Five Star Technology Solutions - Plan 3 (PPO) Medical Benefits Schedule

This article outlines the complete medical and prescription drug benefits for Five Star Technology Solutions employees enrolled in Plan 3 (PPO). The plan is effective October 1, 2025, and administered through CIGNA's PPO network with out-of-network pricing through PHIA. Key highlights include separate in-network and out-of-network deductibles and out-of-pocket maximums that do not accumulate toward each other, prescription drug coverage through TrueScripts with combined out-of-pocket maximums, comprehensive PPACA-compliant preventive care at 100% coverage in-network with deductible waived, various copayments for physician visits and services, required precertification for all inpatient hospitalizations, and No Surprises Act protections for certain out-of-network services.

Plan Administration Information

Detail	Information
Employer	Five Star Technology Solutions
Plan Name	Plan 3
Managed Care Type	PPO
Group Number	001R2571
Effective Date	October 1, 2025
Plan Status	NGF
Document Status	DRAFT as of 9-16-2025 PM, 9-25-25 PM
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
MCC Creditable	No
Prescription Drug Administrator	TrueScripts

Approval Information

Role	Name	Date
TRU Department	TRU	Click here to enter a date
Account Manager	Kate Gilpatrick	Click here to enter a date
Compliance	Patrick Moore	Click here to enter a date

Prescription Drug Benefits - Administered by TrueScripts

Important Prescription Drug Information

Out-of-Pocket Maximum: Prescription drug copayments and coinsurance accumulate toward the out-of-pocket maximum. Once the out-of-pocket maximums have been met, prescription drugs are covered at 100% for the balance of the calendar year.
Combined vs. Separate OOP: Prescription drug costs count toward the COMBINED medical out-of-pocket maximum (not a separate Rx OOP max)
Deductible Requirement: Prescriptions are NOT subject to deductibles
Non-Participating Pharmacy Coverage: NO
Out-of-Network Pharmacy Coverage: NOT COVERED

Contraceptive Coverage

Generic FDA-approved contraceptive medications and devices: Covered at 100%
Preferred brand name contraceptives: Subject to copayments and coinsurance as shown below
Non-preferred brand name contraceptives: Subject to copayments and coinsurance as shown below
Exception: If the generic form is not available, the available preferred brand name drug (or non-preferred brand name if preferred brand name is not available) will be covered at 100%

Tobacco Cessation Products

Covered at 100%

Retail Card Program (Up to 30-day supply)

Drug Type	You Pay
Generic	$15 copayment per drug
Preferred Brand Name	$60 copayment per drug
Non-Preferred Brand Name	$100 copayment per drug

Retail Pharmacy (Up to 90-day supply)

Drug Type	You Pay
Generic	$37.50 copayment per drug
Preferred Brand Name	$150 copayment per drug
Non-Preferred Brand Name	$250 copayment per drug

Mail Order Pharmacy (Up to 90-day supply)

Drug Type	You Pay
Generic	$37.50 copayment per drug
Preferred Brand Name	$150 copayment per drug
Non-Preferred Brand Name	$250 copayment per drug

Specialty Drugs - Retail and Mail Order (Up to 30-day supply)

Tier	You Pay
Tier 1 Specialty Drug	25% coinsurance up to a $300 copayment maximum per drug
Tier 2 Specialty Drug	20% coinsurance up to a $550 copayment maximum per drug
Tier 3 Specialty Drug	20% coinsurance up to a $2,000 copayment maximum per drug
Tier 4 Specialty Drug	20% coinsurance per drug (no copayment maximum)
Tier 5 Specialty Drug	50% coinsurance per drug (no copayment maximum)

Note: See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs.

Medical Calendar Year Deductible

Deductible Amounts

Coverage Type	In-Network Providers	Out-of-Network Providers
Single Plan (Employee Only)	$2,500	$5,000
Family Plan (Employee & Family)	$2,500 per person, up to $5,000 per family	$5,000 per person, up to $10,000 per family

Important Deductible Information

Individual Deductible Included in Family Coverage: YES
In/Out-of-Network Deductibles: SEPARATE (do not accumulate toward each other)
Medical Calendar Year Deductible Carryover: NO

Family Deductible Explanation

The Family Plan contains both an individual deductible and a family deductible. Once an individual family member satisfies the individual deductible, claims will be paid for that individual. Otherwise, the entire family deductible must be satisfied before claims will be paid for any family members. The family deductible may be met by any combination of family members.

