Reynolds, Bone, Griesbeck HDHP Health Plan 2026 - Complete Benefits Guide

Plan Information

Field	Details
Group Name	REYNOLDS, BONE, GRIESBECK
Legal Name	REYNOLDS, BONE, GRIESBECK
Effective Date	1/1/2026
Master Group Number	64400
Subgroup(s)	64410
Benefit Plan(s)	HDHP
Document Type	Initial ☐ Renewal ☑ Mid-Term Change ☐
ERISA Plan	Yes
Qualified High Deductible Health Plan	Yes
Grandfather Status	No
Dental/Vision Benefits	Excepted (unbundled)
Fiscal Year Date (Plan Funding)	1/1-12/31
Benefits Applied Per	Calendar Year
TPA	90 Degree Benefits
TPA Hours	8:00am-5:00pm CST
Number of Employees	350
Document Last Updated	1/30/2019 (Form), 12/5/2025 (Plan Build), 12/23/2025 (Final Approval)

IMPORTANT NOTE: Special COB rules may apply for employees with Medicare if employer has less than 100 employees.

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Network & Program Information

Network Tiers

Tier	Network	PPO Code	Notes
Tier 1	Aetna	5100-5129	For 90 Degree Benefits Use only
Tier 2	Out of Network	0	OUT OF NETWORK
TIER 1 Override	Override to Tier 1	11111	OVERRIDE TO TIER 1

Additional Programs & Pricing

Program	Status	Details
RBP (Reference Based Pricing)	Yes	150/150% of Medicare
PHX (Zelis)	Yes	NSA only (Full ☐ Partial ☐)
Patient Defender	Yes	Active
Pace	Yes	Active
CareConnect	Yes	Benchmark State: UTAH

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Deductible Structure

Annual Deductible (Per Calendar/Plan Year)

Coverage Level	Tier 1	Tier 2
Per Person	$4,000	$10,000
Per Family	$7,000	$20,000

Deductible Rules

Rule	Status	Notes
In/Out Network Deductibles Cross-Apply	No	Separate deductibles
Deductible Applies to Out-of-Pocket Maximum	Yes (Tier 1), Yes (Tier 2)	Counts toward OOP
Last 3 Months Carry Over to Following Year	No	Does not apply
If Yes, Applies To	N/A	Individual ☐ Family ☐ Both ☐
If Yes, Deductible Carry Over Applies to OOP	N/A

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Coinsurance Rate

Tier	Plan Pays (After Deductible)	Member Pays
Tier 1	70%	30%
Tier 2	50%	50%

Unless otherwise stated in specific benefit sections

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Out-of-Pocket Maximum

Annual Out-of-Pocket Maximum

Coverage Level	Tier 1	Tier 2
Per Person	$7,000	$21,000
Per Family	$14,000	$42,000

Out-of-Pocket Rules

Rule	Status	Notes
In/Out Network OOP Maximums Cross-Apply	No	Separate OOP maximums
3-Month Carry Over Out-of-Pocket Benefit	No	Does not apply
If Yes, Applies To	N/A	Individual ☐ Family ☐ Both ☐
OOP Integrated with Pharmacy	Yes (Tier 1), Yes (Tier 2)	Pharmacy counts toward OOP
Copays Apply to Out-of-Pocket Maximum	No (Tier 1), No (Tier 2)	N/A - no copays on plan

IMPORTANT: All benefit maximums are a combination of services received from either in-network AND out-of-network providers or facilities: YES

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Mental Health & Substance Abuse

Service Type	Tier 1	Tier 2
Mental/Nervous Services Covered	Yes	Yes
Substance Abuse Services Covered	Yes	Yes

COVERAGE NOTE: When covered, all Mental Nervous and Substance Abuse benefits are paid as any other illness.

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Specialty Drugs & Appeals

Item	Details
Specialty Drugs - New to Market Waiting Period	6 months (Tier 1), 6 months (Tier 2)
Appeal Levels Before IRO	1 level, then to IRO (Independent Review Organization)

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Additional Programs

Teladoc

• Cost to Member: NO CHARGE
• Services: Virtual medical consultations

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Precertification/Notification Requirements

Contact Information

Item	Details
Precertification/Notification Provider	AHH
Precertification Phone Number	888-832-0354
Retroactive Precertification Allowed	Yes
Post-Service Precertification Penalty	Yes - $250
If No Retroactive Precert	Services requiring precertification will be denied if not on file
Precert Required for Medicare Primary	Yes
Precert Required if Other Coverage Primary	Yes

CRITICAL: Precertification requirements should be implemented only for those services listed within the Summary Plan Description as requiring prenotification or precertification and not defined as excluded.

