Reynolds, Bone, Griesbeck PPO Insurance Plan 2026

 

Plan Overview & Basic Information

Item	Details
Plan Type	2-Tier PPO (Preferred Provider Organization)
Document Type	Install Plan Document
Administrator	90 Degree Benefits
TPA	90 Degree Benefits
Network Provider	AETNA (Tier 1)
Out-of-Network	Tier 2
Group Legal Name	REYNOLDS, BONE, GRIESBECK
Master Group Number	64400
Subgroup Number(s)	64401
Effective Date	January 1, 2026
Plan Year Type	Calendar Year (1/1 - 12/31)
Benefits Applied Per	Calendar Year
Fiscal Year	January 1 - December 31
Benefit Plan(s)	PPO
ERISA Plan	Yes
Grandfather Status	No (Non-Grandfathered Plan)
Qualified High Deductible Health Plan	No
Number of Employees	350
Special Employee Note	Special COB rules may apply for employees with Medicare if employer has less than 100 employees
Dental Benefits	Not Covered (Unbundled/Separate)
Vision Benefits	Not Covered (Unbundled/Separate - See Delta Vision)
Hours of Operation	8:00 AM - 5:00 PM CST
Last Updated	December 5, 2025
Completed By	Ashlie McNabb (Plan Build)

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Deductible & Out-of-Pocket Structure

Annual Deductibles (Per Calendar Year)

Deductible Detail	Tier 1	Tier 2
Per Person Deductible	$2,500	$7,500
Per Family Deductible	$5,000	$15,000
In/Out-of-Network Cross-Apply	Yes	Checked (Yes)
Deductible Applies to OOP Maximum	Yes	Yes
3-Month Carryover from Prior Year	No	No
Deductible Carryover Applies to OOP	N/A	N/A

Annual Out-of-Pocket Maximum (Per Calendar Year)

OOP Detail	Tier 1	Tier 2
Per Person OOP Maximum	$5,000	$15,000
Per Family OOP Maximum	$10,000	$30,000
In/Out-of-Network OOP Cross-Apply	Yes	Checked (Yes)
3-Month Carryover OOP Benefit	No	No
Integrated with Pharmacy	Yes	Yes
Copays Apply to OOP Maximum	Yes	Yes
All Benefit Maximums Combined	In- and out-of-network providers/facilities combined

Coinsurance Rates (Post-Deductible)

• Tier 1: Plan pays 80%
• Tier 2: Plan pays 50%

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Eligibility & Enrollment Details

Employee Coverage

• Benefits Limited to Full-Time Employees Only: Yes
• Dependent Coverage Available: Yes

Eligible Dependents & Family Members

Category	Coverage
Dependents	Yes
Adopted Children	Yes
Foster Children	Yes
Children Under Legal Guardianship	Yes
Grandchildren	No
Domestic Partners	Yes
Common Law Spouses	Yes
Maximum Dependent Age	26 years old

Spousal Coverage Rules

• Spouse Eligible if Able to Obtain Coverage Elsewhere: No (NOT eligible for plan if they can get coverage elsewhere)

Continuation of Coverage Options

Coverage Type	Status	Details
Standard FMLA	Yes	Standard FMLA continuation applies
Disability Continuation (Outside FMLA)	No	NOT available outside FMLA requirements
Layoff Continuation	COBRA	COBRA coverage available
Leave of Absence (Non-FMLA Qualifying)	Yes	Allowed per employee handbook
Reinstatement After Termination	N/A	Employee treated as new hire; waiting periods apply unless rehired within specified timeframe

Stop Loss Coverage

Type	Details
Specific Stop Loss	Tracks to Specific (Medical & Pharmacy)
Aggregate Stop Loss	Tracks to Aggregate (Medical & Pharmacy)

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Continuity of Care

Item	Details
Continuity of Care Available	Yes
Covered Situations	Persons under care for serious illness or pregnancy
Coverage Details	Network benefits available for limited period if primary care physician leaves network
Standard Duration	90 days

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Precertification & Notification Requirements

General Precertification Information

Item	Details
Precertification Provided By	AHH (Authorization House Health)
Precertification Phone Number	888-832-0354
Hours	8:00 AM - 5:00 PM CST
Allow Retroactive Precertification	No - Services requiring precertification WILL BE DENIED if not pre-approved
Post-Service Precertification Penalty	$250 per service
Medicare Primary - Precert Required	Yes
Other Coverage Primary - Precert Required	Yes

Services Requiring Precertification/Prenotification

ALL INPATIENT ADMISSIONS (Precertification Required):

• Acute care admissions
• Long-term acute care
• Rehabilitation
• Mental health/substance use disorder treatment
• Transplant procedures
• Skilled nursing facility
• Residential treatment facility
• Obstetric admissions (Prenotification only; precertification required only if days exceed federal mandate)

OUTPATIENT SURGICAL PROCEDURES:

Prenotification Only (No Precert Required):

• Biopsies (excluding skin)
• Vascular access devices for chemotherapy infusion (PICC lines, 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
• Osteochondral allograft (knee)
• Hysterectomy (including prophylactic)
• Autologous chondrocyte implantation (Carticel)
• Transplant (excluding cornea)
• Balloon sinuplasty
• Sleep apnea-related surgeries:
  • Radiofrequency ablation (Coblation, Somnoplasty)
  • Uvulopalatopharyngoplasty (UPPP) including laser-assisted
• Potentially cosmetic procedures:
  • Abdominoplasty
  • Blepharoplasty
  • Cervicoplasty (neck lift)
  • Facial skin lesions (phototherapy, laser therapy - excluding MOHS)
  • Hernia repair, abdominal and incisional (only when associated with cosmetic procedure)
  • IDET (thermal intradiscal procedures)
  • Liposuction/lipectomy
  • Mammoplasty (augmentation, reduction, implant removal)
  • Mastectomy (including gynecomastia and prophylactic)
  • Morbid obesity procedures
  • Orthognathic procedures (genioplasty, LeFort osteotomy, mandibular ORIF, TMJ)
  • Otoplasty
  • Panniculectomy
  • Rhinoplasty
  • Rhytidectomy
  • Scar revisions
  • Septoplasty
  • Varicose vein surgery/sclerotherapy

OUTPATIENT DIAGNOSTIC SERVICES:

Prenotification Only:

• CT imaging for non-orthopedic conditions
• MRI for non-orthopedic conditions

Precertification Required:

• PET imaging
• Capsule endoscopy
• Genetic testing (including BRCA)
• Sleep studies

OUTPATIENT CONTINUING CARE SERVICES:

Prenotification Only:

• Dialysis

Precertification Required:

• Chemotherapy (including oral)
• Radiation therapy
• Oncology and transplant-related injections, infusions, and treatments (CAR-T, endocrine, immunotherapy) - excluding supportive drugs (antiemetic, antihistamine)
• Hyperbaric oxygen therapy
• Home health care
• Durable medical equipment (electric/motorized scooters, wheelchairs, pneumatic compression devices)

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Plan Benefit Code Reference

Benefit Plan Codes

Tier	Network	Coverage Codes	Provider
Tier 1	In-Network	5100-5129	AETNA
Tier 1 Ologist Override	In-Network (Specialists)	11111	AETNA (Hospitalists, Radiologists, Pathologists, Anesthesiologists, Emergency Physicians)
Tier 2	Out-of-Network	0	Out-of-Network

Common Medical Service Coverage Codes

Service Category	Coverage Codes
Medical Office Visits	AOV, AOVS, OV, OVS, POV, SMV, SOV, TELM, TELS, ZPOV, ZSMV, ZSOV
Office Surgery & Anesthesia	AF, AFQ, AFS, OPM, OPMS, SF, SFS
Injections (Therapeutic)	INJ, INJS, MINJ, ZMIN
Allergy Services	ALI, ALIS, ALS, ALSS (Injections/Serum); ALT, ALTS (Testing)
Radiology (Office)	XRDR, XRDS
Laboratory (Office)	LBDR, LBDS, MOXL, SMOX, SOXL, ZMOX, ZSMX, ZSOXX
Diagnostic Testing (Office)	ODX, ODXS
Other Office Services	HBOO, HBOS, HBPO, HBPS, OIV, OIVS, OMS, OMSS, OWCT
Independent Laboratory	LAB
Outpatient Lab/Imaging (Physician)	PRF
Outpatient Lab/Imaging (Facility)	CUS, HLAB, HXL, HXR, MXL, OPDX, OUSS, SMXL, SXL, US, XRAY
Major Diagnostic (Physician)	PRF
Major Diagnostic (Facility)	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
Sleep Studies	OSLP, SLPS
Acupuncture	AP, APS
Ambulance	AMB, AMBR, AR
Chiropractic	CH, CHX
Durable Medical Equipment	BRA, DIEQ, DME, DMS, DTE, MMS
Extended Care Facility	SNF
Home Health Care	HHC, HHS, PHC, PHS
Hospice Care	HO, OHO
Bereavement Counseling	HBC, HFC
Emergency Room Facility	ER, MNO, NER, SMOF, SNO
Emergency Room Professional	ERD, MERD, NERD, SAER, SMER
Inpatient Facility	BC, HM, HNS, ICU, IMC, MHM, MRB, RB, SHM, SMHM, SMRB, SRB
Ancillary Inpatient	DX, HV, MID, MNI, PAT, RAD, SID, SIP, SMID, SMNI, WC
Infusion Therapy	IVIN
Anesthesia	AI, AIQ, AO, AOQ, MNA, SMA
Surgeon/Assistant	CIRC, SI, SO, STER, TI, TO
Outpatient Surgery	ASF, OHS
Maternity Surgery	MAT, MATD, MATO
Newborn Care	CIRC, HNS, WC
Outpatient Hospital	CO, HBO, HMIS, HOBS, HWCT, MNOP, PA, PADR, SAOP, SMPH
Outpatient Physician	DIED, HBP, PM
Dialysis	DI, HDI
Urgent Care	URG
Chemotherapy Professional	CT, HCT, HRT, RT
Chemotherapy Facility	CT, HCT, HRT, RT
Hearing Aids	HA, HA2, HARC
Orthotics	DS, OR, ORH, ORI, ORS
Prosthetics	PRO
Infertility Services	INF, INFS, INFT, INHT, INIT, IVF, IVSF, SINT
Mental Health Residential	MRES, SRES
Mental Health Outpatient Facility	DT, SDT, SMDT
Transplant Services	TRN
Transplant Travel/Housing	TRL, TRNT
Physical Therapy	DPT, HPT, PT
Occupational Therapy	HOT, OT
Speech Therapy	HST, ST
Rehab Services	ABA, ABAH, COGR, CR, PRHB
Massage Therapy	MT
Wigs/Cancer Treatment	WIG
TMJ Treatment	TMJ, TMJO, TMJS
Prescription Drugs	PCS (Invoice only)
Specialty Pharmacy Injectables	SPD
Preventive Care (ACA)	AB, AB1, AB2, AB3, AB4, AB5, AB6, AB7, ABCV, ABH, ABNC, ABR, ABX
Routine/Wellness Exams	HWC, WCB, WCBS, WLB, WLBS
Immunizations	IMAS, IMM, IMMA, IMMB, IMMG, IMMS, IMSH
Routine Diagnostics	HWL, WLAB, WXL, WXR
Routine Mammogram	MAM, MAM2, OMAM, OMAS, OMA2, OM2S
Routine Pap Smear	PAP, PAPR, PAPS
Routine Fecal Culture	WLB
Routine PSA/Prostate	PS, PSS
Routine Colonoscopy	OCOL, OCOS, WLAB, WLB, WXL, WXLS
Contraceptive Management	BCI, BCIS, BCR, BCRS, BINJ, BINS, CONS, CONT
Routine Hearing Exam	RHE
Vision Exam	REE, VEX
Dental Exclusions	Abortion: ABO; Alternative Treatment: INEL

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Office Visit Coverage Details

Service	Covered	Deductible	Copay (T1)	Copay (T2)	Plan Pays (T1)	Plan Pays (T2)	Notes
Medical Office Visit	Yes	No	$30	None	100% after copay	50%	Standard visit
Specialist Office Visit	Yes	No	$55	None	100% after copay	50%	Higher copay
Office Surgery (includes anesthesia)	Yes	No	$30	None	100% after copay	50%	Minor procedures
Specialist Office Surgery	Yes	No	$55	None	100% after copay	50%	-
Therapeutic Injections (Office)	Yes	Yes	None	None	80%	50%	Deductible applies
Allergy Injections & Serum	Yes	Yes	None	None	80%	50%	Deductible applies
Allergy Testing	Yes	Yes	None	None	80%	50%	Deductible applies

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Diagnostic, Imaging & Testing Services

Service	Covered	Deductible	Copay (T1)	Copay (T2)	Plan Pays (T1)	Plan Pays (T2)	Special Notes
Office X-ray & Professional	Yes	No	$30	None	100%	50%	Includes high-cost imaging
Office Laboratory & Professional	Yes	No	$30	None	100%	50%	Deductible waived
Office Diagnostic Testing	Yes	Yes	None	None	80%	50%	-
Independent Laboratory	Yes	Yes	None	None	100%	50%	Deductible waived
Lab/X-ray/Diagnostic (Physician)	Yes	Yes	None	None	80%	50%	Lab = 100% deductible waived
Lab/X-ray/Diagnostic (Facility)	Yes	Yes	None	None	80%	50%	Lab = 100% deductible waived
Major Diagnostic - MRI, CT, PET, Nuclear	Yes	Yes	None	None	80%	50%	Requires precertification
Sleep Studies	Yes	Yes	None	None	80%	50%	Requires precertification