Deductible Credit for 2025

For the Calendar Year starting 1/1/2025: Any deductible expenses incurred during the period 1/1/2025 through 9/30/2025 shall be credited and used to satisfy the deductible for the calendar year starting 1/1/2025 and ending 12/31/2025.

Reimbursement Percentage (Coinsurance)

Provider Type	Coverage
In-Network Providers	80% of the Contracted Rate (after deductible; unless otherwise stated) until the out-of-pocket maximums has been reached, then 100% thereafter for the balance of the calendar year
Out-of-Network Providers	50% of the Allowed Amount* (after deductible; unless otherwise stated) until the out-of-pocket maximums has been reached, then 100% thereafter for the balance of the calendar year

*See No Surprises Act section below for exceptions regarding emergency services and certain out-of-network providers.

Calendar Year Out-of-Pocket Maximums

Out-of-Pocket Maximum Amounts

Coverage Type	In-Network Providers	Out-of-Network Providers
Single Plan (Employee Only)	$5,500	$11,000
Family Plan (Employee & Family)	$5,500 per person, up to $11,000 per family	$11,000 per person, up to $22,000 per family

What Counts Toward Out-of-Pocket Maximum

The out-of-pocket maximum includes:

All applicable copayments
Calendar year deductible
Coinsurance
Prescription drug copayments and coinsurance

What Does NOT Count Toward Out-of-Pocket Maximum

The following expenses are excluded from the out-of-pocket maximum(s):

Precertification penalties

Important Out-of-Pocket Maximum Information

Individual OOPM Included in Family Coverage: YES
In/Out-of-Network Out-of-Pocket Maximums: SEPARATE (do not accumulate toward each other)

Family Out-of-Pocket Maximum Explanation

The Family Plan contains both an individual out-of-pocket maximum and a family out-of-pocket maximum. Once an individual family member satisfies the individual out-of-pocket maximum, claims will be paid for that individual at 100%. Otherwise, once the entire family out-of-pocket maximum is satisfied, claims will be paid at 100% for all covered family members. The family out-of-pocket maximum may be met by any combination of family members.

Out-of-Pocket Maximum Credit for 2025

For the Calendar Year starting 1/1/2025: Any out-of-pocket maximum expenses incurred during the period 1/1/2025 through 9/30/2025 shall be credited and used to satisfy the out-of-pocket maximums for the calendar year starting 1/1/2025 and ending 12/31/2025.

No Surprises Act (NSA) Information

Services Paid at In-Network Levels

The following services rendered by out-of-network providers will be paid at the In-Network Provider deductible, copayment and coinsurance levels, subject to the Qualifying Payment Amount, provided the Covered Person has not validly waived the applicability of the No Surprises Act of the Consolidated Appropriations Act of 2021 (NSA):

Emergency services rendered by out-of-network providers for "Emergency Care" as defined in the Definitions section
Air ambulance services rendered by out-of-network providers of air ambulance services
Non-emergency services rendered by out-of-network providers on an inpatient or outpatient basis at an in-network hospital or facility for:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory
- Neonatology
- Assistant surgeon
- Hospitalist
- Intensivist services

Balance Billing Protection

When emergency services are rendered by an out-of-network provider for Emergency Care, or air ambulance services are rendered by an out-of-network provider, the out-of-network provider CANNOT balance bill the covered person.
When non-emergency services (listed above) are rendered by an out-of-network provider on an inpatient or outpatient basis at an in-network hospital or facility, the out-of-network provider CANNOT balance bill the covered person unless the covered person gives written consent and gives up their protections in accordance with the NSA.

If NSA Protections Are Waived

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.

When Balance Billing May Occur

When services are rendered by an out-of-network provider in any instance other than the reasons listed above, covered persons may be responsible for any amount above the Allowed Amount when services are rendered by an out-of-network provider.

Separate Accumulation Note

The In-Network Provider and Out-of-Network Deductible and Out-of-Pocket Maximums are separate and do not accumulate. 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.

