Seacoast Church HDHP Plan (QHDHP) — Summary of Benefits
This document is the Schedule of Medical Benefits for Seacoast Community Church, Inc. — HDHP Plan (QHDHP), a PPO managed care plan (Group #001R2636, Status: NGF), effective March 1, 2026. It details benefit levels for in-network and out-of-network providers across medical, prescription drug, preventive care, vision, physician, hospital, mental health/substance use, and other services. The PPO network is CIGNA, out-of-network claims are priced by Phia, utilization management is through Cigna Payer Solutions, case management through MedWatch, disease management is N/A, and customer service through Karias Care Concierge. Prescription drugs are administered by TrueScripts. This plan is not MCC Creditable.
Seacoast Community Church – Summary of Benefits
Effective Date: March 1, 2026 Plan Year: 3/1/2026 – 2/28/2027
Document Link : HDHP Plan pdf
Table of Contents
- Standardly Covered & Excluded Services
- Prescription Drug Benefit
- Medical Benefits — Deductibles, Coinsurance & Out-of-Pocket Maximums
- Emergency & No Surprises Act Provisions
- Preventive Care
- Vision Care
- Physician Services
- Hospital Services — Inpatient
- Hospital Services — Outpatient
- Mental Health / Substance Use
- Other Services & Supplies
- Wellness Benefits
- Disclaimer
1. Standardly Covered & Excluded Services
Standardly Covered Services
| Service | Notes |
|---|---|
| Breast Reduction Surgery | Covered when Medically Necessary; precertification required |
| Orthoptics | Covered unless otherwise listed as excluded in the Plan Document |
| Breastfeeding Support, Supplies and Counseling | If there are no INN lactation providers, then OON providers should be covered at the INN level of benefits with no cost sharing. If the only reason for the visit with the provider is lactation, it should be with no cost-sharing. |
| Child/Adolescent MH/SU Services | Includes but is not limited to CBAT and ICBAT, Intensive care coordination, in-home behavioral services and therapies as well as therapeutic monitoring services — coverage/cost varies based on where the services are rendered |
| Transplant Services | Includes non-experimental human organ transplant of an organ or tissue from one person to another or grafting living tissue from its normal position to another site. Transplant procedures can include human tissue or human cartilage transplants, as well as transplants for permanent artificial heart when Medically Necessary and Covered Person is already on the transplant list. |
Standardly Excluded Services
| Excluded Service |
|---|
| Sex therapy |
| Xenotransplants (cross-species) transplants |
2. Prescription Drug Benefit – Administered by TrueScripts
How It Works: Covered Persons pay 100% until the satisfaction of the applicable Plan Year Deductible. Once the Plan Year Deductible has been met, the Covered Person pays Copayments and Coinsurance, if applicable, which accumulate toward the Out-of-Pocket Maximums. Once the Out-of-Pocket Maximums have been met, prescription drugs will be covered at 100% for the balance of the Plan Year.
Special Coverage Rules:
- Generic FDA-approved contraceptive medications and devices are covered at 100% (Deductible waived). Preferred brand name and non-preferred brand name contraceptive medications are subject to cost-sharing as shown, unless the generic form is not available. In that case, the available preferred brand name drug (or non-preferred brand name if preferred brand name is not available) will be covered at 100% (Deductible waived).
- Tobacco cessation products are covered at 100% (Deductible waived).
- Preventive Care medications are not subject to the Deductible.
Retail Card Program (Up to a 30-Day Supply) — After Deductible
| Drug Type | You Pay |
|---|---|
| Generic drug | 50% Coinsurance |
| Preferred brand name drug | 50% Coinsurance |
| Non-preferred brand name drug | 50% Coinsurance |
Mail Order Pharmacy (Up to a 90-Day Supply) — After Deductible
| Drug Type | You Pay |
|---|---|
| Generic drug | 50% Coinsurance |
| Preferred brand name drug | 50% Coinsurance |
| Non-preferred brand name drug | 50% Coinsurance |
Specialty Drugs – Retail Only (Up to a 30-Day Supply) — After Deductible
| Drug Type | You Pay |
|---|---|
| Specialty Drug | 50% Coinsurance |
See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs.
