PPO Plan Summary of Benefits and Coverage - Matrix Sciences International Inc.

Plan Overview

Plan Name: PPO Plan
Employer: Matrix Sciences International Inc.
Coverage: Employee & Dependents
Plan Type: PPO (Preferred Provider Organization)
Coverage Period: January 1, 2026 – December 31, 2026
Customer Service: 1-888-832-0354
Provider Search: provider-search.kariashealth.com
Care Concierge: Karias Care Concierge at 1-888-832-0354
Prescription Drug Information: hpiTPA.com

Key Plan Features at a Glance

Deductibles

In-Network:

Single Plan: $500 per employee
Family Plan: $500 per person / $1,500 family maximum

Out-of-Network:

Single Plan: $3,000 per employee
Family Plan: $3,000 per person / $9,000 family maximum

Important Note: Generally, you must pay all costs from providers up to the deductible amount before the plan begins to pay. For family plans, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Services Covered Before Meeting Deductible

Yes, the following services are covered before you meet your deductible:

In-network preventive services
Physician office visits (primary care and specialist)
Diagnostic tests (x-ray, blood work)
Urgent care visits

Note: Copayments apply to these services even though the deductible is waived.

Specific Service Deductibles

No – You don't have to meet separate deductibles for specific services.

Out-of-Pocket Limits

In-Network:

Single Plan: $4,000 per employee
Family Plan: $4,000 per person / $10,200 family maximum

Out-of-Network:

Single Plan: $12,000 per employee
Family Plan: $12,000 per person / $26,400 family maximum

Prescription Drug Out-of-Pocket Maximum:

Individual: $1,000
Family: $3,000

Important: The out-of-pocket limit is the maximum you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit is met.

What's NOT Included in Out-of-Pocket Limit

The following expenses do NOT count toward your out-of-pocket limit:

Premiums
Prescription drugs (counted separately under prescription drug out-of-pocket maximum)
Balance billing charges
Health care services this plan doesn't cover

Network Providers

Do you pay less with network providers? Yes.

This plan uses a provider network. You will pay significantly less if you use a provider in the plan's network. Out-of-network providers cost considerably more, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing).

Important Warning: Your network provider might use an out-of-network provider for some services (such as lab work). Always check with your provider before you get services.

Specialist Referrals

Do you need a referral? No.

You may see a specialist you choose without a referral.

Detailed Cost Breakdown by Service Type

Office Visits and Preventive Care

Service	In-Network	Out-of-Network	Notes
Primary Care Visit (injury/illness)	$20 copay per visit (deductible waived)	50% coinsurance	Ask your provider if services are preventive vs. treatment
Specialist Visit	$40 copay per visit (deductible waived)	50% coinsurance	No referral required
Preventive Care/Screening/Immunization	No charge (deductible waived)	50% coinsurance	Confirm with provider that services are preventive

Diagnostic Tests and Imaging

Service	In-Network	Out-of-Network	Notes
Diagnostic Test (x-ray, blood work)	$20 copay per visit (deductible waived)	50% coinsurance	None
Imaging (CT/PET scans, MRIs)	20% coinsurance	50% coinsurance	Deductible applies

Prescription Drug Coverage

Available at: hpiTPA.com

Prescription Drug Out-of-Pocket Maximum:

$1,000 per person (individual plans)
$1,000 per person / $3,000 family (family plans)

In-Network Coverage:

Drug Type	Retail (30 days)	Mail Order (90 days)
Generic Drugs	$10 copay per prescription	$20 copay per prescription
Preferred Brand Drugs	$35 copay per prescription	$70 copay per prescription
Non-Preferred Brand Drugs	$75 copay per prescription	$150 copay per prescription
Specialty Drugs	$150 copay per prescription	Retail Only (30 days)

Out-of-Network Coverage:

Retail Only (30 days)
You Pay: Applicable copay, then 25% coinsurance

Special Insulin Coverage: Your cost for a covered insulin drug will not exceed $100 per 30-day supply.

Important: See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs.