Medical Copayments

Service	In-Network Providers	Out-of-Network Providers
Inpatient Hospital Copayment	$500	NONE
Inpatient Hospital Copayment Maximum	NONE	NONE
Outpatient Hospital Surgery Copayment	NONE	NONE
Outpatient Hospital Surgery Copayment Maximum	NONE	NONE
Primary Care Physician Copayment	$30	NONE
Specialty Care Physician Copayment	$60	NONE

Precertification Requirements

Inpatient Hospitalization - Always Required

Precertification for inpatient hospitalization is always required. If a covered person is scheduled to be admitted to a hospital, he or she must have the hospitalization precertified:

Prior to the date of admission, OR
Within two business days of admission in the case of emergency admissions

Consequences of Not Obtaining Precertification

Failure to obtain precertification for inpatient admissions may result in a reduction in benefits.

Other Services Requiring Precertification

Other services, including those services deemed cosmetic or Experimental/Investigational, may also require precertification regardless of whether the service is rendered inpatient, outpatient or in an office setting. See individual benefits for those services requiring precertification.

Medical Necessity Determination

If precertification is required but is not obtained, coverage may not be available for services not determined to be Medically Necessary. The Plan also 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.

Responsibility for Penalties

Any penalty incurred due to failure to obtain precertification or preauthorization for services may be the responsibility of the Covered Person.

Preventive Care Services

PPACA Compliance Information

The preventive care services marked below with ** are provided according to the terms prescribed by the regulations issued under the Patient Protection and Affordable Care Act of 2010 (PPACA).

The majority of the PPACA preventive care services recommendations are issued by the U.S. Preventive Service Task Force (USPSTF). These may be amended from time to time. Please see the Medical Benefits section for additional details about the preventive coverage provided, or a complete listing can be found here.

New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance of the revised recommendation.

Out-of-Network Provider NSA Coverage

Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.

Preventive Care Benefits Table

Service	Frequency/Limits	In-Network Providers	Out-of-Network Providers
**Routine Physical Exams (including routine and travel immunizations and flu shots)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Routine Well Child Care (including screenings, routine and travel immunizations and flu shots)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Fluoride Varnish (up to age 6)	Up to four (4)* varnish treatments per person, per Calendar Year	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Breastfeeding Support, Supplies and Counseling (during pregnancy and/or in the postpartum period and rental or purchase of breastfeeding equipment)	See breast pump limits below	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Contraceptive Services and Supplies for Women (FDA approved only; includes education and counseling)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Routine Gynecological/Obstetrical Care (including preconception and prenatal services)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Routine Pap Smears	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Breast Cancer Screening including Routine Mammograms and BRCA testing	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Routine Immunizations (if not billed with an office visit; includes flu shots and travel immunizations)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Routine Lab, X-rays, and Clinical Tests (including those related to maternity care)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**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)
**Lung Cancer Screening, including Low-Dose Computed Tomography (LDCT) (as recommended by the US Preventive Service Task Force)	Up to one (1)* per person, per Calendar Year	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Nutritional Counseling	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Smoking Cessation Counseling and Intervention (including smoking cessation clinics and programs)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Routine Hearing Exams	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Routine Prostate Exams and Prostate-Specific Antigen (PSA) Screenings	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**Abdominal Aortic Aneurysm Screening (as recommended by the US Preventive Service Task Force)	Up to one (1)* per person, per lifetime	100% (Deductible waived)	50% Allowed Amount (after Deductible)
**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)

*These maximums are combined In-Network and Out-of-Network maximums.

Breast Pump Limits (Breastfeeding Support)

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 for Breastfeeding Support

INTERNAL NOTE: If there are no INN lactation providers, then OON providers should be covered at the INN level of benefits with no cost sharing. If the only reason for the visit with the provider is lactation, it should be with no cost-sharing.

Vision Care

Service	In-Network Providers	Out-of-Network Providers
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)

*These maximums are combined In-Network and Out-of-Network maximums.

Physician Services

Out-of-Network Provider NSA Coverage

Physician Services Benefits Table

Service	Frequency/Limits	In-Network Providers	Out-of-Network Providers
Allergy Testing	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Allergy Treatment	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Anesthesia (Inpatient/Outpatient)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Chiropractic Services	Up to 20* visits per person per Calendar Year	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Maternity—Employee & Spouse Only - Prenatal care	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Maternity—Employee & Spouse Only - Physician delivery charges	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Maternity—Employee & Spouse Only - Postnatal care	—	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
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)	—	$30 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)	—	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Second Surgical Opinion	—	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
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)

*These maximums are combined In-Network and Out-of-Network maximums.

