Carolina Orthopaedic and Neurosurgical Associates Base WLT CIP Standard 2 Tier

Plan Overview

Detail	Information
Group Name	Carolina Orthopaedic and Neurosurgical Associates
Legal Name	Carolina Orthopaedic and Neurosurgical Associates
Effective Date	January 1, 2026
Master Group Number	65100
Subgroup	65110
Benefit Plan	Base Plan
TPA	90 Degree Benefits
Hours of Operation	8:00 AM - 5:00 PM CST
ERISA Plan	Yes
Plan Type	Initial ☐ Renewal ☐ Mid-Term Change ☐
Fiscal Year Date (Plan Funding)	1/1 - 12/31
Benefits Applied	Per Calendar Year
Plan Year	Calendar Year (1/1 - 12/31)
Grandfather Status	No
Qualified HDHP	No
Dental/Vision Benefits	Excepted (unbundled)
Number of Employees	174
Medicare COB Note	Special COB rules may apply for employees with Medicare if employer has less than 100 employees

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Annual Deductibles

Category	Tier 1 (CIGNA Network)	Tier 2 (Out-of-Network)
Per Person	$2,750	$5,000
Per Family	$5,500	$10,000
Cross-Apply	No - Deductibles are SEPARATE
Applies to OOP Max	Yes	Yes
3-Month Carry Over	Yes (Individual, Family, and Both)	Yes (Individual, Family, and Both)
Deductible Carry Over Applies to OOP	Yes	Yes

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Coinsurance Rates

Tier	Plan Pays	Member Pays
Tier 1	70%	30%
Tier 2	50%	50%

(After deductible is satisfied)

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Annual Out-of-Pocket Maximum

Category	Tier 1	Tier 2
Per Person	$7,900	$15,000
Per Family	$15,800	$30,000
Cross-Apply	No - OOP maximums are SEPARATE
3-Month Carry Over	No
Integrated with Pharmacy	Yes	Yes
Copays Apply to OOP Max	Yes	Yes

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Network Structure

Tier 1 - CIGNA Network

• Network Code: 3002 (CIGNA)
• PPO Code: 65101
• Override Code: 11111 (to pay Tier 1)

Tier 2 - Reference-Based Pricing

• Professional Services: 130% of Medicare
• Facility Services: 150% of Medicare
• UCR Percentile: 80th percentile (Standard)

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Additional Programs

Program	Availability
Teladoc	$0 Consult Fee
A&G Editing/Bill Review	Yes
Patient Defender	Yes
Pace	Yes
CareConnect	Yes (Benchmark State: Utah)
Continuity of Care	Yes (Standard 90 days for serious illness/pregnancy)

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Precertification Requirements

Detail	Information
Provider	CIGNA Precertification
Phone Number	888-832-0354
Retroactive Precert Allowed	Yes
Post-Service Penalty	No
Required for Medicare Primary	No
Required if Other Coverage Primary	No
Appeals Before IRO	1 level

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Medical Office Visits

Primary Care & Specialist Visits

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Primary Care Copay	$30 per provider per day	N/A
Specialist Copay	$60 per provider per day	N/A
Deductible Applies	No (Tier 1)	Yes (Tier 2)
Plan Pays After Copay	100%	50% (after deductible)
Coverage Codes	AOV, AOVS, OV, OVS, POV, SMV, SOV, TELM, TELS, ZPOV, ZSMV, ZSOV

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Office-Based Services

Office Surgery (includes anesthesia)

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Primary Care Copay	$30 per provider per day	N/A
Specialist Copay	$60 per provider per day	N/A
Plan Pays After Copay	100%	50% (after deductible)
Coverage Codes	AF, AFQ, AFS, OPM, OPMS, SF, SFS

Therapeutic Injections (Office)

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Primary Care Copay	$30 per provider per day	N/A
Specialist Copay	$60 per provider per day	N/A
Plan Pays After Copay	100%	50% (after deductible)
Coverage Codes	INJ, INJS, MINJ, ZMIN

Allergy Testing

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Primary Care Copay	$30 per provider per day	N/A
Specialist Copay	$60 per provider per day	N/A
Plan Pays After Copay	100%	50% (after deductible)
Coverage Codes	ALT, ALTS

Allergy Injections and Serum

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Copay	No copay	No copay
Deductible Applies	Yes	Yes
Plan Pays	70%	50% (after deductible)
Coverage Codes	ALI, ALIS, ALS, ALSS

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Diagnostic Services

Office X-ray & Professional Component

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Includes High-Cost Imaging	Yes (MRI, CT, PET)	Yes
Copay	No	No
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	XRDR, XRDS

Office Laboratory & Professional Component

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Copay	No	No
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	LBDR, LBDS, MOXL, SMOX, SOXL, ZMOX, ZSMX, ZSOXX

Office Diagnostic Testing

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Copay	No	No
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	ODX, ODXS

All Other Office Related Services

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Copay	No	No
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	HBOO, HBOS, HBPO, HBPS, OIV, OIVS, OMS, OMSS, OWCT
Note	Includes other office-based services not otherwise specified

Independent Laboratory

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Copay	No	No
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Code	LAB

Outpatient Lab/X-ray/Diagnostic Imaging

Service Type	Tier 1	Tier 2
Physician Component	70% (after deductible)	50% (after deductible)
Testing/Facility Fee	70% (after deductible)	50% (after deductible)
Coverage Codes - Professional	PRF
Coverage Codes - Facility	CUS, HLAB, HXL, HXR, MXL, OPDX, OUSS, SMXL, SXL, US, XRAY

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Major Diagnostic Procedures

High-Cost Imaging (MRI, PET, CT, Nuclear Medicine, etc.)

