Five Star Technology Solutions - Plan 11 Complete Medical Benefits Schedule Guide
This comprehensive guide contains every detail of the medical and prescription drug benefits for Five Star Technology Solutions employees enrolled in Plan 11 (PPO). The plan provides separate in-network and out-of-network coverage with CIGNA network providers and prescription drug benefits administered by TrueScripts.
Plan Identification & Status
| Field | Details |
|---|---|
| Company Name | Five Star Technology Solutions |
| Plan Name | Plan 11 |
| Group Number | 001R2571 |
| Effective Date | October 1, 2025 |
| Plan Status | NGF (New Group Filing) |
| Managed Care Type | PPO |
| Document Status | DRAFT |
| Draft Versions | 9-16-2025 PM, 9-23-2025 PM, 9-25-25 PM, 10-20-2025 PM |
| Plan Document Version | 25.1 |
| MCC Creditable | No |
Plan Administration & Approvals
| Role/Function | Provider/Contact |
|---|---|
| PPO Network | CIGNA |
| Out-of-Network Pricing | PHIA |
| Utilization Management (UM) | Cigna Payer Solutions |
| Case Management (CM) | MedWatch |
| Disease Management (DM) | N/A |
| Customer Service | Karias Care Concierge |
| Prescription Drug Administrator | TrueScripts |
| TRU Department Approval | TRU |
| Account Manager | Kate Gilpatrick |
| Compliance Officer | Patrick Moore |
PRESCRIPTION DRUG BENEFITS
Prescription Drug Structure
| Feature | Details |
|---|---|
| Administrator | TrueScripts |
| Scripts Subject to Deductibles | NO |
| Out-of-Pocket Maximum | COMBINED with medical OOP max |
| Non-Participating Pharmacy Coverage | NO |
| Out-of-Network Pharmacy Coverage | NOT COVERED |
Retail Card Program - Up to 30 Day Supply
| Drug Type | Your Cost |
|---|---|
| Generic Drug | $10 Co-payment per prescription |
| Preferred Brand Name Drug | $50 Co-payment per prescription |
| Non-Preferred Brand Name Drug | $100 Co-payment per prescription |
Retail Pharmacy - Up to 90 Day Supply
| Drug Type | Your Cost |
|---|---|
| Generic Drug | $25 Co-payment per prescription |
| Preferred Brand Name Drug | $125 Co-payment per prescription |
| Non-Preferred Brand Name Drug | $250 Co-payment per prescription |
Mail Order Pharmacy - Up to 90 Day Supply
| Drug Type | Your Cost |
|---|---|
| Generic Drug | $25 Co-payment per prescription |
| Preferred Brand Name Drug | $125 Co-payment per prescription |
| Non-Preferred Brand Name Drug | $250 Co-payment per prescription |
Specialty Drugs (Retail and Mail Order) - Up to 30 Day Supply
| Specialty Tier | Your Cost |
|---|---|
| Tier 1 Specialty Drug | 25% Coinsurance up to a $300 Co-payment maximum |
| Tier 2 Specialty Drug | 20% Coinsurance up to a $550 Co-payment maximum |
| Tier 3 Specialty Drug | 20% Coinsurance up to a $2,000 Co-payment maximum |
| Tier 4 Specialty Drug | 20% Coinsurance (no maximum) |
| Tier 5 Specialty Drug | 50% Coinsurance (no maximum) |
Note: See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs.
Prescription Drug Special Coverage Rules
| Coverage Type | Rule |
|---|---|
| Generic U.S. FDA Approved Contraceptives | Covered at 100% (medications and devices) |
| Preferred Brand Name Contraceptives | Subject to Co-payments and Coinsurance as shown, unless generic form is not available |
| Non-Preferred Brand Name Contraceptives | Subject to Co-payments and Coinsurance as shown, unless generic and preferred brand name forms are not available |
| When Generic Not Available | Available preferred brand name drug covered at 100% |
| When Generic and Preferred Not Available | Available non-preferred brand name drug covered at 100% |
| Tobacco Cessation Products | Covered at 100% |
Prescription Drug Out-of-Pocket Maximum
| Expense Type | Applies to OOP Max? |
|---|---|
| Prescription Drug Co-payments | YES - counts toward COMBINED medical out-of-pocket maximum |
| Prescription Drug Coinsurance | YES - counts toward COMBINED medical out-of-pocket maximum |
Once Out-of-Pocket Maximums have been met: Prescription drugs are covered at 100% for the balance of the Calendar Year.