Note: Maternity coverage includes Physician delivery charges, prenatal and postpartum care. Coverage applies to Employee & Spouse Only.

Hospital Services - Inpatient

Critical Precertification Information

Precertification is always required for inpatient hospitalization. Failure to obtain precertification may result in a reduction in benefits. The reduction in benefits cannot be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan.

Inpatient Hospital Copayment

A separate $500 Hospital Co-payment will apply to each inpatient admission in an In-Network facility.

Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.

Private Room Coverage

Note: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.

Out-of-Network Provider NSA Coverage

Inpatient Hospital Services Benefits Table

Service	Room Type/Additional Info	In-Network Providers	Out-of-Network Providers
Hospital Room & Board (Precertification required)	Semi-private room or special care unit	$500 Co-payment per admission, then 80% (after Deductible)	50% Allowed Amount (after Deductible)
Maternity Services—Employee & Spouse only (Precertification required for stays in excess of 48 hours vaginal; 96 hours cesarean)	Semi-private room or special care unit	$500 Co-payment per admission, then 80% (after Deductible)	50% Allowed Amount (after Deductible)
Birthing Center—Employee & Spouse only	—	$500 Co-payment per admission, then 80% (after Deductible)	50% Allowed Amount (after Deductible)
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)
Organ, Bone Marrow and Stem Cell Transplants (Precertification required; see Medical Benefits section for other limitations)	Semi-private room or special care unit; Transportation/food/lodging limits: $5,000 per Transplant	$500 Co-payment per admission, then 80% (after Deductible); Managed through Cigna's LifeSOURCE Transplant Network®	50% Allowed Amount (after Deductible)
Surgical Facility & Supplies	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Miscellaneous Hospital Charges	—	80% (after Deductible)	50% Allowed Amount (after Deductible)

Hospital Services - Outpatient

Out-of-Network Provider NSA Coverage

Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency services rendered for "Emergency Care" as defined in the section titled "Definitions"; and Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.

Outpatient Hospital Services Benefits Table

Service	Additional Information	In-Network Providers	Out-of-Network Providers
Clinic Services (At a Hospital)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Emergency Room Expenses (Includes Facility, Lab, X-ray & Physician services)	Co-payment is waived if admitted on an inpatient basis to a Hospital	$300 Co-payment per visit, then 80% (after Deductible)	$300 Co-payment per visit, then 80% (after In-Network Deductible)
Outpatient Department	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc.	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Preadmission Testing	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Urgent Care Facility/Walk-In Clinic	—	$75 Co-payment per visit, then 80% (Deductible waived)	50% Allowed Amount (after Deductible)

Mental Health & Substance Use Services

Critical Precertification Information

Inpatient Hospital Copayment

A separate $500 Hospital Co-payment will apply to each inpatient admission in an In-Network facility.

Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.

Private Room Coverage

Note: A private room is covered only when Medically Necessary or when a facility does not provide semi-private rooms.

Out-of-Network Provider NSA Coverage

Mental Health & Substance Use Benefits Table

Service	Additional Information	In-Network Providers	Out-of-Network Providers
Inpatient Hospitalization (Precertification required)	—	$500 Co-payment per admission, then 80% (after Deductible)	50% Allowed Amount (after Deductible)
Partial Hospitalization/Intensive Outpatient Treatment	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Inpatient Physician Visit	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Hospital Clinic Visit	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Office Visit	—	$30 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Methadone Maintenance/Treatment	—	NOT COVERED	NOT COVERED

Other Services & Supplies

Out-of-Network Provider NSA Coverage

Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for air ambulance services rendered by an Out-of-Network Provider of air ambulance services; and Out-of-Network Providers will be paid at In-Network Provider levels, subject to the Qualifying Payment Amount, for emergency

medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services rendered to a Covered Person on an inpatient or outpatient basis in an In-Network Hospital or facility, provided the Covered Person has not validly waived the applicability of the NSA.

