Matrix Sciences International Inc. - CIGNA PPO Health Benefits Guide
This plan offers comprehensive medical coverage through the CIGNA PPO network with separate in-network and out-of-network benefits. Key features include prescription drug coverage through TrueScripts, preventive care at 100% coverage in-network, and various copayments and deductibles based on service type. The plan includes coverage for medical services, mental health, substance use treatment, and wellness benefits.
Matrix Sciences International Inc. - PPO Health Benefits Guide
Effective Date: January 1, 2026
Group Number: 001R2613
Plan Type: PPO (Preferred Provider Organization)
Status: NGF (New Group Formation)
Network: CIGNA
Document Version: DRAFT as of 11/18/25
Meta Description
Comprehensive guide to Matrix Sciences International Inc. PPO health insurance benefits effective January 1, 2026, including prescription drug coverage, medical benefits, preventive care, and cost-sharing details for in-network and out-of-network providers through CIGNA network.
Summary
This plan offers comprehensive medical coverage through the CIGNA PPO network with separate in-network and out-of-network benefits. Key features include prescription drug coverage through TrueScripts with separate $1,000/$3,000 out-of-pocket maximums, preventive care at 100% coverage in-network, medical deductibles of $500/$1,500 (INN) and $3,000/$9,000 (OON), and medical out-of-pocket maximums of $4,000/$10,200 (INN) and $12,000/$26,400 (OON). The plan includes comprehensive coverage for medical services, mental health, substance use treatment, and various specialty services.
Table of Contents
- Plan Administration & Key Contacts
- Prescription Drug Benefits
- Medical Plan Overview
- Preventive Care Services
- Vision Care
- Physician Services
- Hospital Services - Inpatient
- Hospital Services - Outpatient
- Mental Health & Substance Use
- Other Services & Supplies
- Wellness Benefits
- Important Plan Features
- Precertification Requirements
Plan Administration & Key Contacts
| Function | Provider/Details |
|---|---|
| Group Number | 001R2613 |
| Effective Date | January 1, 2026 |
| Plan Status | NGF (New Group Formation) |
| PPO Network | CIGNA |
| Prescription Drug Administrator | TrueScripts |
| 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 |
| Medicare Creditable Coverage (MCC) | Yes |
Plan Approvals (Internal Use)
- TRU Department: [Approval pending]
- Account Manager: Julie Elwell/Kate Kilpatrick
- Compliance: Margaret Sargent
Prescription Drug Benefits
Administrator: TrueScripts
Retail Pharmacy Coverage (Up to 30-day supply)
| Drug Type | Copayment |
|---|---|
| Generic Drug | $10 |
| Preferred Brand Name Drug | $35 |
| Non-Preferred Brand Name Drug | $75 |
Mail Order Pharmacy Coverage (Up to 90-day supply)
| Drug Type | Copayment |
|---|---|
| Generic Drug | $20 |
| Preferred Brand Name Drug | $70 |
| Non-Preferred Brand Name Drug | $150 |
Specialty Drugs (Retail Only - 30-day supply)
| Drug Type | Copayment |
|---|---|
| Specialty Drug | $150 per prescription |
Note: See Covered Services, Prescription Drugs in Medical Benefits section for coverage requirements and other limitations related to specialty drugs
Prescription Drug Out-of-Pocket Maximum (Calendar Year)
| Plan Type | Annual Maximum |
|---|---|
| Single Plan (Employee Only) | $1,000 |
| Family Plan | $1,000 per person, up to $3,000 per family |
Individual OOPM included in family coverage: YES
Includes: All applicable prescription drug copayments and coinsurance
Out-of-Network Pharmacy Coverage (Retail Only - Up to 30-day supply)
Cost: Applicable copayment, then 25% coinsurance, subject to Allowed Amount
Important Prescription Drug Notes
✓ FDA-approved contraceptive medications and devices: Covered at 100%