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Emergency & Hospital Services

Emergency Room Coverage

Service	Covered	Deductible	Copay	Plan Pays	Notes
ER Facility Services	Yes	No	$350 per visit	100%	In-network preferred
ER Professional Services	Yes	No	None	100%	In-network preferred
ER Copay Waived if Admitted Within 24 Hours	Yes	-	Waived	-	Copay does not apply to admission
Emergency Services Paid In-Network	Yes	-	-	Network rate	All emergency services available in-network

Inpatient Hospital Coverage

Service	Covered	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Notes
Inpatient Facility Services	Yes	Yes	None	80%	50%	Includes room, board, general care
Ancillary Services	Yes	Yes	None	80%	50%	All other inpatient services
ER Copay Waived if Admitted	Yes	-	Waived	-	-	From emergency admission
Semi-Private Room Rate	Applied when available	-	-	-	-	Reduced to semi-private rate if applicable
Notification Penalty Waived	Yes for emergencies	-	-	-	-	Emergency admissions exempt from penalty

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Surgical Services Coverage

Service	Covered	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Special Notes
Anesthesia	Yes	Yes	None	80%	50%	Includes monitored anesthesia care
Surgeon/Assistant Surgeon	Yes	Yes	None	80%	50%	Assistant limited to 25% of surgeon's fee
Second Surgical Opinion	Yes	Varies	Varies	Varies	Varies	Coverage code: SAAOI
Outpatient Hospital Surgery	Yes	Yes	None	80%	50%	After copay and deductible
Ambulatory Surgical Center (ASC)	Yes	Yes	None	80%	50%	After copay and deductible
Maternity Surgery	Yes	Yes	None	80%	50%	Includes physician attendance
Routine Newborn Care	Yes	Yes	None	80%	50%	Circumcision and standard care

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Mental Health & Substance Abuse Services

Coverage Overview

Item	Details
Mental Health Services Covered	Yes
Substance Abuse Services Covered	Yes
Coverage Treatment	Paid as any other illness (parity)
Separate Limitations	No separate limits apply

Mental Health Treatment Providers

The following providers are covered for mental health treatment:

Provider Type	Notes
Psychologist (PSY.D.)	With PhD or Master's in psychiatry or related field
State-Licensed Psychologist	Full licensure required
State-Licensed/Certified Social Worker	Full licensure/certification required
Masters in Social Work (MSW)	Advanced social work degree
Licensed Professional Counselor	State licensure required
Certified Addiction Counselor	For substance abuse treatment

Mental Health Inpatient Treatment

Service	Covered	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Precert
Residential Treatment Facility	Yes	Yes	None	80%	50%	Required
Mental Health Inpatient	Yes	Yes	None	80%	50%	Required

Mental Health Outpatient Treatment

Service	Covered	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Precert
Outpatient Facility (PHP, DT, IOP, etc.)	Yes	Yes	None	80%	50%	Required
Individual Therapy	Yes	Varies	Varies	Varies	Varies	-

Substance Abuse Services

Service Type	Covered	Treatment
Substance Abuse Inpatient	Yes	Paid as any other illness
Substance Abuse Outpatient	Yes	Paid as any other illness
Substance Abuse Residential Treatment	Yes	Plan pays 80% (T1) / 50% (T2)

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Rehabilitation & Therapy Services

Physical Therapy & Occupational Therapy

Service	Covered	Combined Benefit	Deductible	Copay (T1)	Copay (T2)	Plan Pays (T1)	Plan Pays (T2)	Maximum
Physical Therapy	Yes	No (separate)	No	$30/visit	None	100%	50%	30 visits/calendar year
Occupational Therapy	Yes	No (separate)	No	$30/visit	None	100%	50%	30 visits/calendar year
Aquatic Therapy (with PT)	Yes	-	No	$30/visit	None	100%	50%	Included in PT max
Massage Therapy (by PT/OT/MD)	Yes	-	No	$30/visit	None	100%	50%	Included in service max

Speech Therapy

Service	Covered	Deductible	Copay (T1)	Copay (T2)	Plan Pays (T1)	Plan Pays (T2)	Maximum
Speech Therapy	Yes	No	$30/visit	None	100%	50%	Unlimited

Other Rehabilitation Services

Service	Covered	Deductible	Copay (T1)	Copay (T2)	Plan Pays (T1)	Plan Pays (T2)	Maximum
ABA Therapy	Yes	No	$30/visit	None	100%	50%	Unlimited
Cognitive Rehabilitation	Yes	No	$30/visit	None	100%	50%	Unlimited
Cardiac Rehabilitation	Yes	No	$30/visit	None	100%	50%	Unlimited
Pulmonary Rehabilitation	Yes	No	$30/visit	None	100%	50%	Unlimited

Massage Therapy (Standalone)

Item	Details
Coverage	Yes (when medically necessary)
Coverage Limitation	Must be performed by physical therapist, occupational therapist, or physician
Deductible	Varies
Copay	Varies
Plan Pays	Varies
Maximum	No benefit maximum

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Extended Care Facility & Home Services

Skilled Nursing Facility

Item	Tier 1	Tier 2
Coverage	Yes	Yes
Deductible Applies	Yes	Yes
Copay	None	None
Plan Pays	80%	50%
Maximum Duration	60 days/calendar year	60 days/calendar year

Home Health Care

Item	Tier 1	Tier 2
Coverage	Yes	Yes
Deductible Applies	Yes	Yes
Copay	None	None
Plan Pays	80%	50%
Maximum Visits	60 visits/calendar year	60 visits/calendar year

Hospice Care

Item	Tier 1	Tier 2
Coverage	Yes	Yes
Deductible Applies	Yes	Yes
Copay	None	None
Plan Pays	80%	50%
Maximum Days	Unlimited	Unlimited
Custodial/Respite Care	Not included	Not included

Bereavement Counseling

Item	Details
Coverage	Yes
Included in Hospice Benefit	Yes
Plan Pays (T1)	Percent varies
Plan Pays (T2)	Percent varies
Maximum Duration	No day maximum
Service Window	Must be provided within 6 months of death

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Specialty Services Coverage

Chiropractic Services

Item	Tier 1	Tier 2
Coverage	Yes	Yes
Deductible	No	No
Copay	$30/visit	None
Plan Pays	100% after copay	50%
Maximum	No visit maximum	No visit maximum
Calendar/Plan Year	Calendar year	Calendar year