Other Services & Supplies Benefits Table - Part 1

Service	Frequency/Limits	In-Network Providers	Out-of-Network Providers
Acupuncture	—	NOT COVERED	NOT COVERED
Alternative/Complementary Care Benefit	—	NOT COVERED	NOT COVERED
Ambulance Services (See Medical Benefits section for limitations)	—	80% (after Deductible)	80% Allowed Amount (after In-Network Deductible)
Autism Spectrum Disorders Treatment (Includes Applied Behavioral Analysis (ABA); 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	—	Benefits are based on services provided	Benefits are based on services provided
Bariatric Surgery	—	NOT COVERED	NOT COVERED
Biofeedback Therapy	—	NOT COVERED	NOT COVERED
Cardiac Rehabilitation (Phase 1 and 2 only; see Medical Benefits section for other limitations)	Up to 36* visits per person per Calendar Year	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Chemotherapy & Radiation Therapy	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Clinical Trials – Routine Services during Approved Clinical Trials (Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services; see Medical Benefits section for other limitations)	—	Benefits are based on services provided	Benefits are based on services provided
Cochlear Implants	—	NOT COVERED	NOT COVERED
Dental/Oral Services (Excludes excision of impacted wisdom teeth; see Medical Benefits section for other limitations)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Diabetes Self-Management Training and Education	—	$30 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Diagnostic Imaging (MRI, CT Scan, PET Scan)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Diagnostic X-ray and Laboratory (Outpatient)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Dialysis/Hemodialysis (See Medical Benefits section for other limitations)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Durable Medical Equipment (See Medical Benefits section for limitations)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Early Intervention Services (See Medical Benefits section for limitations) (Up to age 3)	—	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Erectile Dysfunction Treatment	—	NOT COVERED	NOT COVERED

*These maximums are combined In-Network and Out-of-Network maximums.

Other Services & Supplies Benefits Table - Part 2

Service	Frequency/Limits	In-Network Providers	Out-of-Network Providers
Family Planning - For Women (Including but not limited to consultations and diagnostic tests) (See also Prescription Drug Benefit and Preventive Care Section)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Family Planning - For Men (Including but not limited to consultations and diagnostic tests)	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Gender Dysphoria Treatment and Related Services	—	NOT COVERED	NOT COVERED
Gene Therapy	—	NOT COVERED	NOT COVERED
Genetic Counseling, Testing and Related Services Note: Coverage is provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services; precertification is not required	—	NOT COVERED	NOT COVERED
Growth Hormones	—	NOT COVERED	NOT COVERED
Hearing Aids	—	NOT COVERED	NOT COVERED
Home Health Care (See Medical Benefits section for limitations)	Up to 60* visits per person per Calendar Year	80% (after Deductible)	50% Allowed Amount (after Deductible)
Hospice Care (Inpatient/Outpatient) (Precertification required for inpatient services; see Medical Benefits section for other limitations)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Infertility Treatment	—	NOT COVERED	NOT COVERED
Injectables	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Learning Deficiencies, Behavioral Problems/Developmental Delays (Precertification and visit limits are based on services provided)	—	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Marital Counseling	—	NOT COVERED	NOT COVERED
Massage Therapy	—	NOT COVERED	NOT COVERED
Medical and Enteral Formula	—	NOT COVERED	NOT COVERED
Modified Low Protein Food Products	—	NOT COVERED	NOT COVERED
Neuromuscular Stimulator Equipment including TENS	—	NOT COVERED	NOT COVERED
Occupational Therapy (For treatment due to Illness or Injury; see Medical Benefits section for other limitations)	Up to 20* visits per person, per Calendar Year	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Oral Pharynx Procedures	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Orthotics (Includes foot orthotics; see Medical Benefits section for limitations)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)

*These maximums are combined In-Network and Out-of-Network maximums.