Service Type	Tier 1	Tier 2
Physician Component	70% (after deductible)	50% (after deductible)
Testing/Facility Fee	70% (after deductible)	50% (after deductible)
Includes	MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans
Coverage Codes - Professional	PRF
Coverage Codes - Facility	BONE, CAT, CST, HCAT, MRIO, MRIS, MYEL, NUC, NUCO, NUCS, OBON, OBOS, OCAT, OCSS, OCST, OCUS, OMRI, OMYE, OMYS, OPES, OPET, OSPC, OSPS, PET, SCAT, SPCT

Sleep Studies

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	OSLP, SLPS

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Hospital Services

Emergency Room Services

Service Type	Tier 1	Tier 2
Facility Services	70% (after deductible)	70% (Tier 1 ded/oop applies)
Professional Services	70% (after deductible)	70% (Tier 1 ded/oop applies)
All ER Services Paid In-Network	Yes	Yes
Copay Waived if Admitted Within 24 Hours	Yes	Yes
Coverage Codes - Facility	ER, MNO, NER, SMOF, SNO
Coverage Codes - Professional	ERD, MERD, NERD, SAER, SMER

Note: Tier 2 emergency services apply Tier 1 deductible and out-of-pocket maximum.

Inpatient Facility Services

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Notification Penalty Waived for Emergency	Yes	Yes
ER Copay Waived if Admitted	Yes	Yes
Semi-Private Room Rate	Yes (if available)	Yes (if available)
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	BC, HM, HNS, ICU, IMC, MHM, MRB, RB, SHM, SMHM, SMRB, SRB

Ancillary Inpatient Services

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	DX, HV, MID, MNI, PAT, RAD, SID, SIP, SMID, SMNI, WC

Outpatient Hospital Services

Benefit Detail	Tier 1	Tier 2
Hospital Services	70% (after deductible)	50% (after deductible)
Physician Services	70% (after deductible)	50% (after deductible)
Coverage Codes - Hospital	CO, HBO, HMIS, HOBS, HWCT, MNOP, PA, PADR, SAOP, SMPH
Coverage Codes - Physician	DIED, HBP, PM

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Surgical Services

Second Surgical Opinion

Benefit Detail	Information
Covered	Yes
Payment	Paid same as any other illness
Coverage Codes	SV, SVS
Comments	No special limitations; follows standard benefit structure

Surgery (Surgeon, Assistant, Co-Surgeon)

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Assistant Surgeon Limitation	25% of UCR	25% of UCR
Coverage Codes	CIRC, SI, SO, STER, TI, TO

Anesthesia

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	AI, AIQ, AO, AOQ, MNA, SMA

Outpatient Surgery & Ambulatory Surgical Center

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	ASF, OHS

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Maternity & Newborn Care

Maternity Surgery

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Office Visits	Paid per office visit schedule	Paid per office visit schedule
Hospital Services	Paid per hospital schedule	Paid per hospital schedule
Coverage Codes	MAT, MATD, MATO

Routine Newborn Care

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Benefit Application	Normal plan benefits apply
Enrollment Requirement	Must be enrolled within 31 days
Coverage Codes	CIRC, HNS, WC

Newborn Coverage Options (Plan Selection)

The plan has selected the following newborn coverage structure:

Selected Option	Details
Apply Normal Plan Benefits	✓ Selected
Process Under Mother	☐ Not Selected

Enrollment Option	Status
Must be enrolled within 31 days	✓ Selected
Automatic 31-day coverage; must enroll thereafter	☐ Not Selected
Automatic 31-day coverage only if EE already has dependent coverage; must enroll thereafter	☐ Not Selected

Pregnancy-Related Services

Service	Coverage
Dependent Daughter Pregnancies	No (PPACA required services covered)
Outpatient Birthing Centers	Yes
Home Deliveries	Yes
Elective Abortions	No
Abortion - Rape/Incest	Yes
Abortion - Life of Mother	Yes
Sterilization	Yes

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Urgent Care

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Copay	$60 per provider per day	N/A
Deductible Applies	No	Yes
Includes All Related Services	Yes	Yes
Plan Pays After Copay	100%	50% (after deductible)
Coverage Code	URG

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Ambulance Services

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Ground & Air	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	70% (Tier 1 ded/oop applies)
Facility to Facility (Medically Necessary)	Yes	Yes
Coverage Codes	AMB, AMBR, AR

Note: Tier 2 ambulance services apply Tier 1 deductible and out-of-pocket maximum.