Durable Medical Equipment (DME)

Item	Coverage	Tier 1	Tier 2
Coverage	Yes	Plan pays 80%	Plan pays 50%
Deductible	Yes	-	-
Copay	No	-	-
Insulin Pumps Covered	Yes	-	-
Pump Supplies Covered	Yes	-	-
Repairs (not from misuse)	Yes	-	-
Replacements (outside warranty)	Yes	-	-
Batteries Covered	Yes	-	-
Sales Tax & Shipping	Yes	-	-
Rental Maximum	Yes (up to purchase price)	-	-

Ambulance & Medical Transport

Item	Coverage	Tier 1	Tier 2	Notes
Ground Ambulance	Yes	80%	80%	Medically appropriate
Air Ambulance	Yes	80%	80%	Medically appropriate
Facility-to-Facility Transport	Yes, when medically necessary	80%	80%	-
Deductible	Yes	-	-	-
Copay	No	-	-	-

Dialysis Services

Item	Coverage	Tier 1	Tier 2	Precert
Dialysis	Yes	80%	50%	Prenotification required
Deductible	Yes	-	-	-
Copay	No	-	-	-

Urgent Care Services

Item	Coverage	Copay	Plan Pays (T1)	Plan Pays (T2)	Applied As
Urgent Care	Yes	$100	100% after copay	50%	Per visit
Related Services	Yes	-	100%	50%	Included
Deductible	Yes	-	-	-	-

Infusion Therapy

Item	Coverage	Tier 1	Tier 2	Deductible
Infusion Therapy	Yes	80%	50%	Yes
Copay	No	-	-	-

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Hearing, Vision, Orthotics & Prosthetics

Hearing Aids

Item	Coverage	Details
Hearing Aids Covered	Yes, Limited	1 per ear every 36 months
Age Limitation	Children under 18 only	NOT covered for ages 18+
Deductible	Yes	-
Copay	No	-
Plan Pays (T1)	80%	-
Plan Pays (T2)	50%	-
Maximum Benefit	No maximum per device	-

Implantable Hearing Devices (Cochlear, SoundTec)

Item	Coverage
Cochlear Implants	Covered (coverage code: CIRH, COCH)
SoundTec Implants	Covered (coverage code: CIRH, COCH)

Vision Care

Item	Details
Separate Medical Benefit	No separate benefit through medical plan
Separate Vision Vendor	Yes - Delta Vision
Vendor Phone Number	1-800-877-7195
Medical Eye Exams	Covered under medical plan
Glaucoma Testing/Care	Covered under medical plan
Cataract Coverage	Covered under medical plan
Routine Eye Exams	Not covered under medical plan (see Delta Vision)
Eye Refractive Correction	Covered under vision vendor
Eye Surgery for Refractive Disorders	Not covered (LASIK, radial keratotomy, etc.)

Vision Services NOT Covered Under Medical

Service	Coverage
Lenses (single vision, bifocal, trifocal, progressive)	Through vision vendor only
Contacts	Through vision vendor only
Frames	Through vision vendor only
Vision Therapy	Not covered
Fitting/Dispensing of Non-Prescription Glasses	Not covered

Orthotics

Item	Coverage	Tier 1	Tier 2	Limits
Custom-Molded Foot Orthotics	Yes	80%	50%	-
Non-Custom Molded Shoe Inserts	Yes	80%	50%	-
Diabetic Shoes	Yes	80%	50%	1 pair/calendar year
Deductible	Yes	-	-	-
Copay	No	-	-	-

Prosthetics

Item	Coverage	Tier 1	Tier 2
Initial Purchase	Yes	80%	50%
Fitting	Yes	80%	50%
Repair	Yes	80%	50%
Replacement	Yes	80%	50%
Deductible	Yes	-	-
Copay	No	-	-

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Maternity & Newborn Benefits

Pregnancy-Related Services

Item	Coverage
Office Visits for Pregnancy	Covered per medical office visit benefits
Hospital Services for Pregnancy	Covered per hospital benefits
Dependent Daughter Pregnancies	Status: Unchecked (coverage status requires confirmation)
Outpatient Birthing Centers	Yes
Home Deliveries	Yes

Abortion & Reproductive Services

Service	Coverage
Elective Abortion	Yes
Abortion (Rape/Incest)	Yes
Abortion (Life of Mother in Danger)	Yes
Coverage Applies To	All females covered under the plan
Sterilization	Yes

Newborn Care

Item	Coverage	Plan Pays (T1)	Plan Pays (T2)
Routine Newborn Care	Yes	80%	50%
Circumcision	Included	80%	50%
Hospital Well-Child Visits	Included	80%	50%
Deductible Applies	Yes	-	-

Newborn Enrollment

Item	Details
Automatic Coverage	31-day automatic coverage from birth
Enrollment Requirement	Must enroll after 31-day period
Effective Coverage	Automatic if parent has dependent coverage; otherwise must enroll

Maternity Services

Service	Coverage	Precert
Obstetric Inpatient Admission	Yes	Prenotification only
Obstetric Precertification	Required only if days exceed federal mandate	-
Maternity Surgery (Physician Attendance)	Covered per surgical benefits	-

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Preventive Care & Wellness Services

ACA Preventive Services

Item	Coverage	Deductible	Copay (T1)	Copay (T2)	Plan Pays (T1)	Plan Pays (T2)
ACA Preventive Services	Yes	No	No	No	100%	50%
USPSTF Recommended	Yes	-	-	-	-	-
In-Network Provider Required	Yes	-	-	-	-	-

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

Routine/Wellness Services NOT Covered Separately

Service	Coverage	Notes
Routine Physical Exams	Not covered separately	Follow USPSTF when preventive
Immunizations (Non-ACA)	Not covered separately	ACA immunizations covered at 100%
Routine Labs/X-rays	Not covered separately	-
Routine Mammogram	Not covered separately	-
Routine Pap Smear	Not covered separately	-
Routine Fecal Occult Blood Culture	Not covered separately	-
Routine PSA/Prostate Exam	Not covered separately	-
Routine Colonoscopy/Sigmoidoscopy	Not covered separately	-
Contraceptive Management	Not covered separately	ACA contraceptives covered
Routine Hearing Exam	Not covered separately	-
Nutritional/Behavioral Counseling	Not covered separately	-

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Prescription Drug Coverage

General Drug Coverage

Item	Details
Drug Plan Coverage	Yes, covered under prescription drug plan
Covered Under	Medical plan or separate drug plan (not both)
Drug Plan Vendor	TRUESCRIPTS
Deductible Applies	Yes
Copay Applies	Yes
Deductible Applied Before/After Copay	Applied with copay (varies by tier)
Specialty Drug Waiting Period	6 months for new-to-market specialty drugs
Specialty Drug Waiting Period (New)	6 months