Key Prescription Drug Details
| Key Detail | Answer |
|---|---|
| Out-of-Network Pharmacy Coverage | Not Covered |
| Do Rx costs count to separate Rx OOP Max or Medical OOP Max? | Combined |
| Are scripts subject to Deductibles? | Yes, Medical Deductible |
3. Medical Benefits — Deductibles, Coinsurance & Out-of-Pocket Maximums
Plan Year Deductible
Individual Deductible Included in Family Coverage: YES
| Coverage Tier | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee only) | $3,500 | $8,000 |
| Family Plan — Per Person | $3,500 | $8,000 |
| Family Plan — Family Maximum | $7,000 | $16,000 |
Family Deductible Rule: The Family Plan contains both an individual Deductible and a family Deductible. Once an individual family member satisfies the individual Deductible, claims will be paid for that individual. Otherwise, the entire family Deductible must be satisfied before claims will be paid for any family members. The family Deductible may be met by any combination of family members.
Deductible Carryover: No
Deductible Credit: For the Plan Year starting 3/1/2026, any Deductible expenses incurred during the period 1/1/2026 through 2/28/2026 shall be credited and used to satisfy the Deductible for the Plan Year starting 3/1/2026 and ending 2/28/2027.
Reimbursement Percentage (Coinsurance)
| Detail | In-Network | Out-of-Network |
|---|---|---|
| Coinsurance Rate | 70% of the Contracted Rate (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximum has been reached, then 100% thereafter for the balance of the Plan Year | 50% of the Allowed Amount (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximum has been reached, then 100% thereafter for the balance of the Plan Year |
Plan Year Out-of-Pocket Maximums
Includes the Plan Year Deductible and Coinsurance, including those for prescription drugs. Individual OOPM Included in Family Coverage: YES
| Coverage Tier | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee only) | $4,500 | $14,000 |
| Family Plan — Per Person | $4,500 | $14,000 |
| Family Plan — Family Maximum | $9,000 | $28,000 |
Family OOP Max Rule: The Family Plan contains both an individual Out-of-Pocket Maximum and a family Out-of-Pocket Maximum. Once an individual family member satisfies the individual Out-of-Pocket Maximum, claims will be paid for that individual at 100%. Otherwise, once the entire family Out-of-Pocket Maximum is satisfied, claims will be paid at 100% for all covered family members. The family Out-of-Pocket Maximum may be met by any combination of family members.
Out-of-Pocket Maximum Credit: For the Plan Year starting 3/1/2026, any Out-of-Pocket Maximum expenses incurred during the period 1/1/2026 through 2/28/2026 shall be credited and used to satisfy the Out-of-Pocket Maximum for the Plan Year starting 3/1/2026 and ending 2/28/2027.
Deductible & OOP Max Accumulation Rules
| Detail | Value |
|---|---|
| In/Out-of-Network Deductibles | Separate |
| In/Out-of-Network Out-of-Pocket Maximums | Separate |
IMPORTANT: The In-Network Provider and Out-of-Network Provider Deductible and Out-of-Pocket Maximums are separate and do not accumulate. Eligible expenses which track toward the In-Network Provider Deductible and Out-of-Pocket Maximums will not be credited toward the satisfaction of the Out-of-Network Deductible and Out-of-Pocket Maximums and vice versa.
NOTE: Covered Services that contain dollar, frequency, or visit limits are combined In-Network and Out-of-Network maximums.
Expenses Excluded from the Out-of-Pocket Maximum:
- Precertification penalties
4. Emergency & No Surprises Act (NSA) Provisions
Emergency services rendered by Out-of-Network Providers for "Emergency Care," air ambulance services rendered by Out-of-Network Providers of air ambulance services, and non-emergency services rendered by Out-of-Network Providers on an inpatient or outpatient basis at an In-Network Hospital or facility for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services (provided the Covered Person has not validly waived the applicability of the No Surprises Act (NSA)) will be paid at the In-Network Provider Deductible, Co-payment, and Coinsurance levels, subject to the Qualifying Payment Amount.
Balance Billing Protections:
- When emergency services are rendered by an Out-of-Network Provider for Emergency Care, or air ambulance services are rendered by an Out-of-Network Provider of air ambulance services, the Out-of-Network Provider cannot balance bill the Covered Person.