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Therapy Services

Physical Therapy

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Combined with Occupational Therapy	Yes	-
Aquatic Therapy	Yes (if with PT)	Yes (if with PT)
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Maximum Visits	36 visits per calendar year	36 visits per calendar year
Includes Massage Therapy	Yes (by covered provider)	Yes (by covered provider)
Coverage Codes	DPT, HPT, PT

Occupational Therapy

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Combined with Physical Therapy	Yes	-
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Maximum Visits	36 visits per calendar year	36 visits per calendar year
Includes Massage Therapy	Yes (by covered provider)	Yes (by covered provider)
Coverage Codes	HOT, OT

Speech Therapy

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Maximum Visits	20 visits per calendar year	20 visits per calendar year
Coverage Codes	HST, ST

Other Rehabilitative/Habilitative Services

Service Type	Coverage
ABA Therapy	Covered
Cognitive Rehab	Covered
Cardiac Rehab	Covered
Pulmonary Rehab	Covered
Plan Pays	70% (Tier 1) / 50% (Tier 2) after deductible
Coverage Codes	ABA, ABAH, COGR, CR, PRHB

Massage Therapy (by Massage Therapist)

Benefit Detail	Information
Covered	Only when medical diagnosis exists and provided by PT, OT, or Physician
By Massage Therapist Alone	Not covered
Coverage Code	MT

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Specialized Services

Chiropractic Services

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Maximum Benefit	$500 per calendar year	$500 per calendar year
Coverage Codes	CH, CHX

Acupuncture Services

Benefit Detail	Tier 1	Tier 2
Covered	No	No
Coverage Codes	AP, APS

Dialysis

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	DI, HDI

Infusion Therapy

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Code	IVIN

Chemotherapy/Radiation Therapy

Component	Tier 1	Tier 2
Professional	70% (after deductible)	50% (after deductible)
Facility	70% (after deductible)	50% (after deductible)
Coverage Codes	CT, HCT, HRT, RT

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Extended Care & Home Health

Extended Care Facility (Skilled Nursing)

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Maximum Days	60 days per calendar year	60 days per calendar year
Coverage Code	SNF

Home Health Care

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Maximum Visits	60 visits per calendar year	60 visits per calendar year
Coverage Codes	HHC, HHS, PHC, PHS

Hospice Care

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Maximum Days	No day maximum	No day maximum
Custodial/Respite Care	Yes (included in hospice benefit)	Yes (included in hospice benefit)
Coverage Codes	HO, OHO

Bereavement Counseling

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Included in Hospice Benefit	Yes	Yes
Timeframe	Within 6 months of death	Within 6 months of death
Plan Pays	70%	50%
Coverage Codes	HBC, HFC

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Durable Medical Equipment (DME)

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Includes DME Supplies	Yes	Yes
Insulin Pumps	Yes (as DME)	Yes (as DME)
Insulin Pump Supplies	Yes	Yes
Repairs (Not Due to Misuse)	Yes	Yes
Replacements	Yes (if not functioning, outside warranty, unable to repair)	Yes
Batteries	Yes	Yes
Sales Tax & Shipping	Yes	Yes
Rental Maximum	Yes (up to purchase price)	Yes (up to purchase price)
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	BRA, DIEQ, DME, DMS, DTE, MMS

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Orthotics & Prosthetics

Orthotics

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Custom-Molded Foot Orthotics	Yes	Yes
Non-Custom Molded Shoe Inserts	No	No
Diabetic Shoes	Yes (1 pair per calendar year up to $500)	Yes (1 pair per calendar year up to $500)
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	DS, OR, ORH, ORI, ORS

Prosthetics

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Initial Purchase	Yes	Yes
Fitting	Yes	Yes
Repair	Yes	Yes
Replacement	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Code	PRO

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Transplant Services

Benefit Detail	Tier 1	Tier 2
Separate Transplant Policy in Place	Yes	Yes
Transplant Administrator	None specified - managed through standard claims process
Recipient - Facility Benefits	70% (after deductible)	Not typically covered
Living Donor - Facility Benefits	Yes	Yes
Donor Covered When Recipient Not on Plan	Yes	Yes
Coverage Code	TRN

Travel and Housing for Transplant - Recipient

Expense Type	Covered
Airfare	Yes
Meals	Yes
Tolls	Yes
Parking Fees	Yes
Apartment Rental	Yes
Hotel/Motel	Yes
Relocation Fees	Yes
Taxes	Yes
Coverage Codes	TRL, TRNT

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Mental Health & Substance Abuse

General Information

Detail	Information
Mental/Nervous Services Covered	Yes
Substance Abuse Services Covered	Yes
Payment	Same as any other illness

Residential Treatment Center

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	MRES, SRES

Outpatient Facility Treatment

Benefit Detail	Tier 1	Tier 2
Covered	Yes (PHP, DT, IOP, etc.)	Yes (PHP, DT, IOP, etc.)
Deductible Applies	Yes	Yes
Plan Pays	70%	50%
Coverage Codes	DT, SDT, SMDT

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All Other Covered Services

Services Not Otherwise Specified

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Yes
Deductible Applies	Yes	Yes
Copay Applies	No	No
Plan Pays	70%	50%
Note	This category covers medically necessary services that are not specifically listed in other benefit categories but are covered under the plan

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Preventive Care (ACA-Covered Services)

General Preventive Care

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Not covered
Follows USPSTF Recommendations	Yes	-
Deductible Applies	No	-
Copay Applies	No	-
Plan Pays	100%	-
Network Requirement	Must use network provider	-
Coverage Codes	AB, AB1, AB2, AB3, AB4, AB5, AB6, AB7, ABCV, ABH, ABNC, ABR, ABX

Reference: US Preventive Services Task Force recommendations at http://www.uspreventiveservicestaskforce.org/BrowseRec/Index

Routine PSA Test and Prostate Exam

Benefit Detail	Tier 1	Tier 2
Covered	Yes	Not covered
Deductible Applies	No	-
Plan Pays	100%	-
Out-of-Network	Not covered	-
Coverage Codes	PS, PSS

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Additional Wellness Benefits (Beyond ACA Requirements)

Note: The sections below detail wellness services beyond those required by the ACA. Most of these are NOT covered as additional wellness benefits under this plan, meaning they follow standard medical benefit rules if covered at all.