Retail vs. Mail Order Copay Structure

Drug Category	Retail (30-Day)	Mail Order (90-Day)	Coinsurance Cap
Generic	$10	$30	N/A
Brand-Preferred	$40	$120	N/A
Brand-Non-Preferred	$70	$210	N/A
Specialty (25% Coinsurance)	25% coinsurance	N/A	Coinsurance to max of [amount not specified]

Specialty Pharmacy Injectable Drugs

Item	Coverage	Details
Specialty Injectable Drugs	Yes	Covered under medical plan
Paid Same As Office Services	Yes	Medical office visit payment rates apply
Medications & Administration Supplies	Both OR one	May be covered under Medical OR Pharmacy benefits, BUT NOT BOTH
Diabetic Supplies	Medical Plan	Covered under medical
Insulin	Medical Plan	Covered under medical
Growth Hormones	Medical Plan	Covered under medical
Take-Home Medications	Medical Plan	Covered under medical

Contraceptive Products Coverage

Item	Coverage Type	Details
Oral Contraceptive Tablets	Drug Plan	Covered under prescription drug plan
Contraceptive Patches	Drug Plan	Covered under prescription drug plan
Vaginal Devices (NuvaRing)	Drug Plan	Covered under prescription drug plan
Contraceptive Injections (Depo-Provera)	Drug Plan	Covered under prescription drug plan
IUDs	Medical Plan	Office-administered, covered under medical
Implants	Medical Plan	Office-administered, covered under medical
ACA Contraceptives	Preventive (100%)	No copay or deductible for ACA-mandated

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Dental Services & Oral Surgery

Dental Services - Plan Status

• Dental Benefits Embedded/Bundled: No (Unbundled/Separate)
• Dental Benefits Covered: Not covered under medical plan
• Separate Dental Vendor: Not specified in this document
• Orthodontia: Not mentioned

Oral Surgery (Covered Under Medical Plan)

Procedure	Coverage	Deductible	Plan Pays
Excision of Partially/Completely Impacted Teeth	Yes	Varies	Varies
Excision of Jaw/Facial Tumors & Cysts	Yes (requires pathology exam)	Varies	Varies
Surgical Repair of Accidental Jaw/Facial Injury	Yes	Varies	Varies
Reduction of Jaw Fractures & Dislocations	Yes	Varies	Varies
External Incision & Drainage of Cellulitis	Yes	Varies	Varies
Incision of Accessory Sinuses	Yes	Varies	Varies
Incision of Salivary Glands/Ducts	Yes	Varies	Varies
Excision of Exostosis of Jaws/Hard Palate	Yes	Varies	Varies
Frenectomy	Yes (tissue cutting mid-tongue)	Varies	Varies
Gingival/Periodontal Surgery	Yes (gingivectomy, osseous, grafting)	Varies	Varies
Apicoectomy	Yes (tooth root excision without full extraction)	Varies	Varies
Root Canal Therapy with Apicoectomy	Yes	Varies	Varies
Alveolectomy	Yes (leveling for denture fitting; NOT with routine extraction)	Varies	Varies

Additional Dental Services

Service	Coverage	Tier 1	Tier 2	Notes
Dental Implants	No	-	-	Not covered
Anesthesia (Dental Hospital)	Yes	-	-	Medically appropriate hospital only
X-ray (Dental Hospital)	Yes	-	-	Medically appropriate hospital only
Lab (Dental Hospital)	Yes	-	-	Medically appropriate hospital only
Other Dental Services Under Medical	No	-	-	Not covered

Temporomandibular Joint (TMJ) Disorder Treatment

Service	Covered	Tier 1	Tier 2	Deductible	Copay	Notes
All TMJ Services (Surgery, Appliances, Adjustments)	Yes	-	-	Yes	No	Standard coverage
TMJ Diagnostic Only	Yes	-	-	Yes	No	To determine diagnosis
TMJ Non-Surgical Treatment	Yes	-	-	Yes	No	-
TMJ Surgery	Yes	-	-	Yes	No	-
Plan Pays (T1)	-	Varies	-	-	-	-
Plan Pays (T2)	-	-	Varies	-	-	-
Maximum Lifetime Benefit	No maximum	-	-	-	-	Applies to surgical & non-surgical
Applied Per	Surgical & Non-Surgical Combined	-	-	-	-	-

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Chemotherapy & Radiation Therapy

Chemotherapy Services

Service	Covered	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Precert
Chemotherapy Professional	Yes	Yes	No	80%	50%	Required
Chemotherapy Facility	Yes	Yes	No	80%	50%	Required
Oral Chemotherapy	Yes	Yes	No	80%	50%	Precertification required

Radiation Therapy Services

Service	Covered	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Precert
Radiation Therapy Professional	Yes	Yes	No	80%	50%	Required
Radiation Therapy Facility	Yes	Yes	No	80%	50%	Required

Oncology-Related Treatments

Service	Coverage	Precertification
Oncology Injections	Covered (CAR-T, endocrine, immunotherapy)	Required
Oncology Infusions	Covered	Required
Oncology Treatments (excluding supportive drugs)	Covered	Required
Supportive Drugs (Antiemetic, Antihistamine)	Covered	NOT required for these
Transplant-Related Injections	Covered	Required
Transplant-Related Infusions	Covered	Required
Transplant-Related Treatments	Covered	Required

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Infertility Treatment Services

Diagnostic & Testing Services

Service	Coverage (T1)	Coverage (T2)
Diagnostic Testing (to determine infertility)	Yes	Yes
Genetic Testing for Infertility Diagnosis	Yes	Yes
Fertility Tests	Yes	Yes
Tests & Exams for Induced Conception Preparation	Yes	Yes

Surgical & Intervention Services

Service	Coverage (T1)	Coverage (T2)
Surgical Reversal of Sterilization	Yes	Yes
Sperm Enhancement Procedures	Yes	Yes
Hormone or Therapy Drugs	Yes	Yes
Artificial Insemination	Yes	Yes
In Vitro Fertilization (IVF)	Yes	Yes
Gamete Intrafallopian Transfer (GIFT)	Yes	Yes
Zygote Intrafallopian Transfer (ZIFT)	Yes	Yes
Embryo Transfer	Yes	Yes
Embryo/Egg/Sperm Freezing or Storage	Yes	Yes

Note: Coverage includes diagnostic and related services; specific drug coverage outlined in prescription section.