✓ Tobacco cessation products: Covered at 100%
✓ Do Rx costs count to separate Rx OOP Max or medical OOP Max? SEPARATE
✓ Are scripts subject to deductibles? NO
✓ Copayment accumulation: Prescription drug copayments accumulate toward the prescription drug Out-of-Pocket Maximums
✓ After OOPM is met: Once prescription drug OOPM is reached, prescription drugs are covered at 100% for the balance of the Calendar Year
Medical Plan Overview
Calendar Year Deductibles
| Coverage Level | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Single Plan (Employee Only) | $500 | $3,000 |
| Family Plan | $500 per person, up to $1,500 per family | $3,000 per person, up to $9,000 per family |
Individual deductible included in family coverage: YES
Calendar Year deductible carryover: NO
Family Plan Deductible Rules
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)
| Provider Type | Reimbursement (After Deductible) |
|---|---|
| In-Network Providers | 80% of the Contracted Rate |
| Out-of-Network Providers | 50% of the Allowed Amount* |
Coverage continues until Out-of-Pocket Maximum is reached, then 100% thereafter for the balance of the Calendar Year
Calendar Year Out-of-Pocket Maximums (Medical)
| Coverage Level | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Single Plan (Employee Only) | $4,000 | $12,000 |
| Family Plan | $4,000 per person, up to $10,200 per family | $12,000 per person, up to $26,400 per family |
Individual OOPM included in family coverage: YES
Includes: All applicable copayments, Calendar Year Deductible, and Coinsurance
Family Plan OOPM Rules
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 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
Network Separation Rules
In/Out-of-Network Deductibles: SEPARATE
In/Out-of-Network Out-of-Pocket Maximums: SEPARATE
⚠️ CRITICAL: The In-Network Provider and Out-of-Network Provider Deductible and Out-of-Pocket Maximums are separate and do not accumulate. 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: Covered Services that contain dollar, frequency, or visit limits are combined In-Network and Out-of-Network maximums.
Exclusions from Medical Out-of-Pocket Maximum
The following expenses are EXCLUDED from the Medical Out-of-Pocket Maximum:
- Precertification penalties
- Prescription drug copayments and coinsurance (refer to Prescription Drug Benefit section for separate Prescription Out-of-Pocket Maximums)
No Surprises Act (NSA) Protections
*Important Balance Billing Protection: Emergency services rendered by Out-of-Network Providers for "Emergency Care" as defined in the Definitions section; 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, Copayment and Coinsurance levels, subject to the Qualifying Payment Amount.
Balance Billing Rules
When Out-of-Network Providers CANNOT balance bill:
- Emergency services rendered by Out-of-Network Provider for Emergency Care
- Air ambulance services rendered by Out-of-Network Provider
When Out-of-Network Providers CAN balance bill (with consent):
- Non-emergency services at In-Network facilities for specified services (emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, intensivist)
- Only if Covered Person gives written consent and waives NSA protections
- If waived, Out-of-Network Providers paid according to Plan's In-Network level of benefits, subject to Allowed Amount
All other scenarios: 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.
Preventive Care Services
All preventive services marked with ** follow PPACA/ACA guidelines
General Preventive Care Information
The preventive care services marked 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 at the official USPSTF website.
New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance of the revised recommendation.
