Medical Plan Summary Plan Description (SPD) For Spectrum Engineers
Page 1Medical PlanSummary Plan Description (SPD)For Spectrum EngineersAmended & Restated January 1, 2021Spectrum Engineers, Inc. Plan Document – 2021
Page 2SPD Table of ContentsIntroduction . 3Eligibility . 4Schedule of Benefits . 7Covered Medical Expenses. 13Care Management Services . 24Plan Exclusions . 26Defined Terms . 30Prescription Drug Coverage . 38How to Submit a Claim . 40Coordination of Benefits . 43Subrogation . 45Responsibilities of Plan Administrator . 50Certain Plan Participants Rights under ERISA . 51Important Notices . 52General Plan Information & Establishment of the Plan . 53For assistance in a non-English language, please call 1-844-302-7773.Para obtener asistencia en Español, por favor llame al número arriba.Spectrum Engineers, Inc. Plan Document – 2021
Page 3IntroductionWelcome to the Spectrum Engineers, Inc. Medical Plan.This document explains the operation of your health plan. Please call 1-844-302-7773 if you have anyquestions.IntroductionThe Plan Sponsor has established the Plan, for the benefit of Employees, to help offset the financialimpact of an Injury or Sickness. This is the final version of your benefits.The Plan Document describes the terms for payment of covered medical and prescription charges.Applicable LawThis is a self-funded benefit plan under the Employee Retirement Income Security Act of 1974 (“ERISA”).Federal law preempts State law.Discretionary AuthorityHealthEZ will have sole and final discretionary authority to interpret all Plan provisions. The Plan Sponsorreserves the right to amend any part of the plan or terminate the Plan at any time.Type of AdministrationThe Plan is a self-funded group health plan and the plan administration is provided by HealthEZ.FiduciaryThe Plan Sponsor is the fiduciary. HealthEZ is not a fiduciary of the Plan.Legal Entity; Service of ProcessThe Plan is a legal entity. Legal notice may be filed with HealthEZ. You must exercise your appeal rightsbefore bringing legal action.Plan Contributions & FundingThe Plan is funded by the Plan Sponsor and covered Employees. The Plan Sponsor determines the levelof Employee contributions. The Plan is insured by a reinsurance carrier.Spectrum Engineers, Inc. Plan Document – 2021
Page 4EligibilityEligibility Requirements are determined by your employer. If you have any questions regarding eligibility,review your Employee handbook and/or call your employer.REQUIREMENTSEmployee30 hours per week, 130 hours per month, or 1,560 hours per calendar yearWaiting PeriodFirst of the month following date of hire.1. An Employee’s lawfully married spouse;2. An Employee’s common-law spouse;3. An Employee’s Domestic Partner;EligibleDependent4. An Employee’s Child who is less than 26 years of age; and5. An Employee’s Child, regardless of age, who was continuouslycovered before reaching the age of 26, who is mentally or physicallyincapable of sustaining his or her own living.The Plan reserves the right to require documentation to establish aDependent relationship.CoverageTerminationRehired EmployeesLast day of the month once no longer eligible.If an Employee is rehired within 13 weeks of their termination, they areeligible no later than first of the month following that rehire.Enrollment. An Employee must enroll for coverage with the Plan Sponsor within 31 days after theEmployee becomes eligible. This enrollment cannot be dropped without a qualifying event. During OpenEnrollment, Employees will be able to elect, change, or discontinue coverage. The Plan Sponsor mustforward the completed enrollment to HealthEZ in a timely manner.SPECIAL ENROLLMENT RIGHTSFederal law allows a Special Enrollment Period if you had a qualifying event. This request for enrollmentmust be made within 31 days of the qualifying event. Coverage will be effective on the date of thequalifying event and an Employee who is already enrolled in one plan may make changes to theirenrollment.Qualifying events include: Loss of health coverageo Losing existing health coverage, including job-based, individual, and student plansSpectrum Engineers, Inc. Plan Document – 2021