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Transplant Services

Recipient Transplant Coverage

Service	Covered	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Precert
Transplant Facility (Recipient)	Yes	Yes	No	80%	50%	Required
Transplant Services	Yes	-	-	-	-	-

Living Donor Transplant Coverage

Item	Coverage
Living Donor Facility Benefits	Yes
Living Donor Care	Covered per medical benefits

Transplant Travel & Housing Benefits (Recipient)

Expense Type	Coverage	Tier 1	Tier 2	Maximum	Notes
Airfare	Yes	100% WD	-	$10K per transplant	Within-deductible
Meals	Yes	100% WD	-	$10K per transplant	Within-deductible
Tolls	Yes	100% WD	-	$10K per transplant	Within-deductible
Parking Fees	Yes	100% WD	-	$10K per transplant	Within-deductible
Apartment Rental	Yes	100% WD	-	$10K per transplant	Within-deductible
Hotel/Motel	Yes	100% WD	-	$10K per transplant	Within-deductible
Relocation Fees	Yes	100% WD	-	$10K per transplant	Within-deductible
Taxes	Yes	100% WD	-	$10K per transplant	Within-deductible

Separate Transplant Policy

Item	Details
Separate Policy Available	Yes
Details/Contact	Not provided in this document

General Transplant Rules

Item	Coverage
Donor Covered Under Plan But Recipient Not	Yes
Covered Procedures	All except cornea (which requires precert)

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Wigs & Cancer Treatment

Item	Coverage	Deductible	Copay	Plan Pays (T1)	Plan Pays (T2)	Maximum
Wigs for Cancer Treatment	Yes	Yes	No	100%	100%	1 per calendar year, up to $500
Wigs for Medically Appropriate Condition	Yes	Yes	No	100%	100%	1 per calendar year, up to $500

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Additional Covered Services (Miscellaneous)

Genetic Services

Service	Coverage	Code
Genetic Counseling	Not covered (except ACA mandate/medical appropriateness)	GEN
Genetic Testing	Not covered (except ACA mandate/medical appropriateness)	GEN
BRCA Testing	Covered (requires precertification)	GEN

Gene Therapy

Item	Coverage	Type
Gene Therapy Medical Charges	Not covered (not specified)	GENE
Gene Therapy Prescription Drug Charges	Not covered (not specified)	GENE

Orphan Drugs

Item	Coverage
Orphan Drugs (Medical charges)	Not specifically covered
Orphan Drugs (Prescription drug charges)	Not specifically covered
Definition	Drugs for rare diseases or discontinued treatments

Enteral & Parenteral Support

Service	Coverage	Code
Enteral Support (tube feeding as sole nutrition)	Covered	MMS
Parenteral Support	Covered	MMS
Oral Nutrition Therapy (medically necessary)	Covered	MMS
Feeding Tubes	Covered	MMS
Pumps & Supplies	Covered	MMS

Medical Conditions & Treatments

Service	Coverage	Code	Notes
Acquired Brain Injury Treatment	Covered	-	Per state mandate or as any other illness
Autism Services (MHPAEA required)	Covered	DEVD	Applies to state-mandated benefits
Applied Behavior Analysis (ABA)	Covered	ABA, ABAH	Autism services
Developmental Delays Treatment	Covered	DEVD	PT, OT, Speech, Medical charges
Learning Disabilities	Covered	DEVD	-
Biofeedback	Not covered	BFF	-

Excluded Services & Treatments

Service	Status	Code	Notes
Elective Abortion	Covered	ABO	Except under life/crime circumstances
Alternative/Complimentary Medicine	Not covered	INEL	Holistic, homeopathic, hypnosis
Blood Pressure Monitors/Cuffs	Not covered	INEL	-
Botox (Medically Necessary)	Covered	BOT	Covered through medical plan
Breast Reduction (Medically Appropriate)	Covered	-	See applicable benefit section
Bunion/Corn/Callus Treatment	Not covered	INEL	Unless medically necessary
Counseling - Marriage	Not covered	INEL	-
Gender Affirming Care	Not covered	INEL	-
Complications from Non-Covered Service	Not covered	INEL	-
Sales Tax, Shipping, Handling	Not covered	INEL	-
Sexual Function Services	Covered (limited)	-	Diagnostic/surgical only; NOT medications/devices
Sleep Disorders (Medically Appropriate)	Covered	OSLP, SLMS, SLDM, SLPS	Sleep studies with precertification
Smoking Cessation Drugs	Covered	SMK	Paid under medical or drug benefit
Weight Control/Bariatric Surgery	Covered	BAR, BARS, OBE	For morbid obesity

Weight Control/Bariatric Procedures

Service	Coverage	Notes
Definition	Morbid obesity treatment	100 lbs over body weight or BMI criteria
Bariatric Therapy	Covered	-
Gastric Bypass	Covered	-
Gastric Intestinal Bypass	Covered	-
Stomach Stapling	Covered	-
Prescription Medication	Covered	For weight loss
Physician Supervised Weight Loss Programs	Covered	-
Diet Supplements	Coverage varies	Check with plan

Alcohol & Drug-Related Injuries

Scenario	Coverage
Injuries While Legally Intoxicated	Not covered
Injuries from Illegal Drug Use	Not covered
Voluntary Use of Controlled Substances	Not covered
Illness/Injury from Hallucinogens or Narcotics	Not covered (if not prescribed by physician)

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Telemedicine & Additional Programs

Telemedicine Coverage

Service	Coverage	Codes
Telemedicine - Patient to Physician	Covered	TELM, TELS
Telemedicine - Physician to Physician	Not covered	TELA, TELB
Telemedicine (Telephone)	Covered	TELM, TELS
Telemedicine (Internet)	Covered	TELM, TELS
Office Visits via Telemedicine	Covered	TELM, TELS

Additional Programs & Features

Program	Status	Details
TELADOC	Available	NO CHARGE - Separate benefit from medical plan
Patient Defender	Available	Yes
Pace	Available	Yes
CareConnect	Available	Yes; Benchmark State: UTAH
PHX (A&G)	Not applicable	No information
RBP (Retiree Benefit Plan)	Not available	No - Not offered
RBP Medicare Percentage	N/A	150/150% N/A

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Network & Provider Information

In-Network vs. Out-of-Network Payment

Item	Details
Out-of-Network Percentile	80th Percentile (Standard)
Alternative Percentile Options	85th, 90th, 95th, % of Medicare (150/150%)
Medical Plan Providers	Yes (standard network providers)
Mental Health Treatment Providers	Yes (specific mental health specialists)

Specialists Paid As In-Network (REAP - Ologist Benefits)

Specialty	Paid In-Network When at Participating Facility	Notes
Hospitalists	Yes	-
Radiologists	Yes	-
Emergency Room Physicians	Yes	-
Anesthesiologists	Yes	-
Pathologists	Yes	-
Override Code	11111	Override to Tier 1 Ologist