- When non-emergency services are rendered by an Out-of-Network Provider on an inpatient or outpatient basis at an In-Network Hospital or facility for the above services, the Out-of-Network Provider cannot balance bill the Covered Person unless the Covered Person gives written consent and gives up their protections in accordance with the NSA. If a Covered Person waives their protections and agrees to balance billing per the NSA, Out-of-Network Providers will be paid according to the Plan's In-Network level of benefits, subject to the Allowed Amount.
- When services are rendered by an Out-of-Network Provider in any instance other than the reasons listed above, Covered Persons may be responsible for any amount above the Allowed Amount.
5. Preventive Care
Services marked with ** are provided according to the terms prescribed by the regulations issued under the Patient Protection and Affordable Care Act of 2010 (PPACA). The majority of the PPACA preventive care services recommendations are issued by the U.S. Preventive Service Task Force (USPSTF). These may be amended from time to time. New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance of the revised recommendation.
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| **Routine Physical Exams (including routine immunizations and flu shots) | 100% (Deductible waived) | Not Covered |
| **Routine Well Child Care (including screenings, routine immunizations and flu shots) | 100% (Deductible waived) | Not Covered |
| **Fluoride Varnish (up to age 6) — Up to 4 varnish treatments per person, per Plan Year | 100% (Deductible waived) | Not Covered |
| **Breastfeeding Support, Supplies and Counseling (during pregnancy and/or in the postpartum period; rental or purchase of breastfeeding equipment). Breast Pump Limits: Hospital Grade — rental covered up to 3 months (precertification required for rental in excess of 3 months); Electric — rent or purchase, whichever is less; Manual — purchase | 100% (Deductible waived) | Not Covered |
| **Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling) | 100% (Deductible waived) | Not Covered |
| **Routine Gynecological/Obstetrical Care (including preconception and prenatal services) | 100% (Deductible waived) | Not Covered |
| **Routine Pap Smears | 100% (Deductible waived) | Not Covered |
| **Breast Cancer Screening including Routine Mammograms and BRCA testing | 100% (Deductible waived) | Not Covered |
| **Routine Immunizations (if not billed with an office visit; includes flu shots) | 100% (Deductible waived) | Not Covered |
| **Routine Lab, X-rays, and Clinical Tests (including those related to maternity care) | 100% (Deductible waived) | Not Covered |
| **Routine Colorectal Cancer Screening, including sigmoidoscopies and colonoscopies (as recommended by USPSTF) | 100% (Deductible waived) | Not Covered |
| **Lung Cancer Screening, including Low-Dose Computed Tomography (LDCT) (as recommended by USPSTF) — Up to 1 per person, per Plan Year | 100% (Deductible waived) | Not Covered |
| **Nutritional Counseling | 100% (Deductible waived) | Not Covered |
| **Smoking Cessation Counseling and Intervention (including smoking cessation clinics and programs) | 100% (Deductible waived) | Not Covered |
| Routine Hearing Exams | Not Covered | Not Covered |
| Routine Prostate Exams and PSA Screenings — Up to 1 exam per person per Plan Year | 100% (Deductible waived) | Not Covered |
| **Abdominal Aortic Aneurysm Screening (as recommended by USPSTF) — Up to 1 per person, per lifetime | 100% (Deductible waived) | Not Covered |
| **Bone Density Screening — Women (as recommended by USPSTF for Osteoporosis Screening) | 100% (Deductible waived) | Not Covered |
| **Bone Density Screening — All other Covered Persons | 100% (Deductible waived) | Not Covered |
| Equipment for those with Chronic Conditions (limited to: blood pressure monitor for hypertension; peak flow meter for asthma; glucometer and selected insulin products such as vial, pump, or inhaler for diabetes) | 100% (Deductible waived) | Not Covered |
| Tests/Screenings for those with Chronic Conditions (limited to: Hemoglobin A1c for diabetes; Retinopathy screening for diabetes; INR for liver disease or bleeding disorders; LDL for heart disease) | 100% (Deductible waived) | Not Covered |
6. Vision Care
| Service | In-Network | Out-of-Network |
|---|---|---|
| Routine Vision Exam | Not Covered | Not Covered |
| Routine Eyewear (lenses, frames, and contact lenses) | Not Covered | Not Covered |
| Eyewear for Special Conditions (initial purchase of non-routine eyewear following surgery; contact lenses needed to treat keratoconus including fitting; intraocular lenses implanted after corneal transplant, cataract surgery, or other covered eye surgery when the natural eye lens is replaced) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
7. Physician Services