Other Services & Supplies Benefits Table - Part 3

Service	Frequency/Limits	In-Network Providers	Out-of-Network Providers
Physical Therapy (For treatment due to Illness or Injury; see Medical Benefits section for other limitations)	Up to 20* visits per person, per Calendar Year	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Podiatry Care (See Medical Benefits section for limitations)	—	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Private Duty Nursing	—	NOT COVERED	NOT COVERED
Prosthetics (See Medical Benefits section for limitations)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Rehabilitation Hospital (Precertification required; see Medical Benefits section for other limitations)	—	$500 Co-payment per admission, then 80% (after Deductible)	50% Allowed Amount (after Deductible)
Respiratory Therapy	Up to 20* visits per person, per Calendar Year	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Sleep Studies (Limited to the testing and treatment of Obstructive Sleep Apnea; see Medical Benefits section for other limitations)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Skilled Nursing Facility/Extended Care Facility (Precertification required; see Medical Benefits section for other limitations)	Up to 60* days per person, per Calendar Year	$500 Co-payment per admission, then 80% (after Deductible)	50% Allowed Amount (after Deductible)
Speech Therapy (For treatment due to Illness or Injury; see Medical Benefits section for other limitations)	Up to 20* visits per person, per Calendar Year	$60 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
Telemedicine (Applies to medical and behavioral health services; includes Doctor on Demand; see Medical Benefits section for additional information) INCLUDES DOCTOR ON DEMAND	—	$30 Co-payment per visit, then 100% (Deductible waived)	50% Allowed Amount (after Deductible)
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
Temporomandibular Joint Disorders (TMJ) Treatment	—	NOT COVERED	NOT COVERED
Termination of Pregnancy (Covered only in circumstances in which the life of the mother would be endangered by continuing the pregnancy to term, as documented by the treating Physician or due to rape or incest)	—	80% (after Deductible)	50% Allowed Amount (after Deductible)
Voluntary Sterilization - For Women	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Voluntary Sterilization - For Men	—	100% (Deductible waived)	50% Allowed Amount (after Deductible)
Wigs (When hair loss is due to the treatment of cancer; see Medical Benefits section for other limitations)	Up to one (1)* wig per person per Calendar Year to a maximum of $300 per wig	80% (after Deductible)	50% Allowed Amount (after Deductible)

*These maximums are combined In-Network and Out-of-Network maximums.

Wellness Benefits

Service	All Providers
Childbirth Classes	NOT COVERED
Fitness Reimbursement Benefit	NOT COVERED
Weight Loss Reimbursement Benefit	NOT COVERED

Additional Benefits Information

Alternative/Complementary Care Benefit - Detailed Exclusions and Inclusions

Service	Excluded	Covered	Additional Details
Biofeedback	X	—	—
Chelation Therapy	X	—	—
Homeopathic Treatment	X	—	—
Hypnosis/Hypnotherapy	X	—	—
Rolfing/Reiki	X	—	—
Applied Behavior Analysis (ABA)	—	X	Covered under Autism Spectrum Disorders treatment; Pays as a MH/SA OP OV (Mental Health/Substance Abuse Outpatient Office Visit)
Breast Reduction Surgery	—	X	When Medically Necessary; precertification required
Cardiac Rehab Phase III (Outpatient maintenance)	X	—	—
Home Visit by Visiting Nurse after early maternity discharge	—	X	—
Planned Home Births	X	—	—
Orthoptics	—	X	Pays as Specialist OP OV (Outpatient Office Visit)
Sex Therapy	X	—	—

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.

Document Reference: 25.1

Quick Reference Summary Tables

Copayment Quick Reference

Service Type	Copayment Amount
Primary Care Physician Office Visit	$30
Specialist Physician Office Visit	$60
Chiropractic Visit	$60
Mental Health/Substance Use Office Visit	$30
Telemedicine/Doctor on Demand	$30
Urgent Care/Walk-In Clinic	$75
Emergency Room	$300 (waived if admitted)
Inpatient Hospital Admission	$500

Therapy Visit Limits (Combined In-Network and Out-of-Network)

Therapy Type	Annual Limit
Chiropractic Services	20 visits per calendar year
Physical Therapy	20 visits per calendar year
Occupational Therapy	20 visits per calendar year
Speech Therapy	20 visits per calendar year
Respiratory Therapy	20 visits per calendar year
Cardiac Rehabilitation (Phase 1 & 2)	36 visits per calendar year

Other Annual/Lifetime Limits (Combined In-Network and Out-of-Network)

Service	Limit
Fluoride Varnish (up to age 6)	4 treatments per calendar year
Lung Cancer Screening (LDCT)	1 per calendar year
Abdominal Aortic Aneurysm Screening	1 per lifetime
Home Health Care	60 visits per calendar year
Skilled Nursing Facility/Extended Care Facility	60 days per calendar year
Wigs (cancer treatment)	1 per calendar year, $300 maximum per wig
Organ/Bone Marrow/Stem Cell Transplants - Transportation/Food/Lodging	$5,000 per transplant

Frequently Asked Questions

General Plan Questions

Q: What is the effective date of this plan? A: October 1, 2025

Q: What is the plan group number? A: 001R2571

Q: What network does this plan use? A: CIGNA PPO Network

Q: Who administers prescription drug benefits? A: TrueScripts

Q: Who should I contact for customer service? A: Karias Care Concierge

Deductible Questions

Q: What is the individual deductible for in-network services? A: $2,500 for single plan; $2,500 per person (up to $5,000 per family) for family plan

Q: What is the individual deductible for out-of-network services? A: $5,000 for single plan; $5,000 per person (up to $10,000 per family) for family plan

Q: Do in-network and out-of-network deductibles accumulate together? A: No, they are SEPARATE and do not accumulate toward each other.