Surgery Services

Outpatient Surgery

Service	In-Network	Out-of-Network	Notes
Facility Fee (e.g., ambulatory surgery center)	$200 copay per visit, then 20% coinsurance	$500 copay per visit, then 50% coinsurance	None
Physician/Surgeon Fees	20% coinsurance	50% coinsurance	Deductible applies

Emergency and Urgent Care

Service	In-Network	Out-of-Network	Notes
Emergency Room Care	$400 copay, then 20% coinsurance	Same as in-network	Copay waived if admitted
Emergency Medical Transportation	In-network deductible, then 20% coinsurance	Same as in-network	None
Urgent Care	$75 copay per visit (deductible waived)	$75 copay per visit (deductible waived)	None

Note: Emergency services are covered at the in-network rate even if you go to an out-of-network facility.

Hospital Stays (Inpatient)

Service	In-Network	Out-of-Network	Notes
Facility Fee (e.g., hospital room)	$250 copay per admission, then 20% coinsurance	$600 copay per admission, then 50% coinsurance	Preauthorization required
Physician/Surgeon Fees	20% coinsurance	50% coinsurance	Preauthorization required

Mental Health, Behavioral Health, and Substance Abuse Services

Service	In-Network	Out-of-Network	Notes
Outpatient Services (office visits)	$20 copay per visit (deductible waived)	50% coinsurance	None
Inpatient Services	$250 copay per admission, then 20% coinsurance	$600 copay per admission, then 50% coinsurance	Preauthorization required for inpatient services

Maternity Care

Service	In-Network	Out-of-Network	Notes
Prenatal Care (office visits)	No charge (deductible waived)	50% coinsurance	Tests and services may be described elsewhere in SBC
Postnatal Care (office visits)	$20 copay per visit (deductible waived)	50% coinsurance	—
Childbirth/Delivery Professional Services	20% coinsurance	50% coinsurance	Deductible applies
Childbirth/Delivery Facility Services	$250 copay per admission, then 20% coinsurance	$600 copay per admission, then 50% coinsurance	Deductible applies

Preauthorization Required: For hospital stays over 48 hours (normal delivery) or 96 hours (caesarean delivery).

Rehabilitation, Recovery, and Special Health Needs

Service	In-Network	Out-of-Network	Notes
Home Health Care	20% coinsurance	50% coinsurance	None
Rehabilitation Services - Outpatient	20% coinsurance	50% coinsurance	None
Rehabilitation Services - Inpatient	$250 copay per admission, then 20% coinsurance	$600 copay per admission, then 50% coinsurance	Preauthorization required for inpatient
Habilitation Services	20% coinsurance	50% coinsurance	Early intervention to age 3. Preauthorization & visit limits based on services provided for Learning Deficiencies, Behavioral Problems/Developmental Delays
Skilled Nursing Care	$250 copay per admission, then 20% coinsurance	$600 copay per admission, then 50% coinsurance	Preauthorization required
Durable Medical Equipment	20% coinsurance	50% coinsurance	Refer to plan document for items requiring preauthorization
Hospice Services	20% coinsurance	50% coinsurance	Preauthorization required for inpatient

Children's Vision and Dental Care

Service	In-Network	Out-of-Network	Notes
Children's Eye Exam	Not covered	Not covered	N/A
Children's Glasses	Not covered	Not covered	N/A
Children's Dental Check-up	Not covered	Not covered	N/A

Services NOT Covered by This Plan

The following services are generally NOT covered (check your policy or plan document for complete information):

Acupuncture
Long-term care
Routine foot care
Cosmetic surgery
Non-emergency care when traveling outside the U.S.
Weight loss programs
Dental care (routine child & adult)
Routine eye care (adult & child)

Other Covered Services (Limitations Apply)

The following services ARE covered, but limitations may apply (this isn't a complete list - see your plan document):

Bariatric Surgery

Coverage available with plan approval.

Infertility Treatment

Four (4) cycles maximum
With special approval: up to six (6) cycles per person, per calendar year

Chiropractic Care

30 visits per year

Private Duty Nursing

Coverage available with plan approval.

Hearing Aids

Under age 18: 1 aid per ear every 24 months
Age 18 and over: $2,500 per aid per ear every 24 months

Coverage Examples: How This Plan Works

Note: These are examples only. Your actual costs will differ based on the care you receive, provider charges, and other factors. These examples are based on self-only coverage.

