount (after deductible) |
Annual Out-of-Pocket Maximums
| Coverage Type | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee Only) | $7,000 | $21,000 |
| Family Plan - Per Person | $7,000 | $21,000 |
| Family Plan - Family Maximum | $14,000 | $42,000 |
What Counts Toward Out-of-Pocket Maximum:
- Calendar year deductible
- Coinsurance payments
- Prescription drug deductible and coinsurance
What Does NOT Count:
- Precertification penalties
Important Notes:
- Individual OOPM is included in family coverage: YES
- In-Network and Out-of-Network OOPMs are SEPARATE and do not accumulate toward each other
- Once the out-of-pocket maximum is met, the plan pays 100% for the remainder of the calendar year
Family Plan Details: The family plan contains both an individual OOPM and a family OOPM. Once an individual family member satisfies the individual OOPM, claims will be paid for that individual at 100%. Otherwise, once the entire family OOPM is satisfied, claims will be paid at 100% for all covered family members. The family OOPM may be met by any combination of family members.
No Surprises Act (NSA) Protection
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"
- Air ambulance services rendered by Out-of-Network providers
- Non-emergency services rendered by Out-of-Network providers at an In-Network hospital or facility for:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory
- Neonatology
- Assistant surgeon
- Hospitalist
- Intensivist services
Balance Billing Protection: When the above conditions are met and the Covered Person has not validly waived the applicability of the NSA, Out-of-Network providers cannot balance bill the Covered Person.
Important: 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.
Prescription Drug Benefits
Administrator: TrueScripts
Deductible Applies to Prescriptions: NO (Note: Covered persons pay 100% until deductible is met)
Prescription Drug OOP Max: COMBINED with Medical OOP Max
How Prescription Drug Coverage Works
- Covered persons pay 100% until the applicable calendar year deductible is met
- Once deductible is met, covered persons pay coinsurance
- Coinsurance accumulates toward the Out-of-Pocket Maximum
- Once OOPM is met, prescription drugs are covered at 100% for the balance of the calendar year
Retail Card Program (Up to 30-day supply)
| Drug Type | After Deductible, You Pay |
|---|---|
| Generic | 20% Coinsurance |
| Preferred Brand Name | 20% Coinsurance |
| Non-Preferred Brand Name | 20% Coinsurance |
Mail Order Pharmacy (Up to 90-day supply)
| Drug Type | After Deductible, You Pay |
|---|---|
| Generic | 20% Coinsurance |
| Preferred Brand Name | 20% Coinsurance |
| Non-Preferred Brand Name | 20% Coinsurance |
Specialty Drugs (Retail Only - 30-day supply)
| Drug Type | After Deductible, You Pay |
|---|---|
| Specialty Drug | 20% Coinsurance |
Note: See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs.
Out-of-Network Pharmacy (Retail Only - Up to 30-day supply)
After Deductible, You Pay: 50% Coinsurance (subject to Allowed Amount)
Prescription Drug Exceptions (Deductible Waived)
The following are covered at 100% with NO deductible:
- FDA-approved contraceptive medications and devices
- Tobacco cessation products
- Preventive Care medications
Important Clarification on "Are scripts subject to Deductibles?: NO"
- There is NO separate prescription drug deductible
- Prescription drug costs DO apply toward the medical calendar year deductible
- You pay 100% of prescription costs until the medical deductible is met
- After meeting the medical deductible, you pay the coinsurance percentages shown above
- Prescription drug costs and coinsurance count toward the combined medical/Rx out-of-pocket maximum
Preventive Care Services
All preventive care services marked with (**) are provided according to the Patient Protection and Affordable Care Act of 2010 (PPACA) and U.S. Preventive Services Task Force (USPSTF) recommendations.
Preventive Care Benefits Table
| Service | In-Network | Out-of-Network |
|---|---|---|
| **Routine Physical Exams (including routine and travel immunizations, flu shots) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **Routine Well Child Care (including screenings, routine and travel immunizations, flu shots) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **Fluoride Varnish (Up to age 6; up to 4 treatments per person per calendar year) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **Breastfeeding Support, Supplies and Counseling (During pregnancy and/or postpartum period) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **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 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 per USPSTF) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **Lung Cancer Screening (Including Low-Dose CT; per USPSTF; up to 1 per person per calendar year) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **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% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Routine Prostate Exams and PSA Screenings | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **Abdominal Aortic Aneurysm Screening (Per USPSTF; up to 1 per person per lifetime) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| **Bone Density Screening - Women (Per USPSTF 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 Chronic Conditions (Blood pressure monitor, peak flow meter, glucometer and selected insulin products) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Tests/Screenings for Chronic Conditions (Hemoglobin A1c, Retinopathy screening, INR, LDL) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
Breast Pump Coverage Limits
- Hospital Grade Breast Pumps: Rental covered up to 3 months; precertification required for rental in excess of 3 months
- Electric Breast Pumps: Rent or purchase, whichever is less
- Manual Breast Pumps: Purchase
Important Note on Preventive Care
New or updated A and B Recommendations from USPSTF generally go into effect on the first plan year one year after issuance of the revised recommendation.