All Inpatient Admissions (PRECERTIFICATION REQUIRED)

All inpatient admissions require precertification:

• Acute
• Long-Term Acute Care
• Rehabilitation
• Mental Health / Substance Use Disorder
• Transplant
• Skilled Nursing Facility
• Residential Treatment Facility
• Obstetric: Prenotification only (precertification only required if days exceed Federal mandate)

Also Required: Precertification for Inpatient and Outpatient procedures that could be considered Experimental/Investigational

Outpatient and Physician – Surgery

PRENOTIFICATION Required (Not Precertification):

• Biopsies (excluding skin)
• Vascular Access Devices for the Infusion of Chemotherapy (e.g., PICC and Central Lines)
• Thyroidectomy, Partial or Complete
• Open Prostatectomy
• Creation and Revision of Arteriovenous Fistula (AV Fistula) or Vessel to Vessel Cannula for Dialysis
• Oophorectomy, unilateral and bilateral

PRECERTIFICATION Required:

• Back Surgeries and hardware related to surgery
• Osteochondral Allograft, knee
• Hysterectomy (including prophylactic)
• Autologous chondrocyte implantation, Carticel
• Transplant (excluding cornea)
• Balloon sinuplasty
• Sleep apnea related surgeries, limited to:
  • Radiofrequency ablation (Coblation, Somnoplasty)
  • Uvulopalatopharyngoplasty (UPPP) (including laser-assisted procedures)

Potentially Cosmetic Procedures (PRECERTIFICATION Required):

• Abdominoplasty
• Blepharoplasty
• Cervicoplasty (neck lift)
• Facial skin lesions (Photo therapy, laser therapy - excluding MOHS)
• Hernia repair, abdominal and incisional (only when associated with a cosmetic procedure)
• IDET (thermal intradiscal procedures)
• Liposuction/lipectomy
• Mammoplasty, augmentation and reduction (including removal of implant)
• Mastectomy (including gynecomastia and prophylactic)
• Morbid obesity procedures
• Orthognathic procedures (e.g., Genioplasty, LeFort osteotomy, Mandibular ORIF, TMJ)
• Otoplasty
• Panniculectomy
• Rhinoplasty
• Rhytidectomy
• Scar revisions
• Septoplasty
• Varicose vein surgery/sclerotherapy

Outpatient and Physician – Diagnostic Services

PRENOTIFICATION Required:

• CT for non-orthopedic
• MRI for non-orthopedic

PRECERTIFICATION Required:

• PET
• Capsule endoscopy
• Genetic Testing (including BRCA)
• Sleep Study

Outpatient and Physician – Continuing Care Services

PRENOTIFICATION Required:

• Dialysis

PRECERTIFICATION Required:

• Chemotherapy (including oral)
• Radiation Therapy
• Oncology and transplant related injections, infusions and treatments (e.g., CAR-T, endocrine and immunotherapy), EXCLUDING supportive drugs (e.g., antiemetic and antihistamine)
• Hyperbaric Oxygen
• Home Health Care
• Durable Medical Equipment, limited to:
  • Electric/motorized scooters or wheelchairs
  • Pneumatic compression devices

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Complete Service Coverage Details

Medical Office Visit

Coverage Codes: AOV, AOVS, OV, OVS, POV, SMV, SOV, TELM, TELS, ZPOV, ZSMV, ZSOV

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Benefit Per	No benefit maximum	No benefit maximum

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Massage Therapy (Performed by a Massage Therapist)

Coverage Code: MT

Detail	Tier 1	Tier 2
Covered Service	No	No

Comments: Massage therapy services are covered when a medical diagnosis exists and services are provided by a Physical Therapist, Occupational Therapist, or Physician.

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Wigs, for Cancer Treatment or a Medically Appropriate Condition

Coverage Code: WIG

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	100%	100%
Maximum Benefit	1 PER CY UP TO $500 MAX	1 PER CY UP TO $500 MAX

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Transplant Services

General Transplant Information

Question	Tier 1	Tier 2
Is there a separate transplant policy in place?	Yes	Yes
Covered when donor is covered under the plan but recipient is not?	Yes	Yes

Transplant Facility Benefits - Recipient

Coverage Code: TRN

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Facility - Travel and Housing - Recipient

Coverage Codes: TRL, TRNT

Detail	Tier 1	Tier 2
Covered Service	Yes	N/A
Airfare	Yes	N/A
Meals	Yes	N/A
Tolls	Yes	N/A
Parking Fees	Yes	N/A
Apartment Rental	Yes	N/A
Hotel / Motel	Yes	N/A
Relocation Fees	Yes	N/A
Taxes	Yes	N/A
Do you allow travel expenses?	Yes	N/A

Comments: 100% WD - MAX 10K PER TRANSPLANT

Facility Benefits - Living Donor

Coverage Code: TRN

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes

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Mental Nervous/Substance Abuse Treatment Facilities

Residential Treatment Center

Coverage Codes: MRES, SRES

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Plan Pays After Deductible	70%	50%

Outpatient Facility Treatment - All (PHP, DT, IOP, etc.)

Coverage Codes: DT, SDT, SMDT

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Plan Pays After Deductible	70%	50%

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All Other Covered Services (Not Otherwise Specified)

Detail	Tier 1	Tier 2
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Plan Pays After Deductible	70%	50%

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Prescription Drugs

Coverage Code: PCS (Invoice only)

General Prescription Drug Information

Question	Answer
Are Prescription Drugs covered under the Medical plan	Drug plan ☑ / Not covered ☐
6-month waiting period for new to market specialty drugs	Yes
Name of RX Vendor	TRUESCRIPTS

Prescription Drug Coverage Structure

Detail	Tier 1	Tier 2
Deductible Applies	Yes	Yes
Co-pay Applies	Yes	Yes
If yes, apply deductible after co-pay?	N/A	N/A

Drug Tier Coverage - Retail 30 Day

Drug Tier	Member Pays
Generic	70% AFTER DED
Brand-Preferred	70% AFTER DED
Brand-Non Preferred	70% AFTER DED
Specialty	70% AFTER DED

Drug Tier Coverage - Mail 90 Day

Drug Tier	Member Pays
Generic	70% AFTER DED
Brand-Preferred	70% AFTER DED
Brand-Non Preferred	70% AFTER DED
Specialty	N/A

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Specialty Pharmacy Injectable Drugs

Coverage Code: SPD

Are benefits for Injectable drugs covered under the medical plan and will they be paid the same as other medical office services? Yes

Comments: Medications and supplies related to the administration of injectable prescription medication may be covered under the Medical or Pharmacy benefits but not both.

