Five Star Technology Solutions - Plan 36 QHDHP PPO Health Insurance Benefits Schedule Guide
This article provides complete details about the Five Star Technology Solutions Plan 36 Qualified High Deductible Health Plan (QHDHP) with PPO network through CIGNA. The plan features separate in-network and out-of-network deductibles and out-of-pocket maximums, with 100% coverage after deductible for in-network services and 50% for out-of-network. Prescription drugs have $0 co-payments after deductible, and most preventive care services are covered at 100% with deductible waived.
Plan Overview
| Plan Detail | Information |
|---|---|
| Plan Name | Plan 36 (QHDHP) - Qualified High Deductible Health Plan |
| Full Plan Title | Schedule of Medical Benefits for Five Star Technology Solutions - Plan 36 (QHDHP) (Managed Care Type: PPO) |
| Employer | Five Star Technology Solutions |
| Group Number | 001R2571 |
| Effective Date | October 1, 2025 |
| Plan Type | PPO (Preferred Provider Organization) |
| Network | CIGNA |
| Status | NGF (New Group Formation) |
| Document Status | DRAFT |
| Draft Version Date | As of 9-16-2025 PM, 9-25-25 PM |
Plan Approvals (Internal Use)
| Approval Role | Name | Date |
|---|---|---|
| TRU Department | TRU | To be entered |
| Account Manager | Kate Gilpatrick | To be entered |
| Compliance | Patrick Moore | To be entered |
Plan Administrators
| Service | Administrator |
|---|---|
| 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 Benefits | TrueScripts |
| MCC Creditable | No |
Prescription Drug Benefits
General Information
- Administered By: TrueScripts
- Deductible Requirement: Yes - Covered persons pay 100% until Calendar Year Deductible is met
- After Deductible Met: Covered persons pay Co-payments and Coinsurance (if applicable), which accumulate toward Out-of-Pocket Maximums
- After Out-of-Pocket Maximum Met: Prescription drugs covered at 100% for the balance of the Calendar Year
- Out-of-Network Pharmacy: NOT COVERED
- Non-Participating Pharmacy: NOT COVERED
- Prescription Drug OOP Max: COMBINED with Medical OOP Max
- Scripts Subject to Deductible: YES
Special Coverage Rules
-
Contraceptives:
- Generic U.S. Food and Drug Administration (FDA) approved contraceptive medications and devices covered at 100% (Deductible waived)
- Preferred brand name and non-preferred brand name contraceptive medications subject to Co-payments and Coinsurance as shown, UNLESS the generic form is not available
- In cases where 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% (Deductible waived)
-
Tobacco Cessation Products: Covered at 100% (Deductible waived)
-
Preventive Care Medications: Not subject to Deductible
Prescription Drug Co-payments (After Deductible Met)
Retail Card Program (Up to 30-day supply)
| Drug Type | Co-payment |
|---|---|
| Generic Drug | $0 |
| Preferred Brand Name Drug | $0 |
| Non-Preferred Brand Name Drug | $0 |
Retail Pharmacy (Up to 90-day supply)
| Drug Type | Co-payment |
|---|---|
| Generic Drug | $0 |
| Preferred Brand Name Drug | $0 |
| Non-Preferred Brand Name Drug | $0 |
Mail Order Pharmacy (Up to 90-day supply)
| Drug Type | Co-payment |
|---|---|
| Generic Drug | $0 |
| Preferred Brand Name Drug | $0 |
| Non-Preferred Brand Name Drug | $0 |
Specialty Drugs - Retail and Mail Order (Up to 30-day supply)
| Drug Type | Co-payment |
|---|---|
| Specialty Drug | $0 |
Important: See Covered Services, Prescription Drugs in the Medical Benefits section of the full Plan Document for coverage requirements and other limitations related to specialty drugs.
Medical Benefits Overview
Calendar Year Deductible
| Plan Type | In-Network | Out-of-Network |
|---|---|---|
| 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 |
Individual Deductible Included in Family Coverage: YES
Deductible Carryover: NO
Special Deductible Credit: For 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 Calendar Year 1/1/2025 - 12/31/2025.