NSA Application: 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 Coverage Table
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| **Routine Physical Exams (including routine and travel immunizations and flu shots) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Routine Well Child Care (including screenings, routine and travel immunizations and flu shots) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Fluoride Varnish (up to age 6) | Up to 4 varnish treatments per person, per Calendar Year | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Breastfeeding Support, Supplies and Counseling (during pregnancy and/or postpartum period, rental or purchase of breastfeeding equipment) | See breast pump limits below | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Routine Gynecological/Obstetrical Care (including preconception and prenatal services) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Routine Pap Smears | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Breast Cancer Screening (including routine mammograms and BRCA testing) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Routine Immunizations (if not billed with office visit; includes flu shots and travel immunizations) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Routine Lab, X-rays, and Clinical Tests (including those related to maternity care) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Routine Colorectal Cancer Screening (including sigmoidoscopies and colonoscopies as recommended by USPSTF) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Lung Cancer Screening (including Low-Dose Computed Tomography (LDCT) as recommended by USPSTF) | Up to 1 per person, per Calendar Year | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Nutritional Counseling | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Smoking Cessation Counseling and Intervention (including smoking cessation clinics and programs) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Routine Hearing Exams | No limit specified | 100% | 50% Allowed Amount (after Deductible) |
| Routine Prostate Exams and Prostate-Specific Antigen (PSA) Screenings | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Abdominal Aortic Aneurysm Screening (as recommended by USPSTF) | Up to 1 per person, per lifetime | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Bone Density Screening - Women (as recommended by USPSTF for Osteoporosis Screening) | No limit specified | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| **Bone Density Screening - All Other Covered Persons | No limit specified | 100% (Deductible waived) | 50% 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:
- Rental or purchase, whichever is less
Manual Breast Pumps:
- Purchase only
Special Breastfeeding Coverage Rule
If there are no In-Network lactation providers: 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 covered with no cost-sharing.
Vision Care
| Service | Coverage Details | In-Network | Out-of-Network |
|---|---|---|---|
| Routine Vision Exam | N/A | NOT COVERED | NOT COVERED |
| Routine Eyewear (lenses, frames, and contact lenses) | N/A | NOT COVERED | NOT COVERED |
| Eyewear for Special Conditions | See details below | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Eyewear for Special Conditions Coverage Includes:
- 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
Physician Services
NSA Application: 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.
Physician Services Coverage
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Physician Office Visits - Primary Care (includes all related charges billed at time of visit) | No limit | $20 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Physician Office Visits - Specialist (includes all related charges billed at time of visit) | No limit | $40 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Second Surgical Opinion | No limit | $40 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Allergy Testing | No limit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Allergy Treatment | No limit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Anesthesia (Inpatient/Outpatient) | No limit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Chiropractic Services (charges for lab and x-ray are paid based on services provided and not subject to office visit or dollar limits) | Up to 30 visits per person, per Calendar Year | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Physician Hospital Visits | No limit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery (Inpatient) | No limit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery (Outpatient) | No limit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery (Physician's Office) | No limit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Maternity Services - Physician Coverage
| Service | In-Network | Out-of-Network |
|---|---|---|
| Prenatal Care | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Physician Delivery Charges | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Postnatal Care (includes home visit with Visiting Nurse following early discharge) | $20 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
Hospital Services - Inpatient
⚠️ 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 Copayments, 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.
Inpatient Hospital Copayments
| Network | Copayment Per Admission |
|---|---|
| In-Network Facility | $250 |
| Out-of-Network Facility | $600 |
Note: A separate Hospital Copayment will apply to each inpatient admission.
Private Room Coverage
A private room is covered ONLY when:
- Medically Necessary, OR
- When a facility does not provide semi-private rooms
NSA Application for Inpatient Services
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 Services Coverage
| Service | Room Type/Details | In-Network | Out-of-Network |
|---|---|---|---|
| Hospital Room & Board (Precertification required) | Semi-private room or special care unit | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Maternity Services (Precertification required for stays exceeding 48 hours [vaginal]; 96 hours [cesarean]) | Semi-private room or special care unit | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Birthing Center | N/A | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Newborn Care (includes Physician visits & circumcision) | Semi-private room or special care unit | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Organ, Bone Marrow and Stem Cell Transplants (Precertification required; Managed through Cigna's LifeSOURCE Transplant Network®; see Medical Benefits section for other limitations) | Semi-private room or special care unit; Transportation/food/lodging limits: $10,000 per Transplant | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Surgical Facility & Supplies | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Miscellaneous Hospital Charges | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Hospital Services - Outpatient
⚠️ PRECERTIFICATION REQUIREMENTS
Precertification for outpatient surgical procedures is REQUIRED.