Routine Physical Exams (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Codes	HWC, WCB, WCBS, WLB, WLBS
Note	ACA-required preventive exams are covered at 100% in-network; no additional wellness benefit

Immunizations (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Codes	IMAS, IMM, IMMA, IMMB, IMMG, IMMS, IMSH
Note	ACA-required immunizations are covered at 100% in-network; no additional wellness benefit

Routine Diagnostic Tests, Labs, X-rays (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Codes	HWL, WLAB, WXL, WXR
Note	ACA-required tests covered at 100% in-network; additional tests follow medical benefit rules

Routine Mammogram (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Codes	MAM, MAM2, OMAM, OMAS, OMA2, OM2S
Note	ACA-required mammograms covered at 100% in-network; no additional wellness benefit

Routine Pap Smear/Test and Pelvic Exam (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Codes	PAP, PAPR, PAPS
Note	ACA-required screenings covered at 100% in-network; no additional wellness benefit

Routine Fecal Blood Culture (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Code	WLB
Note	ACA-required screenings covered at 100% in-network; no additional wellness benefit

Routine Colonoscopy, Sigmoidoscopy (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Codes	OCOL, OCOS, WLAB, WLB, WXL, WXLS
Note	ACA-required preventive colonoscopies covered at 100% in-network; no additional wellness benefit

Contraceptive Management (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Codes	BCI, BCIS, BCR, BCRS, BINJ, BINS, CONS, CONT
Note	ACA-required contraceptive coverage applies; no additional wellness benefit

Routine Hearing Exam (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Code	RHE
Note	No wellness benefit; medical hearing exams covered under medical benefits

Nutritional Counseling (Non-ACA)

Benefit Detail	Tier 1	Tier 2
Additional Coverage Beyond ACA	No	No
Coverage Code	WCBS
Note	ACA-required counseling covered at 100% in-network; no additional wellness benefit

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Vision Care

Medical Eye Exams

Service	Coverage
Medical-Related Eye Exams	Covered under medical
Glaucoma Testing	Covered under medical
Cataracts	Covered under medical
Routine Eye Exams	Not covered under medical (separate VSP vendor)

Separate Vision Vendor

Detail	Information
Vision Vendor	VSP
Phone Number	See VSP documentation
Routine Eye Refractions	Not covered under medical

Vision Services Under Medical

Service	Tier 1	Tier 2
Lenses (Single, Bifocal, Trifocal, Lenticular, Progressive)	Not covered	Not covered
Lens Coating	Not covered	Not covered
Frames	Not covered	Not covered
Contacts	Not covered	Not covered
Safety Lenses/Frames	Not covered	Not covered
Sunglasses	Not covered	Not covered
Lasik/Refractive Surgery	Not covered	Not covered
Vision Therapy	Not covered	Not covered

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Dental Services Under Medical

Covered Oral Surgery

Service	Covered
Impacted Teeth Excision	Yes (See comments)
Tumors & Cysts of Jaw/Mouth	Yes (requiring pathological exam)
Accidental Injury Repair	Yes
Jaw Fractures/Dislocations	Yes
External Incision & Drainage of Cellulitis	Yes
Incision of Sinuses/Salivary Glands	Yes
Exostosis Excision	Yes
Frenectomy	Yes
Gingival/Mucosal Surgery	Yes (to treat gingivitis/periodontitis)
Apicoectomy	Yes
Root Canal with Apicoectomy	Yes
Alveolectomy	Yes (not with routine extraction)

Other Dental Services

Service	Tier 1	Tier 2
Dental Implants	No	No
Anesthesia/X-ray/Lab for Hospital Dental	Yes	Yes
TMJ Treatment	Not covered	Not covered

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Hearing Services

Hearing Aids

Benefit Detail	Tier 1	Tier 2
Covered	No	No
Coverage Codes	HA, HA2, HARC

Implantable Hearing Devices

Device	Coverage
Cochlear Implants	Not covered
Soundtec	Not covered
Coverage Codes	CIRH, COCH

Routine Hearing Exam

Benefit Detail	Information
Covered as Wellness	No additional coverage beyond ACA requirements

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Infertility Treatment

Service	Tier 1	Tier 2
Diagnostic Only	Not covered	Not covered
Genetic Testing for Infertility	Not covered	Not covered
Fertility Tests	Not covered	Not covered
Hormone/Therapy Drugs	Not covered	Not covered
Artificial Insemination	Not covered	Not covered
In Vitro Fertilization	Not covered	Not covered
GIFT/ZIFT/Embryo Transfer	Not covered	Not covered
Freezing/Storage of Embryos	Not covered	Not covered
Surgical Reversal of Sterilization	Not covered	Not covered
Coverage Codes	INF, INFS, INFT, INHT, INIT, IVF, IVSF, SINT

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TMJ Treatment

Benefit Detail	Tier 1	Tier 2
Covered	No	No
Coverage Codes	TMJ, TMJO, TMJS

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Prescription Drug Benefits

Plan Overview

Detail	Information
Covered	Yes (Under Drug Plan)
Pharmacy Benefit Manager (PBM)	TrueScripts
Integrated with Medical OOP	Yes
Deductible Applies	Yes
Copay Applies	Yes
Specialty Drug Waiting Period	6 months (new to market)
Coverage Code	PCS (Invoice only)