Special In-Network Circumstances

Scenario	Paid In-Network	Details
Referred by Participating Physician	Yes	Automatic in-network rate
Services Outside Service Area	Yes	Within 100 miles of participant residence
Services Unable to be Provided by Network	Yes	When unavailable in network
Emergency Care Out-of-Area	Yes	For accidental bodily injury or emergency
Non-Network Hospital Emergency	Yes	Accidental injury or emergency only; network rate applies

Covered Healthcare Professionals (Medical Plan)

Provider Type	Coverage	Notes
Certified Nurse Midwife (CNM)	Yes	Within scope of license, performing payable services
Chiropractor	Yes	Focuses on musculoskeletal/nervous system
Massage Therapist	Yes	State licensed or certified
Licensed Professional Counselor	Yes	Licensed by state

Covered Healthcare Professionals (Mental Health Only)

Provider Type	Coverage	Requirements
Psychologist (PSY.D.)	Yes	PhD or Master's in psychiatry/related field
State-Licensed Psychologist	Yes	Full state license required
State-Licensed/Certified Social Worker	Yes	Full licensure/certification required
Masters in Social Work (MSW)	Yes	Advanced degree
Certified Addiction Counselor	Yes	For substance abuse treatment

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Coordination of Benefits (COB)

General COB Rules

Item	Details
COB Same for Medicare-Eligible Employees	Yes
Medicare Part B Assumption	If covered person has Part A but not Part B, plan assumes Part B was elected
Primary Carrier Selection Rule	Birthday Rule (birthday = month/day, not year)
Question Primary Carrier	Yes - plan will question primary carrier
Timely Filing Period	12 months

COB Savings Method (Accumulator)

Method	Code	Description
Method Used	0	Accumulated COB savings applied to deductible and copayment reduction on current and future claims until exhausted (individual "COB bank")

COB Payment Processing Code

Code	Description
Code Used	1

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Appeals & Dispute Resolution

Item	Details
Internal Appeal Levels	2 levels of appeals before escalation
Independent Review Organization (IRO)	Available after 2 internal appeals
IRO Contact	Information in plan documents

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General Plan Features & Rules

Coverage Maximums & Limitations

Item	Details
Are All Benefit Maximums Combined	Yes - combination of in- and out-of-network services
Special Limitations	Not specified for combined maximums

Service Area & Distance Parameters

Parameter	Details
Service Area Miles for Specialist In-Network	100 miles from participant residence
Services Outside Service Area	Treated as in-network if over 100 miles

Timely Filing & Claims

Item	Details
Timely Filing Period	12 months

Plan Year & Benefit Application

Item	Details
Benefit Year	Calendar Year (January 1 - December 31)
Fiscal Year for Funding	January 1 - December 31

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Complete Service Index with Coverage Codes

Index of All Covered & Non-Covered Services by Code

Service	Coverage Code	Covered	Tier 1	Tier 2	Notes
Medical Office Visit	AOV, AOVS, OV, OVS, POV, SMV, SOV	Yes	$30 copay	50%	Standard visit
Specialist Office Visit	ZPOV, ZSMV, ZSOV	Yes	$55 copay	50%	Higher copay
Telemedicine Office	TELM, TELS	Yes	Varies	50%	Phone/Internet
X-ray & Professional	XRDR, XRDS	Yes	$30 copay	50%	Office-based
Laboratory & Professional	LBDR, LBDS, MOXL	Yes	$30 copay	50%	Office-based, ded waived
Diagnostic Testing	ODX, ODXS	Yes	Ded applied, 80%	50%	Office-based
Injections (Therapeutic)	INJ, INJS, MINJ	Yes	Ded applied, 80%	50%	-
Allergy Services	ALI, ALIS, ALS, ALT	Yes	Ded applied, 80%	50%	-
Independent Lab	LAB	Yes	Ded waived, 100%	50%	Professional component
Major Diagnostic	BONE, CAT, HCAT, MRIO, PET	Yes	Ded applied, 80%	50%	Requires precert
Sleep Studies	OSLP, SLPS	Yes	Ded applied, 80%	50%	Requires precert
Emergency Room	ER, MNO, NER	Yes	$350 copay, 100%	100%	Waived if admitted
Inpatient	BC, HM, ICU, RB	Yes	Ded applied, 80%	50%	-
Surgery	AF, SI, SO	Yes	Ded applied, 80%	50%	-
Anesthesia	AI, AO, MNA	Yes	Ded applied, 80%	50%	-
Maternity Surgery	MAT, MATD	Yes	Ded applied, 80%	50%	-
Newborn Care	CIRC, HNS, WC	Yes	Ded applied, 80%	50%	-
Dialysis	DI, HDI	Yes	Ded applied, 80%	50%	Prenotification required
Urgent Care	URG	Yes	$100 copay, 100%	50%	Per visit
Chiropractic	CH, CHX	Yes	$30 copay, 100%	50%	No visit max
Physical Therapy	DPT, HPT, PT	Yes	$30/visit, 100%	50%	30 visits/year
Speech Therapy	HST, ST	Yes	$30/visit, 100%	50%	Unlimited
Occupational Therapy	HOT, OT	Yes	$30/visit, 100%	50%	30 visits/year
Home Health Care	HHC, HHS, PHC	Yes	Ded applied, 80%	50%	60 visits/year
Skilled Nursing	SNF	Yes	Ded applied, 80%	50%	60 days/year
Hospice	HO, OHO	Yes	Ded applied, 80%	50%	Unlimited
DME	DME, DMS	Yes	Ded applied, 80%	50%	-
Ambulance	AMB, AMBR	Yes	Ded applied, 80%	80%	Ground & air
Infusion Therapy	IVIN	Yes	Ded applied, 80%	50%	-
Chemotherapy	CT, HCT, RT	Yes	Ded applied, 80%	50%	Requires precert
Mental Health Inpatient	MRES, SRES	Yes	Ded applied, 80%	50%	Requires precert
Mental Health Outpatient	DT, SDT, SMDT	Yes	Ded applied, 80%	50%	Requires precert
Hearing Aids	HA, HA2, HARC	Limited	80%	50%	Children <18 only, 1/36mo
Prosthetics	PRO	Yes	Ded applied, 80%	50%	-
Orthotics	DS, OR, ORS	Yes	Ded applied, 80%	50%	Custom/non-custom/diabetic
Infertility	INF, IVF, IVSF	Yes	Varies	Varies	Diagnostic & related
Hearing Implants	CIRH, COCH	Yes	Varies	Varies	Cochlear, SoundTec
Genetic Testing	GEN	Limited	Varies	Varies	ACA mandate only
Gene Therapy	GENE	Not covered	-	-	-
Orphan Drugs	ORPH	Limited	Varies	Varies	Rare disease drugs
Acupuncture	AP, APS	No	-	-	Not covered
Botox	BOT	Covered	Via medical	Via medical	Medically necessary only
Bunions/Corns	INEL	No	-	-	Unless medically necessary
Marriage Counseling	INEL	No	-	-	-
Gender Affirming Care	INEL	No	-	-	-
Blood Pressure Monitors	INEL	No	-	-	-
Abortion (Elective)	ABO	Yes	-	-	All circumstances
Alternative Medicine	INEL	No	-	-	Holistic, homeopathic
Sales Tax/Shipping	INEL	No	-	-	-
Smoking Cessation	SMK	Yes	Medical/Drug	Medical/Drug	Either benefit
Weight Control Surgery	BAR, BARS	Yes	Varies	Varies	Morbid obesity