Page 5oLosing eligibility for Medicare, Medicaid, or CHIP o If an Employee has declined enrollment in the Plan for themselves or dependentsbecause of coverage under Medicaid or the CHIPRA, there may be a right toenroll in this Plan if there is a loss of the government-provided coverage.However, a request for enrollment must be made within 60 days after thegovernment-provided coverage ends.Turning 26 and losing coverage through a parent’s planChanges in householdo Getting married or divorcedoHaving a baby or adopting a childoDeath in the familyNote: If other health plan coverage was lost because of failure to pay coverage premiums orrequired contributions, that individual does not have a Special Enrollment Period right.TERMINATION OF COVERAGEThe Plan Sponsor or HealthEZ have the right to rescind any coverage for cause, including making afraudulent claim or lying when obtaining coverage. The Employee or Dependent will be responsible for allclaims paid on their behalf.Coverage TerminationCoverage will terminate on the earliest of these dates: The date the Plan is terminated; The last day of the month the Employee ceases to be EligibleCoverage during Disability or Leave of AbsenceA person may remain eligible for a limited time if disabled or during a leave of absence. Refer to yourEmployee handbook for further information. If coverage continuance is granted, coverage will end at theearliest of these dates: The employer ends the continuance or Maximum period available under FMLA and/or COBRA.Employees on Military Leave (USERRA). For Employees who continue coverage while in militaryservice, coverage will terminate at the earliest of these dates: The 24-month period beginning on the date absence begins; or The date the Employee fails to return to work as requiredA person who elects to continue health plan coverage may be required to pay up to 102% of the fullcontribution under the Plan, unless on active duty for 30 days or less.Spectrum Engineers, Inc. Plan Document – 2021
Page 6A Waiting Period may not be imposed upon reemployment if one would not have been imposed hadcoverage not been terminated because of military service. However, an exclusion or Waiting Period maybe imposed for coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to havebeen incurred in, or aggravated during, the performance of active military service.The Employee may also have continuation rights under USERRA. In general, the Employee must meetthe same requirements for electing USERRA coverage as are required under COBRA continuationcoverage requirements. Coverage elected under these circumstances is concurrent, not cumulative.Dependents do not have any independent right to elect USERRA health plan continuationSpectrum Engineers, Inc. Plan Document – 2021
Page 7Schedule of BenefitsCall 1-844-302-7773 to verify eligibility for benefits before the charge is Incurred.Reimbursement from the Plan may be reduced or denied due to the provisions in the Plan, such ascoordination of benefits, subrogation, or medical necessity.DEDUCTIBLEDeductible Amount. Before benefits can be paid in a Plan Year, a Plan Participant must pay theDeductible shown in the Schedule of Benefits.OUT-OF-POCKET MAXIMUMAfter the deductible is met, a Plan Participant will be required to continue to pay for a share of theCovered Expenses until the out-of-pocket maximum is met. Once the out-of-pocket maximum is reached,the Plan will pay for the entirety of the Covered Expenses.For those Employees who have elected family coverage:For the 6,750 HSA Plan and Copay Plan: The health plan(s) offered have an embedded Deductible.This means that each individual will only have to meet the individual Deductible before the Plan beginspaying benefits.For 1,400 HSA Plan: The health plan(s) offered has a non-embedded Deductible. This means that thefamily Deductible must be met before the Plan begins paying benefits.For the 6,750 HSA Plan and Copay Plan: The health plan(s) offered have an embedded out-of-pocketmaximum. This means that each individual will only have to meet the individual out-of-pocket maximumbefore the Plan begins paying in full.For 1,400 HSA Plan: The health plan(s) offered has a non-embedded out-of-pocket maximum. Thismeans that the family out-of-pocket maximum must be met before the Plan begins paying in full.COPAY AND COINSURANCECopay. A flat fee that is paid each time a service is provided.Coinsurance. A portion of the cost of the service that the Plan Participant pays after the deductible ismet.Copayments and coinsurance accrue toward the out-of-pocket maximum, but not toward the deductible.PROVIDER NETWORKYour provider network is displayed on the front of your ID card.This Plan has entered into an agreement with provider networks. In-network Providers have agreed tocharge reduced fees to Plan Participants.The Plan may pay for out-of-network services at the in-network benefit level if: A Plan Participant has no in-Network Providers in the necessary specialty within the PPO servicearea; orSpectrum Engineers, Inc. Plan Document – 2021
