Five Star Technology Solutions: Plan 3 - Summary of Benefits and Coverage
Plan Overview
Coverage Period: October 1, 2025 – September 30, 2026
Plan Type: PPO (Preferred Provider Organization)
Coverage For: Employee & Dependents
Contact: 1-888-832-0354
Provider Search: provider-search.kariashealth.com
Karias Care Concierge: 888-832-0354
Prescription Drug Information: hpiTPA.com
Key Plan Features
Overall Deductible
In-Network:
- Single Plan: $2,500 per employee
- Family Plan: $2,500 per person / $5,000 family
Out-of-Network:
- Single Plan: $5,000 per employee
- Family Plan: $5,000 per person / $10,000 family
Important Note: Generally, you must pay all costs from providers up to the deductible amount before this plan begins to pay. For family plans, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Services Covered Before Meeting Deductible
Yes, certain services are covered before you meet your deductible:
- In-network preventive services
- Physician office visits
These services may have a copayment or coinsurance. The plan covers certain preventive services without cost sharing and before you meet your deductible.
Out-of-Pocket Limit
In-Network:
- Single Plan: $5,500 per employee
- Family Plan: $5,500 per person / $11,000 family
Out-of-Network:
- Single Plan: $11,000 per employee
- Family Plan: $11,000 per person / $22,000 family
What This Means: The out-of-pocket limit is the most you could pay in a year for covered services. Family members must meet their own out-of-pocket limits until the overall family out-of-pocket limit is met.
What's NOT Included in Out-of-Pocket Limit
- Premiums
- Balance billing charges
- Health care services this plan doesn't cover
Network Provider Benefits
Do You Pay Less with Network Providers? Yes. This plan uses a provider network. You pay less if you use a provider in the plan's network. You pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing).
Important: Your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Specialist Referrals
Do You Need a Referral? No. You may see a specialist you choose without a referral.
Special Carryover Provision
For the Calendar Year starting January 1, 2025, any Deductible & Out-of-Pocket expenses incurred during the period January 1, 2025 through September 30, 2025 shall be credited and used to satisfy the Deductible & Out-of-Pocket for the Calendar Year starting January 1, 2025 and ending December 31, 2025.
Detailed Coverage and Costs
Note: All copayment and coinsurance costs shown are after your deductible has been met, if a deductible applies.
Office and Clinic Visits
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Primary care visit (injury/illness) | $30 copay per visit; deductible waived | 50% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if services are preventive, then check what your plan will pay. |
| Specialist visit | $60 copay per visit; deductible waived | 50% coinsurance | Same as above |
| Preventive care/screening/immunization | No charge; deductible waived | 50% coinsurance | Same as above |
Testing and Imaging
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Diagnostic test (x-ray, blood work) | 20% coinsurance | 50% coinsurance | None |
| Imaging (CT/PET scan, MRI) | 20% coinsurance | 50% coinsurance | None |
Prescription Drugs
More information available at: hpiTPA.com
| Drug Type | Retail (30-day supply) | Retail/Mail Order (90-day supply) | Out-of-Network |
|---|---|---|---|
| Generic drugs | $15 copay per prescription | $37.50 copay per prescription | Not covered |
| Preferred brand drugs | $60 copay per prescription | $150 copay per prescription | Not covered |
| Non-preferred brand drugs | $100 copay per prescription | $250 copay per prescription | Not covered |
| Specialty drugs (Tier 1) | 25% coinsurance ($300 maximum) | N/A | Not covered |
Important Notes:
- Deductible does not apply to prescription drugs
- See Schedule of Medical Benefits for specialty drug Tier costs
- See Covered Services, Prescription Drugs in the Medical Benefits section for coverage requirements and other limitations related to specialty drugs
Outpatient Surgery
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Facility fee (ambulatory surgical center) | 20% coinsurance | 50% coinsurance | None |
| Physician/surgeon fees | 20% coinsurance | 50% coinsurance | None |
Immediate Medical Attention
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Emergency room care | In-Network deductible; then $300 copay per visit; then 20% coinsurance | In-Network deductible; then $300 copay per visit; then 20% coinsurance | Copay waived if admitted |
| Emergency medical transportation | In-Network deductible; then 20% coinsurance | In-Network deductible; then 20% coinsurance | None |
| Urgent care | $75 copay per visit; then 20% coinsurance; deductible waived | 50% coinsurance | None |
Hospital Stay
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Facility fee (hospital room) | Deductible; then $500 copay per visit; then 20% coinsurance | 50% coinsurance | Preauthorization required |
| Physician/surgeon fees | 20% coinsurance | 50% coinsurance | Preauthorization required |
Mental Health, Behavioral Health, and Substance Abuse Services
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Outpatient services - Office visit | $30 copay per visit; deductible waived | 50% coinsurance | Preauthorization required for Inpatient services |
| Outpatient services - Intensive outpatient treatment | No charge; deductible waived | 50% coinsurance | Preauthorization required for Inpatient services |
| Inpatient services | Deductible; then $500 copay per visit; then 20% coinsurance | 50% coinsurance | Preauthorization required |
Pregnancy and Maternity Care