How Specific Items Are Covered

Item	Medical Plan Tier 1	Medical Plan Tier 2	Drug Plan	Not Covered
Diabetic Supplies	No	No	Yes	No
Insulin	No	No	Yes	No
Growth Hormones	Yes	Yes	No	No
Take home medications	Yes	Yes	No	No

Contraceptive Products Coverage

Product	Medical Plan Tier 1	Medical Plan Tier 2	Drug Plan	Not Covered
Contraceptive patches, oral tablets, or self-insertable vaginal devices containing contraceptives hormones (i.e. Nuva ring)	No	No	Yes	No
Contraceptive Injections (such as Depo-Provera)	No	No	Yes	No
Contraceptives administered in the Dr. Office (i.e. IUDs, implants)	No	No	Yes	No

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Miscellaneous Services - Excluded/Covered

Service	Status	Coverage Code
Abortion - elective	Excluded	ABO
Alternative/Complimentary Treatment	Excluded	INEL
- Holistic or homeopathic medicine	Excluded
- Hypnosis	Excluded
- Other alternative treatment not accepted medical practice	Excluded
Treatment for Acquired Brain Injury	See appropriate benefit section	DEVD
Autism Services required per MHPAEA	Covered	DEVD
If yes, Applied Behavior Analysis	Covered	ABA, ABAH
Biofeedback	Excluded	BFF
Blood Pressure Cuffs/Monitors	Excluded	INEL
Botox (medically necessary)	Covered	BOT
If covered, covered through	Medical ☑ PBM ☐ Both ☐
Breast Reductions if medically appropriate	See appropriate benefit section
Counseling – Marriage	Excluded	INEL
Developmental Delays	Covered	DEVD
- Occupational Therapy	Covered
- Physical Therapy	Covered
- Speech Therapy	Covered
- Medical Charges	Covered
Treatment of bunions, corns, calluses and toenails	Excluded (unless medically necessary)	INEL
Gender Affirming Care	Excluded	INEL
Genetic Counseling or Testing	Covered (based on Medical Appropriateness or family history except as mandated by ACA)	GEN
Gene Therapy	Excluded	GENE
Orphan drugs	Excluded	ORPH
Implantable hearing devices (i.e., cochlear, soundtec)	Excluded	CIRH, COCH
Learning Disability	Excluded	DEVD
Enteral and Parenteral Support	Covered	MMS
Oral Nutrition Therapy if medically necessary	Covered	MMS
Supplies including feeding tubes, pumps, bags and products	Covered	MMS
Orthognathic, Prognathic and Maxillofacial Surgery	See appropriate benefit section if covered (Unless covered under TMJ benefit or Reconstructive Surgery)
Panniculectomy/Abdominoplasty	Excluded	INEL
Sales Tax, shipping and handling	Excluded	INEL
Complications from a non covered service	Excluded	INEL

Sexual Function Services

Service	Status
Any medications, oral or other, used to increase sexual function or satisfaction or penile pumps and erectaid devices	See appropriate benefit section
- Diagnostic	See appropriate benefit section
- Non Surgical	See appropriate benefit section
- Surgical	See appropriate benefit section
- Prescription Drugs	See appropriate benefit section

Sleep Disorders (If Medically Appropriate)

Service	Status	Coverage Code
Sleep Studies	Covered	OSLP, SLMS, SLDM, SLPS

Telemedicine

Service	Status	Coverage Code
Patient to Physician	Covered	TELM, TELS
Physician to Physician	Excluded	INEL
Teladoc (separate benefit from medical)	Covered	TELA, TELB

Smoking Cessation Drugs

Service	Status	Coverage Code
Smoking cessation drugs	Covered	SMK
If covered, Paid under medical benefit	Yes
If covered, Paid under Prescription Drug benefit	No

Weight Control (Morbid Obesity)

Service	Status	Coverage Code
Covered Service?	No	BAR, BARS, OBE
Definition of body mass index (or) 100 pounds over body weight	N/A
Bariatric Therapy	No
Gastric or intestinal bypass	No
Stomach stapling	No
Prescription medication needed for weight loss	No
Physician supervised weight loss programs	No
Diet Supplements	No

Injuries

Type	Status
Incurred while legally intoxicated	Excluded
Illegal Drugs or Medicines (illness or Injury resulting from that Covered Individual's voluntary taking of or being under the influence of any controlled substance, drug, hallucinogen, or narcotic not administered on the advice of a Physician)	Excluded

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General Items

Administrative Details

Item	Details
Dependent Age Limitations	26
Percentile of Usual and Customary used (Out of Network)	70th (Standard) ☑ / 85th ☐ / 90th ☐ / 95th ☐
Percent of Medicare	150/150%
Timely Filing Period	12 Months ☑ / 15 Months ☐ / 18 Months ☐ / 24 Months ☐ / Other ☐