Retail Pharmacy Copays

Drug Tier	Days Supply	Copay
Tier 1	1-30 days	$15
Tier 1	31-90 days	$25
Tier 2	1-30 days	$40
Tier 2	31-90 days	$90
Tier 3	1-30 days	$70
Tier 3	31-90 days	$175

Specialty Drug Copays

Specialty Tier	Days Supply	Copay Structure
Specialty Tier 1	1-30 days	$125
Specialty Tier 2	1-30 days	20% up to $550 maximum
Specialty Tier 3	1-30 days	20% up to $2,000 maximum
Specialty Tier 4	1-30 days	20% (no maximum)
Specialty Tier 5	1-30 days	50% (no maximum)

Specialty Injectable Drugs

Detail	Information
Covered Under Medical Plan	Yes (paid same as other office services)
Coverage Code	SPD
Note	Medications and supplies related to injectable Rx may be covered under Medical OR Pharmacy, but not both

Specific Drug Coverage

Item	Coverage
Diabetic Supplies	Yes (Drug Plan)
Insulin	Yes (Drug Plan)
Growth Hormones	Yes (Medical Plan - Tier 1)
Take-Home Medications	Yes (Drug Plan)

Contraceptive Products

Product Type	Coverage
Patches, Oral Tablets	Yes (Drug Plan)
Self-Insertable Vaginal Devices (NuvaRing)	Yes (Drug Plan)
Contraceptive Injections (Depo-Provera)	Yes (Medical Plan - Tier 1)
IUDs & Implants (Dr. Office)	Yes (Medical Plan - Tier 1)

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REAP Benefits (Ologist Services)

Radiology, Emergency, Anesthesiology, Pathology, Hospitalists

Scenario	In-Network Benefits Apply?
Services at Participating Facility	Yes
Emergency Room Physicians	Yes
Referred by Participating Physician	Yes
Outside Service Area (100+ miles from residence)	Yes
Service Unable to be Provided by Network Provider	Yes
Emergency Care Out of Area or at Non-Network Hospital	Yes

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Covered Miscellaneous Services

Special Services & Treatments

Service	Tier 1	Tier 2	Notes
Autism Services (per MHPAEA)	Yes	Yes	Includes ABA therapy
Applied Behavior Analysis (ABA)	Yes	Yes	Coverage codes: ABA, ABAH
Biofeedback	Yes	Yes	Coverage code: BFF
Botox (Medically Necessary)	Yes	Yes	Covered through Medical; Code: BOT
Breast Reductions (Medically Appropriate)	Yes	Yes	See appropriate benefit section
Developmental Delays	Yes	Yes	OT, PT, Speech, Medical charges; Code: DEVD
Bunions, Corns, Calluses, Toenails	Yes	Yes	Only if medically necessary
Genetic Counseling/Testing	Yes	Yes	Based on medical appropriateness or family history; Code: GEN
Gene Therapy	Yes	Yes	Medical and/or Rx charges; Code: GENE
Orphan Drugs	Yes	Yes	Medical and/or Rx charges; Code: ORPH
Implantable Hearing Devices	No	No	Codes: CIRH, COCH
Learning Disability	Yes	Yes	Code: DEVD
Enteral/Parenteral Support	Yes	Yes	Tube feeding as sole nutrition source; Code: MMS
Oral Nutrition Therapy	Yes	Yes	If medically necessary; Code: MMS
Feeding Tubes, Pumps, Products	Yes	Yes	Code: MMS
Sleep Disorders	Yes	Yes	If medically appropriate
Telemedicine (Patient to Physician)	Yes	Yes	Includes telephone and internet; Codes: TELM, TELS
Telemedicine (Physician to Physician)	No	No	Not covered
Teladoc (Separate Benefit)	$0 copay	$0 copay	Separate from medical; Codes: TELA, TELB
Smoking Cessation Drugs	Yes	Yes	Code: SMK; covered under Rx benefit
Wigs (Cancer/Medical Condition)	No	No	Code: WIG

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Excluded Services & Treatments

Not Covered Under This Plan

Service/Treatment	Coverage
Acupuncture	Not covered
Alternative/Complementary Treatment	Not covered (holistic, homeopathic, hypnosis)
Blood Pressure Cuffs/Monitors	Not covered
Marriage Counseling	Not covered
Gender Affirming Care	Not covered
Hearing Aids	Not covered
Orthognathic/Prognathic/Maxillofacial Surgery	Not covered (unless TMJ or reconstructive)
Panniculectomy/Abdominoplasty	Not covered
Sales Tax, Shipping, Handling	Not covered (except DME)
Complications from Non-Covered Service	Not covered
Sexual Function Enhancement	Not covered
Sexual Function - Diagnostic	Not covered
Sexual Function - Non-Surgical Treatment	Not covered
Sexual Function - Surgical Treatment	Not covered
Sexual Function - Prescription Drugs	Not covered (includes oral medications, penile pumps, erectaid devices)
Vision Therapy	Not covered
Massage Therapy by Massage Therapist	Not covered (must be by PT/OT/Physician)
Infertility Treatment	Not covered
TMJ Treatment	Not covered
Injuries While Legally Intoxicated	Not covered
Illegal Drug Use	Not covered

Weight Control (Morbid Obesity)