MEDICAL DEDUCTIBLES
Annual Calendar Year Deductibles
| Coverage Level | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Single Plan (Employee Only) | $5,000 | $10,000 |
| Family Plan - Individual Deductible | $5,000 per person | $10,000 per person |
| Family Plan - Family Maximum | $10,000 per family | $20,000 per family |
Deductible Structure
| Feature | Details |
|---|---|
| Individual Deductible Included in Family Coverage | YES |
| In-Network and Out-of-Network Deductibles | SEPARATE - Do not accumulate together |
| Medical Calendar Year Deductible Carryover | NO |
Family Deductible Rules
| Scenario | How It Works |
|---|---|
| Individual Family Member Meets Individual Deductible | Claims will be paid for that individual |
| No Individual Meets Individual Deductible | Entire family deductible must be satisfied before claims will be paid for any family members |
| Meeting Family Deductible | May be met by any combination of family members |
Special Deductible Credit for Calendar Year 2025
| Period | Credit Applied |
|---|---|
| Expenses Incurred | 1/1/2025 through 9/30/2025 |
| Credit Applied To | Calendar Year starting 1/1/2025 and ending 12/31/2025 |
| Purpose | Deductible expenses incurred during transition period shall be credited and used to satisfy the Deductible for the full Calendar Year |
COINSURANCE (REIMBURSEMENT PERCENTAGE)
In-Network Providers
| Phase | Coinsurance Rate | Applied To |
|---|---|---|
| Before Out-of-Pocket Maximum Met | 80% of the Contracted Rate | After Deductible; unless otherwise stated |
| After Out-of-Pocket Maximum Met | 100% | For the balance of the Calendar Year |
Out-of-Network Providers
| Phase | Coinsurance Rate | Applied To |
|---|---|---|
| Before Out-of-Pocket Maximum Met | 50% of the Allowed Amount | After Deductible; unless otherwise stated |
| After Out-of-Pocket Maximum Met | 100% | For the balance of the Calendar Year |
OUT-OF-POCKET MAXIMUMS
Annual Calendar Year Out-of-Pocket Maximums
| Coverage Level | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Single Plan (Employee Only) | $7,000 | $14,000 |
| Family Plan - Individual OOPM | $7,000 per person | $14,000 per person |
| Family Plan - Family Maximum | $14,000 per family | $28,000 per family |
Out-of-Pocket Maximum Structure
| Feature | Details |
|---|---|
| Individual OOPM Included in Family Coverage | YES |
| In-Network and Out-of-Network OOPM | SEPARATE - Do not accumulate together |
| What Counts Toward OOPM | All applicable Co-payments, Calendar Year Deductible, Coinsurance (including those for prescription drugs) |
Family Out-of-Pocket Maximum Rules
| Scenario | How It Works |
|---|---|
| Individual Family Member Meets Individual OOPM | Claims will be paid for that individual at 100% |
| No Individual Meets Individual OOPM | Once entire family OOPM is satisfied, claims will be paid at 100% for all covered family members |
| Meeting Family OOPM | May be met by any combination of family members |
Expenses EXCLUDED from Out-of-Pocket Maximum
| Expense Type | Excluded? |
|---|---|
| Precertification Penalties | YES - Excluded from OOPM |
Special Out-of-Pocket Maximum Credit for Calendar Year 2025
| Period | Credit Applied |
|---|---|
| Expenses Incurred | 1/1/2025 through 9/30/2025 |
| Credit Applied To | Calendar Year starting 1/1/2025 and ending 12/31/2025 |
| Purpose | Out-of-Pocket Maximum expenses incurred during transition period shall be credited and used to satisfy the OOPM for the full Calendar Year |
MEDICAL CO-PAYMENTS
Facility Co-Payments - In-Network Only
| Service Type | In-Network Co-payment | Co-payment Maximum | Out-of-Network |
|---|---|---|---|
| Inpatient Hospital | $500 per admission | NONE | NONE |
| Outpatient Hospital Surgery | $250 per procedure | NONE | NONE |
Important Notes:
- Outpatient Hospital Co-payment does NOT apply to office surgery
- Co-payment applies to each outpatient procedure in an In-Network facility
Office Visit Co-Payments - In-Network Only
| Service Type | In-Network Co-payment | Out-of-Network |
|---|---|---|
| Primary Care Physician | $25 per visit | NONE |
| Specialty Care Physician | $50 per visit | NONE |
PRECERTIFICATION REQUIREMENTS
Inpatient Hospitalization - ALWAYS REQUIRED
| Requirement | Details |
|---|---|
| When Precertification Must Occur | Prior to the date of admission |
| Emergency Admission Exception | Within two (2) business days of admission |
| Failure to Obtain Precertification | May result in a reduction in benefits |
| Penalty Application | Reduction in benefits CANNOT be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan |
| Responsibility for Penalty | Any penalty incurred due to failure to obtain precertification or preauthorization for services may be the responsibility of the Covered Person |
Other Services Requiring Precertification
| Service Category | Precertification Required? |
|---|---|
| Services deemed cosmetic | May require precertification regardless of setting (inpatient, outpatient, or office) |
| Services deemed Experimental/Investigational | May require precertification regardless of setting (inpatient, outpatient, or office) |
| Services determined not to be Medically Necessary | Coverage may not be available if precertification required but not obtained |
Plan Rights Regarding Precertification
| Authority | Details |
|---|---|
| Prospective Denial | The Plan reserves the right to deny coverage prospectively for any service that may not require precertification but is determined in advance not to be medically necessary |
See individual benefits for specific services requiring precertification.