Covered Providers Under Medical Plan

Provider Type	Covered for Medical	Covered for Mental Health Treatment
CNM – Certified Nurse Midwife (when acting within the scope of their license in the state in which they practice and performing a service which would be payable under this plan when performed by a MD)	Yes	Yes
PSY.D. - Therapist with a PhD or master's degree in psychiatry or related field	Yes	Yes
Chiropractor - a health care professional that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health	Yes	Yes
State licensed psychologist	Yes	Yes
Massage Therapist	Yes	Yes
State licensed or certified Social Worker	Yes	Yes
Licensed Professional Counselor	Yes	Yes
MSW - Masters in Social Work	Yes	Yes
Certified addiction counselor (for substance abuse)	Yes	Yes

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Coordination of Benefits (COB)

COB Rules

Question	Answer
Is COB the same for Medicare eligible employees?	Yes
If no, what COB provision should be used for Medicare eligible employees?	N/A
Medicare – If plan is not primary and a covered person has Part A, but has not elected Part B, will this plan reduce the benefits as if Part B was elected?	Yes
Birthday Rule or Gender Rule	Birthday
Do you question primary carrier for their Rule?	Yes

Coordination of Benefits Savings

COB Savings Code: 0

Code 0 Explanation: Accumulated COB savings are applied toward satisfying the deductible and reducing the copayment on claims (both the current COB claim and future claims) until accumulated savings are used up. COB savings accumulate for each plan participant in a "COB bank" in the claimant's name.

Other COB Savings Options (Not Selected):

• Code 1: COB savings are applied toward satisfying the claimant's deductible and reducing the copayment portion of only the current claim.
• Code 2: Carve Out COB – COB saving is not used to satisfy a member's deductible or reduce the copayment on the current or future claims. Saving accumulate in the plan's name and reduce the plan's liability only.

COB Payment Code: 1

Code 1 Explanation: COB savings are applied only to charges that are eligible under the plan.

Other COB Payment Options (Not Selected):

• Code 0: COB Savings are applied to the entire claimant's incurred charges, even if the charges are not eligible under the plan. For example, COB savings are used to pay for services denied as cosmetic.
• Code 2: COB savings are applied only to charges that are eligible under the plan, BUT savings will not be applied toward the annual accumulators.
• Code 3: The COB Savings code is not considered, and savings will not be generated.
• Code 9: COB processing will be ignored for the group, regardless of any COB amounts that may be entered on the claim.

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Eligibility

Employee Eligibility

Question	Answer
Standard FMLA	Yes
Do you allow Continuation of coverage for disability outside of FMLA?	NO
Do you allow Continuation of coverage for layoff?	COBRA
Do you allow Leave of absence that doesn't meet requirements of FMLA?	YES - REFER TO HANDBOOK
Are benefits limited to full-time employees only?	No
If No, who else would qualify?	(See employee handbook)

Dependent Eligibility

Is coverage available for the following? (Refer to the plan document for eligibility requirements)

Dependent Type	Eligible
Domestic Partners	Yes
Common Law Spouse	Yes
Dependents	Yes
Adopted children	Yes
Foster children	Yes
Children under a legal guardianship	Yes
Grandchildren	Yes

Is Spouse eligible for coverage if able to obtain coverage elsewhere? Yes

Reinstatement of Coverage

Question	Answer
Employee is treated as a new hire	Yes
If no, waiting period is waived if rehired within _______ days/months	No (N/A)

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Stop Loss

Type	Tracks To
Stop Loss – Specific	MED / RX ☑
Stop Loss – Aggregate	MED / RX ☑

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Continuity of Care

Question	Answer
Does the plan offer continuity of care benefits?	Yes

Notes: For persons under care for a serious illness or pregnancy, network benefits are available for a limited period if the primary care physician leaves the network.

Comments: Standard 90 days

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Document Completion & Approval

Document Completed By

Field	Details
This Form Completed by	ASHLIE MCNABB
Title	PLAN BUILD
Date Completed	12/5/2025

Customer Approval Section

NOTE: Your approval of this installation document is of critical importance. This information is used to ensure we quote benefits correctly and must accurately reflect your plan document.

Any changes requested after you approve this document or after the effective date of your plan will need to be submitted to us so we do not quote benefits incorrectly.

Fields for Completion:

• Customer Comments (if any): _________________
• Date: _________________
• Signature of Customer: _________________ (An electronic signature will be accepted)

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Plan Modifications Section

Group Name: _________________
Effective Date: _________________
Group Number: _________________

The Install Plan Document is hereby modified as follows:

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This Form Completed by: ________@ 90 Degree Benefits
Date Completed: _________________

Customer Approval Section for Modifications

NOTE: Your approval of these modifications is of critical importance. This information is used to ensure we quote benefits correctly and must accurately reflect your plan document.

Any further changes requested after you approve this document or after the effective date of your plan will need to be submitted to us so we do not quote benefits incorrectly.

