Taunton Federal Credit Union — HSA Health Plan

1. Client & Plan Overview

Client: Taunton Federal Credit Union

Number of Plan Options: 1 Plan Option (HSA Health Plan), offered under 2 networks based on geographic location, with 4 Med Ben Plan Code combinations (Employee/Family × Harvard Pilgrim/UHC Options)

Field	Detail
Plan Name	HSA Health Plan
Plan Type	QHDHP PPO
Network (Inside MA, ME, NH, RI & VT)	Harvard Pilgrim
Network (Outside MA, ME, NH, RI & VT)	UHC Options PPO
Network Provider Lookup Tool	Harvard Pilgrim Provider Lookup Tool — point32health.healthsparq.com (insurerCode=HARVARDPILGRIM_I, brandCode=A002); this tool will direct members to the UHC network if they are located outside of the Harvard Pilgrim service area
TPA	Health Plans, Inc. (HPI)
PBM	TrueScripts

Med Ben Plan Code Mapping:

Med Ben Plan Code	Medical Benefit Plan Name	Network
D2650U6MSI1	HSA Health Plan (Employee)	Harvard Pilgrim
D2650U6MFA1	HSA Health Plan (Family)	Harvard Pilgrim
D2650U4MSI1	HSA Health Plan (Employee)	UHC Options
D2650U4MFA1	HSA Health Plan (Family)	UHC Options

(All four codes are associated with Group #62650, Taunton Federal Credit Union, effective 8/1/2026.)

---

2. TPA & PBM Contact Information

TPA: Health Plans, Inc. (HPI)

Field	Detail
Website	www.hpiTPA.com
Member Phone Line	877-906-5730
Member Portal	HPI – Log in to My Plan, at healthplansinc.com/members/members-secured
Claims Questions	Via Member Services Phone Line (877-906-5730), or via Employer Portal (Employer Portal has access to claims)

PBM: TrueScripts

Field	Detail
Website	www.truescripts.com
Member Portal	Member Portal Registration available via TrueScripts website
Help Desk / Member Services	844-257-1955

Prescription Benefit Info (for JDC):

Field	Value
RxBin	025862
RxPCN	TSAC
RxGroup	00026204

---

3. Plan Identification & Internal Use Information

Document Title: Schedule of Medical Benefits for Taunton Federal Credit Union – Eff 8/1/26 & Corr 7/10/26: HSA Health Plan PPO Plan

Template Reference: 2026 2-Tier New England Schedule Template (as of 9/3/2025)

Document Version Trail: Taunton Federal Credit Union_United Schedule_PPO Plan_Effective Date 8/1/2026_DRAFT as of 6/30/2026 RL; 7/10/2026 RL; 7/13/2026 RL; 7/15/2026 RL; 7/20/2026 RL

Field	Value
Managed Care Type	QHDHP (PPO)
Group #	D2650
Effective Date	8/1/2026
Status	NGF

Approval Signatures (blank in draft):

Role	Name	Date
TRU	—	-
Acct Manager	Brittney Chappell / Jennifer Keifer	-
Compliance	Rita Lyakhovetskaya	-

Internal Use Only:

Field	Detail
PPO Network	United Options (44/6)
Is this an LP Plan?	NO
UM (Utilization Management)	Carelon for Genetic Testing (see Genetic Testing benefit to confirm if covered under the Plan); HPI CMS for all other services
CM (Case Management)	HPI CMS
DM (Disease Management)	HPI CMS
Customer Service	HPI CS
MCC Creditable	Yes

---

4. Standardly Covered Services

• Breast Reduction Surgery, when Medically Necessary; precertification required
• Orthoptics, unless otherwise listed as excluded in the Plan Document
• For Breastfeeding Support, Supplies and Counseling: If there are no In-Network (INN) lactation providers, then Out-of-Network (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.
• Coverage for Child/Adolescent MH/SU (Mental Health/Substance Use) 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 include 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.

