Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Coverage Period: 01/01/2025-12/31/2025 Coverage for: Individual/Family | Plan Type: PPO
HMMG, LLC Employee Benefits Plan: Copay Plan
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 1-312-906- 8080 or go to www.alliedbenefit.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. www.alliedbenefit.com or call 1-312-906-8080 to request a copy. Important Questions Answers Why This Matters:
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 plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible .
For Tier I providers:$500 person / $1,000 family; For Tier II network providers:$1,000 person / $2,000 family for Tier III out- of-network providers $2,000 person / $4,000 family Yes. Tier I prescription drugs, the following services for Tier 1 and Tier II only preventive care, physician/specialist exam charges, urgent care exam charges, second surgical opinions, allergy testing/serum/injections, Physical/Occupational/Speech therapy, chiropractic care, home health care, hospice care, bereavement counseling, and nutritional counseling, the following services for all Tiers: outpatient/office/independent laboratory diagnostic tests, radiology and pathology administration and interpretation services, renal dialysis, emergency room services, and ambulance services are covered before you meet your deductible. Yes. $200 person/ $400 family for prescription drug coverage. For Tier I providers:$4,000 person / $8,000 family; For Tier II network providers:$4,000 person / $8,000 family for Tier III out- of-network providers $10,000 person / $20,000 family Penalties for failure to obtain precertification/preauthorization, services in excess of Plan maximums or limits, premiums, balance-billing charges, and health care this plan doesn’t cover.
What is the overall 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 a list of covered preventive services at https://www.healthcare.gov/coverage/preventive- care-benefits/. You must pay all of the costs for these services (other than Tier I medications) up to the specific deductible amount before this plan begins to pay for these services. 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 has been met. Even though you pay these expenses, they don’t count toward the out- of-pocket limit.
Are there services covered before you meet your deductible?
Are there other deductibles for specific services? What is the out-of-pocket limit for this plan?
What is not included in the out-of-pocket limit?
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Important Questions
Answers
Why This Matters:
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will 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.
Will you pay less if you use a network provider?
Yes. See www.alliedbenefit.com or call 1-312-906-8080 for a list of network providers.
Do you need a referral to see a specialist?
You can see the specialist you choose without a referral .
No.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Tier III (Out-of-Network) Provider (You will pay the most) Payment of all Out-Of- Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out-Of-Network facility services will be limited to 175% of the Medicare fee schedule
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
Copay applies to exam charge only. Does not include office surgery. Limited to general practice, family practice, OB/GYN, internal medicine, osteopaths, pediatricians, nurse practitioners, physician assistants, and mental health providers. Chiropractic coverage is limited to 30 visits. See Plan Document for other services.
$25 copay/office visit, deductible does not apply, and 20% coinsurance for other outpatient services
$25 copay/office visit, deductible does not apply, and 20% coinsurance for other outpatient services
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
40% coinsurance
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What You Will Pay
Tier III (Out-of-Network) Provider (You will pay the most) Payment of all Out-Of- Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out-Of-Network facility services will be limited to 175% of the Medicare fee schedule
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
$50 copay/visit, deductible does not apply No charge, deductible does not apply No charge, deductible does not apply 20% coinsurance
$50 copay/visit, deductible does not apply No charge, deductible does not apply No charge, deductible does not apply
Copay applies to exam charge only. Does not include office surgery. See Plan Document for other services. Routine labs and x-rays are covered for out-of-network providers at no charge. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Does not include emergency room or urgent care diagnostic services. Does not include urgent care imaging services. Covers up to a 30-day supply (retail prescription); 90-day supply (extended retail and mail order prescription). Rx Deductible applies to Tier II, Tier III, and specialty medications only. Once the out- of-pocket maximum has been met, prescription drugs shall be covered at 100% for the remainder of the calendar year. Mail order is only available through Proact Pharmacy Services. Please contact ProAct 866–287–9885
Specialist visit
40% coinsurance
Preventive care/screening/ immunization
40% coinsurance
Diagnostic test (x- ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs (Tier 1) Preferred brand drugs (Tier 2) Non-preferred brand drugs (Tier 3) Specialty drugs (Tier 4)
No charge, deductible does not apply
If you have a test
20% coinsurance 40% coinsurance
$10 copay/prescription (retail) $20 copay/prescription (extended retail and mail-order) $30 copay/prescription (retail) $60 copay/prescription (extended retail and mail-order) $60 copay/prescription (retail) $120 copay/prescription (extended retail and mail-order) Please contact Noble Specialty Pharmacy 888-843-2040 Web: www.noblehealthservices.com $120 copay per prescription
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.proactrx.com
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What You Will Pay
Tier III (Out-of-Network) Provider (You will pay the most) Payment of all Out-Of- Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out-Of-Network facility services will be limited to 175% of the Medicare fee schedule
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
Web:www.ProActPharmacyServices.com *See Plan Document for non-use of generic drug penalty. Pre-notification is recommended for certain surgeries.
Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care
20% coinsurance
20% coinsurance 40% coinsurance
If you have outpatient surgery
20% coinsurance
20% coinsurance 40% coinsurance
None
$150 copay/visit, deductible does not apply 20% coinsurance, deductible does not apply $25 copay for services provided at Hughston Urgent Orthopedics; $60 copay all other urgent care visits, deductible does not apply
$150 copay/visit, deductible does not apply
Copay waived if admitted to Hospital directly from Emergency Room. Pre-notification is recommended for elective (non-emergent) transportation by ambulance or medical van, and all transfers via air ambulance.
Paid Same as Tier II
Emergency medical transportation
Paid Same as Tier I
Paid Same as Tier I
If you need immediate medical attention
$60 copay/visit, deductible does not apply
Urgent care
40% coinsurance
None
If you have a hospital stay
Facility fee (e.g., hospital room)
20% coinsurance
20% coinsurance 40% coinsurance
Pre-notification is recommended
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What You Will Pay
Tier III (Out-of-Network) Provider (You will pay the most) Payment of all Out-Of- Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out-Of-Network facility services will be limited to 175% of the Medicare fee schedule
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
Physician/surgeon fees
20% coinsurance
20% coinsurance 40% coinsurance
None.
$25 copay/office visit, deductible does not apply, and 20% coinsurance for other outpatient services
$25 copay/office visit, deductible does not apply, and 20% coinsurance for other outpatient services 20% coinsurance $25 copay/office visit, deductible does not apply
If you need mental health, behavioral health, or substance abuse services
Outpatient services
40% coinsurance
None
Inpatient services
20% coinsurance 40% coinsurance
Pre-notification is recommended.
Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Pre-notification is recommended for vaginal deliveries requiring more than a 48 hour stay and for cesarean section deliveries requiring more than a 96 hour stay.
$25 copay/office visit, deductible does not apply
Office visits
40% coinsurance
Childbirth/delivery professional services Childbirth/delivery facility services
If you are pregnant
20% coinsurance
20% coinsurance 40% coinsurance
20% coinsurance
20% coinsurance 40% coinsurance
If you need help recovering or have other special health needs
$25 copay/visit, deductible does not apply
$25 copay/visit, deductible does not apply
Pre-notification is recommended. Limited to 120 visits/calendar year
Home health care
40% coinsurance
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What You Will Pay
Tier III (Out-of-Network) Provider (You will pay the most) Payment of all Out-Of- Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out-Of-Network facility services will be limited to 175% of the Medicare fee schedule
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
$25 copay/visit, deductible does not apply $25 copay/visit, deductible does not apply
$25 copay/visit, deductible does not apply $25 copay/visit, deductible does not apply
Physical and occupational therapy: limited to a combined maximum of 30 visits of office and outpatient facility services per calendar year. Speech therapy: limited to 30 visit maximum per calendar year.
Rehabilitation services
40% coinsurance
Habilitation services
40% coinsurance
Skilled nursing care 20% coinsurance
20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
30 visits/calendar year
Durable medical equipment
Pre-notification is recommended for certain Durable medical equipment.
20% coinsurance No charge, deductible does not apply No charge, deductible does not apply
No charge, deductible does not apply No charge, deductible does not apply
Hospice services
40% coinsurance
Pre-notification is recommended.
Children’s eye exam
40% coinsurance
Applies from birth through age 5.
If your child needs dental or eye care
Children’s glasses Children’s dental check-up
Not covered Not covered
Not covered Not covered
Not covered Not covered
Not covered. Not covered.
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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.)
• Glasses (Child) • Hearing Aids • Long Term Care • Non-emergency care when traveling outside the U.S.
• Bariatric Surgery • Cosmetic Surgery • Dental Care (Adult) • Dental check-ups (Child)
• Private-duty nursing • Routine eye care (Adult) • Routine Foot Care • Weight Loss Programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture • Chiropractic Care (limited to 30 visits per calendar year)
• Infertility treatment (except promotion of conception)
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: Department of Labor’s 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 on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: the Plan Administrator at 706-494-3480 or the Department of Labor’s 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 the 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.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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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.
Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)
Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)
Mia’s Simple Fracture (in-network emergency room visit and follow up care)
The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance
$500 $50 20%
The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance
$500 $50 20%
The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance
$500 $50 20%
Other coinsurance 20% 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 In this example, Peg would pay: Cost Sharing Deductibles $500 Copayments $0 Coinsurance $2,100 What isn’t covered Limits or exclusions $60 The total Peg would pay is $2,660
Other coinsurance 20% 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 In this example, Joe would pay: Cost Sharing Deductibles* $700 Copayments $800 Coinsurance $60 What isn’t covered Limits or exclusions $20 The total Joe would pay is $1,580
Other coinsurance 20% 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
In this example, Mia would pay: Cost Sharing Deductibles*
$500 $400 $100
Copayments Coinsurance
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is $1000 *Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”. The plan would be responsible for the other costs of these EXAMPLE covered services.
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