Page 8 A Plan Participant unavoidably receives services from an out-of-network Provider at an in-Networkfacility.Additional information about this option, as well as a list of in-network Providers, will be made available toa Plan Participant as needed.INFORMATION AND RECORDSHealthEZ may require additional information to make a benefit determination. The Plan Participant orProvider must send this information in the timeframe requested. Failure to send will result in denial ofpayment.CLAIMS REVIEWHealthEZ may use its discretionary authority to utilize an independent bill review and/or claim auditprogram.HealthEZ has the discretionary authority to reduce any charge to a Usual and Customary or Reasonableamount. The Medicare reimbursement methodology is used in determining a Usual and Customary orReasonable amount by the Plan.Spectrum Engineers, Inc. Plan Document – 2021
Page 9Schedule of Benefits 1,400 HSA PLANNon-Embedded DeductibleNon-Embedded Out-of-Pocket MaximumIn NetworkOut of NetworkIndividual Coverage 1,400 2,800Family Coverage 2,800 5,600DEDUCTIBLEDeductible accumulates towards out of pocket maximum.OUT-OF-POCKET MAXIMUMIndividual Coverage 7,000 14,000Family Coverage 14,000 28,000Both Medical and Pharmacy copayments will accrue toward the out-of-pocket maximumDeductible YearGrandfathered statusCoinsurance/CopayCalendarNot grandfatheredIndicates Plan Participant responsibility.PREVENTIVE CARE SERVICESWell Child Care (up to age 18)No Charge40% CoinsuranceAfter DeductibleNo Charge40% CoinsuranceAfter DeductibleRoutine Prenatal care.No Charge40% CoinsuranceAfter DeductibleBreast Feeding EquipmentLimit to one pump per pregnancy with a 250 limit forreimbursement.No ChargeNo ChargeRoutine Eye ExamOne per 12 monthsNo Charge40% CoinsuranceAfter DeductibleAdult Preventive CareSpectrum Engineers, Inc. Plan Document – 2021
Page 10CLINIC CHARGESPhysician Office VisitIncludes office visits and associated labs & x-rays20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleSpecialist Office Visit20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleUrgent Care Clinic20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleAllergy Shots20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleImmunizations-Foreign Travel20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleTemporomandibular Joint Disorder (TMJ)No Hardware coverage20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleInfertilityCare, services, supplies for the diagnosis and charges forsurgical correction of physical abnormalities.No coverage for assisted reproduction.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleInfusions and InjectionsMay require precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOutpatient Lab, Pathology, X-Ray20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleComplex Imaging: MRI/CT/PET ScansMay require precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleLABS AND SCANSHOSPITAL CHARGESInpatient Hospital ServicesRequires precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOutpatient ProceduresMay require precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOrgan TransplantsMust be performed at a Designated Center of Excellence forTransplants.Requires precertification.20% CoinsuranceAfter DeductibleNot CoveredEmergency Room CareCovered at in-network benefit level if determined medicallynecessary20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleAmbulance20% Coinsurance40% CoinsuranceSpectrum Engineers, Inc. Plan Document – 2021
Page 11Covered at in-network benefit level if determined medicallynecessarySkilled Nursing FacilityRequires precertification. 60 days per year maximumAfter DeductibleAfter Deductible20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleMENTAL HEALTH & SUBSTANCE ABUSE SERVICESInpatient, Residential, Partial Hospitalization, or IntensiveOutpatientRequires precertification20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOffice Visit20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleREHABILITATIVE/ HABILITATIVE OUTPATIENT THERAPYBehavioral, Occupational, and Speech TherapyRequires precertification. 20 visit limit per therapy per year.60 visit limit for preventative therapy for multiple sclerosis.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductiblePhysical Therapy20 visit limit per year.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOther Therapy36 visit limit for Cardiac Therapy30 visit limit for post-cochlear implant aural therapy20 visit limit for cognitive rehabilitation therapy20 visits of pulmonary rehabilitation20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleChiropractic Services20 visit limit per year.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleANCILLARY SERVICESHospiceRequires precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductiblePrivate Duty Nursing CareInpatient, only when ICU is not available.Requires precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleHome Health CareRequires precertification. 60 days per year maximum.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleMEDICAL EQUIPMENTMedical EquipmentRequires precertification for items over 2,500 and all insulinpumps.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleProstheticsCoverage only applies to the initial purchase, fitting and repair.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleSpectrum Engineers, Inc. Plan Document – 2021