Failure to obtain precertification for outpatient surgical procedures may result in a reduction in benefits.
IMPORTANT: 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.
Outpatient Hospital Copayments
| Network | Copayment Per Outpatient/Surgical Procedure |
|---|---|
| In-Network Facility | $200 |
| Out-of-Network Facility | $500 |
Note:
- A separate Hospital Copayment will apply to each outpatient/surgical procedure performed in a facility
- The Copayment will NOT apply to office surgery
NSA Application for Outpatient Services
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 Definitions section
- 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 Services Coverage
| Service | Special Notes | In-Network | Out-of-Network |
|---|---|---|---|
| Emergency Room Expenses (includes Facility, Lab, X-ray & Physician services) | Copayment is waived if admitted on inpatient basis to Hospital | $400 copay per visit, then 80% (after Deductible) | $400 copay per visit, then 80% (after In-Network Deductible) |
| Urgent Care Facility/Walk-In Clinic | N/A | $75 copay per visit, then 100% (Deductible waived) | $75 copay per visit, then 100% Allowed Amount (Deductible waived) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. | N/A | $200 copay per visit, then 80% (after Deductible) | $500 copay per visit, then 50% Allowed Amount (after Deductible) |
| Clinic Services (At a Hospital) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Outpatient Department | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Preadmission Testing | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Mental Health & Substance Use
⚠️ 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 Copayments, 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.
Mental Health/Substance Use Hospital Copayments
| Network | Copayment Per Admission |
|---|---|
| In-Network Facility | $250 |
| Out-of-Network Facility | $600 |
Note:
- A separate Hospital Copayment will apply to each inpatient admission
- A private room is covered ONLY when Medically Necessary or when a facility does not provide semi-private rooms
NSA Application
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 Coverage
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospitalization (Precertification required) | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Partial Hospitalization/Intensive Outpatient Treatment | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Inpatient Physician Visit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Hospital Clinic Visit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Office Visit | $20 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Methadone Maintenance/Treatment | Coverage details not specified in plan document | Coverage details not specified in plan document |
Covered Child/Adolescent MH/SU Services
Coverage for Child/Adolescent Mental Health/Substance Use services includes, but is not limited to:
- CBAT (Community-Based Acute Treatment)
- ICBAT (Intensive Community-Based Acute Treatment)
- Intensive care coordination
- In-home behavioral services and therapies
- Therapeutic monitoring services
Note: Coverage/cost varies based on where the services are rendered
Other Services & Supplies
NSA Application for Other Services
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for:
- Air ambulance services rendered by Out-of-Network Provider of air ambulance services
- 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
Services A-B
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Acupuncture | N/A | NOT COVERED | NOT COVERED |
| Alternative/Complementary Care Benefit (Chelation Therapy, Homeopathic treatment, Hypnosis/Hypnotherapy, Rolfing/Reiki) | N/A | NOT COVERED | NOT COVERED |
| Ambulance Services (See Medical Benefits section for limitations) | N/A | 80% (after Deductible) | 80% Allowed Amount (after In-Network Deductible) |
| Autism Spectrum Disorders Treatment (Includes Applied Behavioral Analysis (ABA); any benefit limits under Plan for occupational, physical and speech therapies do not apply; precertification required for ABA; see Medical Benefits section for limitations) Note: Screenings covered under Preventive Care | N/A | Benefits based on services provided | Benefits based on services provided |
| Bariatric Surgery (See Medical Benefits section for other limitations) | N/A | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Biofeedback Therapy | N/A | NOT COVERED | NOT COVERED |
Services C-D
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Cardiac Rehabilitation (Phase 1 and 2 only - Phase 3 is excluded; see Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Chemotherapy & Radiation Therapy | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Clinical Trials - Routine Services during Approved Clinical Trials (Limited to routine Covered Services under Plan, including Hospital visits, laboratory, and imaging services; see Medical Benefits section for other limitations) | N/A | Benefits based on services provided | Benefits based on services provided |
| Cochlear Implants | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Dental/Oral Services (Includes excision of impacted wisdom teeth; see Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Diabetes Self-Management Training and Education | N/A | $20 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) | N/A | $20 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Dialysis/Hemodialysis (See Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Durable Medical Equipment (See Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Services E-G
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Early Intervention Services (See Medical Benefits section for limitations) (Up to age 3) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Erectile Dysfunction Treatment (Precertification required for implants; see Medical Benefits section for limitations) | N/A | Not Covered, except for medication covered through Prescription Drug Program | Not Covered, except for medication covered through Prescription Drug Program |