Fields for Completion:

• Customer Comments (if any): _________________
• Date: _________________
• Signature of Customer: _________________ (An electronic signature will be accepted)

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Contact Information

Purpose	Contact	Phone Number
TPA (Plan Administration)	90 Degree Benefits	See plan administrator
TPA Hours	Monday-Friday	8:00am - 5:00pm CST
Precertification	AHH	888-832-0354
Pharmacy Benefits	TrueScripts	Contact for details
Vision Benefits	Delta Vision	1-800-877-7195
Teladoc	Teladoc	Contact for details

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Quick Reference Summary

Key Plan Features at a Glance

✓ Qualified HDHP - HSA eligible
✓ Two-Tier Plan - Aetna (Tier 1) / Out-of-Network (Tier 2)
✓ No Copays - Deductible + coinsurance only
✓ Teladoc - No charge
✓ Preventive Care - 100% in-network (Tier 1)
✓ Emergency Services - Always 70% (facility), both tiers
✓ Mental Health - Covered as any other illness
✓ Precertification - Required for many services (call AHH)
✓ Combined PT/OT - 30 visits total per year
✓ No Infertility Coverage - All infertility services excluded
✓ Vision - Through Delta Vision (separate)
✓ Pharmacy - Integrated with medical OOP, 70% after deductible

Important Reminders

⚠️ Always call AHH (888-832-0354) for precertification before:

• All inpatient admissions
• Back surgeries
• Sleep studies
• Major diagnostic procedures (PET scans, genetic testing)
• Chemotherapy/radiation therapy
• Home health care
• Certain DME (motorized wheelchairs/scooters)

⚠️ $250 penalty for post-service precertification

⚠️ Deductibles and OOP maximums DO NOT cross-apply between Tier 1 and Tier 2

⚠️ Specialty drugs have 6-month waiting period for new to market

⚠️ Hearing aids covered only for children under 18

⚠️ Diabetic shoes limited to 1 pair per calendar year

⚠️ Wigs for cancer treatment - $500 max, 1 per calendar year

⚠️ Transplant travel - Up to $10,000 per transplant

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Document Information:

• Document Title: RBG CIP HDHP PLAN 2026.01 12.23.25
• Form Last Updated: 1/30/2019 (90 Degree Benefits)
• Plan Build Date: 12/5/2025
• Effective Date: January 1, 2026
• Page Count: 28 pages (original document)

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This knowledge base article is for reference purposes only and contains all details from the official plan document. For complete plan details and any questions, refer to the official Summary Plan Description (SPD) or contact 90 Degree Benefits during business hours (8:00am-5:00pm CST). For precertification questions, contact AHH at 888-832-0354. | | Co-pay Applies | No | No | | Co-pay Amount | $ | $ | | Plan Pays After Deductible | 70% | 50% | | Different Co-pay for Specialists | No | No |

Office Surgery (Includes related anesthesia services)

Coverage Codes: AF, AFQ, AFS, OPM, OPMS, SF, SFS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

Therapeutic Injections (Office)

Coverage Codes: INJ, INJS, MINJ, ZMIN

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

Allergy Injections and Serum

Coverage Codes: ALI, ALIS, ALS, ALSS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

Allergy Testing

Coverage Codes: ALT, ALTS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

Office Charges for X-ray & Professional Component

Coverage Codes: XRDR, XRDS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Includes High Cost Imaging (MRI, CT, PET, etc.)	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

Office Charges for Laboratory & Professional Component

Coverage Codes: LBDR, LBDS, MOXL, SMOX, SOXL, ZMOX, ZSMX, ZSOXX

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

Office Charges Diagnostic Testing

Coverage Codes: ODX, ODXS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

All Other Office Related Services

Coverage Codes: HBOO, HBOS, HBPO, HBPS, OIV, OIVS, OMS, OMSS, OWCT

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Different Co-pay for Specialists	No	No

Independent Laboratory & Professional Component

Coverage Code: LAB

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Lab/Xray/Diagnostic Imaging – Including Ultrasound - Outpatient Physician

Coverage Code: PRF

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Lab/Xray/Diagnostic Imaging – Including Ultrasound - Outpatient Testing and/or Facility Fee

Coverage Codes: CUS, HLAB, HXL, HXR, MXL, OPDX, OUSS, SMXL, SXL, US, XRAY

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Major Diagnostic Procedures - Physician

Coverage Code: PRF

Including but not limited to: MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, and Bone Scans, facility/professional expenses, all Outpatient and office places of service

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Major Diagnostic Procedures - Testing and/or Facility Fee

Coverage Codes: BONE, CAT, CST, HCAT, MRIO, MRIS, MYEL, NUC, NUCO, NUCS, OBON, OBOS, OCAT, OCSS, OCST, OCUS, OMRI, OMYE, OMYS, OPES, OPET, OSPC, OSPS, PET, SCAT, SPCT

Including but not limited to: MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, and Bone Scans, facility/professional expenses, all Outpatient and office places of service

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Sleep Studies

Coverage Codes: OSLP, SLPS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Acupuncture Services

Coverage Codes: AP, APS

Detail	Tier 1	Tier 2
Covered Service	No	No
Maximum Visits	N/A	N/A
Maximum Benefit	N/A	N/A

Ambulance and Other Medically Appropriate Transport (Ground and Air)

Coverage Codes: AMB, AMBR, AR

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	70%
Include Facility to Facility When Medically Necessary	Yes	Yes

Chiropractic Services

Coverage Codes: CH, CHX

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Visits/Benefit	No benefit maximum	No benefit maximum

Durable Medical Equipment (Includes DME Supplies)