Family Deductible Rules
- Family Plan contains both individual and family deductible
- Once an individual family member meets their individual deductible, claims are paid for that individual
- Otherwise, entire family deductible must be satisfied before claims are paid for any family members
- Family deductible may be met by any combination of family members
Reimbursement Percentage (Coinsurance)
| Service Location | Coverage |
|---|---|
| In-Network Providers | 100% of Contracted Rate (after Deductible) until Out-of-Pocket Maximum reached, then 100% for remainder of Calendar Year |
| Out-of-Network Providers | 50% of Allowed Amount (after Deductible) until Out-of-Pocket Maximum reached, then 100% for remainder of Calendar Year |
Calendar Year Out-of-Pocket Maximums
| Plan Type | In-Network | Out-of-Network |
|---|---|---|
| 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 |
Individual OOPM Included in Family Coverage: YES
What Counts Toward OOPM: All applicable co-payments, Calendar Year Deductible, and Coinsurance (including prescription drugs)
Special Out-of-Pocket Maximum Credit: For Calendar Year starting 1/1/2025, any OOPM expenses incurred during 1/1/2025 through 9/30/2025 shall be credited toward OOPM for Calendar Year 1/1/2025 - 12/31/2025.
Family Out-of-Pocket Maximum Rules
- Family Plan contains both individual and family OOPM
- Once an individual family member meets individual OOPM, claims paid at 100% for that individual
- Once entire family OOPM is satisfied, claims paid at 100% for all covered family members
- Family OOPM may be met by any combination of family members
Important Notes About Deductibles and OOPM
- In-Network and Out-of-Network Are SEPARATE: Do not accumulate together
- Expenses DO NOT Cross-Credit: In-Network expenses don't count toward Out-of-Network and vice versa
Excluded from Out-of-Pocket Maximum:
- Precertification penalties
Medical Co-payments
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospital Co-payment | NONE | NONE |
| Inpatient Hospital Co-payment Maximum | NONE | NONE |
| Outpatient Hospital Surgery Co-payment | NONE | NONE |
| Outpatient Hospital Surgery Co-payment Maximum | NONE | NONE |
| Primary Care Physician Co-payment | NONE | NONE |
| Specialty Care Physician Co-payment | NONE | NONE |
No Surprises Act (NSA) Protections
When Out-of-Network Services Are Covered at In-Network Rates
Out-of-Network providers will be paid at In-Network levels (subject to Qualifying Payment Amount) for:
- Emergency Services rendered by Out-of-Network providers for "Emergency Care" as defined in plan
- Air Ambulance Services rendered by Out-of-Network air ambulance providers
- Non-Emergency Services at In-Network hospitals/facilities for:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory
- Neonatology
- Assistant surgeon
- Hospitalist services
- Intensivist services
Condition: Covered person has NOT validly waived applicability of No Surprises Act
Balance Billing Protections
- Out-of-Network providers CANNOT balance bill for emergency services or air ambulance
- Out-of-Network providers CANNOT balance bill for non-emergency services at In-Network facilities UNLESS covered person gives written consent and waives NSA protections
- If protections are waived, Out-of-Network providers paid according to plan's In-Network benefits subject to Allowed Amount
Important Note About Out-of-Network Services
When services are rendered by an Out-of-Network Provider in any instance other than the reasons listed above (emergency services, air ambulance, or covered services at In-Network facilities), Covered Persons may be responsible for any amount above the Allowed Amount when services are rendered by an Out-of-Network Provider.
This means you could be balance-billed for the difference between what the provider charges and what the plan's Allowed Amount is.
Precertification Requirements
Always Required
- Inpatient Hospitalization: Must be precertified prior to admission or within 2 business days for emergency admissions
- Failure to Precertify: May result in benefit reduction
- Critical Note: The reduction in benefits due to failure to obtain precertification CANNOT be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan
- Penalty Responsibility: Any penalty for failure to obtain precertification or preauthorization for services may be the responsibility of the Covered Person
May Be Required
- Services deemed cosmetic or Experimental/Investigational
- Other services as specified in individual benefit sections
- If precertification is required but not obtained, coverage may not be available for services not determined to be Medically Necessary
- Plan reserves right to deny coverage prospectively for any service that may not require precertification but is determined in advance not to be medically necessary
- Any penalty incurred due to failure to obtain precertification or preauthorization for services may be the responsibility of the Covered Person
Preventive Care Services
All preventive services marked with ** follow Patient Protection and Affordable Care Act (PPACA) requirements and U.S. Preventive Service Task Force (USPSTF) recommendations.