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Allergy Testing | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Allergy Treatment | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Anesthesia (Inpatient/Outpatient) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Chiropractic Services — Up to $1,000 per person per Plan Year (charges for lab and x-ray are paid based on services provided and are not subject to any office visit or dollar limits) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Maternity – Employee & Spouse only: Prenatal care | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Maternity – Employee & Spouse only: Physician delivery charges (including home births) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Maternity – Employee & Spouse only: Postnatal care (includes home visit with a Visiting Nurse following early discharge) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Physician Hospital Visits | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Physician Office Visits (includes all related charges billed at time of visit) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Second Surgical Opinion | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery (Inpatient) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery (Outpatient) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery (Physician's office) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
8. Hospital Services — Inpatient
Precertification Required: Precertification is always required for inpatient hospitalization. Failure to obtain precertification may result in a reduction in benefits. The reduction in benefits cannot be used to satisfy any applicable Co-payments, Deductibles, or Out-of-Pocket Maximums under this Plan.
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Private Room: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Hospital Room & Board (precertification required) — Semi-private room or special care unit | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Maternity Services — Employee & Spouse only (precertification required for stays in excess of 48 hours [vaginal]; 96 hours [cesarean]) — Semi-private room or special care unit | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Birthing Center — Employee & Spouse only | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Newborn Care (includes Physician visits & circumcision) — Semi-private room or special care unit | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Organ, Bone Marrow and Stem Cell Transplants (precertification required; managed through Cigna's LifeSOURCE Transplant Network; see Medical Benefits section for other limitations) — Semi-private room or special care unit; excludes transportation/food/lodging expenses | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgical Facility & Supplies | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Miscellaneous Hospital Charges | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
9. Hospital Services — Outpatient
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency services rendered for "Emergency Care" as defined in the section titled "Definitions"; and for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Clinic Services (at a Hospital) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Emergency Room Expenses (includes Facility, Lab, X-ray & Physician services) | 70% (after Deductible) | 70% (after In-Network Deductible) |
| Outpatient Department | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Preadmission Testing | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Urgent Care Facility / Walk-In Clinic | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
10. Mental Health / Substance Use
Precertification Required: Precertification is always required for inpatient hospitalization. Failure to obtain precertification may result in a reduction in benefits. The reduction in benefits cannot be used to satisfy any applicable Co-payments, Deductibles, or Out-of-Pocket Maximums under this Plan.
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Private Room: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospitalization (precertification required) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Partial Hospitalization / Intensive Outpatient Treatment | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Inpatient Physician Visit | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Hospital Clinic Visit | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Office Visit | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Methadone Maintenance / Treatment | Not Covered | Not Covered |
11. Other Services & Supplies
Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for air ambulance services rendered by an Out-of-Network Provider of air ambulance services; and for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Acupuncture | Not Covered | Not Covered |
| Alternative/Complementary Care Benefit (Chelation Therapy, Homeopathic treatment, Hypnosis/Hypnotherapy, Rolfing/Reiki) | Not Covered | Not Covered |
| Ambulance Services (see Medical Benefits section for limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Autism Spectrum Disorders Treatment (includes Applied Behavioral Analysis (ABA); any benefit limits under the Plan for OT, PT, and speech therapies do not apply; precertification is required for ABA; see Medical Benefits section for limitations). Note: Screenings are covered under Preventive Care. | Benefits are based on services provided | Not Covered |
| Bariatric Surgery | Not Covered | Not Covered |
| Biofeedback Therapy | Not Covered | Not Covered |
| Cardiac Rehabilitation (Phase 1 and 2 only; Phase 3 is excluded; see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Chemotherapy & Radiation Therapy | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Clinical Trials — Routine Services during Approved Clinical Trials (limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services; see Medical Benefits section for other limitations) | Benefits are based on services provided | Benefits are based on services provided |