Coverage Codes: BRA, DIEQ, DME, DMS, DTE, MMS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Are Insulin Pumps Considered DME	Yes	Yes
Does This Include Insulin Pump Supplies	Yes	Yes
Cover Cost of Repairs Not Due to Misuse	Yes	Yes
Cover Cost of Replacements (Outside Warranty, Unable to Repair)	Yes	Yes
Cover Batteries	Yes	Yes
Cover Sales Tax and Shipping Charges	Yes	Yes
Rental Maximum Up to Purchase Price of Equipment	Yes	Yes

Extended Care Facility Benefits (Skilled Nursing, Subacute Facility)

Coverage Code: SNF

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Days/Visits	60 DAYS	60 DAYS

Home Health Care Benefits

Coverage Codes: HHC, HHS, PHC, PHS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Days/Visits	60 VISITS	60 VISITS

Hospice Care Benefits

Coverage Codes: HO, OHO

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Days/Visits	No day maximum	No day maximum
Allow Custodial / Respite Care	Yes	Yes
If Yes, Should This Be Included in Hospice Benefit	Yes	Yes

Bereavement Counseling

Coverage Codes: HBC, HFC

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Include Bereavement Counseling in Hospice Benefit	Yes	Yes
Maximum Visits for Bereavement Counseling	No day maximum	No day maximum

IMPORTANT: Services must be furnished within 6 months of death.

Emergency Room Hospital Facility Services

Coverage Codes: ER, MNO, NER, SMOF, SNO

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Want All Emergency Services Paid In-Network	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
If Admitted Within 24 Hours Waive Co-pay	Yes	Yes
Plan Pays After Deductible	70%	70%

Emergency Room Hospital Professional Services

Coverage Codes: ERD, MERD, NERD, SAER, SMER

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Want All Emergency Services Paid In-Network	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Inpatient Facility Services

Coverage Codes: BC, HM, HNS, ICU, IMC, MHM, MRB, RB, SHM, SMHM, SMRB, SRB

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Notification Penalty Waived for Emergency Admissions	Yes	Yes
If Admitted Through ER, Is ER Copay Waived	Yes	Yes
Reduce to Semi-Private Room Rate if Available in Hospital	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Ancillary (All Other Inpatient) Services

Coverage Codes: DX, HV, MID, MNI, PAT, RAD, SID, SIP, SMID, SMNI, WC

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Infusion Therapy

Coverage Code: IVIN

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Expenses Related to Surgery

Second Surgical Opinion

Coverage Codes: SV, SVS
Comments: SAAOI

Anesthesia

Coverage Codes: AI, AIQ, AO, AOQ, MNA, SMA

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Surgeon / Assistant Surgeon / Co-Surgeon

Coverage Codes: CIRC, SI, SO, STER, TI, TO

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Assistant Surgeon Bills Limited to 25% of U&C Fee	Yes	Yes

Outpatient Hospital Surgery and Ambulatory Surgical Center

Coverage Codes: ASF, OHS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Co-pay and Deductible	70%	50%

Maternity Surgery (Includes Physician Attendance)

Coverage Codes: MAT, MATD, MATO

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Routine Newborn Care

Coverage Codes: CIRC, HNS, WC

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Outpatient Hospital Services – Unless Otherwise Specified

Coverage Codes: CO, HBO, HMIS, HOBS, HWCT, MNOP, PA, PADR, SAOP, SMPH

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Outpatient Physician Services – Unless Otherwise Specified

Coverage Codes: DIED, HBP, PM

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Dialysis

Coverage Codes: DI, HDI

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Urgent Care Services

Coverage Code: URG

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Include All Related Services	Yes	Yes
Plan Pays After Deductible	70%	50%

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REAP Ologist Benefits

(Radiology, Emergency Room Physicians, Anesthesiology, Pathology, Hospitalists)

Question	Answer
Are services for Hospitalists, Radiology, Pathology and Anesthesiology providers paid as in-network when performed at a participating facility?	Yes
Are services for Emergency Room Physicians paid as In-Network?	Yes
Are charges paid in network if referred by a participating physician?	Yes
Are services performed outside of the service area paid as In-Network?	Yes
If yes, how many miles from the participant's residence?	100 MILES
Are services, unable to be provided by a network provider, paid as In-Network?	Yes
Is the Network level of benefits payable when a participant receives emergency care either out of area or at non-network hospital for an accidental bodily injury or emergency?	Yes

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Infertility Treatment Services

Coverage Codes: INF, INFS, INFT, INHT, INIT, IVF, IVSF, SINT

Service Type	Tier 1	Tier 2
Covered Service	No	No

Specific Infertility Services Coverage

Type of Service	Tier 1	Tier 2
Diagnostic only (to determine diagnosis)	No	No
Genetic testing to diagnose infertility	No	No
Diagnostic & other services	No	No
Fertility Test	No	No
Tests and exams done to prepare for induced conception	No	No
Surgical reversal of sterilized state which was the result of a previous surgery	No	No
Sperm enhancement procedures	No	No
Direct attempts to cause pregnancy including:	No	No
- Hormone or therapy drugs	No	No
- Artificial Insemination	No	No
- Invitro Fertilization	No	No
- Gamete Intrafallopian Transfer (GIFT)	No	No
- Zygote Intrafallopian Transfer (ZIFT)	No	No
- Embryo Transfer	No	No
- Freezing or storage of embryo, eggs or semen	No	No