Q: Do prescription drug costs count toward my deductible? A: No, prescription drugs are NOT subject to deductibles.

Q: Is there a deductible carryover provision? A: No, there is no deductible carryover.

Q: Is there a deductible credit for 2025? A: Yes, for the calendar year starting 1/1/2025, any deductible expenses incurred during 1/1/2025 through 9/30/2025 shall be credited toward the deductible for the calendar year ending 12/31/2025.

Out-of-Pocket Maximum Questions

Q: What is the out-of-pocket maximum for in-network services? A: $5,500 for single plan; $5,500 per person (up to $11,000 per family) for family plan

Q: What is the out-of-pocket maximum for out-of-network services? A: $11,000 for single plan; $11,000 per person (up to $22,000 per family) for family plan

Q: Do in-network and out-of-network out-of-pocket maximums accumulate together? A: No, they are SEPARATE and do not accumulate toward each other.

Q: Do prescription drug costs count toward my out-of-pocket maximum? A: Yes, prescription drug copayments and coinsurance count toward the COMBINED medical out-of-pocket maximum.

Q: What counts toward the out-of-pocket maximum? A: All applicable copayments, the calendar year deductible, coinsurance, and prescription drug copayments/coinsurance.

Q: What does NOT count toward the out-of-pocket maximum? A: Precertification penalties.

Q: Is there an out-of-pocket maximum credit for 2025? A: Yes, for the calendar year starting 1/1/2025, any OOPM expenses incurred during 1/1/2025 through 9/30/2025 shall be credited toward the OOPM for the calendar year ending 12/31/2025.

Prescription Drug Questions

Q: How much do I pay for generic drugs at retail (30-day supply)? A: $15 copayment

Q: How much do I pay for preferred brand name drugs at retail (30-day supply)? A: $60 copayment

Q: How much do I pay for non-preferred brand name drugs at retail (30-day supply)? A: $100 copayment

Q: How much do I pay for a 90-day supply at retail or mail order? A: Generic: $37.50; Preferred brand: $150; Non-preferred brand: $250

Q: Are specialty drugs covered? A: Yes, with coinsurance ranging from 20-50% depending on the tier, with copayment maximums for Tiers 1-3.

Q: Are out-of-network pharmacies covered? A: No, out-of-network pharmacy coverage is NOT COVERED.

Q: Are contraceptives covered? A: Yes, generic FDA-approved contraceptive medications and devices are covered at 100%. Brand name contraceptives are subject to copayments unless generic is not available.

Q: Are tobacco cessation products covered? A: Yes, at 100%.

Preventive Care Questions

Q: What preventive care services are covered at 100% in-network? A: All preventive care services listed in the preventive care section are covered at 100% in-network with the deductible waived, including routine physical exams, well child care, immunizations, screenings, and more.

Q: Do I need to pay a copayment for my annual physical exam? A: No, routine physical exams are covered at 100% in-network with the deductible waived.

Q: Are mammograms covered? A: Yes, routine mammograms and BRCA testing are covered at 100% in-network with the deductible waived.

Q: Are colonoscopies covered? A: Yes, routine colorectal cancer screening including colonoscopies is covered at 100% in-network with the deductible waived.

Precertification Questions

Q: What services require precertification? A: All inpatient hospitalizations ALWAYS require precertification. Other services that may require precertification include those deemed cosmetic or experimental/investigational. See individual benefit sections for specific requirements.

Q: When do I need to get precertification for a hospital stay? A: Prior to the date of admission, or within two business days of admission for emergency admissions.

Q: What happens if I don't get precertification? A: Benefits may be reduced, and the penalty does NOT count toward your deductible or out-of-pocket maximum. The penalty is your responsibility.

Q: Does maternity require precertification? A: Precertification is required for maternity stays exceeding 48 hours for vaginal delivery or 96 hours for cesarean delivery.