Service	Coverage
Bariatric Surgery	Not covered
Gastric/Intestinal Bypass	Not covered
Stomach Stapling	Not covered
Prescription Weight Loss Medication	Not covered
Physician-Supervised Weight Loss Programs	Not covered
Diet Supplements	Not covered
Coverage Codes	BAR, BARS, OBE

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Eligibility & Enrollment

Employee Eligibility

Requirement	Details
Number of Employees	174
Standard FMLA	Yes
Disability Continuation (Outside FMLA)	No
Layoff Continuation	No
Leave of Absence (Non-FMLA)	No
Full-Time Employees Only	No
Part-Time Eligibility	[If applicable, specify requirements]

Coverage Continuation Rules

Situation	Allowed	Details
FMLA Leave	Yes	Standard FMLA rules apply
Disability (Non-FMLA)	No	Continuation not allowed
Layoff	No	Continuation not allowed
Leave of Absence (Non-FMLA)	No	Leave must meet FMLA requirements

Dependent Eligibility

Dependent Type	Eligible
Spouse	Yes
Spouse with Other Coverage Available	Yes
Domestic Partners	No
Common Law Spouse	No
Children	Yes (to age 26)
Adopted Children	Yes
Foster Children	No
Children Under Legal Guardianship	No
Grandchildren	No

Reinstatement of Coverage

• Treated as new hire if terminated
• Waiting period waived if rehired within 30 days

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Coordination of Benefits (COB)

COB Rules

Detail	Policy
Primary Determination	Birthday Rule
Question Primary Carrier Rule	Yes
Medicare Part B Reduction	Yes (if Part A elected but not Part B, plan reduces benefits as if Part B was elected)
Same COB for Medicare-Eligible Employees	Yes
Medicare Primary Employees (less than 100 EEs)	Special COB rules may apply

COB Savings Code Options

Purpose: Establishes how the plan will process savings for members with Other Insurance.

Code	Description	Application
0	Accumulated COB savings are applied toward satisfying the deductible and reducing the copayment on claims (both current COB claim and future claims) until accumulated savings are used up	COB savings accumulate for each plan participant in a "COB bank" in the claimant's name
1	COB savings are applied toward satisfying the claimant's deductible and reducing the copayment portion of only the current claim	Savings do not carry forward to future claims
2	Carve Out COB – COB savings not used to satisfy a member's deductible or reduce copayment on current or future claims	Savings accumulate in the plan's name and reduce the plan's liability only

Plan's COB Savings Code: [To be confirmed by plan administrator]

COB Payment Code Options

Purpose: Determines how COB savings are applied to charges.

Code	Description	When Used
0	COB Savings are applied to the entire claimant's incurred charges, even if charges are not eligible under the plan	Example: COB savings used to pay for services denied as cosmetic
1	COB savings are applied only to charges that are eligible under the plan	Most common setting
2	COB savings are applied only to charges that are eligible under the plan, BUT savings will not be applied toward the annual accumulators	Protects plan accumulators
3	The COB Savings code is not considered, and savings will not be generated	No COB savings processed
9	COB processing will be ignored for the group, regardless of any COB amounts that may be entered on the claim	Complete COB bypass

Plan's COB Payment Code: [To be confirmed by plan administrator]

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Covered Providers

Provider Types Covered

Provider Type	Covered	Specialty Use
CNM - Certified Nurse Midwife	Yes	Obstetrics
Chiropractor	Yes	Musculoskeletal/nervous system
Massage Therapist	No	-
Licensed Professional Counselor	Yes	Mental health
Certified Addiction Counselor	Yes	Substance abuse
Psy.D.	Yes	Mental health treatment
State Licensed Psychologist	Yes	Mental health treatment
MSW - Masters in Social Work	Yes	Mental health treatment
State Licensed/Certified Social Worker	Yes	Mental health treatment

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Administrative Details

Timely Filing

Detail	Information
Timely Filing Period	12 months

Stop Loss

Type	Tracking
Specific Stop Loss	Tracks to Specific MED/RX
Aggregate Stop Loss	Tracks to Aggregate MED/RX

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Important Contact Information

Key Phone Numbers

Service	Phone Number
TPA (90 Degree Benefits)	See plan documentation
Hours of Operation	8:00 AM - 5:00 PM CST
CIGNA Precertification	888-832-0354
Pharmacy (TrueScripts)	See plan documentation
Vision (VSP)	See plan documentation

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Notes & Special Instructions

Important Plan Notes

1. Deductible and OOP Cross-Apply: In-network (Tier 1) and out-of-network (Tier 2) deductibles and out-of-pocket maximums DO NOT cross-apply. They are SEPARATE.

2. 3-Month Carry Over: Amounts applied in the last 3 months of the plan year carry over to the following year for both Individual and Family deductibles and out-of-pocket maximums.

3. Emergency Services: Emergency room services (both facility and professional) are always paid at Tier 1 rates (70% after deductible), even if received out-of-network. Tier 2 emergency services apply Tier 1 deductible and out-of-pocket maximum.

4. Ambulance Services: Ambulance services in Tier 2 are paid at 70% and apply the Tier 1 deductible and out-of-pocket maximum.

5. Mental Health & Substance Abuse: All mental health and substance abuse benefits are paid the same as any other illness.

6. Preventive Care: ACA preventive services are covered at 100% with no deductible or copay when using in-network providers only. Out-of-network preventive services are not covered.