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Chemotherapy / Radiation Therapy

Professional Services

Coverage Codes: CT, HCT, HRT, RT

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

Facility Services

Coverage Codes: CT, HCT, HRT, RT

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

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Hearing Aids

Coverage Codes: HA, HA2, HARC

Detail	Tier 1	Tier 2
Covered Service	Yes (Children Under 18 Only)	No
Deductible Applies	Yes	N/A
Co-pay Applies	No	N/A
Co-pay Amount	$	N/A
Plan Pays After Deductible	70%	N/A
Maximum Benefit	1 PER EAR EVERY 36 MO	N/A

IMPORTANT: HEARING AID NOT COVERED AGE 18+

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Orthotics

Coverage Codes: DS, OR, ORH, ORI, ORS

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Allow Custom-Molded Foot Orthotics	Yes	Yes
Allow Non-Custom Molded Shoe Inserts	Yes	Yes
Allow Diabetic Shoes	Yes	Yes
If Yes, Limits	1 PAIR PER CAL YEAR	1 PAIR PER CAL YEAR

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Prosthetics

Coverage Code: PRO

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Initial Purchase, Fitting, Repair and Replacement Covered	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%

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Pregnancy / Maternity Benefits

Pregnancy Benefits Coverage

Question	Answer
Are services performed in a Physician's office paid according to the benefits outlined in the Medical Office Visit section of this form?	Yes
Are services performed in a Hospital paid according to the benefits outlined in the Hospital section?	Yes
Allow dependent daughter pregnancies?	Yes (If no, PPACA required services are covered)
Allow outpatient birthing centers?	Yes
Allow home deliveries?	Yes
Allow all elective abortions?	No
Do you cover elective abortions when pregnancy is the result of a crime (rape or incest)?	Yes
Do you cover elective abortions when the life of mother is in danger?	Yes
Are abortions covered for	All females covered under the plan / Employee/Spouse only
Allow sterilization?	Yes

Newborn Coverage Rules

Newborn Dependents Coverage:

• ☐ Apply normal plan benefits
• ☐ Process under mother
• ☑ Newborn dependents Must be enrolled on the plan
• ☐ Automatic 31-days coverage, must enroll thereafter
• ☑ Automatic 31-day coverage only if EE already has Dependent coverage, must enroll thereafter

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Preventive Care Services for ACA Covered Services

Coverage Codes: AB, AB1, AB2, AB3, AB4, AB5, AB6, AB7, ABCV, ABH, ABNC, ABR, ABX

Non-Grandfathered Plan: The plan will follow the US Preventive Services Task Force recommendations, found at http://www.uspreventiveservicestaskforce.org/BrowseRec/Index

IMPORTANT: Preventive services are covered without cost sharing. This generally applies only when services are rendered by a network provider.

Detail	Tier 1	Tier 2
Deductible Applies	No	Yes
Co-pay Applies	No	Yes
Co-pay Amount	$	$
Plan Pays	100%	50%

Are there any additional services covered under a separate Wellness Benefit not included in the US Preventive Services Task Force recommendations? NO

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Routine/Wellness Outside of ACA

Routine Physical Exam

Coverage Codes: HWC, WCB, WCBS, WLB, WLBS

Question	Tier 1	Tier 2
Are there any routine physical exams not already required to be covered by the ACA, covered as wellness?	No	No

Immunization

Coverage Codes: IMAS, IMM, IMMA, IMMB, IMMG, IMMS, IMSH

Question	Tier 1	Tier 2
Are there any Immunizations, not already required to be covered by the ACA, covered as wellness?	No	No

List any non-covered immunizations: (None specified)

Routine Diagnostic Tests, Labs, X-rays

Coverage Codes: HWL, WLAB, WXL, WXR

Question	Tier 1	Tier 2
Are there any Routine Diagnostic Tests, Labs, X-rays, not already required to be covered by the ACA, covered as wellness?	No	No

Routine Mammogram

Coverage Codes: MAM, MAM2, OMAM, OMAS, OMA2, OM2S

Question	Tier 1	Tier 2
Are there any Routine Mammograms, not already required to be covered by the ACA, covered as wellness?	No	No

Routine Pap Smear / Test and Pelvic Exam

Coverage Codes: PAP, PAPR, PAPS

Question	Tier 1	Tier 2
Are there any additional circumstances for Routine Pap Smear / Test and Pelvic exams to be covered as wellness?	No	No

Routine Fecal Blood Culture

Coverage Code: WLB

Question	Tier 1	Tier 2
Are there any additional circumstances for Routine Fecal Blood Culture to be covered as wellness?	No	No

Routine PSA Test and Prostate Exam

Coverage Codes: PS, PSS

Detail	Tier 1	Tier 2
Cover Routine PSA Test and Prostate Exam as routine	Yes	No
Deductible Applies	No	N/A
Co-pay Applies	No	N/A
Co-pay Amount	$	N/A
Plan Pays	100%	N/A

Routine Colonoscopy, Sigmoidoscopy and Similar Preventative Routine Procedures

Coverage Codes: OCOL, OCOS, WLAB, WLB, WXL, WXLS

Question	Tier 1	Tier 2
Are there any additional circumstances for Routine Colonoscopy, Sigmoidoscopy or similar Preventative routine procedures to be covered as wellness?	No	No