Copayment Questions

Q: What is the copayment for a primary care physician office visit? A: $30

Q: What is the copayment for a specialist office visit? A: $60

Q: What is the copayment for urgent care? A: $75

Q: What is the copayment for the emergency room? A: $300 (waived if admitted to the hospital on an inpatient basis)

Q: What is the copayment for an inpatient hospital admission? A: $500 per admission (in-network only)

Q: What is the copayment for telemedicine/Doctor on Demand? A: $30

Coverage Questions

Q: Are routine vision exams covered? A: No, routine vision exams and routine eyewear are NOT COVERED. Only eyewear for special medical conditions is covered.

Q: Are hearing aids covered? A: No, hearing aids are NOT COVERED.

Q: Is bariatric surgery covered? A: No, bariatric surgery is NOT COVERED.

Q: Is infertility treatment covered? A: No, infertility treatment is NOT COVERED.

Q: Are dental services covered? A: Dental/oral services are covered at 80% in-network after deductible, excluding excision of impacted wisdom teeth. See Medical Benefits section for limitations.

Q: Is chiropractic care covered? A: Yes, up to 20 visits per calendar year with a $60 copayment per visit in-network.

Q: How many physical therapy visits are covered? A: Up to 20 visits per person per calendar year.

Q: Is home health care covered? A: Yes, up to 60 visits per person per calendar year.

Q: Are ambulance services covered? A: Yes, at 80% after deductible for both in-network and out-of-network (out-of-network uses in-network deductible).

Q: Is gender dysphoria treatment covered? A: No, gender dysphoria treatment and related services are NOT COVERED.

Q: Are cochlear implants covered? A: No, cochlear implants are NOT COVERED.

Q: Is TMJ treatment covered? A: No, temporomandibular joint disorders (TMJ) treatment is NOT COVERED.

Maternity Questions

Q: Who is covered for maternity services? A: Employee & Spouse Only

Q: What is the coverage for prenatal care? A: 100% in-network with deductible waived

Q: What is the coverage for physician delivery charges? A: 80% in-network after deductible

Q: What is the coverage for postnatal care? A: $60 copayment per visit in-network, then 100% with deductible waived

Q: What is the coverage for hospital maternity services? A: $500 copayment per admission, then 80% after deductible in-network

Q: Is newborn care covered? A: Yes, including physician visits and circumcision, with $500 copayment per admission, then 80% after deductible in-network

No Surprises Act Questions

Q: What is the No Surprises Act (NSA)? A: Federal legislation that protects covered persons from surprise medical bills for certain out-of-network services.

Q: What services are protected under the NSA? A: Emergency care, air ambulance services, and certain non-emergency services (emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, intensivist) provided by out-of-network providers at in-network facilities.

Q: Can out-of-network providers balance bill me for emergency services? A: No, when NSA protections apply, out-of-network providers CANNOT balance bill you.

Q: Can I waive NSA protections? A: Yes, for non-emergency services only, you can give written consent to waive protections and agree to balance billing.

Q: What happens if I waive NSA protections? A: Out-of-network providers will be paid at in-network levels subject to the Allowed Amount, but you may be responsible for amounts above the Allowed Amount.

Coinsurance Questions

Q: What is the coinsurance percentage for in-network services? A: 80% (you pay 20%) after the deductible until the out-of-pocket maximum is reached, then 100%.

Q: What is the coinsurance percentage for out-of-network services? A: 50% (you pay 50%) after the deductible until the out-of-pocket maximum is reached, then 100%.

Mental Health & Substance Use Questions

Q: Is mental health treatment covered? A: Yes, both inpatient and outpatient mental health services are covered.

Q: What is the copayment for a mental health office visit? A: $30 in-network

Q: Is precertification required for mental health inpatient hospitalization? A: Yes, precertification is ALWAYS required for all inpatient hospitalizations, including mental health.

Q: Is partial hospitalization/intensive outpatient treatment covered? A: Yes, at 100% in-network with deductible waived.

Q: Is methadone maintenance/treatment covered? A: No, methadone maintenance/treatment is NOT COVERED.

Therapy Limits Questions

Q: How many therapy visits are covered per year? A:

Chiropractic: 20 visits
Physical Therapy: 20 visits
Occupational Therapy: 20 visits
Speech Therapy: 20 visits
Respiratory Therapy: 20 visits
Cardiac Rehabilitation (Phase 1 & 2): 36 visits

Q: Are these limits combined for in-network and out-of-network? A: Yes, all limits with an asterisk (*) are combined in-network and out-of-network maximums.