Vision Care
| Service | In-Network | Out-of-Network |
|---|---|---|
| Routine Vision Exam | NOT COVERED | NOT COVERED |
| Routine Eyewear (Lenses, frames, contact lenses) | NOT COVERED | NOT COVERED |
| Eyewear for Special Conditions (Initial purchase of non-routine eyewear following surgery; contact lenses for keratoconus; intraocular lenses after corneal transplant, cataract surgery, or other covered eye surgery when natural lens is replaced) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
Physician Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Allergy Testing | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Allergy Treatment | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Anesthesia (Inpatient/Outpatient) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Chiropractic Services (Lab and x-ray charges paid based on services provided; up to 30 visits per person per calendar year) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Maternity - Prenatal Care | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Maternity - Physician Delivery Charges | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Maternity - Postnatal Care (Includes home visit with Visiting Nurse following early discharge) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Physician Hospital Visits | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Physician Office Visits - Primary Care (Includes all related charges billed at time of visit) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Physician Office Visits - Specialist (Includes all related charges billed at time of visit) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Second Surgical Opinion | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Surgery - Inpatient | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Surgery - Outpatient | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Surgery - Physician's Office | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
Hospital Services - Inpatient
⚠️ 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.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Hospital Room & Board (Semi-private room or special care unit; precertification required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Maternity Services (Semi-private room or special care unit; precertification required for stays in excess of 48 hours [vaginal] or 96 hours [cesarean]) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Birthing Center | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Newborn Care (Includes physician visits and circumcision; semi-private room or special care unit) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Organ, Bone Marrow and Stem Cell Transplants (Precertification required; managed through Cigna's LifeSOURCE Transplant Network®; transportation/food/lodging limit: $10,000 per transplant) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Surgical Facility & Supplies | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Miscellaneous Hospital Charges | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
Hospital Services - Outpatient
⚠️ 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.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Clinic Services (At a Hospital) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Emergency Room Expenses (Includes facility, lab, x-ray, and physician services) | 80% (after Deductible) | 80% (after In-Network Deductible) |
| Outpatient Department | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Outpatient Surgery (In hospital, ambulatory surgical center, etc.) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Preadmission Testing | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Urgent Care Facility/Walk-In Clinic | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
Mental Health and Substance Use Services
⚠️ 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.
Note: A private room is covered only when medically necessary or when a facility does not provide semi-private rooms.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospitalization (Precertification required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Partial Hospitalization/Intensive Outpatient Treatment | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Inpatient Physician Visit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Hospital Clinic Visit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Office Visit | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Methadone Maintenance/Treatment | Coverage/cost varies based on where services are rendered | Coverage/cost varies based on where services are rendered |
Child/Adolescent MH/SU Services: Coverage includes, but is not limited to, CBAT (Community-Based Acute Treatment) and ICBAT (Intensive Community-Based Acute Treatment), 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.
Other Services & Supplies
| Service | In-Network | Out-of-Network |
|---|---|---|
| Acupuncture | NOT COVERED | NOT COVERED |
| Alternative/Complementary Care (Chelation therapy, homeopathic treatment, hypnosis/hypnotherapy, Rolfing/Reiki) | NOT COVERED | NOT COVERED |
| Ambulance Services (See Medical Benefits section for limitations) | 80% (after Deductible) | 80% Allowed Amount (after In-Network Deductible) |
| Autism Spectrum Disorders Treatment (Includes ABA; benefit limits for occupational, physical, and speech therapies do not apply; precertification required for ABA) | Benefits based on services provided | Benefits based on services provided |
| Bariatric Surgery (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Biofeedback Therapy | NOT COVERED | NOT COVERED |
| Cardiac Rehabilitation (Phase 1 and 2 only; Phase 3 excluded) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Chemotherapy & Radiation Therapy | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Clinical Trials - Routine Services (Limited to routine covered services under plan, including hospital visits, laboratory, and imaging services) | Benefits based on services provided | Benefits based on services provided |
| Cochlear Implants | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Dental/Oral Services (Includes excision of impacted wisdom teeth; see Medical Benefits section) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Diabetes Self-Management Training and Education | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Dialysis/Hemodialysis (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Durable Medical Equipment (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Early Intervention Services (Up to age 3; see Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Erectile Dysfunction Treatment | Not covered under medical plan; medication may be covered through Prescription Drug Program | N/A |
| Family Planning - For Women (Including consultations and diagnostic tests) | 100% (Deductible waived) | 60% Allowed Amount (after Deductible) |
