Seacoast Community Church – PPO Plan Summary of Benefits
This article provides a comprehensive reference to the Schedule of Medical Benefits for Seacoast Community Church, Inc. – PPO Plan, effective March 1, 2026. The plan uses the CIGNA PPO network for in-network providers, with out-of-network claims priced through Phia. Utilization management is handled by Cigna Payer Solutions, case management by MedWatch, and customer service by Karias Care Concierge. Prescription drugs are administered by TrueScripts. The plan is not MCC Creditable. This article covers all benefit categories including deductibles, coinsurance, out-of-pocket maximums, prescription drug benefits, preventive care, physician services, hospital services (inpatient and outpatient), mental health/substance use, vision care, and all other covered and excluded services. In-network and out-of-network deductibles and out-of-pocket maximums are SEPARATE and do not cross-accumulate.
Seacoast Community Church – PPO Plan Summary of Benefits
Effective Date: March 1, 2026 Plan Year: 3/1/2026 – 2/28/2027 Group #: 001R2636 Plan Type: PPO (Managed Care) PPO Network: CIGNA Status: NGF
Document Link : PPO Plan pdf
1. Plan Administration & Internal Details
| Item | Detail |
|---|---|
| Plan Sponsor | Seacoast Community Church, Inc. |
| Plan Name | PPO Plan (Managed Care Type: PPO) |
| Group Number | 001R2636 |
| Effective Date | March 1, 2026 |
| Status | NGF |
| PPO Network | CIGNA |
| Out-of-Network Claims Pricing | Phia |
| Utilization Management (UM) | Cigna Payer Solutions |
| Case Management (CM) | MedWatch |
| Disease Management (DM) | N/A |
| Customer Service | Karias Care Concierge |
| Prescription Drug Administrator | TrueScripts |
| MCC Creditable | No |
| Approved By (TRU) | TRU Department (Date: pending) |
| Account Manager | Julie Elwell / Kate Gilpatrick (Date: pending) |
| Compliance | Patrick Moore (Date: pending) |
2. 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 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, and therapeutic monitoring services. Coverage/cost varies based on where 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. Includes 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. |
3. Standardly Excluded Services
| Excluded Service |
|---|
| Sex therapy |
| Xenotransplants (cross-species) transplants |
4. Prescription Drug Benefit – Administered by TrueScripts
Key Rules:
- Prescription drug copayments and coinsurance accumulate toward the Plan Year Out-of-Pocket Maximum.
- Once the OOP Max is met, prescriptions are covered at 100% for the balance of the Plan Year.
- Prescriptions are NOT subject to Deductibles.
- Prescription drug costs count toward the COMBINED Medical OOP Max (not a separate Rx OOP Max).
- Out-of-Network pharmacy coverage is NOT COVERED.
Contraceptives: Generic FDA-approved contraceptive medications and devices are covered at 100%. Preferred brand name and non-preferred brand name contraceptive medications are subject to the copays shown below, 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%.
Tobacco Cessation: Tobacco cessation products are covered at 100%.
Retail Card Program (Up to 30-Day Supply)
| Drug Tier | You Pay |
|---|---|
| Generic | $15 copay |
| Preferred Brand Name | $40 copay |
| Non-Preferred Brand Name | $70 copay |
Retail Card Program (Up to 90-Day Supply)
| Drug Tier | You Pay |
|---|---|
| Generic | $45 copay |
| Preferred Brand Name | Not available at retail for 90-day supply |
| Non-Preferred Brand Name | Not available at retail for 90-day supply |
Mail Order Pharmacy (Up to 90-Day Supply)
| Drug Tier | You Pay |
|---|---|
| Generic | $25 copay |
| Preferred Brand Name | $90 copay |
| Non-Preferred Brand Name | $175 copay |
Specialty Drugs – Retail Only (Up to 30-Day Supply)
| Specialty Tier | You Pay |
|---|---|
| Tier 1 Specialty | $125 copay |
| Tier 2 Specialty | 20% coinsurance, up to $550 maximum |
| Tier 3 Specialty | 20% coinsurance, up to $2,000 maximum |
| Tier 4 Specialty | 20% coinsurance |
| Tier 5 Specialty | 50% coinsurance |
See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs.