Important Information About PPACA Preventive Care
- The preventive care services marked with ** are provided according to the terms prescribed by regulations issued under the Patient Protection and Affordable Care Act of 2010 (PPACA)
- The majority of PPACA preventive care services recommendations are issued by the U.S. Preventive Service Task Force (USPSTF)
- These recommendations may be amended from time to time
- New or updated A and B Recommendations generally go into effect on the first Plan Year one year after issuance of the revised recommendation
- A complete listing of covered preventive services can be found at the links provided in the full Plan Document
- Please see the Medical Benefits section for additional details about the preventive coverage provided
Routine Examinations and Screenings
| Service | In-Network | Out-of-Network |
|---|---|---|
| Routine Physical Exams (including routine and travel immunizations, flu shots) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Routine Well Child Care (including screenings, routine and travel immunizations, flu shots) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Fluoride Varnish (up to age 6) - Up to 4 treatments per person per Calendar Year* | 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 office visit; includes flu shots and travel immunizations) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Routine Lab, X-rays, and Clinical Tests (including maternity care related) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Routine Colorectal Cancer Screening (sigmoidoscopies and colonoscopies per USPSTF) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Lung Cancer Screening (Low-Dose CT per USPSTF) - Up to 1 per person per Calendar Year* | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Routine Hearing Exams | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Routine Prostate Exams and PSA Screenings | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Abdominal Aortic Aneurysm Screening (per USPSTF) - Up to 1 per person per lifetime* | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Bone Density Screening - Women (per USPSTF for Osteoporosis) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Bone Density Screening - All Other Covered Persons | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
*Maximums are combined In-Network and Out-of-Network
Women's Health Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Breastfeeding Support, Supplies and Counseling (during pregnancy and/or postpartum period, including breast pump rental/purchase) | 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) |
Breast Pump Coverage Limits
| Pump Type | Coverage |
|---|---|
| Hospital Grade Breast Pumps | Rental covered up to 3 months; precertification required for rental exceeding 3 months |
| Electric Breast Pumps | Rent or purchase, whichever is less |
| Manual Breast Pumps | Purchase |
Special Note: If no In-Network lactation providers available, Out-of-Network providers covered at In-Network level with no cost sharing when visit is solely for lactation.
Counseling and Education
| Service | In-Network | Out-of-Network |
|---|---|---|
| Nutritional Counseling | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Smoking Cessation Counseling and Intervention (including clinics and programs) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
Chronic Condition Management
| Service | In-Network | Out-of-Network |
|---|---|---|
| Equipment for Chronic Conditions (blood pressure monitor for hypertension, peak flow meter for asthma, glucometer and insulin products for diabetes) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Tests/Screenings for Chronic Conditions (Hemoglobin A1c for diabetes, Retinopathy screening for diabetes, INR for liver disease/bleeding disorders, LDL for heart disease) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
Vision Care
| Service | In-Network | Out-of-Network |
|---|---|---|
| Routine Vision Exam | NOT COVERED | NOT COVERED |
| Routine Eyewear (lenses, frames, contact lenses) | NOT COVERED | NOT COVERED |
| Eyewear for Special Conditions (non-routine eyewear after surgery, contact lenses for keratoconus including fitting, intraocular lenses after corneal transplant/cataract surgery/covered eye surgery) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
Physician Services
| Service | Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Allergy Testing | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Allergy Treatment | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Anesthesia (Inpatient/Outpatient) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Chiropractic Services | Up to 20 visits per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Physician Hospital Visits | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Physician Office Visits (includes all related charges billed at time of visit) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Second Surgical Opinion | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Surgery (Inpatient) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Surgery (Outpatient) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Surgery (Physician's Office) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
*Maximums are combined In-Network and Out-of-Network
Maternity Services - Employee & Spouse Only
| Service Component | In-Network | Out-of-Network |
|---|---|---|
| Prenatal Care | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Physician Delivery Charges | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Postnatal Care | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
Hospital Services - Inpatient
IMPORTANT: Precertification is ALWAYS required for inpatient hospitalization. Failure to obtain precertification may result in benefit reduction. The reduction in benefits CANNOT be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan.