Page 12OrthoticsCoverage only applies to the initial purchase, fitting and repair oforthotic appliances such as braces, splints or other applianceswhich are required for support for an injured or deformed part ofthe body as a result of a disabling congenital condition or anInjury or Sickness.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOstomy Supplies 2,500 limit per year20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleHearing AidsCovered Persons under age 19: One hearing aid per hearingimpaired ear every three (3) years.Covered Persons age 19 and over: One hearing aid per hearingimpaired ear every three (3) years up to a 2,500 limit perpurchase, including repair or replacement.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleMedically Necessary Wigs 1000 Lifetime MaximumPRESCRIPTION DRUG SERVICESRetail (per 30-day supply)Mail Order (per 90-day Supply)Generic20% Coinsurance After Deductible20% Coinsurance After DeductiblePreferred Brand(when generic is not available)20% Coinsurance After Deductible20% Coinsurance After DeductiblePreferred Brand(when generic is available)Non-Preferred Brand(when generic is not available)Non-Preferred Brand(when generic is available)Specialty Drugs20% Coinsurance After Deductible 20% Coinsurance After Deductible Difference between Generic & Brand cost Difference between Generic & Brand cost20% Coinsurance After Deductible20% Coinsurance After Deductible20% Coinsurance After Deductible 20% Coinsurance After Deductible Difference between Generic & Brand cost Difference between Generic & Brand cost20% Coinsurance After DeductibleSpectrum Engineers, Inc. Plan Document – 2021(Only available up to a 30-day supply)
Page 13Schedule of Benefits 7,000 HSA PLANEmbedded DeductibleEmbedded Out-of-Pocket MaximumIn NetworkOut of NetworkIndividual Coverage 7,000 14,000Family Coverage 14,000 28,000DEDUCTIBLEDeductible accumulates towards out of pocket maximum.This plan is considered a High Deductible Health Plan and eligible for HSA.OUT-OF-POCKET MAXIMUMIndividual Coverage 7,000 14,000Family Coverage 14,000 28,000Both Medical and Pharmacy copayments will accrue toward the out-of-pocket maximumDeductible YearGrandfathered statusCoinsurance/CopayCalendarNot grandfatheredIndicates Plan Participant responsibility.PREVENTIVE CARE SERVICESWell Child Care (up to age 18)No Charge40% CoinsuranceAfter DeductibleNo Charge40% CoinsuranceAfter DeductibleRoutine Prenatal care.No Charge40% CoinsuranceAfter DeductibleBreast Feeding EquipmentLimit to one pump per pregnancy with a 250 limit forreimbursement.No ChargeNo ChargeRoutine Eye ExamOne per 12 monthsNo Charge40% CoinsuranceAfter DeductibleAdult Preventive CareSpectrum Engineers, Inc. Plan Document – 2021
Page 14CLINIC CHARGESPhysician Office VisitIncludes office visits and associated labs & x-raysNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleSpecialist Office VisitNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleUrgent Care ClinicNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleAllergy ShotsNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleImmunizations-Foreign TravelNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleTemporomandibular Joint Disorder (TMJ)No Hardware coverageNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleInfertilityCare, services, supplies for the diagnosis and charges forsurgical correction of physical abnormalities.No coverage for assisted reproduction.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleInfusions and InjectionsMay require precertification.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleOutpatient Lab, Pathology, X-RayNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleComplex Imaging: MRI/CT/PET ScansMay require precertification.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleLABS AND SCANSHOSPITAL CHARGESInpatient Hospital ServicesRequires precertification.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleOutpatient ProceduresMay require precertification.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleOrgan TransplantsMust be performed at a Designated Center of Excellence forTransplants.Requires precertification.No ChargeAfter DeductibleNot CoveredEmergency Room CareCovered at in-network benefit level if determined medicallynecessaryNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleSpectrum Engineers, Inc. Plan Document – 2021