| Cochlear Implants | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Dental/Oral Services (excludes excision of impacted wisdom teeth; see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Diabetes Self-Management Training and Education | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Dialysis/Hemodialysis (see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Durable Medical Equipment (see Medical Benefits section for other limitations) | 70% (after Deductible) | Not Covered |
| Early Intervention Services (up to age 3; see Medical Benefits section for limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Erectile Dysfunction Treatment | Not Covered | Not Covered |
| Family Planning — For Women (see also Prescription Drug Benefit and Preventive Care Section) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Family Planning — For Men | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Gender Dysphoria Treatment and Related Services | Not Covered | Not Covered |
| Gene Therapy (precertification required for inpatient hospitalization) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Genetic Counseling, Testing and Related Services (Note: Coverage is provided for BRCA Testing — see Breast Cancer Screening in Preventive Care Services; precertification is not required) | Not Covered | Not Covered |
| Growth Hormones (see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Hearing Aids | Not Covered | Not Covered |
| Home Health Care — Up to 60 visits per person per Plan Year (see Medical Benefits section for limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Hospice Care — Inpatient/Outpatient (precertification required for inpatient services; see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Infertility Treatment | Not Covered | Not Covered |
| Injectables | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Learning Deficiencies, Behavioral Problems/Developmental Delays (precertification and visit limits are based on services provided) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Marital Counseling | Not Covered | Not Covered |
| Massage Therapy | Not Covered | Not Covered |
| Medical and Enteral Formula | Not Covered | Not Covered |
| Modified Low Protein Food Products | Not Covered | Not Covered |
| Neuromuscular Stimulator Equipment including TENS | Not Covered | Not Covered |
| Occupational Therapy (for treatment due to Illness or Injury; see Medical Benefits section for other limitations) — Up to 30 visits per person, per Plan Year, combined with Physical Therapy | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Oral Pharynx Procedures | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Orthotics (includes foot orthotics; see Medical Benefits section for other limitations) | 70% (after Deductible) | Not Covered |
| Physical Therapy (for treatment due to Illness or Injury; see Medical Benefits section for other limitations) — Up to 30 visits per person, per Plan Year, combined with Occupational Therapy | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Podiatry Care (see Medical Benefits section for limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Private Duty Nursing | Not Covered | Not Covered |
| Prosthetics (see Medical Benefits section for limitations) | 70% (after Deductible) | Not Covered |
| Rehabilitation Hospital (precertification required; see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Respiratory Therapy | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Sleep Studies | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Skilled Nursing Facility / Extended Care Facility (precertification required; see Medical Benefits section for other limitations) — Up to 60 days per person, per Plan Year | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Speech Therapy (for treatment due to Illness or Injury; see Medical Benefits section for other limitations) — Up to 20 visits per person, per Plan Year | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Telemedicine (applies to medical and behavioral health services; see Medical Benefits section for additional information) — Includes Doctor on Demand | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Temporomandibular Joint Disorders (TMJ) Treatment | Not Covered | Not Covered |
| Termination of Pregnancy (covered only in circumstances in which the life of the mother would be endangered by continuing the pregnancy to term, as documented by the treating Physician) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Travel Immunizations | Not Covered | Not Covered |
| Voluntary Sterilization — For Women | 100% (Deductible waived) | Not Covered |
| Voluntary Sterilization — For Men | 100% (after Deductible) | Not Covered |
| Wigs | Not Covered | Not Covered |
12. Wellness Benefits
| Service | All Providers |
|---|---|
| Childbirth Classes | Not Covered |
| Fitness Reimbursement Benefit | Not Covered |
| Weight Loss Reimbursement Benefit | Not Covered |
13. Disclaimer
IMPORTANT: This Internal Schedule is not a complete listing of all Plan benefits and exclusions. Please refer to the Medical Benefits Section and the Medical Limitations and Exclusions Section in the Plan Document/Summary Plan Description for a complete list of benefit and non-benefit type exclusions.
This article is for support and reference purposes only. For the most current and complete benefit information, consult the official Plan Document/Summary Plan Description.