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Document Completion & Approval Information

Item	Details
Completed By	Ashlie McNabb
Position/Title	Plan Build
Date Completed	December 5, 2025
Document Status	FINAL - Approved
Effective Date	January 1, 2026
Last Updated	January 30, 2019 (Footer Note)
Form Version	Install Plan Document (Page 2 of 28 referenced)

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Important Caveats & Notes

Special Provisions & Clarifications

Item	Details
Special COB Rules	May apply for employees with Medicare if employer has <100 employees
Dependent Daughter Pregnancies	Coverage status unclear in document (requires confirmation)
Massage Therapy Note	Covered only when performed by PT, OT, or Physician with medical diagnosis
Deductible Carryover	NO 3-month carryover from prior year to current year
OOP Carryover	NO 3-month carryover applies
Mental Health Parity	Mental nervous and substance abuse paid as any other illness
Specialty Drug Waiting Period	6 months for drugs new to market
Post-Service Precertification Penalty	$250 per service if not pre-approved
Retroactive Precertification	NOT allowed - services denied if not pre-approved
Assistant Surgeon Fee	Limited to 25% of usual and customary surgeon fee
Semi-Private Room Reduction	Applied when available in hospital
ER Copay Per Bill	Applied per bill submitted

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Frequently Asked Questions (FAQ)

Coverage & Benefits Questions

Q: Is preventive care really free? A: Yes, for ACA-recommended preventive services when rendered by in-network providers, there is no deductible or copay for both tiers.

Q: What's the difference between Tier 1 and Tier 2? A: Tier 1 has lower deductibles ($2,500/$5,000), lower OOP max ($5,000/$10,000), and plan pays 80%. Tier 2 has higher deductibles ($7,500/$15,000), higher OOP max ($15,000/$30,000), and plan pays 50%.

Q: Do out-of-pocket maximums include copays? A: Yes, copays apply toward the out-of-pocket maximum for both tiers.

Q: Can I get a home delivery? A: Yes, home deliveries are covered under maternity benefits.

Q: Are mental health services limited? A: No. Mental health and substance abuse services are covered without separate limitations, supporting mental health parity.

Q: What happens if I don't go to a network provider? A: Out-of-network services are paid at the 80th percentile of usual and customary charges. You may pay higher out-of-pocket costs.

Q: Is acupuncture covered? A: No, acupuncture is not a covered service under this plan.

Q: What about vision and dental? A: Vision is provided through Delta Vision (1-800-877-7195). Dental is not covered under this medical plan.

Precertification Questions

Q: Do I need precertification for all surgeries? A: No. Some surgeries only require prenotification. Contact AHH at 888-832-0354 to determine your specific procedure's requirements.

Q: What if I get precertification after the service? A: Post-service precertification incurs a $250 penalty. It's best to call before the service.

Q: Do emergency services need precertification? A: Emergency admissions don't require notification penalty, but precertification is still recommended when possible.

Q: Is precertification required for diabetes supplies? A: No, diabetes supplies are covered under medical benefits without precertification requirement.

Prescription Drug Questions

Q: What's the most I pay for a generic drug? A: Retail generic copay is $10 (30-day), or $30 via mail order (90-day).

Q: Are brand-name drugs more expensive? A: Yes. Brand-Preferred copay is $40 retail/$120 mail; Brand-Non-Preferred is $70 retail/$210 mail.

Q: How long do I wait for new specialty drugs? A: There's a 6-month waiting period for specialty drugs new to market.

Q: Is insulin covered? A: Yes, insulin is covered under the medical plan (not the pharmacy plan).

Q: Are contraceptives free? A: ACA-covered contraceptives are 100% covered with no copay. See prescriptiondetails for drug plan copays on other contraceptive products.

Provider & Network Questions

Q: Will my specialist be in-network? A: Specialists (hospitalists, radiologists, emergency physicians, anesthesiologists, pathologists) are paid in-network when treated at participating facilities.

Q: What if I need care 100+ miles from home? A: Services over 100 miles from your residence are treated as in-network.

Q: Can I see a psychologist? A: Yes, state-licensed psychologists are covered providers for mental health treatment.

Q: Who counts as a mental health provider? A: Psychologists, social workers, counselors, addiction counselors, and psychiatrists with appropriate credentials are covered.

Cost-Sharing Questions

Q: Do I have to pay the deductible before copays? A: Copays apply regardless of deductible. Deductible is satisfied separately for items without copays.

Q: Does the deductible apply to emergency room visits? A: No, the ER copay ($350) applies; deductible is waived for emergency facility services.

Q: What's the maximum I'll pay out-of-pocket? A: Tier 1: $5,000 individual/$10,000 family. Tier 2: $15,000 individual/$30,000 family per calendar year.

Q: Can I use out-of-network and still meet my deductible/OOP? A: Yes, in/out-of-network deductibles and OOP cross-apply for Tier 1. For Tier 2, you should verify with the plan.

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Support Resources & Contact Information

Service	Contact	Hours
Plan Administrator	90 Degree Benefits	8 AM - 5 PM CST
Precertification	AHH: 888-832-0354	8 AM - 5 PM CST
Vision Benefits	Delta Vision: 1-800-877-7195	See vendor
Pharmacy Plan	TRUESCRIPTS	See vendor
Teladoc	No charge	Separate benefit
Employee Handbook	Refer to employee handbook	See HR

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Document Version & History

Item	Details
Install Document Version	2026.01
Last Updated Document Footer	January 30, 2019
Document Completion Date	December 5, 2025
Effective Plan Date	January 1, 2026
Total Pages (Referenced)	28 pages
Document Type	Install Plan Document
Initial/Renewal/Mid-Term	Renewal
Requires Customer Approval	Yes

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Document Status: FINAL - Approved for January 1, 2026 Effective Date
Customer Approval Required: Per signature section of plan document
For Updates or Changes: Submit to 90 Degree Benefits to prevent incorrect benefit quotations