7. Therapy Visit Maximums:

   • Physical Therapy & Occupational Therapy: Combined 36 visits per calendar year
   • Speech Therapy: 20 visits per calendar year

8. Chiropractic Maximum: $500 per calendar year

9. Extended Care Maximums:

   • Skilled Nursing Facility: 60 days per calendar year
   • Home Health Care: 60 visits per calendar year

10. Newborn Enrollment: Newborn dependents must be enrolled on the plan within 31 days.

11. Specialty Drugs: 6-month waiting period for new-to-market specialty drugs.

12. Injectable Medications: May be covered under Medical OR Pharmacy benefits, but not both.

13. REAP Services: Radiology, Emergency Room Physicians, Anesthesiology, Pathology, and Hospitalist services are paid at in-network rates when performed at a participating facility or when the service cannot be provided by a network provider.

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Definitions

Term	Definition
Tier 1	In-network services using CIGNA provider network (PPO Code 3002)
Tier 2	Out-of-network services paid at 130% of Medicare (professional) or 150% of Medicare (facilities)
Deductible	The amount you must pay out-of-pocket before the plan begins to pay benefits
Coinsurance	The percentage of costs you pay after meeting your deductible
Out-of-Pocket Maximum	The maximum amount you pay in a plan year; after this, the plan pays 100%
Copay	A fixed amount you pay for certain services
UCR	Usual, Customary, and Reasonable charges
RBP	Reference-Based Pricing (payment based on percentage of Medicare)
REAP	Radiology, Emergency, Anesthesiology, Pathology services
DME	Durable Medical Equipment
ACA	Affordable Care Act (includes mandated preventive services)
USPSTF	United States Preventive Services Task Force

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Frequently Asked Questions

Q: Do my Tier 1 and Tier 2 deductibles combine? A: No. Tier 1 and Tier 2 deductibles are SEPARATE and do not cross-apply.

Q: What happens if I go to the emergency room at a non-network hospital? A: Emergency services are always paid at Tier 1 rates (70% after deductible), even at non-network facilities.

Q: How does the 3-month carry over work? A: Any amounts you pay toward your deductible or out-of-pocket maximum in the last 3 months of the year (October, November, December) will carry over and count toward the next year's deductible and OOP maximum.

Q: Are preventive services covered if I use an out-of-network provider? A: No. ACA preventive services are only covered at 100% when you use in-network (Tier 1) providers.

Q: Do my therapy visits have a limit? A: Yes. Physical therapy and occupational therapy are combined for a maximum of 36 visits per calendar year. Speech therapy has a separate limit of 20 visits per calendar year.

Q: Is massage therapy covered? A: Only when performed by a Physical Therapist, Occupational Therapist, or Physician with a medical diagnosis. Massage therapy by a massage therapist alone is not covered.

Q: What if I need a specialist? A: Specialist office visits have a $60 copay (compared to $30 for primary care) in Tier 1.

Q: Are my prescription drugs covered? A: Yes, through TrueScripts pharmacy benefit manager. Copays vary by drug tier and days supply.

Q: What is Teladoc? A: Teladoc is a telemedicine service available with a $0 consult fee for virtual doctor visits.

Q: How does the plan handle ologist services (radiologists, emergency room physicians, anesthesiologists, pathologists, hospitalists)? A: These services are paid at in-network rates when:

• Performed at a participating facility
• Referred by a participating physician
• Outside service area (100+ miles from residence)
• Unable to be provided by network provider
• Emergency care situation

Q: What if I need a service that requires precertification but don't get it in advance? A: The plan allows retroactive precertification, so services won't automatically be denied. However, it's best to call CIGNA at 888-832-0354 before receiving care that requires precertification.

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Plan-Specific Notes & Special Rules

Critical Plan Features

1. Separate Accumulators: Tier 1 and Tier 2 deductibles and out-of-pocket maximums are completely separate. Money spent on Tier 2 services does NOT count toward Tier 1 accumulators and vice versa.

2. 3-Month Carry Over Rule: Any amounts paid toward your deductible or out-of-pocket maximum in October, November, or December will carry forward and apply to the next year's accumulators. This applies to both deductibles and out-of-pocket maximums for both individual and family levels.

3. Emergency Service Exception: Emergency room services (both facility and professional) are ALWAYS paid at Tier 1 rates (70% after deductible), even if received at a non-network facility. Emergency room claims apply Tier 1 deductible and out-of-pocket maximum, never Tier 2.

4. Ambulance Service Exception: Ambulance services (ground and air) are paid at 70% and apply Tier 1 deductible and out-of-pocket maximum, even if provided by non-network providers.

5. Preventive Care Network Requirement: ACA preventive services are covered at 100% with no deductible or copay ONLY when using in-network (Tier 1) providers. Using out-of-network providers means preventive services will not be covered at the preventive care level.

6. Mental Health & Substance Abuse Parity: All mental health and substance abuse services are paid the same as any other medical illness - no special limitations or separate maximums apply.

7. Therapy Visit Limits:

   • Physical Therapy and Occupational Therapy are COMBINED for a maximum of 36 visits per calendar year
   • Speech Therapy has a SEPARATE limit of 20 visits per calendar year
   • These limits apply whether services are provided in Tier 1 or Tier 2

8. Chiropractic Annual Maximum: $500 per calendar year maximum benefit, after which services are not covered regardless of tier.