| Family Planning - For Women (Including but not limited to consultations and diagnostic tests) (See also Prescription Drug Benefit and Preventive Care Section) | N/A | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Family Planning - For Men | N/A | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Gender Dysphoria Treatment and Related Services (Includes gender identity counseling, gender reassignment surgery and hormone replacement therapy; precertification required for gender reassignment surgery; see Medical Benefits section for other limitations) | N/A | Benefits based on services provided | Benefits based on services provided |
| Gene Therapy (Precertification required for inpatient hospitalization) | N/A | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Genetic Counseling, Testing and Related Services (Note: Coverage provided for BRCA Testing - See Breast Cancer Screening in Preventive Care Services; precertification is not required) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Growth Hormones (See Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Services H-I
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Hearing Aids - Under Age 18 | Up to 1 hearing aid per hearing impaired ear, every 24 months | 80% (after Deductible) | 50% 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) | 50% Allowed Amount (after Deductible) |
| Home Health Care (See Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Hospice Care (Inpatient/Outpatient) (Precertification required for inpatient services; see Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Infertility Treatment (See Medical Benefits section for other limitations) | Up to 4 cycles per person, per Calendar Year | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Injectables | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Services L-M
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Learning Deficiencies, Behavioral Problems/Developmental Delays (Precertification and visit limits are based on services provided) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Marital Counseling | Limits not specified in plan document | Coverage not specified in plan document | Coverage not specified in plan document |
| Massage Therapy | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Medical and Enteral Formula (Including metabolic formula; precertification required; see Medical Benefits section for other limitations) | N/A | Coverage details based on services provided | Coverage details based on services provided |
| Modified Low Protein Food Products (See Medical Benefits section for limitations) | Dollar amount and time period not specified in plan document | Coverage details not specified | Coverage details not specified |
Services N-P
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Neuromuscular Stimulator Equipment including TENS (Precertification required) | N/A | Coverage percentage not specified in plan document | Coverage percentage not specified in plan document |
| Occupational Therapy (For treatment due to Injury or Illness) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Oral Pharynx Procedures | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Orthotics (Includes foot orthotics; see Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Physical Therapy (For treatment due to Injury or Illness; see Medical Benefits section for other limitation) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Podiatry Care (See Medical Benefits section for limitations) | N/A | $40 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Private Duty Nursing (See Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Prosthetics (See Medical Benefits section for limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Services R-S
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Rehabilitation Hospital (Precertification required; see Medical Benefits section for other limitations) | N/A | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Respiratory Therapy | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Sleep Studies | N/A | $20 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Skilled Nursing Facility/Extended Care Facility (Precertification required; see Medical Benefits section for other limitations) | N/A | $250 copay per admission, then 80% (after Deductible) | $600 copay per admission, then 50% Allowed Amount (after Deductible) |
| Speech Therapy (For treatment due to Injury or Illness; see Medical Benefits section for other limitations) | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Services T-W
| Service | Frequency/Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Telemedicine (Applies to medical and behavioral health services; see Medical Benefits section for additional information) INCLUDES DOCTOR ON DEMAND | N/A | $20 copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Telemedicine - All Other Virtual Visits with Provider with Established Relationship (Including but not limited to Occupational Therapy, Physical Therapy and Speech Therapy) | N/A | Paid based on services provided | Paid based on services provided |
| Temporomandibular Joint Disorders (TMJ) Treatment (Precertification required) | Limits not specified in plan document | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Termination of Pregnancy | N/A | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Travel Immunizations [Include only if not covered at same level as routine immunizations under Preventive Care] | Limits not specified in plan document | Coverage details not specified | Coverage details not specified |
| Voluntary Sterilization - For Women | N/A | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Voluntary Sterilization - For Men | N/A | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Wigs | N/A | NOT COVERED | NOT COVERED |
Wellness Benefits
Note: The following wellness benefit sections contain template language that has not been finalized in this draft plan document. Specific coverage amounts and reimbursement percentages are pending determination.