5. Deductibles, Coinsurance & Out-of-Pocket Maximums
Medical Plan Year Deductible
Individual Deductible Included in Family Coverage: YES
| Coverage Level | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee only) | $2,000 | $6,000 |
| Family Plan – Per Person | $2,000 | $6,000 |
| Family Plan – Family Maximum | $4,000 | $12,000 |
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 OOP Max is reached, then 100% thereafter | 50% of the Allowed Amount* (after Deductible; unless otherwise stated) until OOP Max is reached, then 100% thereafter |
Plan Year Deductible & Coinsurance Maximums
Includes Plan Year Deductible, Coinsurance, and Prescription Drug Copayments and Coinsurance. Individual OOP Max Included in Family Coverage: YES
| Coverage Level | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee only) | $5,000 | $14,000 |
| Family Plan – Per Person | $5,000 | $14,000 |
| Family Plan – Family Maximum | $10,000 | $28,000 |
Plan Year Out-of-Pocket Maximums
Includes all applicable Copayments, Plan Year Deductible and Coinsurance, including those for prescription drugs. Individual OOP Max Included in Family Coverage: YES
| Coverage Level | In-Network | Out-of-Network |
|---|---|---|
| Single Plan (Employee only) | $7,900 | Unlimited |
| Family Plan – Per Person | $7,900 | Unlimited |
| Family Plan – Family Maximum | $15,800 | Unlimited |
Family OOP Max Rule: The Family Plan contains both an individual and a family Out-of-Pocket Maximum. Once an individual family member satisfies the individual OOP Max, claims for that individual are paid at 100%. Once the entire family OOP Max is satisfied, claims are paid at 100% for all covered family members. The family OOP Max 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 Deductible for the Plan Year starting 3/1/2026 and ending 2/28/2027.
6. Deductible & OOP Max Accumulation Rules
IMPORTANT: In-Network and Out-of-Network Deductibles are SEPARATE and do not cross-accumulate. Eligible expenses which track toward the In-Network Deductible and OOP Max will NOT be credited toward the Out-of-Network Deductible and OOP Max, and vice versa.
IMPORTANT: In-Network and Out-of-Network Out-of-Pocket Maximums are SEPARATE.
NOTE: Covered Services that contain dollar, frequency, or visit limits are combined In-Network and Out-of-Network maximums.
Expenses Excluded from Out-of-Pocket Maximum:
- Precertification penalties
7. No Surprises Act (NSA) Provisions
Emergency services rendered by Out-of-Network Providers for "Emergency Care" (as defined in the Plan's Definitions section), air ambulance services rendered by Out-of-Network Providers, and non-emergency services rendered by Out-of-Network Providers on an inpatient or outpatient basis at an In-Network Hospital or facility for the following specialties will be paid at In-Network Deductible, Copayment, and Coinsurance levels, subject to the Qualifying Payment Amount:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory
- Neonatology
- Assistant surgeon
- Hospitalist
- Intensivist
This applies provided the Covered Person has NOT validly waived the applicability of the No Surprises Act of the Consolidated Appropriations Act of 2021 (NSA).
Balance Billing Protections: Out-of-Network Providers CANNOT balance bill the Covered Person for emergency services or air ambulance services. For non-emergency services at In-Network facilities (for the specialties listed above), the OON Provider cannot balance bill UNLESS the Covered Person gives written consent and waives their NSA protections. If a Covered Person waives their protections, OON Providers will be paid according to the Plan's In-Network level of benefits, subject to the Allowed Amount.
Other OON Services: When services are rendered by an Out-of-Network Provider in any instance other than those listed above, Covered Persons may be responsible for any amount above the Allowed Amount.