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Note: Private room covered only when Medically Necessary or when facility does not provide semi-private rooms.
| Service | Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Hospital Room & Board (Precertification required) - Semi-private or special care unit | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Maternity Services - Employee & Spouse Only (Precertification required for stays exceeding 48 hours for vaginal delivery; 96 hours for cesarean delivery) - Semi-private or special care unit | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Birthing Center - Employee & Spouse Only | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Newborn Care (includes Physician visits & circumcision) - Semi-private or special care unit | 100% (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 or special care unit | Transportation/food/lodging limits: $5,000 per Transplant | 100% (after Deductible) - Managed through Cigna's LifeSOURCE Transplant Network® | 50% Allowed Amount (after Deductible) |
| Surgical Facility & Supplies | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Miscellaneous Hospital Charges | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
Hospital Services - Outpatient
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
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.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Clinic Services (at a Hospital) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Emergency Room Expenses (includes Facility, Lab, X-ray & Physician services) | 100% (after Deductible) | 100% (after In-Network Deductible) |
| Outpatient Department | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Outpatient Surgery in Hospital, Ambulatory Surgical Center, etc. | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Preadmission Testing | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Urgent Care Facility/Walk-In Clinic | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
Mental Health/Substance Use Services
IMPORTANT: Precertification is ALWAYS required for inpatient hospitalization. Failure to obtain precertification may result in benefit reduction. The reduction in benefits CANNOT be used to satisfy any applicable Co-payments, Deductibles or Out-of-Pocket Maximums under this Plan.
Any penalty incurred due to failure to obtain notification or prior authorization for services is the responsibility of the Covered Person.
Note: Private room covered only when Medically Necessary or when facility does not provide semi-private rooms.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Inpatient Hospitalization (Precertification required) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Partial Hospitalization/Intensive Outpatient Treatment | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Inpatient Physician Visit | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Hospital Clinic Visit | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Office Visit | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Methadone Maintenance/Treatment | NOT COVERED | NOT COVERED |
Other Services & Supplies
Therapy Services
| Service | Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Cardiac Rehabilitation (Phase 1 and 2 only) | Up to 36 visits per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Occupational Therapy (for treatment due to Illness or Injury) | Up to 20 visits per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Physical Therapy (for treatment due to Illness or Injury) | Up to 20 visits per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Respiratory Therapy | Up to 20 visits per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Speech Therapy (for treatment due to Illness or Injury) | Up to 20 visits per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
*Maximums are combined In-Network and Out-of-Network
Medical Services
| Service | Limits | In-Network | Out-of-Network |
|---|---|---|---|
| Ambulance Services | 100% (after Deductible) | 50% Allowed Amount (after 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 based on services provided | Benefits based on services provided | Benefits based on services provided |
| Chemotherapy & Radiation Therapy | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Clinical Trials - Routine Services (limited to routine covered services: Hospital visits, laboratory, imaging) | Benefits based on services provided | Benefits based on services provided | |