PREVENTIVE CARE SERVICES
Preventive Care General Information
| Information Type | Details |
|---|---|
| PPACA Compliance | Services marked with ** are provided according to terms prescribed by regulations issued under the Patient Protection and Affordable Care Act of 2010 (PPACA) |
| Recommendations Source | Majority of PPACA preventive care services recommendations are issued by the U.S. Preventive Service Task Force (USPSTF) |
| Updates | Recommendations may be amended from time to time |
| New Recommendations Effective | New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance of the revised recommendation |
| Complete Listing | Available at specified link (see Medical Benefits section) |
Preventive Care - Routine Exams and Screenings
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits |
|---|---|---|---|
| Routine Physical Exams (includes routine and travel immunizations and flu shots) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Routine Well Child Care (includes screenings, routine and travel immunizations and flu shots) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Fluoride Varnish (up to age 6) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to four (4) varnish treatments per person, per Calendar Year (combined in/out-of-network) |
| Routine Hearing Exams | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
Preventive Care - Women's Health Services
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Breastfeeding Support, Supplies and Counseling (during pregnancy and/or in the postpartum period and rental or purchase of breastfeeding equipment) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | See Breast Pump Limits below |
| Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | FDA approved only |
| Routine Gynecological/Obstetrical Care (including preconception and prenatal services) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Routine Pap Smears | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Breast Cancer Screening including Routine Mammograms and BRCA testing | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
Breast Pump Coverage Limits
| Breast Pump Type | Coverage Details |
|---|---|
| Hospital Grade Breast Pumps | Rental covered up to 3 months; precertification required for rental in excess of 3 months |
| Electric Breast Pumps | Rent or purchase, whichever is less |
| Manual Breast Pumps | Purchase |
INTERNAL NOTE: If there are no INN (in-network) lactation providers, then OON (out-of-network) providers should be covered at the INN level of benefits with no cost sharing. If the only reason for the visit with the provider is lactation, it should be with no cost-sharing.
Preventive Care - Immunizations and Lab Tests
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Routine Immunizations (if not billed with an office visit; includes flu shots and travel immunizations) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Routine Lab, X-rays, and Clinical Tests (including those related to maternity care) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
Preventive Care - Cancer Screenings
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits |
|---|---|---|---|
| Routine Colorectal Cancer Screening, including sigmoidoscopies and colonoscopies (as recommended by the US Preventive Service Task Force) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Lung Cancer Screening, including Low-Dose Computed Tomography (LDCT) (as recommended by the US Preventive Service Task Force) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to one (1) per person, per Calendar Year (combined in/out-of-network) |
Preventive Care - Other Screenings and Counseling
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits |
|---|---|---|---|
| Nutritional Counseling | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Smoking Cessation Counseling and Intervention (including smoking cessation clinics and programs) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Routine Prostate Exams and Prostate-Specific Antigen (PSA) Screenings | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Abdominal Aortic Aneurysm Screening (as recommended by the US Preventive Service Task Force) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to one (1) per person, per lifetime (combined in/out-of-network) |
Preventive Care - Bone Density Screening
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Bone Density Screening - Women (as recommended by the US Preventive Service Task Force for Osteoporosis Screening) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Bone Density Screening - All Other Covered Persons | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
VISION CARE
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Routine Vision Exam | NOT COVERED | NOT COVERED |
| Routine Eyewear (lenses, frames, and contact lenses) | NOT COVERED | NOT COVERED |
| Eyewear for Special Conditions (initial purchase of non-routine eyewear following surgery; contact lenses needed to treat keratoconus including the fitting of these contact lenses; intraocular lenses implanted after corneal transplant, cataract surgery or other covered eye surgery when the natural eye lens is replaced) | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
PHYSICIAN SERVICES
Physician Services - Testing and Treatment
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits |
|---|---|---|---|
| Allergy Testing | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Allergy Treatment | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Anesthesia (Inpatient/Outpatient) | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Chiropractic Services | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to 20 visits per person per Calendar Year (combined in/out-of-network) |
Physician Services - Maternity Care (Employee & Spouse Only)
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Prenatal Care | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Physician Delivery Charges | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Postnatal Care | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Note: Maternity coverage applies to Employee & Spouse Only. Includes Physician delivery charges, prenatal and postpartum care.