Page 15AmbulanceCovered at in-network benefit level if determined medicallynecessaryNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleSkilled Nursing FacilityRequires precertification. 60 days per year maximumNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleMENTAL HEALTH & SUBSTANCE ABUSE SERVICESInpatient, Residential, Partial Hospitalization, or IntensiveOutpatientRequires precertificationNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleOffice VisitNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleREHABILITATIVE/ HABILITATIVE OUTPATIENT THERAPYBehavioral, Occupational, and Speech TherapyRequires precertification. 20 visit limit per therapy per year.60 visit limit for preventative therapy for multiple sclerosis.No ChargeAfter Deductible40% CoinsuranceAfter DeductiblePhysical Therapy20 visit limit per year.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleOther Therapy36 visit limit for Cardiac Therapy30 visit limit for post-cochlear implant aural therapy20 visit limit for cognitive rehabilitation therapy20 visits of pulmonary rehabilitationNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleChiropractic Services20 visit limit per year.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleANCILLARY SERVICESHospiceRequires precertification.No ChargeAfter Deductible40% CoinsuranceAfter DeductiblePrivate Duty Nursing CareInpatient, only when ICU is not available.Requires precertification.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleHome Health CareRequires precertification. 60 days per year maximum.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleMEDICAL EQUIPMENTMedical EquipmentRequires precertification for items over 2,500 and all insulinpumps.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleProstheticsCoverage only applies to the initial purchase, fitting and repair.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleSpectrum Engineers, Inc. Plan Document – 2021
Page 16OrthoticsCoverage only applies to the initial purchase, fitting and repair oforthotic appliances such as braces, splints or other applianceswhich are required for support for an injured or deformed part ofthe body as a result of a disabling congenital condition or anInjury or Sickness.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleOstomy Supplies 2,500 limit per yearNo ChargeAfter Deductible40% CoinsuranceAfter DeductibleHearing AidsCovered Persons under age 19: One hearing aid per hearingimpaired ear every three (3) years.Covered Persons age 19 and over: One hearing aid per hearingimpaired ear every three (3) years up to a 2,500 limit perpurchase, including repair or replacement.No ChargeAfter Deductible40% CoinsuranceAfter DeductibleMedically Necessary Wigs 1000 Lifetime MaximumPRESCRIPTION DRUG SERVICESRetail (per 30-day supply)Mail Order (per 90-day Supply)GenericNo Charge After DeductibleNo Charge After DeductiblePreferred Brand(when generic is not available)No Charge After DeductibleNo Charge After DeductibleNo Charge After Deductible Differencebetween Generic & Brand costNo Charge After Deductible Differencebetween Generic & Brand costNo Charge After DeductibleNo Charge After DeductibleNo Charge After Deductible Differencebetween Generic & Brand costNo Charge After Deductible Differencebetween Generic & Brand costNo Charge After Deductible(Only available up to a 30-day supply)Preferred Brand(when generic is available)Non-Preferred Brand(when generic is not available)Non-Preferred Brand(when generic is available)Specialty DrugsSpectrum Engineers, Inc. Plan Document – 2021
Page 17Schedule of BenefitsCOPAY PLANEmbedded DeductibleEmbedded Out-of-Pocket MaximumIn NetworkOut of Network 500 1,000 1,000 2,000DEDUCTIBLEIndividual CoverageFamily CoverageDeductible accumulates towards out of pocket maximum.OUT-OF-POCKET MAXIMUMIndividual Coverage 5,000 10,000Family Coverage 9,000 20,000Both Medical and Pharmacy copayments will accrue toward the out-of-pocket maximumDeductible YearGrandfathered statusCoinsurance/CopayCalendarNot grandfatheredIndicates Plan Participant responsibility.PREVENTIVE CARE SERVICESWell Child Care (up to age 18)No ChargeNot CoveredAdult Preventive CareNo ChargeNot CoveredRoutine Prenatal care.No ChargeNot CoveredBreast Feeding EquipmentLimit to one pump per pregnancy with a 250 limit forreimbursement.No ChargeNo ChargeRoutine Eye ExamOne per 12 monthsNo ChargeNot CoveredSpectrum Engineers, Inc. Plan Document – 2021