Childbirth Classes
Coverage percentage and maximum dollar amount not specified in plan document
Benefit would be for childbirth classes for each covered expectant mother.
Fitness Reimbursement Benefit - Standard Option
Coverage percentage and maximum dollar amount not specified in plan document
Would cover health club membership fees. Requirements:
- Must be paid in the current year for membership in that year
- Paid date must be within dates of enrollment in this Plan
- Requests for reimbursement must be submitted according to company procedures (approval process not finalized)
- Reimbursement available after providing proof of 4 months of membership in that year after enrollment into this Plan
Fitness Reimbursement Benefit - Expanded Option
Coverage percentage, maximum dollar amount, and time period not specified in plan document
Would cover monthly fees paid to a facility that provides cardiovascular and strength-training equipment for exercising and improving physical fitness.
Qualified Facilities Include:
- Health clubs
- Fitness centers
- YMCA's, YWCA's
- Jewish Community Centers
- Municipal fitness centers
Qualifying Facilities Also Include, But 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
- Personal training taught by a certified instructor
Requirements:
- A qualified health and fitness club is defined as a facility with cardiovascular and strength-training equipment and facilities for exercising and improving physical fitness
- Requests for reimbursement must be submitted according to company procedures (approval process not finalized)
- Reimbursement available after providing proof of 4 months of membership in that year after enrollment into this Plan
Weight Loss Reimbursement Benefit
NOT COVERED
Important Plan Features
Standardly Covered Services
The following services are covered under this plan:
✓ Breast Reduction Surgery - When Medically Necessary; precertification required
✓ Orthoptics - Unless otherwise listed as excluded in the Plan Document
✓ Breastfeeding Support, Supplies and Counseling - Special coverage rule: If there are no INN lactation providers, then OON providers should be covered at the INN 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 not limited to:
- CBAT (Community-Based Acute Treatment)
- ICBAT (Intensive Community-Based Acute Treatment)
- Intensive care coordination
- In-home behavioral services and therapies
- Therapeutic monitoring services
- Coverage/cost varies based on where 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 transplants
- Human cartilage transplants
- 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
Precertification Requirements
Services Requiring Precertification
The following services REQUIRE precertification. Failure to obtain precertification may result in benefit reduction:
Always Requires Precertification:
- All inpatient hospitalizations (medical, surgical, maternity stays exceeding standard length, mental health, substance use)
- Outpatient surgical procedures (except office surgery)
Specific Services Requiring Precertification:
- Applied Behavioral Analysis (ABA) for Autism Spectrum Disorders
- Bariatric surgery
- Breast reduction surgery
- Breast pump rental exceeding 3 months (hospital grade)
- Erectile dysfunction treatment (implants only)
- Gender reassignment surgery
- Gene therapy (inpatient hospitalization)
- Hospice care (inpatient services)
- Medical and enteral formula
- Organ, bone marrow, and stem cell transplants (managed through Cigna's LifeSOURCE Transplant Network®)
- Rehabilitation hospital
- Skilled nursing facility/extended care facility
- TMJ treatment
Services That Do NOT Require Precertification:
- BRCA testing (covered under preventive care)
- Genetic counseling and testing (except where noted above)
- Office surgery
- Outpatient services in physician's office
Precertification Contact Information
Contact Cigna Payer Solutions (Utilization Management provider) for precertification requirements.