---

5. Standardly Excluded Services

• Sex therapy
• Xenotransplants (cross-species) transplants

---

6. Prescription Drug Benefit (Administered by TrueScripts)

General Terms:

• 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 has been met, prescription drugs will be covered at 100% for the balance of the Plan Year.
• U.S. Food and Drug Administration (FDA) approved contraceptive medications and devices are covered at 100% (Deductible waived)
• Tobacco cessation products are covered at 100% (Deductible waived)
• Preventive Care medications are not subject to the Deductible

Eff 8/1/26 & Corr 7/10/26:

Program	Supply	Generic	Preferred Brand	Non-Preferred Brand
Retail Card Program (After Deductible, You Pay)	Up to 30-day supply	$0 Co-Payment	$20 $10 Co-Payment	$30 Co-Payment
Retail Card Program (After Deductible, You Pay)	Up to 90-day supply	$0 Co-Payment	$40 $20 Co-Payment	$60 $40 Co-Payment
Mail Order Pharmacy (After Deductible, You Pay)	Up to 90-day supply	$0 Co-Payment	$40 $20 Co-Payment	$60 $40 Co-Payment

Specialty Drugs (Retail and Mail Order) — After Deductible, You Pay:
(30-90 day supply): 20% Coinsurance up to $200 per prescription for Specialty drugs.

Out-of-Network Pharmacy Coverage: Not Covered

Question	Answer
Do Prescription Drug Costs count to a Separate Rx OOP Max or count toward Medical OOP Max?	COMBINED
Are scripts subject to Deductibles?	YES, MEDICAL DEDUCTIBLE

---

7. Medical Benefits — Deductible, Coinsurance, Out-of-Pocket Maximums

Medical Plan Year Deductible

Eff 8/1/26 & Corr 7/10/26

Field	Value
Individual Deductible Included in Family Coverage	NO

Benefit Levels	In-Network Providers	Out-of-Network Providers
Single Plan (Employee only)	$1,700	$10,000
Family Plan (Employee & family)	$3,400 per family	$20,000 per family

Note: Family Plan members – The entire family Deductible must be satisfied before claims are paid for any covered family member. It may be satisfied by any combination of one or more family members.

Medical Plan Year Deductible Carryover: NO

Reimbursement Percentage ("Coinsurance")

In-Network Providers	Out-of-Network Providers
100% of the Contracted Rate (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximums has been reached, then 100% thereafter for the balance of the Plan Year	80% of the Allowed Amount (after Deductible; unless otherwise stated) until the Out-of-Pocket Maximums has been reached, then 100% thereafter for the balance of the Plan Year

Plan Year Out-of-Pocket Maximums

Eff 8/1/26 & Corr 7/20/26
(Including all applicable Co-payments, Year Deductible and Coinsurance, including those for prescription drugs)

Field	Value
Individual OOPM Included in Family Coverage	YES

Benefit Levels	In-Network Providers	Out-of-Network Providers
Single Plan (Employee only)	$7,500	$18,000
Family Plan (Employee & family)	$10,600 per person, up to $15,000 per family	$18,000 per person, up to $36,000 per family

Note: The Family Plan contains both an individual Out-of-Pocket Maximums and a family Out-of-Pocket Maximums. 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 Maximums is satisfied, claims will be paid at 100% for all covered family members. The family Out-of-Pocket Maximums may be met by any combination of family members.

Network Notes:

• Primary network for subscribers residing in the 5 New England states and their covered dependents: HPHC (Harvard Pilgrim Health Care)
• Primary network for subscribers residing in the other 45 states and their covered dependents: UnitedHealthcare
• Please note that other networks may apply. Covered Persons should refer to their ID Cards for the network that applies to them.

---

8. Important Notes on Network Rules & No Surprises Act (NSA)

Emergency & Surprise Billing Protections:
Emergency services rendered by Out-of-Network Providers for "Emergency Care" as defined in the section titled "Definitions"; 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 of the Consolidated Appropriations Act of 2021 (NSA), will be paid at the In-Network Provider Deductible, Co-payment and Coinsurance levels, subject to the Qualifying Payment Amount.

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 emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist 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 Out-of-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 when services are rendered by an Out-of-Network Provider.

Deductible/OOPM Combination Rules:

• The In-Network Provider and Out-of-Network Provider Deductible and Out-of-Pocket Maximums are combined. 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.
• In addition, Covered Services that contain dollar, frequency, or visit limits are combined In-Network and Out-of-Network maximums.