Example 1: Peg is Having a Baby

Scenario: 9 months of in-network prenatal care and a hospital delivery

Services included:

Specialist office visits (prenatal care)
Childbirth/delivery professional services
Childbirth/delivery facility services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)

Total Example Cost: $12,700

What Peg Pays:

Deductibles: $500
Copayments: $600
Coinsurance: $200
Limits or exclusions: $60
Total Peg pays: $1,360

Key plan details used:

Overall deductible: $500
Specialist copayment: $40
Hospital facility copayment: $250
Other copayment: $20

Example 2: Mia's Simple Fracture

Scenario: In-network emergency room visit and follow-up care

Services included:

Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost: $2,800

What Mia Pays:

Deductibles: $500
Copayments: $500
Coinsurance: $200
Limits or exclusions: $400
Total Mia pays: $1,600

Key plan details used:

Overall deductible: $500
Specialist copayment: $40
Hospital facility copayment: $250
Other coinsurance: 20%

Example 3: Managing Joe's Type 2 Diabetes

Scenario: A year of routine in-network care for a well-controlled condition

Services included:

Primary care physician office visits (including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)

Total Example Cost: $5,600

What Joe Pays:

Deductibles: $500
Copayments: $600
Coinsurance: $60
Limits or exclusions: $20
Total Joe pays: $1,180

Key plan details used:

Overall deductible: $500
Specialist copayment: $40
Hospital facility copayment: $250
Other coinsurance: 20%

Important Plan Information

Minimum Essential Coverage

Does this plan provide Minimum Essential Coverage? Yes.

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Minimum Value Standards

Does this plan meet Minimum Value Standards? Yes.

If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Your Rights and Resources

Rights to Continue Coverage

If you want to continue your coverage after it ends, agencies can help:

Department of Labor's Employee Benefits Security Administration
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform
Health Insurance Marketplace
- Website: www.HealthCare.gov
- Phone: 1-800-318-2596

Other coverage options may be available, including buying individual insurance coverage through the Health Insurance Marketplace.

Grievance and Appeals Rights

If you have a complaint against your plan for a denial of a claim (called a grievance or appeal):

Review the explanation of benefits you receive for that medical claim
Check your plan documents for complete information on submitting a claim, appeal, or grievance
Contact the plan: 1-888-832-0354
Contact U.S. Department of Labor's Employee Benefits Security Administration:
- Phone: 1-866-444-EBSA (3272)
- Website: www.dol.gov/ebsa/healthreform

Language Access Services

Assistance is available in multiple languages:

Spanish (Español): Para obtener asistencia en Español, llame al 1-888-832-0354
Portuguese (Português): De assistência em Português, ligue 1-888-832-0354
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-832-0354

Important Definitions

For definitions of common terms used in this document (such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, and other underlined terms), view the Glossary at:

Online: healthcare.gov/sbc-glossary
By phone: Call 1-888-832-0354 to request a copy

Contact Information Summary

Purpose	Contact
General Questions	1-888-832-0354
Provider Search	provider-search.kariashealth.com
Care Concierge	1-888-832-0354
Prescription Drug Info	hpiTPA.com
Plan Documents	Call 1-888-832-0354
Appeals/Grievances	1-888-832-0354

Key Reminders for Plan Members

Always verify if services are preventive – Some services may be covered differently if they're preventive vs. diagnostic/treatment
Get preauthorization when required – Failure to get preauthorization may result in denied claims
Use in-network providers – You'll pay significantly less with in-network providers
Check if your provider uses out-of-network services – Even in-network providers may use out-of-network labs or specialists
Track your out-of-pocket expenses – Keep records to know when you've met your deductible and out-of-pocket maximum
Prescription drug costs count separately – Prescription drugs have a separate out-of-pocket maximum
Emergency care is covered at in-network rates – Even at out-of-network facilities
Premium costs are separate – The costs in this document don't include your monthly premium

Document Version: v1.0
Last Updated: Coverage effective January 1, 2026

Disclaimer: This is only a summary. For complete terms of coverage, call 1-888-832-0354 or refer to your complete plan documents.