9. Extended Care Limits:

   • Skilled Nursing Facility: 60 days per calendar year
   • Home Health Care: 60 visits per calendar year
   • These limits apply across both tiers combined

10. Newborn Enrollment Deadline: Newborn dependents MUST be enrolled within 31 days of birth. After 31 days, the next open enrollment period must be used unless a qualifying event occurs.

11. Injectable Medications Rule: Medications and supplies related to injectable prescription medications may be covered under Medical OR Pharmacy benefits, but NOT both. Check with the plan administrator before receiving treatment.

12. Specialty Drug Waiting Period: New-to-market specialty drugs have a 6-month waiting period before coverage begins.

13. Diabetic Shoe Benefit: Diabetic shoes are covered up to $500 for 1 pair per calendar year under the Orthotics benefit.

14. Reinstatement After Termination: If you terminate coverage and are rehired within 30 days, your waiting period is waived. If rehired after 30 days, you're treated as a new hire.

15. COB and Medicare: Special COB rules may apply for employees with Medicare if the employer has less than 100 employees. The plan may reduce benefits as if Medicare Part B was elected even if the member only has Part A.

16. Timely Filing: Claims must be submitted within 12 months of the date of service.

17. Appeals Process: 1 level of internal appeal is required before external review to an Independent Review Organization (IRO).

18. Continuity of Care: For members under care for serious illness or pregnancy, network benefits are available for 90 days if the primary care physician leaves the network.

Reference-Based Pricing Details (Tier 2)

When using out-of-network providers (Tier 2):

• Professional services are paid at 130% of Medicare rates
• Facility services are paid at 150% of Medicare rates
• The plan uses the 80th percentile of Usual, Customary, and Reasonable (UCR) charges
• Members may receive balance bills from providers

Copay Application Rules

When copays apply, they are applied "PER PROVIDER PER DAY" which means:

• If you see multiple providers in one day, you pay a copay for each provider
• If you see the same provider multiple times in one day, you typically pay only one copay
• Copays for Primary Care Physicians (PCP): $30
• Copays for Specialists: $60
• Urgent Care copay: $60

Allowable Providers

The plan covers services from:

• Medical Doctors (MD) and Doctors of Osteopathy (DO)
• Certified Nurse Midwives (CNM) - within scope of license
• Chiropractors - for covered chiropractic services only
• Licensed Professional Counselors - for mental health treatment
• Certified Addiction Counselors - for substance abuse treatment
• Psychologists (Psy.D., Ph.D.) - for mental health treatment
• Licensed/Certified Social Workers (MSW, LCSW) - for mental health treatment
• Physical Therapists, Occupational Therapists - for therapy services
• Physicians providing massage therapy services - massage therapists alone are NOT covered

Not Covered by This Plan

These services are explicitly NOT covered under any circumstances:

• Acupuncture
• Alternative/complementary medicine (holistic, homeopathic, hypnosis)
• Marriage counseling
• Gender affirming care
• Hearing aids and implantable hearing devices (cochlear implants)
• Infertility treatment (diagnostic or treatment)
• TMJ treatment (all types)
• Orthognathic/prognathic/maxillofacial surgery (unless part of TMJ or reconstructive surgery)
• Panniculectomy/abdominoplasty (cosmetic abdomen surgery)
• Sales tax, shipping, and handling (except for DME)
• Complications arising from non-covered services
• Sexual function enhancement (all types: diagnostic, non-surgical, surgical, medications, devices)
• Vision therapy
• Massage therapy by massage therapists (must be provided by PT/OT/Physician)
• Weight control/morbid obesity treatment (bariatric surgery, gastric bypass, etc.)
• Services related to injuries incurred while legally intoxicated
• Services related to illegal drug use
• Blood pressure cuffs and monitors (for home use)
• Wigs (even for cancer treatment)

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Frequently Asked Questions

Document Version Control

Detail	Information
Document Date	December 26, 2025
Effective Date	January 1, 2026
Plan Type	2-Tier Network Plan
Form Template Last Updated	January 30, 2019
Form Completed By	Susan Green
Title	Plan Build
Date Completed	12/26/2025
Final Approval Status	Approved by (Date): [Pending Customer Signature]

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Customer Approval Section

Important Note: Customer approval of this installation document is of critical importance. This information is used to ensure benefits are quoted correctly and must accurately reflect the plan document.

Any changes requested after approval of this document or after the effective date of the plan will need to be submitted so benefits are not quoted incorrectly.

Customer Signature Required: Electronic signature accepted
Date: [Pending]
Customer Comments: [None at time of document creation]

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Plan Modifications Process

If modifications are needed after initial approval, they must be submitted through the formal Plan Modifications process:

1. Group Name and Effective Date must be specified
2. Group Number must be included
3. All modifications must be detailed in writing
4. Completed by authorized 90 Degree Benefits staff
5. Customer approval required via signature
6. Any further changes after modification approval require new submission

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CIGNA Pre-Certification List

Note: A separate CIGNA Pre-Certification List document exists that details all services requiring pre-certification. This list should be referenced for complete pre-certification requirements.

Services requiring precertification must be called into CIGNA at 888-832-0354.

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This knowledge base article is for informational purposes only and is based on the Install Plan Document dated 12/26/2025. For official plan documentation or questions about specific coverage, please contact 90 Degree Benefits during business hours (8:00 AM - 5:00 PM CST) or refer to the complete plan documents.

Customer approval is pending and required for this plan to become official. Electronic signatures are accepted.