Field	Status
In/Out-of-Network Deductibles	COMBINED
In/Out-of-Network Out-of-Pocket Maximums	COMBINED

Expenses excluded from the Medical Out-of-Pocket Maximum:

• Precertification penalties

---

9. Preventive Care

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. Please see the Medical Benefits section for additional details about the preventive coverage provided, or a complete listing can be found via the referenced full listing. 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 Providers	Out-of-Network Providers
**Routine Physical Exams (Including routine and travel immunizations and flu shots)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Routine Well Child Care (Including screenings, routine and travel immunizations and flu shots)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Fluoride Varnish (Up to age 6; up to four (4) varnish treatments per person, per Plan Year)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Breastfeeding Support, Supplies and Counseling (During pregnancy and/or in the postpartum period and rental or purchase of breastfeeding equipment) Breast Pump Limits: 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)	80% Allowed Amount (after Deductible)
**Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Routine Gynecological/Obstetrical Care (Including preconception and prenatal services)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Routine Pap Smears	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Breast Cancer Screening including Routine Mammograms and BRCA testing	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Routine Immunizations (If not billed with an office visit; includes flu shots and travel immunization)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Routine Lab, X-rays, and Clinical Tests (Including those related to maternity care)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Routine Colorectal Cancer Screening, including sigmoidoscopies and colonoscopies (As recommended by the USPSTF)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Lung Cancer Screening, including Low-Dose Computed Tomography (LDCT) (As recommended by USPSTF; up to one (1) per person, per Calendar Year)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Nutritional Counseling	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Smoking Cessation Counseling and Intervention (Including smoking cessation clinics and programs)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Routine Hearing Exams	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Routine Prostate Exams and Prostate-Specific Antigen (PSA) Screenings	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Abdominal Aortic Aneurysm Screening (As recommended by USPSTF; up to one (1) per person, per lifetime)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Bone Density Screening — Women (As recommended by USPSTF for Osteoporosis Screening)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
**Bone Density Screening — All other Covered Persons	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Equipment for those with Chronic Conditions (Limited to: Blood pressure monitor [hypertension]; Peak flow meter [asthma]; Glucometer and selected insulin products such as vial, pump or inhaler [diabetes])	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Tests/Screenings for those with Chronic Conditions (Limited to: Hemoglobin A1c [diabetes]; Retinopathy screening [diabetes]; INR [liver disease or bleeding disorders]; LDL [heart disease])	100% (Deductible waived)	80% Allowed Amount (after Deductible)

---

10. Vision Care

Service	In-Network Providers	Out-of-Network Providers
Routine Vision Exam (Excludes contact lens fitting)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Routine Eyewear (Lenses, frames, and contact lenses) — Up to $150 per person per Plan Year — Eff 8/1/26 & Corr 7/15/26	100% (after Deductible)	80% Allowed Amount (after Deductible)
Eyewear for Special Conditions (Initial purchase of non-routine eyewear following surgery; contact lenses needed to treat keratoconus, including the fitting of these contact lenses; intraocular lenses implanted after corneal transplant, cataract surgery or other covered eye surgery when the natural eye lens is replaced)	100% (after Deductible)	80% Allowed Amount (after Deductible)

Note: Per the original (pre-correction) draft, Routine Eyewear was listed as NOT COVERED for both In-Network and Out-of-Network; this was updated per Eff 8/1/26 & Corr 7/15/26 to the coverage shown above.

---

11. 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 Providers	Out-of-Network Providers
Allergy Testing	100% (after Deductible)	80% Allowed Amount (after Deductible)
Allergy Treatment	100% (after Deductible)	80% Allowed Amount (after Deductible)
Anesthesia (Inpatient/Outpatient)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Chiropractic Services (Charges for lab and x-ray paid based on services provided, not subject to office visit or dollar limits; up to 50 visits per person per Plan Year)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Maternity – Prenatal care (Eff 8/1/26 & Corr 7/15/26)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Maternity – Physician delivery charges (Excluding Including home births)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Maternity – Postnatal care (Includes home visit with a Visiting Nurse following early discharge)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Physician Hospital Visits	100% (after Deductible)	80% Allowed Amount (after Deductible)
Physician Office Visits – Primary Care (Includes naturopaths and all related charges billed at time of visit)	100% (after Deductible), then $25 Co-payment per visit	80% Allowed Amount (after Deductible)
Physician Office Visits – Specialist (Includes all related charges billed at time of visit) — Eff 8/1/26 & Corr 7/10/26	100% (after Deductible), then $25 Co-payment per visit 100% (after Deductible), then $40 Co-payment per visit	80% Allowed Amount (after Deductible)
Second Surgical Opinion — Eff 8/1/26 & Corr 7/10/26	100% (after Deductible), then $25 Co-payment per visit 100% (after Deductible), then $40 Co-payment per visit	80% Allowed Amount (after Deductible)
Surgery (Inpatient)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Surgery (Outpatient)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Surgery (Physician's office)	100% (after Deductible)	80% Allowed Amount (after Deductible)