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Office visits - Prenatal Care | No charge; deductible waived | 50% coinsurance | Maternity care may include tests and services described elsewhere in SBC |
| Office visits - Postnatal Care | $60 copay per visit; deductible waived | 50% coinsurance | Requires preauthorization for stays over 48 hrs (normal delivery) or 96 hrs (caesarean) |
| Childbirth/delivery professional services | 20% coinsurance | 50% coinsurance | Same as above |
| Childbirth/delivery facility services | Deductible; then $500 copay per visit; then 20% coinsurance | 50% coinsurance | Same as above |
Recovery and Special Health Needs
| Service | In-Network Cost | Out-of-Network Cost | Additional Information |
|---|---|---|---|
| Home health care | 20% coinsurance | 50% coinsurance | 60 visits per year |
| Rehabilitation services - Inpatient | Deductible; then $500 copay per visit; then 20% coinsurance | 50% coinsurance | Preauthorization required for Inpatient |
| Rehabilitation services - Outpatient | $60 copay per visit; deductible waived | 50% coinsurance | 20 visits per year each for Occupational, Speech and Physical therapies |
| Habilitation services - Early Intervention | $60 copay per visit; deductible waived | 50% coinsurance | To age 3; Preauthorization & visit limits based on provided services |
| Habilitation services - Developmental Delay | $60 copay per visit; deductible waived | 50% coinsurance | Preauthorization & visit limits based on provided services |
| Skilled nursing care | Deductible; then $500 copay per visit; then 20% coinsurance | 50% coinsurance | 60 days per year; Preauthorization required |
| Durable medical equipment | 20% coinsurance | 50% coinsurance | Please refer to plan document for items requiring preauthorization |
| Hospice services | 20% coinsurance | 50% coinsurance | Preauthorization required for Inpatient |
Child Dental and Eye Care
| Service | In-Network Cost | Out-of-Network Cost |
|---|---|---|
| Children's eye exam | Not covered | Not covered |
| Children's glasses | Not covered | Not covered |
| Children's dental check-up | Not covered | Not covered |
Excluded Services
Services Your Plan Generally Does NOT Cover:
- Acupuncture
- Hearing aids
- Non-emergency care when traveling outside U.S.
- Routine foot care
- Bariatric Surgery
- Infertility Treatment
- Private Duty Nursing
- Weight loss programs
- Dental care (routine child & adult)
- Long term care
- Routine eye care (child & adult)
Other Covered Services
Limitations may apply to these services. This isn't a complete list. Please see your plan document.
- Chiropractic care (20 visits per year)
Coverage Examples
Example 1: Peg is Having a Baby
9 months of in-network pre-natal care and a hospital delivery
Services Included:
- Specialist office visits (prenatal care)
- Childbirth/Delivery Professional Services
- Childbirth/Delivery Facility Services
- Diagnostic tests (ultrasounds and blood work)
- Specialist visit (anesthesia)
Total Example Cost: $12,700
What Peg Would Pay:
- Deductibles: $2,500
- Copayments: $500
- Coinsurance: $80
- Limits or exclusions: $60
- Total Peg would pay: $3,140
Example 2: Mia's Simple Fracture
In-network emergency room visit and follow up care
Services Included:
- Emergency room care (including medical supplies)
- Diagnostic test (x-ray)
- Durable medical equipment (crutches)
- Rehabilitation services (physical therapy)
Total Example Cost: $2,800
What Mia Would Pay:
- Deductibles: $1,700
- Copayments: $400
- Coinsurance: $0
- Limits or exclusions: $0
- Total Mia would pay: $2,100
Example 3: Managing Joe's Type 2 Diabetes
A year of routine in-network care of a well-controlled condition
Services Included:
- Primary care physician office visits (including disease education)
- Diagnostic tests (blood work)
- Prescription drugs
- Durable medical equipment (glucose meter)
Total Example Cost: $5,600
What Joe Would Pay:
- Deductibles: $900
- Copayments: $700
- Coinsurance: $0
- Limits or exclusions: $20
- Total Joe would pay: $1,620
Important Note: These are not cost estimators. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. These coverage examples are based on self-only coverage.
Your Rights and Additional Information
Rights to Continue Coverage
Agencies that can help if you want to continue your coverage after it ends:
- Department of Labor's Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
- Health Insurance Marketplace: www.HealthCare.gov or 1-800-318-2596
Grievance and Appeals Rights
If you have a complaint against your plan for a denial of a claim (called a grievance or appeal):
- Contact the plan: 1-888-832-0354
- U.S. Department of Labor's Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
- Review your explanation of benefits and plan documents for complete information
Minimum Essential Coverage
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Value Standards
Does this plan meet Minimum Value Standards? Yes.
Language Access Services
- Spanish (Español): Para obtener asistencia en Español, llame al 1-888-832-0354
- Portuguese (Portuguès): De assistència em Portuguès, ligue 1-888-832-0354
- Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-888-832-0354
Quick Reference
Plan Contact Information:
- Phone: 1-888-832-0354
- Provider Search: provider-search.kariashealth.com
- Karias Care Concierge: 888-832-0354
- Prescription Drug Info: hpiTPA.com
Key Cost-Sharing Summary:
- In-Network Deductible (Single): $2,500
- In-Network Out-of-Pocket Max (Single): $5,500
- Primary Care Copay: $30
- Specialist Copay: $60
- Hospital Copay: $500
- Emergency Room: Deductible + $300 copay + 20% coinsurance
Document Version: v1.0
Effective Date: October 1, 2025