8. 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 these recommendations are issued by the U.S. Preventive Service Task Force (USPSTF) and 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.
| 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 postpartum period; rental or purchase of breastfeeding equipment. Hospital Grade Breast Pumps: rental covered up to 3 months; precertification required for rental in excess of 3 months. Electric Breast Pumps: rent or purchase, whichever is less. Manual Breast Pumps: 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 the USPSTF) | 100% (Deductible waived) | NOT COVERED |
| **Lung Cancer Screening, including LDCT (As recommended by the 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 the 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 |
9. 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) |
10. Physician Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Allergy Testing | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Allergy Treatment | $25 PCP or $50 Specialist Copay, then 100% (Deductible waived) | 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. Lab and x-ray charges paid based on services provided, not subject to office visit or dollar limits.) | $50 Copay per visit, then 100% (Deductible waived) | 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 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 – Primary Care (Includes all related charges billed at time of visit) | $25 Copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Physician Office Visits – Specialist (Includes all related charges billed at time of visit) | $50 Copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Second Surgical Opinion | $50 Copay per visit, then 100% (Deductible waived) | 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) | $25 PCP or $50 Specialist Copay, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
11. 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 Copayments, Deductibles, or Out-of-Pocket Maximums under this Plan. Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Private Room: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.
| 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 hrs [vaginal]; 96 hrs [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®; semi-private room or special care unit; excludes transportation/food/lodging expenses; see Medical Benefits section for other limitations) | 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) |
12. Hospital Services – Outpatient
| 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. Copayment waived if admitted inpatient to a Hospital.) | $500 Copay per visit, then 100% (Deductible waived) | $500 Copay per visit, then 100% (Deductible waived) |
| 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 | $50 Copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
13. 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 Copayments, Deductibles, or Out-of-Pocket Maximums under this Plan. Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Private Room: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospitalization (Precertification required) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Partial Hospitalization / Intensive Outpatient Treatment | 100% (Deductible waived) | 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 | $25 Copay per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Methadone Maintenance / Treatment | NOT COVERED | NOT COVERED |
14. Other Services & Supplies
| 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 ABA; OT, PT, speech therapy benefit limits do not apply; precertification required for ABA; screenings covered under Preventive Care; see Medical Benefits section for limitations) | 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 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 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 | $25 Copay per visit, then 100% (Deductible waived) | 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) – Independent Facilities | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) – All Other Facilities | 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 Rx Benefit and Preventive Care Section; including but not limited to consultations and diagnostic tests) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Family Planning – For Men (Including but not limited to consultations and diagnostic tests) | 100% (Deductible waived) | 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: BRCA Testing is covered under Breast Cancer Screening in Preventive Care Services; precertification is not required for BRCA) | 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 other 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; up to 30 visits per person, per Plan Year, combined with Physical Therapy; see Medical Benefits section for other limitations) | 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; up to 30 visits per person, per Plan Year, combined with Occupational Therapy; see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Podiatry Care (See Medical Benefits section for limitations) | $50 Copay per visit, then 100% (Deductible waived) | 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 – Independent Facilities | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Sleep Studies – All Other Facilities | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Skilled Nursing Facility / Extended Care Facility (Precertification required; up to 60 days per person, per Plan Year; see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Speech Therapy (For treatment due to Illness or Injury; up to 20 visits per person, per Plan Year; see Medical Benefits section for other limitations) | 70% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Telemedicine (Applies to medical and behavioral health services; includes Doctor On Demand; see Medical Benefits section for additional information) | $25 Copay per visit, then 100% (Deductible waived) | 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% (Deductible waived) | NOT COVERED |
| Wigs | NOT COVERED | NOT COVERED |
15. Wellness Benefits
| Service | All Providers |
|---|---|
| Childbirth Classes | NOT COVERED |
| Fitness Reimbursement Benefit | NOT COVERED |
| Weight Loss Reimbursement Benefit | NOT COVERED |
16. 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.
Document Version: 26.0 Draft History: 2-6-2026 PM, 2-10-2026 PM, 2-12-2026 PM, 2-20-2026 PM, 2-25-2026 PM
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.