 

---

12. Hospital Services — Inpatient

General Notes:

• 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.
• Note: 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 Providers	Out-of-Network Providers
Hospital Room & Board (Precertification required; Semi-private room or special care unit)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Maternity Services (Precertification required for stays in excess of 48 hours [vaginal]; 96 hours [cesarean]; Semi-private room or special care unit)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Birthing Center	100% (after Deductible)	80% Allowed Amount (after Deductible)
Newborn Care (Includes Physician visits & circumcision; Semi-private room or special care unit)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Organ, Bone Marrow and Stem Cell Transplants (Precertification required; see Medical Benefits section for other limitations) Semi-private room or special care unit; Transportation/food/lodging limits: Up to $50,000 per person per lifetime maximum — Eff 8/1/26 & Corr 7/15/26	100% (after Deductible)	80% Allowed Amount (after Deductible)
Surgical Facility & Supplies	100% (after Deductible)	80% Allowed Amount (after Deductible)
Miscellaneous Hospital Charges	100% (after Deductible)	80% Allowed Amount (after Deductible)

---

 

13. Hospital Services — Outpatient

Outpatient Hospital Co-payment: A separate $25 Hospital Co-payment will apply to each outpatient/surgical procedure performed in an In-Network facility up to a maximum of $[blank in source]. (The Co-payment will not apply to office surgery)

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 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 Providers	Out-of-Network Providers
Clinic Services (At a Hospital)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Emergency Room Expenses (Includes Facility, Lab, X-ray & Physician services)	Deductible, then $250 Co-payment per visit, then 100%	In-Network Deductible, then $250 Co-payment per visit, then 100%
Outpatient Department	100% (after Deductible)	80% Allowed Amount (after Deductible)
Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. (Precertification required for total joint replacement and non-emergent spine surgeries) — Eff 8/1/26 & Corr 7/13/26	100% (after Deductible) 100% (Deductible waived)	Deductible, then $25 Co-payment per visit, then 100% — 80% Allowed Amount (after Deductible)
Preadmission Testing	100% (after Deductible)	80% Allowed Amount (after Deductible)
Urgent Care Facility/Walk-In Clinic	Deductible, then $25 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)

Note: The Outpatient Surgery in Hospital/Ambulatory Surgical Center row contains overlapping formatting in the source draft. As shown in the source: In-Network reads "Eff 8/1/26 & Corr 7/13/26: 100% (after Deductible)" struck through to "100% (Deductible waived)"; Out-of-Network column text reads "Deductible, then $25 Copayment per visit, then 100%" followed by "80% Allowed Amount (after Deductible)" — both values are reproduced here exactly as they appear in the draft source.

 

---

14. Mental Health / Substance Use

General Notes:

• 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.
• Outpatient Hospital Co-payment: A separate $25 Hospital Co-payment will apply to each outpatient/surgical procedure performed in an In-Network facility up to a maximum of $[blank in source]. (The Co-payment will not apply to office surgery)
• Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
• Note: 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 Providers	Out-of-Network Providers
Inpatient Hospitalization (Precertification required)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Partial Hospitalization/Intensive Outpatient Treatment (Precertification required)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Inpatient Physician Visit	100% (after Deductible)	80% Allowed Amount (after Deductible)
Hospital Clinic Visit	100% (after Deductible)	80% Allowed Amount (after Deductible)
Office Visit	Deductible, then $25 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Methadone Maintenance/Treatment	Deductible, then $25 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)

 
 