Penalty for Non-Compliance
⚠️ IMPORTANT: Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person. The reduction in benefits cannot be used to satisfy any applicable Copayments, Deductibles, or Out-of-Pocket Maximums under this Plan.
Quick Reference Guide
Most Common Copayments & Costs
| Service | In-Network Cost |
|---|---|
| Primary Care Office Visit | $20 copay |
| Specialist Office Visit | $40 copay |
| Urgent Care | $75 copay |
| Emergency Room | $400 copay |
| Inpatient Hospital Admission | $250 copay |
| Outpatient Surgery (Hospital/ASC) | $200 copay |
| Generic Rx (30-day retail) | $10 copay |
| Preferred Brand Rx (30-day retail) | $35 copay |
| Specialty Rx (30-day retail) | $150 copay |
| Diagnostic X-ray/Lab (Outpatient) | $20 copay |
| Sleep Studies | $20 copay |
| Diabetes Self-Management Training | $20 copay |
| Telemedicine/Doctor on Demand | $20 copay |
| Podiatry Care | $40 copay |
| Mental Health Office Visit | $20 copay |
Annual Deductibles & Out-of-Pocket Maximums
| Coverage Type | Deductible (INN) | Deductible (OON) | OOPM (INN) | OOPM (OON) |
|---|---|---|---|---|
| Medical - Single | $500 | $3,000 | $4,000 | $12,000 |
| Medical - Family | $1,500 family max | $9,000 family max | $10,200 family max | $26,400 family max |
| Prescription Drug - Single | N/A | N/A | $1,000 | N/A |
| Prescription Drug - Family | N/A | N/A | $3,000 family max | N/A |
Important Notes & Disclaimers
Document Status
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 Number: 26.0
For Support Team Reference
Account Managers: Julie Elwell / Kate Kilpatrick
Compliance Officer: Margaret Sargent
Plan Effective Date: January 1, 2026
Plan Status: NGF (New Group Formation) - DRAFT as of 11/18/25
Key Terms & Definitions
Allowed Amount: The maximum amount the plan will pay for covered services.
Contracted Rate: The negotiated rate between the insurance plan and in-network providers.
Qualifying Payment Amount: The amount used for out-of-network services under the No Surprises Act protections.
Medically Necessary: Services or supplies that are appropriate and necessary for the symptoms, diagnosis, or treatment of a medical condition; provided for the diagnosis or direct care and treatment of a medical condition; within standards of good medical practice within the medical community; not mainly for the convenience of the member or provider; and the most appropriate level of service that can safely be provided.
Calendar Year: January 1 through December 31 of each year.
Precertification: Prior approval required for certain services before they are performed to ensure medical necessity and appropriate level of care.
NSA (No Surprises Act): Federal law protecting patients from surprise medical bills in certain situations.
Frequently Asked Questions
Q: Do prescription drug costs count toward my medical deductible?
A: No. Prescription drugs are NOT subject to medical deductibles. However, prescription copayments count toward a SEPARATE prescription drug out-of-pocket maximum.
Q: If I meet my in-network deductible, does it count toward my out-of-network deductible?
A: No. In-network and out-of-network deductibles and out-of-pocket maximums are SEPARATE and do not cross-accumulate.
Q: What happens if I go to an out-of-network provider at an in-network hospital?
A: Under the No Surprises Act, certain services (emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services) will be covered at in-network levels, subject to the Qualifying Payment Amount, provided you haven't waived your NSA protections.
Q: Do I need precertification for office surgery?
A: No. Precertification is NOT required for outpatient surgical procedures performed in a physician's office. However, it IS required for procedures performed in a hospital or ambulatory surgical center.
Q: What is the difference between the hospital copayment and facility charges?
A: The hospital copayment ($250 inpatient INN, $200 outpatient surgery INN) is a flat fee per admission/procedure. After paying this copayment, you're responsible for coinsurance (typically 20% in-network after deductible) on the remaining facility charges.