Page 18CLINIC CHARGESPhysician Office VisitIncludes office visits and associated labs & x-rays 30 Copay40% CoinsuranceAfter DeductibleSpecialist Office Visit 60 Copay40% CoinsuranceAfter DeductibleUrgent Care Clinic 75 Copay40% CoinsuranceAfter DeductiblePCP: 30 CopaySpecialty: 60 Copay40% CoinsuranceAfter DeductibleImmunizations-Foreign Travel20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleTemporomandibular Joint Disorder (TMJ)No Hardware coverage20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleInfertilityCare, services, supplies for the diagnosis and charges forsurgical correction of physical abnormalities.No coverage for assisted reproduction.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleInfusions and InjectionsMay require precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductiblePathology and X-RayNo Charge40% CoinsuranceAfter DeductibleOutpatient LabNo Charge40% CoinsuranceAfter DeductibleOutpatient Hospital Labs20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleComplex Imaging: MRI/CT/PET ScansMay require precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleAllergy ShotsLABS AND SCANSHOSPITAL CHARGESInpatient Hospital ServicesRequires precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOutpatient ProceduresMay require precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOrgan TransplantsMust be performed at a Designated Center of Excellence forTransplants.Requires precertification.20% CoinsuranceAfter DeductibleNot CoveredSpectrum Engineers, Inc. Plan Document – 2021
Page 19Emergency Room CareCovered at in-network benefit level if determined medicallynecessary 150 Copay40% CoinsuranceAfter DeductibleAmbulanceCovered at in-network benefit level if determined medicallynecessary20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleSkilled Nursing FacilityRequires precertification. 60 days per year maximum20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleMENTAL HEALTH & SUBSTANCE ABUSE SERVICESInpatient, Residential, Partial Hospitalization, or IntensiveOutpatientRequires precertification20% CoinsuranceAfter Deductible40% CoinsuranceAfter Deductible 30 Copay40% CoinsuranceAfter DeductibleOffice VisitREHABILITATIVE/ HABILITATIVE OUTPATIENT THERAPYBehavioral, Occupational, and Speech TherapyRequires precertification. 20 visit limit per therapy per year.60 visit limit for preventative therapy for multiple sclerosis. 30 Copay40% CoinsuranceAfter DeductiblePhysical Therapy20 visit limit per year. 30 Copay40% CoinsuranceAfter DeductibleOther Therapy36 visit limit for Cardiac Therapy30 visit limit for post-cochlear implant aural therapy20 visit limit for cognitive rehabilitation therapy20 visits of pulmonary rehabilitation 30 Copay40% CoinsuranceAfter DeductibleChiropractic Services20 visit limit per year. 30 Copay40% CoinsuranceAfter DeductibleHospiceRequires precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductiblePrivate Duty Nursing CareInpatient, only when ICU is not available.Requires precertification.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleHome Health CareRequires precertification. 60 days per year maximum.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleANCILLARY SERVICESMEDICAL EQUIPMENTMedical EquipmentRequires precertification for items over 2,500 and all insulinpumps.Spectrum Engineers, Inc. Plan Document – 202120% CoinsuranceAfter Deductible40% CoinsuranceAfter Deductible
Page 20ProstheticsCoverage only applies to the initial purchase, fitting and repair.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOrthoticsCoverage only applies to the initial purchase, fitting and repair oforthotic appliances such as braces, splints or other applianceswhich are required for support for an injured or deformed part ofthe body as a result of a disabling congenital condition or anInjury or Sickness.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleOstomy Supplies 2,500 limit per year20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleHearing AidsCovered Persons under age 19: One hearing aid per hearingimpaired ear every three (3) years.Covered Persons age 19 and over: One hearing aid per hearingimpaired ear every three (3) years up to a 2,500 limit perpurchase, including repair or replacement.20% CoinsuranceAfter Deductible40% CoinsuranceAfter DeductibleMedically Necessary Wigs 350 LimitPRESCRIPTION DRUG SERVICESRetail (per 30-day supply)Mail Order (per 90-day Supply)Generic 10 Copay 25 CopayPreferred Brand(when generic is not available) 35 Copay 87.50 Copay
Page 1 Spectrum Engineers, Inc. Plan Document - 2021 Medical Plan Summary Plan Description (SPD) For Spectrum Engineers Amended & Restated January 1, 2021
Loans 28 Loan eligibility 29 Loan application 29 Types of loans and their maximum repayment periods 29 Amount and number of loans 29 Source of loan funds 30 . Hewlett Packard Enterprise 401(k) Plan Summary Plan Description represents your summary plan description (SPD) under the Employee Retirement Income Security Act of 1974, as amended .
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