---

15. 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 Providers	Out-of-Network Providers
Acupuncture (Up to 20 visits per person per Plan Year)	Deductible, then $30 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Alternative/Complementary Care Benefit (Biofeedback, Chelation Therapy, Homeopathic treatment, Hypnosis/Hypnotherapy, Rolfing/Reiki)	NOT COVERED	NOT COVERED
Ambulance Services (Precertification required for non-emergent air ambulance services; see Medical Benefits section for limitations)	100% (after Deductible)	100% Allowed Amount (after In-Network Deductible)
Autism Spectrum Disorders Treatment (Includes Applied Behavioral Analysis [ABA]; any benefit limits under the Plan for occupational, physical and speech therapies do not apply; precertification required for ABA; see Medical Benefits section for limitations.) Note: Screenings are covered under Preventive Care	Benefits are based on services provided	Benefits are based on services provided
Bariatric Surgery (Precertification required; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Cardiac Rehabilitation (Phase 1 and 2 only; Phase 3 excluded; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Chemotherapy (Precertification required for chemotherapy, including chemotherapy services administered in a Physician's office; precertification not required for Chemotherapy support drugs)	100% (after Deductible)	80% 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 (Precertification required)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Dental/Oral Services (Excludes excision of impacted wisdom teeth; precertification required for facility and anesthesia services; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Diabetes Self-Management Training and Education	100% (after Deductible)	80% Allowed Amount (after Deductible)
Diagnostic Imaging (MRI, CT Scan, PET Scan) – Freestanding Facility	100% (after Deductible)	80% Allowed Amount (after Deductible)
Diagnostic Imaging (MRI, CT Scan, PET Scan) – All Other Facilities	Deductible, then $200 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Diagnostic X-ray and Laboratory (Outpatient)	Deductible, then $25 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Dialysis/Hemodialysis (Precertification required for initial treatment; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Durable Medical Equipment (Precertification required for equipment purchase in excess of $1,000, or for equipment rental in excess of three (3) months when cost exceeds $1,000, implantable loop recorders, and implantable defibrillators; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Early Intervention Services (Up to age 3; see Medical Benefits section for limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Erectile Dysfunction Treatment (Precertification required for surgical procedures; see Medical Benefits section for limitations)	NOT COVERED	NOT COVERED
Family Planning – For Women (Including but not limited to consultations and diagnostic tests; see also Prescription Drug Benefit and Preventive Care Section)	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Family Planning – For Men	100% (after Deductible)	80% Allowed Amount (after Deductible)
Gender Dysphoria Treatment and Related Services (Includes gender identity counseling, gender reaffirmation surgery and hormone replacement therapy; precertification required for gender reaffirmation surgery; see Medical Benefits section for other limitations)	Benefits are based on services provided	Benefits are based on services provided
Gene Therapy (Precertification required)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Genetic Counseling, Testing and Related Services (Precertification required for genetic testing; Note: Coverage is provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services; precertification is not required)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Growth Hormones (Precertification required; see Medical Benefits section for other limitations)	NOT COVERED	NOT COVERED
Hearing Aids (Up to $500 per aid each ear every two years)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Home Health Care (Precertification required; see Medical Benefits section for other limitations; up to 60 visits per person per Plan Year)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Hospice Care (Inpatient/Outpatient) (Precertification required; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Infertility Treatment (Precertification required; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Injectables (Precertification required for treatments in excess of $2,000; Note: See Chemotherapy benefit for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Learning Deficiencies, Behavioral Problems/Developmental Delays (Precertification and visit limits are based on services provided)	Deductible, then $25 Co-payment per visit, then 100%	80% 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 60 visits per person, per Plan Year, combined with Physical Therapy and Speech Therapy) — Eff 8/1/26 & Corr 7/13/26	Deductible, then $25 Co-payment per visit, then 100% Deductible, then $50 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Orthotics (Precertification required as noted under the Durable Medical Equipment benefit; includes foot orthotics; see Medical Benefits section for other limitations; up to age 18) — Eff 8/1/26 & Corr 7/15/26	100% (after Deductible)	80% Allowed Amount (after Deductible)
Physical Therapy (For treatment due to Illness or Injury; see Medical Benefits section for other limitations; up to 60 visits per person, per Plan Year, combined with Occupational Therapy and Speech Therapy) — Eff 8/1/26 & Corr 7/13/26	Deductible, then $25 Co-payment per visit, then 100% Deductible, then $50 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Podiatry Care (See Medical Benefits section for limitations)	Deductible, then $25 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Private Duty Nursing	NOT COVERED	NOT COVERED
Prosthetics (Precertification required as noted under the Durable Medical Equipment benefit; see Medical Benefits section for limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Radiation Therapy (Precertification required for intensity-modulated radiation therapy [IMRT], stereotactic body radiation therapy [SBRT], image-guided radiation therapy [IGRT], proton beam, stereotactic and internal radiation therapy)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Rehabilitation Hospital (Precertification required; see Medical Benefits section for other limitations; up to 100 days per person, per Plan Year, combined with Skilled Nursing Facility)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Respiratory Therapy	100% (after Deductible)	80% Allowed Amount (after Deductible)
Skilled Nursing Facility/Extended Care Facility (Precertification required; see Medical Benefits section for other limitations; up to 100 days per person, per Plan Year, combined with Rehabilitation Hospital)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Sleep Studies (Inpatient/Outpatient) (Limited to the testing and treatment of Obstructive Sleep Apnea; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Speech Therapy (For treatment due to Illness or Injury; precertification required; see Medical Benefits section for other limitations; up to 60 visits per person, per Plan Year, combined with Occupational Therapy and Physical Therapy) — Eff 8/1/26 & Corr 7/13/26	Deductible, then $25 Co-payment per visit, then 100% Deductible, then $50 Co-payment per visit, then 100%	80% Allowed Amount (after Deductible)
Telemedicine (Applies to medical and behavioral health services; see Medical Benefits section for additional information)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Temporomandibular Joint Disorders (TMJ) Treatment (Precertification required; see Medical Benefits section for other limitations)	100% (after Deductible)	80% Allowed Amount (after Deductible)
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, or due to rape or incest)	100% (after Deductible)	80% Allowed Amount (after Deductible)
Voluntary Sterilization – For Women	100% (Deductible waived)	80% Allowed Amount (after Deductible)
Voluntary Sterilization – For Men	100% (after Deductible)	80% Allowed Amount (after Deductible)
Wigs (When hair loss is due to the treatment of cancer, other serious medical condition, trauma, Injury or alopecia; see Medical Benefits section for other limitations; up to $1,000 limit per person per Plan Year)	100% (after Deductible)	80% Allowed Amount (after Deductible)