Physician Services - Hospital and Office Visits
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Physician Hospital Visits | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Physician Office Visits - Primary Care (includes all related charges billed at time of visit) | $25 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Physician Office Visits - Specialist (includes all related charges billed at time of visit) | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Second Surgical Opinion | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
Physician Services - Surgery
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Surgery - Inpatient | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery - Outpatient | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Surgery - Physician's Office | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
HOSPITAL SERVICES - INPATIENT
Inpatient Hospital Requirements and Co-payments
| Requirement/Feature | Details |
|---|---|
| Precertification | ALWAYS required for inpatient hospitalization |
| Failure to Obtain Precertification | May result in a reduction in benefits |
| Penalty Usage | The reduction in benefits CANNOT be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan |
| Inpatient Hospital Co-payment | A separate $500 Hospital Co-payment will apply to each inpatient admission in an In-Network facility |
| Penalty Responsibility | Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person |
| Private Room Coverage | Covered only when Medically Necessary or when a facility does not provide semi-private rooms |
Inpatient Hospital Services
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Hospital Room & Board (semi-private room or special care unit) | $500 Co-payment per admission, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Precertification required |
| Maternity Services - Employee & Spouse only (semi-private room or special care unit) | $500 Co-payment per admission, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Precertification required for stays in excess of 48 hours vaginal; 96 hours cesarean |
| Birthing Center - Employee & Spouse only | $500 Co-payment per admission, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Newborn Care (includes Physician visits & circumcision; semi-private room or special care unit) | $500 Co-payment per admission, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Organ, Bone Marrow and Stem Cell Transplants (semi-private room or special care unit) | $500 Co-payment per admission, then 80% (after Deductible); Managed through Cigna's LifeSOURCE Transplant Network® | 50% Allowed Amount (after Deductible) | Precertification required; Transportation/food/lodging limits: $5,000 per Transplant; See Medical Benefits section for other limitations |
| Surgical Facility & Supplies | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Miscellaneous Hospital Charges | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
HOSPITAL SERVICES - OUTPATIENT
Outpatient Hospital Requirements and Co-payments
| Requirement/Feature | Details |
|---|---|
| Outpatient Hospital Co-payment | A separate $250 Hospital Co-payment will apply to each outpatient procedure in an In-Network facility |
| Co-payment Application | The Co-payment will NOT apply to office surgery |
| Penalty Responsibility | Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person |
Outpatient Hospital Services
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Clinic Services (at a Hospital) | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Emergency Room Expenses (includes Facility, Lab, X-ray & Physician services) | $400 Co-payment per visit, then 80% (after Deductible) | $400 Co-payment per visit, then 80% (after In-Network Deductible) | Co-payment is waived if admitted on an inpatient basis to a Hospital |
| Outpatient Department | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. | $250 Co-payment per visit, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Preadmission Testing | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Urgent Care Facility/Walk-In Clinic | $75 Co-payment per visit, then 80% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
MENTAL HEALTH & SUBSTANCE USE SERVICES
Mental Health/Substance Use Requirements and Co-payments
| Requirement/Feature | Details |
|---|---|
| Precertification | ALWAYS required for inpatient hospitalization |
| Failure to Obtain Precertification | May result in a reduction in benefits |
| Penalty Usage | The reduction in benefits CANNOT be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan |
| Inpatient Hospital Co-payment | A separate $500 Hospital Co-payment will apply to each inpatient admission in an In-Network facility |
| Penalty Responsibility | Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person |
| Private Room Coverage | Covered only when Medically Necessary or when a facility does not provide semi-private rooms |
Mental Health/Substance Use Services
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Inpatient Hospitalization | $500 Co-payment per admission, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Precertification required |
| Partial Hospitalization/Intensive Outpatient Treatment | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Inpatient Physician Visit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Hospital Clinic Visit | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Office Visit | $25 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
| Methadone Maintenance/Treatment | NOT COVERED | NOT COVERED | None specified |
OTHER SERVICES & SUPPLIES
Other Services - Alternative and Complementary Care
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Acupuncture | NOT COVERED | NOT COVERED |
| Alternative/Complementary Care Benefit | NOT COVERED | NOT COVERED |
Other Services - Emergency and Transportation
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Ambulance Services | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
Other Services - Autism Treatment
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Autism Spectrum Disorders Treatment (includes Applied Behavioral Analysis (ABA)) | Benefits are based on services provided | Benefits are based on services provided | Benefit limits do NOT apply to occupational, physical and speech therapies; Precertification IS required for ABA; See Medical Benefits section for limitations; Note: Screenings are covered under Preventive Care |
Other Services - Weight Loss and Cardiac
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits |
|---|---|---|---|
| Bariatric Surgery | NOT COVERED | NOT COVERED | N/A |
| Biofeedback Therapy | NOT COVERED | NOT COVERED | N/A |
| Cardiac Rehabilitation (Phase 1 and 2 only) | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to 36 visits per person per Calendar Year (combined in/out-of-network); See Medical Benefits section for other limitations |
Other Services - Cancer Treatment
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Chemotherapy & Radiation Therapy | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Other Services - Clinical Trials and Implants
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Clinical Trials - Routine Services during Approved Clinical Trials | Benefits are based on services provided | Benefits are based on services provided | Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services; See Medical Benefits section for other limitations |
| Cochlear Implants | NOT COVERED | NOT COVERED | None specified |
Other Services - Dental and Oral
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Dental/Oral Services | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Excludes excision of impacted wisdom teeth; See Medical Benefits section for other limitations |
Other Services - Diabetes
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Diabetes Self-Management Training and Education | $25 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
Other Services - Diagnostic Imaging (CORRECTED 10-20-25, EFF 10-1-25)
| Service | Facility Type | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|---|
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | Freestanding Facility | $250 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | All Other Facilities | $250 Co-payment per visit, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Other Services - Diagnostic X-ray, Lab, and Tests (CORRECTED 10-20-25, EFF 10-1-25)
| Service | Facility Type | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|---|
| Diagnostic X-ray and Laboratory (Outpatient) | Office Setting/Freestanding Facilities Outpatient Lab | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Diagnostic X-ray and Laboratory (Outpatient) | Outpatient Hospital Facility | $250 Co-payment per visit, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
| All Other Diagnostic Tests | All Facilities | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Other Services - Dialysis and Equipment
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Dialysis/Hemodialysis | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | See Medical Benefits section for other limitations |
| Durable Medical Equipment | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
Other Services - Early Intervention and Erectile Dysfunction
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Early Intervention Services (up to age 3) | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
| Erectile Dysfunction Treatment | NOT COVERED | NOT COVERED | None specified |
Other Services - Family Planning
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Family Planning - For Women (including but not limited to consultations and diagnostic tests) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | See also Prescription Drug Benefit and Preventive Care Section |
| Family Planning - For Men (including but not limited to consultations and diagnostic tests) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | None specified |
Other Services - Gender Dysphoria and Gene Therapy
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Gender Dysphoria Treatment and Related Services | NOT COVERED | NOT COVERED |
| Gene Therapy | NOT COVERED | NOT COVERED |
Other Services - Genetic Services
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Genetic Counseling, Testing and Related Services | NOT COVERED | NOT COVERED | Note: Coverage IS provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services; Precertification is NOT required for BRCA testing |
Other Services - Growth Hormones and Hearing
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Growth Hormones | NOT COVERED | NOT COVERED |
| Hearing Aids | NOT COVERED | NOT COVERED |
Other Services - Home Health and Hospice
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits | Special Notes |
|---|---|---|---|---|
| Home Health Care | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Up to 60 visits per person per Calendar Year (combined in/out-of-network) | See Medical Benefits section for limitations |
| Hospice Care (Inpatient/Outpatient) | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified | Precertification required for inpatient services; See Medical Benefits section for other limitations |
Other Services - Infertility and Injectables
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Infertility Treatment | NOT COVERED | NOT COVERED |
| Injectables | 80% (after Deductible) | 50% Allowed Amount (after Deductible) |
Other Services - Learning and Behavioral
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Learning Deficiencies, Behavioral Problems/Developmental Delays | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Precertification and visit limits are based on services provided |
| Marital Counseling | NOT COVERED | NOT COVERED |
Other Services - Massage and Medical Foods
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Massage Therapy | NOT COVERED | NOT COVERED |
| Medical and Enteral Formula | NOT COVERED | NOT COVERED |
| Modified Low Protein Food Products | NOT COVERED | NOT COVERED |
Other Services - Neuromuscular Equipment
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Neuromuscular Stimulator Equipment including TENS | NOT COVERED | NOT COVERED |
Other Services - Therapy Services (All 20 visits per Calendar Year combined in/out-of-network)
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits | Special Notes |
|---|---|---|---|---|
| Occupational Therapy | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to 20 visits per person, per Calendar Year (combined in/out-of-network) | For treatment due to Illness or Injury; See Medical Benefits section for other limitations |
| Physical Therapy | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to 20 visits per person, per Calendar Year (combined in/out-of-network) | For treatment due to Illness or Injury; See Medical Benefits section for other limitations |
| Speech Therapy | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to 20 visits per person, per Calendar Year (combined in/out-of-network) | For treatment due to Illness or Injury; See Medical Benefits section for other limitations |