Q: Are preventive services covered at 100%?
A: Yes, preventive services marked with ** (following ACA/PPACA guidelines) are covered at 100% with no deductible when you use in-network providers. Out-of-network preventive services are covered at 50% after deductible.
Q: Is there a separate deductible for prescription drugs?
A: No. Prescription drugs are not subject to deductibles. You pay only the copayment for each prescription.
Q: What is the maximum I could pay out-of-pocket in a year?
A: For in-network medical services: $4,000 (single) or $10,200 (family). For prescription drugs: $1,000 (single) or $3,000 (family). These are SEPARATE maximums, so the total maximum out-of-pocket would be $5,000 (single) or $13,200 (family) if you use only in-network providers and reach both maximums.
Q: How do I know if a service requires precertification?
A: Refer to the Precertification Requirements section above. Generally, all inpatient hospitalizations, outpatient surgeries (except office surgery), and certain specialty services require precertification. Contact Cigna Payer Solutions if unsure.
Q: What happens to my unused deductible at the end of the year?
A: The plan has NO deductible carryover. Your deductible resets to $0 on January 1st each year.
Q: Can I use mail order for maintenance medications?
A: Yes. Mail order pharmacy provides up to a 90-day supply at discounted copayments ($20 generic, $70 preferred brand, $150 non-preferred brand) compared to retail 30-day pricing.
Contact Information for Members
For Medical Benefits Questions
Customer Service: Karias Care Concierge
Network: CIGNA
Utilization Management: Cigna Payer Solutions
For Prescription Drug Questions
Pharmacy Benefit Manager: TrueScripts
For Precertification
Contact: Cigna Payer Solutions (Utilization Management)
For Claims Questions
In-Network Claims: Processed by CIGNA
Out-of-Network Claims Pricing: Phia
For Case Management
Provider: MedWatch
Additional Coverage Details
Coinsurance Summary
- In-Network: Plan pays 80% of contracted rate (after deductible), you pay 20%
- Out-of-Network: Plan pays 50% of allowed amount (after deductible), you pay 50% + any balance billing (except where NSA protections apply)
When Services Are Covered at 100% (No Coinsurance)
- After copayment for primary care visits (in-network)
- After copayment for specialist visits (in-network)
- After copayment for mental health office visits (in-network)
- After copayment for urgent care (in-network and out-of-network)
- After copayment for diagnostic x-ray/lab outpatient (in-network)
- After copayment for sleep studies (in-network)
- After copayment for diabetes self-management (in-network)
- After copayment for telemedicine (in-network)
- After copayment for podiatry care (in-network)
- Preventive care services (in-network only)
- Partial hospitalization/intensive outpatient mental health treatment (in-network)
- After out-of-pocket maximum is met (all services)
Services With Visit or Frequency Limits
| Service | Limit |
|---|---|
| Chiropractic Services | 30 visits per person per Calendar Year |
| Fluoride Varnish | 4 treatments per person per Calendar Year (up to age 6) |
| Lung Cancer Screening (LDCT) | 1 per person per Calendar Year |
| Abdominal Aortic Aneurysm Screening | 1 per person per lifetime |
| Hearing Aids (Under 18) | 1 per hearing impaired ear every 24 months |
| Hearing Aids (18+) | Up to $2,500 per ear every 24 months |
| Infertility Treatment | 4 cycles per person per Calendar Year |
Services With Dollar Limits
| Service | Limit |
|---|---|
| Transplant Transportation/Food/Lodging | $10,000 per transplant |
| Hearing Aids (Age 18+) | $2,500 per hearing aid per ear every 24 months |
Version Control & Updates
Current Version: 26.0
Document Type: DRAFT Schedule
Draft Date: November 18, 2025
Effective Date: January 1, 2026
Group Number: 001R2613
Employer: Matrix Sciences International Inc.
Important: This is a DRAFT document. Final approved version may contain changes. Always refer to the official Plan Document/Summary Plan Description for complete details and legal language.