---

16. Wellness Benefits

Benefit	Coverage (All Providers)
Childbirth Classes	100% up to a maximum of $150 for childbirth classes for each covered expectant mother
Fitness Reimbursement Benefit	100% up to a total reimbursement of $150 per person per Plan Year for health club membership fees (Must be paid in the current Plan Year for membership in that year, and the paid date must be within your dates of enrollment in this Plan. Requests for reimbursement must be submitted to and approved by the Taunton Federal Credit Union Human Resource Department and submitted to the Claim Administrator for reimbursement. Reimbursement is available after providing proof of 4 months of membership in that year after enrollment into this Plan)
Weight Loss Reimbursement Benefit	100% up to a total reimbursement of $150 per person per Plan Year for weight loss clinics/programs such as Weight Watchers® or Savory Living®. Requests for reimbursement must be submitted to and approved by the Taunton Federal Credit Union Human Resource Department and submitted to the Claim Administrator for reimbursement. (Reimbursement is available after providing proof of 4 months of membership in that year after enrollment into this Plan)

This is not a complete listing of all Plan 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.

---

17. SBC: Important Questions & Answers

Document Header: Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Field	Value
Coverage Period	08/01/2026 – 07/31/2027
Plan Name	Taunton Federal Credit Union: HSA Health Plan
Coverage For	Employee & Dependents
Plan Type	QHDHP-PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-888-832-0354. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider or other underlined terms see the Glossary. You may view the Glossary at healthcare.gov/sbc-glossary or call 1-888-832-0354 to request a copy.

Important Question	Answer	Why This Matters
What is the overall deductible?	In-network — Single Plan: $1,700 employee; Family Plan: $3,400 family. Out-of-network — Single Plan: $10,000 employee; Family Plan: $20,000 family	Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.
Are there services covered before you meet your deductible?	Yes. In-network preventive services and routine vision exams are some of the services covered before you meet your deductible.	This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?	No.	You don't have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	In-network — Single Plan: $7,500 employee; Family Plan: $10,600 person/$15,000 family. Out-of-network — Single Plan: $18,000 employee; Family Plan: $18,000 person/$36,000 family	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit is met.
What is not included in the out-of-pocket limit?	Premiums, balance-billing charges and health care this plan doesn't cover.	Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See hpiTPA.com or call 1-888-832-0354 for a list of network providers.	This plan uses a provider network. You pay less if you use a provider in the plan's network. You pay the most if you use an out-of-network provider and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You may see a specialist you choose without a referral.