| Family Planning - For Men (Including consultations and diagnostic tests) | 100% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Gender Dysphoria Treatment and Related Services (Includes gender identity counseling, gender reassignment surgery, hormone replacement therapy; precertification required for gender reassignment surgery) | Benefits based on services provided | Benefits based on services provided |
| Gene Therapy (Precertification required for inpatient hospitalization) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Genetic Counseling, Testing and Related Services (BRCA Testing covered under Preventive Care; precertification not required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Growth Hormones (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Hearing Aids - Under Age 18 (Up to 1 hearing aid per hearing impaired ear, every 24 months) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Hearing Aids - Age 18 and Over (Up to $2,500 per hearing aid, per hearing impaired ear, every 24 months) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Home Health Care (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Hospice Care (Inpatient/Outpatient; precertification required for inpatient services) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Infertility Treatment (Up to 4 cycles per person per calendar year; see Medical Benefits section) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Injectables | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Learning Deficiencies, Behavioral Problems/Developmental Delays (Precertification and visit limits based on services provided) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Marital Counseling (Limits not specified in draft) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Massage Therapy | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Medical and Enteral Formula (Including metabolic formula; precertification required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Modified Low Protein Food Products (See Medical Benefits section for limitations; dollar limit per person per calendar/plan year not specified in draft) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Neuromuscular Stimulator Equipment including TENS (Precertification required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Occupational Therapy (For treatment due to injury or illness) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Oral Pharynx Procedures | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Orthotics (Includes foot orthotics; see Medical Benefits section) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Physical Therapy (For treatment due to injury or illness) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Podiatry Care (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Private Duty Nursing (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Prosthetics (See Medical Benefits section for limitations) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Rehabilitation Hospital (Precertification required; see Medical Benefits section) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Respiratory Therapy | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Sleep Studies | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Skilled Nursing Facility/Extended Care Facility (Precertification required; see Medical Benefits section) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Speech Therapy (For treatment due to injury or illness) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Telemedicine (Applies to medical and behavioral health services; includes Doctor on Demand; includes virtual visits with established provider relationship including occupational therapy, physical therapy, speech therapy) | 80% (after Deductible) or paid based on services provided | 60% Allowed Amount (after Deductible) or paid based on services provided |
| Temporomandibular Joint (TMJ) Treatment (Precertification required) | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| Termination of Pregnancy | 80% (after Deductible) | 60% Allowed Amount (after Deductible) |
| 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 |
Standardly Covered Services (Special Notes)
The following services are covered under this plan when medically necessary:
- Breast Reduction Surgery: Covered when medically necessary; precertification required
- Orthoptics: Covered unless otherwise listed as excluded in the Plan Document
- Breastfeeding Support: 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.
- 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 NOT COVERED under this plan:
- Sex therapy
- Xenotransplants (cross-species transplants)
Wellness Benefits
| Service | Coverage Details |
|---|---|
| Childbirth Classes | % up to a maximum of $ for childbirth classes for each covered expectant mother |
| Fitness Reimbursement Benefit | Not specified in draft document |
| Weight Loss Reimbursement Benefit | NOT COVERED |
Note: Specific dollar amounts and percentages for wellness benefits are not finalized in this draft document.
Important Plan Notes
Combined vs. Separate Limits
SEPARATE:
- In-Network and Out-of-Network deductibles
- In-Network and Out-of-Network out-of-pocket maximums
COMBINED:
- Prescription drug costs count toward Medical OOP Max (not a separate Rx OOP Max)
- Covered services that contain dollar, frequency, or visit limits are combined In-Network and Out-of-Network maximums
Precertification Requirements
Services requiring precertification include but are not limited to:
- All inpatient hospitalizations (medical, mental health, substance use)
- Outpatient surgical procedures (except those in physician's office)
- Bariatric surgery
- Breast reduction surgery
- Gender reassignment surgery
- Organ, bone marrow, and stem cell transplants
- Hospice care (inpatient)
- Rehabilitation hospital
- Skilled nursing facility/extended care facility
- TMJ treatment
- ABA therapy for autism
- Hospital grade breast pump rental exceeding 3 months
- Medical and enteral formula
- TENS equipment
- Gene therapy (inpatient)
- Erectile dysfunction implants
⚠️ CRITICAL: Failure to obtain precertification may result in a reduction in benefits. Any penalty incurred is the responsibility of the Covered Person and cannot be used to satisfy applicable co-payments, deductibles, or out-of-pocket maximums.
Balance Billing
When services are rendered by an Out-of-Network provider in any instance other than those protected by the No Surprises Act (listed above), Covered Persons may be responsible for any amount above the Allowed Amount when services are rendered by an Out-of-Network Provider.
Helpful Resources
Customer Service: Karias Care Concierge
Prescription Drug Questions: TrueScripts
Utilization Management: Cigna Payer Solutions
Case Management: MedWatch
Disclaimer
This knowledge base article is a summary of benefits based on the draft schedule dated 11/18/25. It 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.
For the most accurate and up-to-date information, always consult the official Plan Document or contact the plan administrator.
Document Version: 26.0
Last Updated: Based on draft dated November 18, 2025
Status: DRAFT - Effective Date January 1, 2026