| Respiratory Therapy | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | Up to 20 visits per person, per Calendar Year (combined in/out-of-network) | None specified |
Other Services - Oral and Orthotic Devices
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Oral Pharynx Procedures | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | None specified |
| Orthotics (includes foot orthotics) | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
Other Services - Podiatry and Nursing
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Podiatry Care | $50 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
| Private Duty Nursing | NOT COVERED | NOT COVERED | None specified |
Other Services - Prosthetics and Rehabilitation
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Prosthetics | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | See Medical Benefits section for limitations |
| Rehabilitation Hospital | $500 Co-payment per admission, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Precertification required; See Medical Benefits section for other limitations |
Other Services - Sleep Studies (CORRECTED 10-20-25, EFF 10-1-25)
| Service | Facility Type | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|---|
| Sleep Studies | Office Setting/Outpatient Lab | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Limited to the testing and treatment of Obstructive Sleep Apnea; See Medical Benefits section for other limitations |
| Sleep Studies | Outpatient Facility | $250 Co-payment per visit, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Limited to the testing and treatment of Obstructive Sleep Apnea; See Medical Benefits section for other limitations |
Other Services - Skilled Nursing Facility
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits | Special Notes |
|---|---|---|---|---|
| Skilled Nursing Facility/Extended Care Facility | $500 Co-payment per admission, then 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Up to 60 days per person, per Calendar Year (combined in/out-of-network) | Precertification required; See Medical Benefits section for other limitations |
Other Services - Telemedicine
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Telemedicine (applies to medical and behavioral health services; includes Doctor on Demand) | $25 Co-payment per visit, then 100% (Deductible waived) | 50% Allowed Amount (after Deductible) | INCLUDES DOCTOR ON DEMAND; See Medical Benefits section for additional information |
| All other virtual visits with a Provider with whom a Covered Person has established relationship (including, but not limited to Occupational Therapy, Physical Therapy and Speech Therapy) | Paid based on services provided | Paid based on services provided | None specified |
Other Services - TMJ and Pregnancy Termination
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Temporomandibular Joint Disorders (TMJ) Treatment | NOT COVERED | NOT COVERED | None specified |
| Termination of Pregnancy | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Covered only in circumstances in which the life of the mother would be endangered by continuing the pregnancy to term, as documented by the treating Physician or due to rape or incest |
Other Services - Sterilization
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Voluntary Sterilization - For Women | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Voluntary Sterilization - For Men | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
Other Services - Wigs
| Service | In-Network Coverage | Out-of-Network Coverage | Limits | Special Notes |
|---|---|---|---|---|
| Wigs | 80% (after Deductible) | 50% Allowed Amount (after Deductible) | Up to one (1) wig per person per Calendar Year to a maximum of $300 per wig (combined in/out-of-network) | When hair loss is due to the treatment of cancer; See Medical Benefits section for other limitations |
WELLNESS BENEFITS
| Benefit | Coverage Status - All Providers |
|---|---|
| Childbirth Classes | NOT COVERED |
| Fitness Reimbursement Benefit | NOT COVERED |
| Weight Loss Reimbursement Benefit | NOT COVERED |
ADDITIONAL BENEFITS - EXCLUSIONS AND COVERED SERVICES
Alternative/Complementary Care Benefit Details
| Specific Service | Status | Additional Details |
|---|---|---|
| Biofeedback | NOT COVERED | Excluded |
| Chelation Therapy | NOT COVERED | Excluded |
| Homeopathic Treatment | NOT COVERED | Excluded |
| Hypnosis/Hypnotherapy | NOT COVERED | Excluded |
| Rolfing/Reiki | NOT COVERED | Excluded |
| Applied Behavior Analysis (ABA) | COVERED | Covered under Autism Spectrum Disorders treatment; Pays as a MH/SA OP OV |
Other Additional Benefits
| Service | Status | Additional Details |
|---|---|---|
| Breast Reduction Surgery | COVERED | When Medically Necessary; Precertification required |
| Cardiac Rehab Phase III (Outpatient maintenance) | NOT COVERED | Excluded |
| Home Visit by Visiting Nurse after early maternity discharge | NOT COVERED | Excluded |
| Planned Home Births | NOT COVERED | Excluded |
| Orthoptics | COVERED | Pays as Specialist OP OV |
| Sex Therapy | NOT COVERED | Excluded |
Important Note: This is not a complete listing of all Plan exclusions. Please refer to the Medical Benefits Section and the Medical Limitations and Exclusions Section in the Plan Document/Summary Plan Description for a complete list of benefit and non-benefit type exclusions.
NO SURPRISES ACT PROTECTION
Services Covered at In-Network Rates (Subject to Qualifying Payment Amount)
| Service Type | Coverage Details |
|---|---|
| Emergency Care Services | Out-of-Network Providers rendering services for "Emergency Care" as defined in the Definitions section will be paid at In-Network Provider Deductible, Co-payment and Coinsurance levels, subject to the Qualifying Payment Amount |
| Air Ambulance Services | Out-of-Network Providers of air ambulance services will be paid at In-Network Provider Deductible, Co-payment and Coinsurance levels, subject to the Qualifying Payment Amount |
| Non-Emergency Services at In-Network Facilities | Out-of-Network Providers rendering services on an inpatient or outpatient basis at an In-Network Hospital or facility for: emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services will be paid at In-Network Provider Deductible, Co-payment and Coinsurance levels, subject to the Qualifying Payment Amount |
CRITICAL CONDITION: Covered Person must have NOT validly waived the applicability of the No Surprises Act of the Consolidated Appropriations Act of 2021 (NSA).