---

18. SBC: Common Medical Events — What You Will Pay

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

If you visit a health care provider's office or clinic

Services You May Need	In-Network Provider (You pay the least)	Out-of-Network Provider (You pay the most)	Limitations, Exceptions, & Other Important Information
Primary care visit to treat an injury or illness	deductible, then $25 copay/visit	20% coinsurance	You may have to pay for services that aren't preventive. Ask your provider if services are preventive. Then check what your plan will pay.
Specialist visit	deductible, then $25 copay/visit	20% coinsurance	(same as above)
Preventive care/screening/immunization	No charge; deductible waived	20% coinsurance	(same as above)

If you have a test

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Diagnostic test (x-ray, blood work)	Deductible, then $25 copay/visit	20% coinsurance	None
Imaging (CT/PET scans, MRIs) @ Freestanding Facilities	deductible only	20% coinsurance	None
Imaging (CT/PET scans, MRIs) @ All Other Facilities	deductible, then $200 copay/visit	20% coinsurance	None

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at hpiTPA.com

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Generic drugs: Retail (30-day supply)	$0 copay/prescription	Not covered	Deductible applies except to preventive care medications.
Generic drugs: Retail/Mail Order (90-day supply)	$0 copay/prescription	Not covered	(same as above)
Preferred brand drugs: Retail (30-day supply)	$20 copay/prescription	Not covered	(same as above)
Preferred brand drugs: Retail/Mail Order (90-day supply)	$40 copay/prescription	Not covered	(same as above)
Non-preferred brand drugs: Retail (30-day supply)	$30 copay/prescription	Not covered	(same as above)
Non-preferred brand drugs: Retail/Mail Order (90-day supply)	$60 copay/prescription	Not covered	(same as above)
Specialty drugs: Retail/Mail Order (30-90 day supply)	20% coinsurance; $200 max	Not covered	(same as above)

If you have outpatient surgery

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Facility fee (e.g., ambulatory surgery center)	deductible only	20% coinsurance	Preauthorization required for total joint replacement & non-emergent spine surgeries
Physician/surgeon fees	deductible only	20% coinsurance	(same as above)

If you need immediate medical attention

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Emergency room care	In-Network deductible; then $250 copay/visit	In-Network deductible; then $250 copay/visit	Copay waived if admitted.
Emergency medical transportation	In-Network deductible only	In-Network deductible only	None
Urgent care	Deductible, then $25 copay/visit	20% coinsurance	None

If you have a hospital stay

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Facility fee (e.g., hospital room)	deductible only	20% coinsurance	Preauthorization required.
Physician/surgeon fees	deductible only	20% coinsurance	(same as above)

If you need mental health, behavioral health or substance abuse services

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Outpatient services	Deductible, then $25 copay/visit	20% coinsurance	Preauthorization required for Inpatient services.
Inpatient services	deductible only	20% coinsurance	(same as above)

If you are pregnant

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Requires preauthorization for stays over 48 hrs (normal delivery) or 96 hrs (caesarean).

Services You May Need	In-Network Provider	Out-of-Network Provider
Office visits — Prenatal Care	No charge; deductible waived	20% coinsurance
Office visits — Postnatal Care	deductible only	20% coinsurance
Childbirth/delivery professional services	deductible only	20% coinsurance
Childbirth/delivery facility services	deductible only	20% coinsurance

If you need help recovering or have other special health needs

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Home health care	deductible only	20% coinsurance	60 visits/yr. Preauthorization required.
Rehabilitation services — Inpatient	deductible only	20% coinsurance	100 days/yr combined with Skilled Nursing care. Preauthorization required for Inpatient services & Speech therapy. 60 visits/yr combined for Occupational, Physical, & Speech therapies.
Rehabilitation services — Outpatient	$25 copay/visit	20% coinsurance	(same as above)
Habilitation services — Early Intervention	deductible only	Not covered	To age 3. Preauthorization requirements apply to coverage for developmental delays.
Habilitation services — Developmental Delay	deductible, then $25 copay/visit	20% coinsurance	(same as above)
Skilled nursing care	deductible only	20% coinsurance	100 days/yr combined with Inpatient Rehabilitation Hospital. Preauthorization required.
Durable medical equipment	deductible only	20% coinsurance	Preauthorization required for rental over 3 months, equipment over $1,000, implantable loop recorders & defibrillators.
Hospice services	deductible only	20% coinsurance	Preauthorization required.