Contraceptive Management

Coverage Codes: BCI, BCIS, BCR, BCRS, BINJ, BINS, CONS, CONT

Question	Tier 1	Tier 2
Are there any additional circumstances for contraceptive management to be covered as wellness?	No	No

Routine Hearing Exam

Coverage Code: RHE

Question	Tier 1	Tier 2
Are there any additional circumstances for Routine Hearing Exams to be covered as wellness?	No	No

Nutritional Counseling

Coverage Code: WCBS

Question	Tier 1	Tier 2
Are there any additional circumstances for Routine Behavioral \ Nutritional Counseling to be covered as wellness?	No	No

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Vision Care Benefits

Coverage Codes: REE, VEX

General Vision Information

Question	Answer
Is there a separate benefit allowed for Vision care?	No
If no, is there another vendor?	Yes
Vendor Name	Delta Vision
Phone Number	1-800-877-7195
Medical related Eye Exams and glaucoma testing covered under medical?	Yes
Glaucoma and cataracts covered under Medical?	Yes
Routine eye exams covered?	No
If yes, are routine eye exams included in the Routine benefits maximum or in the Vision care benefits?	N/A (Routine benefit ☐ / Vision care benefit ☐)

Routine Eye Refractions

Detail	Tier 1	Tier 2
Is there a benefit for routine eye refractions?	No	No

Other Vision Care Services Under Medical Plan

Coverage Codes: HW, PHW, VANA, VBL, VCD, VCL, VFR, VINE, VLB, VLS, VLT, VSL, VTL, VTNT

Service	Covered?	Maximum
Lenses - Single Vision	No	$
Lenses - Bifocal	No	$
Lenses - Trifocal	No	$
Lenses - Lenticular	No	$
Lenses - Progressive Lens	No	$
Lens Coating	No	$
Frames	No	$
Contacts	No	$
Safety Lenses and Frames	No	$
Sunglasses or subnormal vision aids	No	$

Additional Vision Services

Service	Tier 1	Tier 2
Eye Surgeries used to improve/correct eyesight for refractive disorders (i.e. Lasik surgery, radial keratotomy, etc.)	No	No
Fitting or dispensing of non-prescription glasses or vision devices whether or not prescribed by a physician	No	No
Vision therapy services including orthoptics?	No	No
Correction of visual acuity or refractive errors	No	No
Aniseikonia (Each eye sees an object differently)	No	No

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Oral Surgery Benefits Paid Under Medical

Coverage Code: See applicable benefit section

Service	Covered?	Comments
Covered Service?	Yes (Tier 1) / Yes (Tier 2)

Specific Oral Surgery Services Coverage

Service	Covered?
Excision of partially or completely impacted teeth	Yes
Excision of tumors and cysts of the jaw, cheeks, lips, tongue, roof and floor of the mouth when such conditions require pathological exams	Yes
Surgical procedures to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth	Yes
Reduction of fractures & dislocations of the jaw	Yes
External incision and drainage of cellulitis	Yes
Incision of accessory sinuses, salivary glands or ducts	Yes
Excision of exostosis of jaws and hard palate	Yes
Frenectomy – (the cutting of the tissue in the midline of the tongue)	Yes
Gingival mucosal surgery (gingivectomy, osseous, periodontal surgery and grafting) to treat gingivitis or periodontitis	Yes
Apicoectomy – (the excision of the tooth root without the extraction of the entire tooth)	Yes
Root canal therapy if performed in conjunction with an Apicoetomy	Yes
Alveolectomy (leveling of structures supporting teeth for the purpose of fitting dentures). Not payable if performed in conjunction with routine extraction of natural teeth.	Yes

---

Other Dental Services

Coverage Code: See applicable benefit section

Service	Tier 1	Tier 2
Allow Dental Implants?	No	No
Allow Anesthesia, X-ray, and Lab for medically appropriate hospital services?	Yes	Yes
Allow coverage for any other dental services under the medical plan?	No	No

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Temporomandibular Joint Disorder Benefits

Coverage Codes: TMJ, TMJO, TMJS

Detail	Tier 1	Tier 2
Covered service?	No	No

---

Physical Therapy (Outpatient Treatment)

Coverage Codes: DPT, HPT, PT

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Are Physical therapy and Occupational therapy a combined benefit?	Yes	Yes
Is Aquatic therapy performed in conjunction with PT covered?	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Benefit Per	30 visits	30 visits

Comments: Includes massage therapy performed by a covered provider.

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Occupational Therapy (Outpatient Treatment)

Coverage Codes: HOT, OT

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Are Physical therapy and Occupational therapy a combined benefit?	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Benefit Per	30 visits	30 visits

Comments: Includes massage therapy performed by a covered provider.

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Speech Therapy

Coverage Codes: HST, ST

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes
Co-pay Applies	No	No
Co-pay Amount	$	$
Plan Pays After Deductible	70%	50%
Maximum Benefit Per	No benefit maximum	No benefit maximum

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Other Outpatient Rehabilitative and Habilitative Services

(ABA therapy, Cognitive Rehab, Cardiac rehab, Pulmonary rehab)
Coverage Codes: ABA, ABAH, COGR, CR, PRHB

Detail	Tier 1	Tier 2
Covered Service	Yes	Yes
Deductible Applies	Yes	Yes