Balance Billing Protection Rules
| Scenario | Balance Billing Allowed? | Details |
|---|---|---|
| Emergency services by Out-of-Network Provider for Emergency Care | NO | The Out-of-Network Provider CANNOT balance bill the Covered Person |
| Air ambulance services by Out-of-Network Provider | NO | The Out-of-Network Provider CANNOT balance bill the Covered Person |
| Non-emergency services by Out-of-Network Provider at In-Network facility (for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services) | NO (unless waived) | The Out-of-Network Provider CANNOT balance bill the Covered Person UNLESS the Covered Person gives written consent and gives up their protections in accordance with the NSA |
| Covered Person waives NSA protections | YES | If a Covered Person waives their protections and agrees to balance billing per the NSA, Out-of-Network Providers will be paid according to the Plan's In-Network level of benefits, subject to the Allowed Amount |
| Services by Out-of-Network Provider in any instance other than above | YES | Covered Persons may be responsible for any amount above the Allowed Amount when services are rendered by an Out-of-Network Provider |
Key NSA Protection Terms
| Term | Definition/Application |
|---|---|
| Qualifying Payment Amount | The amount used to determine In-Network cost-sharing for protected services |
| Written Consent Requirement | Covered Person must give written consent AND give up their protections in accordance with the NSA for balance billing to be allowed |
| NSA Waiver | Covered Person must validly waive the applicability of the No Surprises Act for balance billing to be permitted |
IN-NETWORK VS OUT-OF-NETWORK ACCUMULATION
Separate Deductibles and Out-of-Pocket Maximums
| Feature | Status |
|---|---|
| In-Network Provider and Out-of-Network Deductibles | SEPARATE - Do not accumulate |
| In-Network Provider and Out-of-Network Out-of-Pocket Maximums | SEPARATE - Do not accumulate |
Credit Rules for Eligible Expenses
| Eligible Expense Type | Credits Toward In-Network | Credits Toward Out-of-Network |
|---|---|---|
| In-Network Provider Deductible | YES | NO |
| In-Network Provider Out-of-Pocket Maximum | YES | NO |
| Out-of-Network Deductible | NO | YES |
| Out-of-Network Out-of-Pocket Maximum | NO | YES |
Important: Eligible expenses which track toward the In-Network Provider Deductible and Out-of-Pocket Maximums will NOT be credited toward the satisfaction of the Out-of-Network Deductible and Out-of-Pocket Maximums and vice versa.
COMBINED IN-NETWORK AND OUT-OF-NETWORK MAXIMUMS
Services with Combined Visit/Treatment Limits
| Service | Combined Maximum | Time Period |
|---|---|---|
| Fluoride Varnish (up to age 6) | 4 varnish treatments | Per person, per Calendar Year |
| Lung Cancer Screening (LDCT) | 1 screening | Per person, per Calendar Year |
| Abdominal Aortic Aneurysm Screening | 1 screening | Per person, per lifetime |
| Chiropractic Services | 20 visits | Per person, per Calendar Year |
| Cardiac Rehabilitation (Phase 1 and 2 only) | 36 visits | Per person, per Calendar Year |
| Occupational Therapy | 20 visits | Per person, per Calendar Year |
| Physical Therapy | 20 visits | Per person, per Calendar Year |
| Speech Therapy | 20 visits | Per person, per Calendar Year |
| Respiratory Therapy | 20 visits | Per person, per Calendar Year |
| Home Health Care | 60 visits | Per person, per Calendar Year |
| Skilled Nursing Facility/Extended Care Facility | 60 days | Per person, per Calendar Year |
| Wigs | 1 wig (up to $300 maximum) | Per person, per Calendar Year |
Note: These maximums are COMBINED In-Network and Out-of-Network maximums. Services received from both in-network and out-of-network providers count toward the same limit.
COMPLETE EXCLUSIONS LIST
Services NOT COVERED Under Any Circumstances
| Service Category | Specific Service | Coverage Status |
|---|---|---|
| Alternative/Complementary | Acupuncture | NOT COVERED |
| Alternative/Complementary | Alternative/Complementary Care Benefit | NOT COVERED |
| Alternative/Complementary | Biofeedback Therapy | NOT COVERED |
| Alternative/Complementary | Massage Therapy | NOT COVERED |
| Alternative/Complementary | Chelation Therapy | NOT COVERED |
| Alternative/Complementary | Homeopathic Treatment | NOT COVERED |
| Alternative/Complementary | Hypnosis/Hypnotherapy | NOT COVERED |
| Alternative/Complementary | Rolfing/Reiki | NOT COVERED |
| Surgical | Bariatric Surgery | NOT COVERED |
| Devices/Equipment | Cochlear Implants | NOT COVERED |
| Devices/Equipment | Hearing Aids | NOT COVERED |
| Devices/Equipment | Neuromuscular Stimulator Equipment (including TENS) | NOT COVERED |
| Sexual/Reproductive | Erectile Dysfunction Treatment | NOT COVERED |
| Sexual/Reproductive | Infertility Treatment | NOT COVERED |
| Gender | Gender Dysphoria Treatment and Related Services | NOT COVERED |
| Genetic | Gene Therapy | NOT COVERED |
| Genetic | Genetic Counseling, Testing and Related Services* | NOT COVERED |
| Medications/Supplements | Growth Hormones | NOT COVERED |