If your child needs dental or eye care

Services You May Need	In-Network Provider	Out-of-Network Provider	Limitations, Exceptions, & Other Important Information
Children's eye exam	No charge; deductible waived	20% coinsurance	None
Children's glasses	deductible only	20% coinsurance	$150 max/year
Children's dental check-up	Not covered	Not covered	n/a

---

19. SBC: Excluded Services & Other Covered Services

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Cosmetic surgery
• Non-emergency care when traveling outside U.S.
• Dental care (routine child & adult)
• Private Duty Nursing
• Long term care
• Routine foot care

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

• Acupuncture (20 visits/yr)
• Hearing aids ($500/aid/ear/2yrs)
• Weight loss programs ($150/yr)
• Bariatric Surgery
• Infertility Treatment
• Chiropractic care (50 visits/yr)
• Routine eye care (adult)

---

 

20. SBC: Rights, Coverage Standards & Language Access

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is the U.S. Department of Labor, Employee Benefits Security Administration, at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, you can contact the plan at 1-888-832-0354. You may also contact the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

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

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

Language Access Services:

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

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

 

---

21. SBC: Coverage Examples

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Example 1: Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Plan Parameters	Amount
The plan's overall deductible	$1,700
Specialist copayment	$25
Hospital (facility) deductible	—
Other copayment	$25

This EXAMPLE event includes services like: Specialist office visits (prenatal care); Childbirth/Delivery Professional Services; Childbirth/Delivery Facility Services; Diagnostic tests (ultrasounds and blood work); Specialist visit (anesthesia)

Total Example Cost: $12,700

Cost Sharing	Amount
Deductibles	$1,700
Copayments	$0
Coinsurance	$0

What isn't covered	Amount
Limits or exclusions	$60

The total Peg would pay is: $1,760

Example 2: Managing Joe's Type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

Plan Parameters	Amount
The plan's overall deductible	$1,700
Specialist copayment	$25
Hospital (facility) deductible	—
Other	no charge

This EXAMPLE event includes services like: Primary care physician office visits (including disease education); Diagnostic tests (blood work); Prescription drugs; Durable medical equipment (glucose meter)

Total Example Cost: $5,600

Cost Sharing	Amount
Deductibles	$1,700
Copayments	$100
Coinsurance	$0

What isn't covered	Amount
Limits or exclusions	$20

The total Joe would pay is: $1,820

Example 3: Mia's Simple Fracture

(in-network emergency room visit and follow up care)

Plan Parameters	Amount
The plan's overall deductible	$1,700
Specialist copayment	$25
Hospital (facility) deductible	—
Other copayment	$25

This EXAMPLE event includes services like: Emergency room care (including medical supplies); Diagnostic test (x-ray); Durable medical equipment (crutches); Rehabilitation services (physical therapy)

Total Example Cost: $2,800

Cost Sharing	Amount
Deductibles	$1,700
Copayments	$300
Coinsurance	$0

What isn't covered	Amount
Limits or exclusions	$400

The total Mia would pay is: $2,400

The plan would be responsible for the other costs of these EXAMPLE covered services.

---

22. Document Notes & Disclaimers

• Both source documents are marked DRAFT and are dated with multiple revision timestamps: 6/30/2026 RL; 7/10/2026 RL; 7/13/2026 RL; 7/15/2026 RL; 7/20/2026 RL (Schedule of Medical Benefits), and are labeled "v1.1" (SBC).
• Several benefit values in the Schedule of Medical Benefits document show struck-through original figures alongside corrected figures (denoted "Eff 8/1/26 & Corr [date]:"). Both the original and corrected values have been preserved in this article exactly as they appear in the source, with the corrected value being the effective one as of 8/1/2026.
• The Schedule of Medical Benefits document states it is not a complete listing of all Plan exclusions and directs readers to the Medical Benefits Section and the Medical Limitations and Exclusions Section in the Plan Document/Summary Plan Description for the complete list.
• The SBC states it is only a summary and directs readers to the complete terms of coverage by calling 1-888-832-0354, or to the Glossary at healthcare.gov/sbc-glossary.
• TPA, PBM, network, and contact details in Sections 1 and 2 were provided directly by the requesting team (separate from the Schedule of Medical Benefits and SBC source documents) for HubSpot Knowledge Base loading purposes.

 

---