| Dental/Oral Services (Excludes excision of impacted wisdom teeth; see Medical Benefits section for other limitations) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Diabetes Self-Management Training and Education | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Diagnostic Imaging (MRI, CT Scan, PET Scan) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Diagnostic X-ray and Laboratory (Outpatient) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Dialysis/Hemodialysis | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Durable Medical Equipment | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Early Intervention Services (up to age 3) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Home Health Care | Up to 60 visits per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Hospice Care (Inpatient/Outpatient) (Precertification required for inpatient) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Injectables | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Learning Deficiencies, Behavioral Problems/Developmental Delays (Precertification and visit limits based on services) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Oral Pharynx Procedures | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Orthotics (includes foot orthotics) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Podiatry Care | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Prosthetics | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Rehabilitation Hospital (Precertification required) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Sleep Studies (limited to testing and treatment of Obstructive Sleep Apnea) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) | |
| Skilled Nursing Facility/Extended Care Facility (Precertification required) | Up to 60 days per person per Calendar Year* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Wigs (when hair loss due to cancer treatment) | Up to 1 wig per person per Calendar Year; maximum $300 per wig* | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
*Maximums are combined In-Network and Out-of-Network
Family Planning Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Family Planning for Women (includes consultations and diagnostic tests; see also Prescription Drug Benefit and Preventive Care sections) | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Family Planning for Men (includes consultations and diagnostic tests) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Voluntary Sterilization - Women | 100% (Deductible waived) | 50% Allowed Amount (after Deductible) |
| Voluntary Sterilization - Men | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| Termination of Pregnancy (covered only when mother's life endangered or due to rape/incest, documented by treating Physician) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
Telemedicine Services
| Service Type | In-Network | Out-of-Network |
|---|---|---|
| Telemedicine (medical and behavioral health services; INCLUDES DOCTOR ON DEMAND) | 100% (after Deductible) | 50% Allowed Amount (after Deductible) |
| All Other Virtual Visits (with Provider with established relationship, including OT, PT, Speech Therapy) | Paid based on services provided | Paid based on services provided |
Services NOT COVERED
Completely Excluded Services
| Service Category | Coverage Status |
|---|---|
| Acupuncture | NOT COVERED |
| Alternative/Complementary Care Benefit | NOT COVERED |
| Bariatric Surgery | NOT COVERED |
| Biofeedback Therapy | NOT COVERED |
| Cochlear Implants | NOT COVERED |
| Erectile Dysfunction Treatment | NOT COVERED |
| Gender Dysphoria Treatment and Related Services | NOT COVERED |
| Gene Therapy | NOT COVERED |
| Genetic Counseling, Testing and Related Services | NOT COVERED |
Note: Coverage IS provided for BRCA Testing – See Breast Cancer Screening in Preventive Care Services section; precertification is NOT required for BRCA testing. | Growth Hormones | NOT COVERED | | Hearing Aids | NOT COVERED | | Infertility Treatment | NOT COVERED | | Marital Counseling | NOT COVERED | | Massage Therapy | NOT COVERED | | Medical and Enteral Formula | NOT COVERED | | Modified Low Protein Food Products | NOT COVERED | | Neuromuscular Stimulator Equipment including TENS | NOT COVERED | | Private Duty Nursing | NOT COVERED | | Temporomandibular Joint Disorders (TMJ) Treatment | NOT COVERED |
Wellness Benefits
| Benefit | Coverage |
|---|---|
| Childbirth Classes | NOT COVERED |
| Fitness Reimbursement Benefit | NOT COVERED |
| Weight Loss Reimbursement Benefit | NOT COVERED |
Additional Benefits - Special Coverage Notes
Covered Under Specific Conditions
| Service | Coverage Details |
|---|---|
| Applied Behavior Analysis (ABA) | Covered under Autism Spectrum Disorders treatment; pays as Mental Health/Substance Abuse Outpatient Office Visit |
| Breast Reduction Surgery | Covered when Medically Necessary; precertification required |
| Orthoptics | Covered; pays as Outpatient Office Visit |
Excluded Alternative/Complementary Services
The following services are specifically excluded:
- Biofeedback
- Chelation Therapy
- Homeopathic Treatment
- Hypnosis/Hypnotherapy
- Rolfing/Reiki
- Cardiac Rehab Phase III (Outpatient maintenance)
- Home Visit by Visiting Nurse after early maternity discharge
- Planned Home Births
- Sex Therapy
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 (Section 25.1) for a complete list of benefit and non-benefit type exclusions.