| Medications/Supplements | Medical and Enteral Formula | NOT COVERED |
| Medications/Supplements | Modified Low Protein Food Products | NOT COVERED |
| Counseling | Marital Counseling | NOT COVERED |
| Counseling | Sex Therapy | NOT COVERED |
| Mental Health | Methadone Maintenance/Treatment | NOT COVERED |
| Nursing | Private Duty Nursing | NOT COVERED |
| Dental | Temporomandibular Joint Disorders (TMJ) Treatment | NOT COVERED |
| Vision | Routine Vision Exam | NOT COVERED |
| Vision | Routine Eyewear (lenses, frames, contact lenses) | NOT COVERED |
| Wellness | Childbirth Classes | NOT COVERED |
| Wellness | Fitness Reimbursement Benefit | NOT COVERED |
| Wellness | Weight Loss Reimbursement Benefit | NOT COVERED |
| Cardiac | Cardiac Rehab Phase III (Outpatient maintenance) | NOT COVERED |
| Maternity | Planned Home Births | NOT COVERED |
| Maternity | Home Visit by Visiting Nurse after early maternity discharge | NOT COVERED |
*Exception: Coverage IS provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services (precertification is NOT required for BRCA testing)
SERVICES THAT ARE COVERED (Previously Listed as Excluded)
| Service | Coverage Details | Payment Structure |
|---|---|---|
| Applied Behavior Analysis (ABA) | Covered under Autism Spectrum Disorders treatment | Pays as a MH/SA OP OV |
| Breast Reduction Surgery | Covered when Medically Necessary | Precertification required |
| Orthoptics | Covered | Pays as Specialist OP OV |
DOCUMENT REFERENCES AND DISCLAIMERS
Important Document Information
| Reference Type | Details |
|---|---|
| Complete Plan Information | See Plan Document/Summary Plan Description |
| Complete Benefits List | See Medical Benefits section in Plan Document |
| Complete Exclusions List | See Medical Limitations and Exclusions Section in Plan Document/Summary Plan Description |
| Definitions | See Definitions section in Plan Document |
| Service Limitations | See Medical Benefits section for specific limitations on individual services |
| Coverage Requirements | See Medical Benefits section for coverage requirements |
Document Status and Version
| Field | Information |
|---|---|
| Document Type | DRAFT |
| Internal Use Only | Yes |
| Draft Date Versions | September 16, 2025 PM; September 23, 2025 PM; September 25, 2025 PM; October 20, 2025 PM |
| Plan Document Version Number | 25.1 |
| Effective Date | October 1, 2025 |
| Total Document Pages | 24 pages |
CONTACT INFORMATION
Customer Service and Support
| Service Need | Contact |
|---|---|
| General Customer Service | Karias Care Concierge |
| Prescription Drug Questions | TrueScripts |
| Network Provider Information | CIGNA |
| Account Management | Kate Gilpatrick |
Plan Administration Contacts
| Function | Contact/Provider |
|---|---|
| Utilization Management | Cigna Payer Solutions |
| Case Management | MedWatch |
| Compliance Questions | Patrick Moore |
GLOSSARY OF KEY TERMS USED IN THIS DOCUMENT
| Term | Meaning in This Document |
|---|---|
| ABA | Applied Behavioral Analysis |
| Calendar Year | January 1 through December 31 |
| CM | Case Management |
| Contracted Rate | The rate negotiated between the Plan and In-Network Providers |
| DM | Disease Management |
| FDA | U.S. Food and Drug Administration |
| INN | In-Network |
| LDCT | Low-Dose Computed Tomography |
| MCC | Medicare Creditable Coverage |
| MH/SA OP OV | Mental Health/Substance Abuse Outpatient Office Visit |
| NGF | New Group Filing |
| NSA | No Surprises Act of the Consolidated Appropriations Act of 2021 |
| OON | Out-of-Network |
| OOPM | Out-of-Pocket Maximum |
| PHIA | Out-of-Network Pricing methodology |
| PPACA | Patient Protection and Affordable Care Act of 2010 |
| PPO | Preferred Provider Organization |
| PSA | Prostate-Specific Antigen |
| TENS | Transcutaneous Electrical Nerve Stimulation |
| TMJ | Temporomandibular Joint |
| TRU | Third-party administrator |
| UM | Utilization Management |
| USPSTF | U.S. Preventive Service Task Force |
SUMMARY OF CORRECTIONS AND EFFECTIVE DATES
Corrections Made to Plan (Effective 10/1/2025)
| Original Date | Correction Date | Service Affected | What Changed |
|---|---|---|---|
| Prior versions | 10-20-2025 | Diagnostic X-ray and Laboratory (Outpatient) | Added clarification for Office Setting/Freestanding Facilities and Outpatient Hospital Facility coverage |
| Prior versions | 10-20-2025 | All Other Diagnostic Tests | Added as separate covered service at 80% after deductible (INN) |
| Prior versions | 10-20-2025 | Sleep Studies | Added clarification for Office Setting/Outpatient Lab versus Outpatient Facility coverage |
All corrections are effective 10/1/2025.
END OF BENEFITS GUIDE
This document contains every detail from the Five Star Technology Solutions Plan 11 Schedule of Medical Benefits. For official plan administration, claims processing, appeals, and complete legal language, please refer to the official Plan Document/Summary Plan Description.
Document prepared for: HubSpot Knowledge Base
For use by: Support Team and AI Assistant
Last updated: Based on draft dated October 20, 2025 PM