Important Definitions and References
Key Terms
- Allowed Amount: The maximum amount the plan will pay for a covered service
- Contracted Rate: The rate negotiated between the plan and In-Network providers
- Qualifying Payment Amount: The amount used to determine cost-sharing for certain Out-of-Network services under the No Surprises Act
- Medically Necessary: Services that are determined to be appropriate and necessary for the diagnosis or treatment of an illness or injury (refer to full Plan Document for complete definition)
- Emergency Care: As defined in the Definitions section of the full Plan Document
- Calendar Year: January 1 through December 31
- Covered Person: An eligible employee or dependent enrolled in the plan
- Covered Services: Services that meet the plan's requirements for coverage
Services Requiring Additional Documentation
Many services listed in this guide reference "See Medical Benefits section for limitations" or "See Medical Benefits section for other limitations." This means:
- Complete coverage details, requirements, and restrictions are in the full Plan Document
- Additional precertification may be required beyond what's listed
- Specific medical criteria may need to be met
- Maximum benefit limits may apply
- Certain services may be subject to medical necessity review
Understanding "Benefits Based on Services Provided"
Some services (like Autism Spectrum Disorders Treatment, Clinical Trials, and Telemedicine virtual visits) show "Benefits based on services provided" instead of specific coverage percentages. This means:
- The benefit level depends on the type of service rendered
- For example, if the service is an office visit, it's covered under Physician Office Visit benefits
- If the service is therapy, it's covered under the applicable therapy benefit (OT, PT, Speech)
- Refer to the specific service category for the applicable deductible, coinsurance, and limits
Where to Find Complete Information
For complete details on:
- All definitions of terms used in this plan
- Complete list of exclusions and limitations
- Detailed coverage requirements
- Medical necessity criteria
- Claims and appeals procedures
Refer to the full Plan Document/Summary Plan Description
Key Plan Features Summary
Deductible and Out-of-Pocket Structure
- In-Network and Out-of-Network are COMPLETELY SEPARATE - expenses do not cross-accumulate
- Same amounts for Deductible and OOPM for single coverage ($5,500 In-Network, $11,000 Out-of-Network)
- Individual deductibles included in family coverage - individual can reach their limit before family maximum
- No Co-payments - All cost sharing through deductible and coinsurance only
Cost Sharing Pattern
- In-Network: 100% after deductible (no coinsurance)
- Out-of-Network: 50% after deductible (50% coinsurance)
- Preventive Care: 100% In-Network with deductible waived; 50% Out-of-Network after deductible
Prescription Drug Structure
- All Rx require deductible to be met first
- After deductible: $0 co-payments for all tiers (generic, preferred brand, non-preferred brand, specialty)
- Exceptions: Contraceptives and tobacco cessation products (deductible waived)
Special Features
- Deductible and OOPM Credit for 2025: Expenses from 1/1/2025-9/30/2025 credited toward full year
- No Surprises Act Protections: Out-of-network emergency and certain services covered at in-network rates
- Precertification Required: Always for inpatient stays; failure results in penalty
- Transplant Network: Managed through Cigna's LifeSOURCE with $5,000 transportation/lodging benefit
Important Contact Information
| Need | Contact |
|---|---|
| Customer Service Questions | Karias Care Concierge |
| Prescription Drug Questions | TrueScripts |
| Network Providers | CIGNA Network |
| Precertification/Utilization Management | Cigna Payer Solutions |
| Case Management | MedWatch |
Document Information
- Document Status: DRAFT
- Last Updated: September 25, 2025
- Plan Effective Date: October 1, 2025
- Plan Year: Calendar Year (January 1 - December 31)
Disclaimer: This knowledge base article is a summary of benefits. Complete details, exclusions, limitations, and definitions are contained in the full Plan Document/Summary Plan Description. In case of any discrepancy, the official Plan Document governs. This is a draft document and subject to final approval.
Frequently Asked Questions
Q: Do I need to meet my deductible before prescription drugs are covered? A: Yes, you must meet your deductible first. However, after meeting the deductible, all prescription drug co-payments are $0. Exceptions: generic contraceptives and tobacco cessation products are covered at 100% with deductible waived.
Q: Are in-network and out-of-network deductibles separate? A: Yes, they are completely separate and do not accumulate toward each other. You have a $5,500 in-network deductible and an $11,000 out-of-network deductible for single coverage.
Q: What happens if I go to an out-of-network provider for emergency care? A: Emergency services are covered at the in-network level (100% after in-network deductible) even when provided by out-of-network providers, thanks to No Surprises Act protections.
Q: Do I need precertification for outpatient surgery? A: Precertification requirements vary by service. Inpatient hospitalization always requires precertification. Check specific service requirements or contact Cigna Payer Solutions.
Q: Is preventive care covered before I meet my deductible? A: Yes, most preventive care services marked with ** are covered at 100% with deductible waived when you use in-network providers.
Q: How many physical therapy visits do I get per year? A: You are covered for up to 20 physical therapy visits per person per calendar year (combined in-network and out-of-network).
Q: Are routine vision exams covered? A: No, routine vision exams and routine eyewear are not covered. However, eyewear for special medical conditions (like after cataract surgery) is covered.
Q: What is the maximum I'll pay out-of-pocket in a year? A: For in-network services, your maximum out-of-pocket is $5,500 for single coverage or $11,000 for family coverage. Out-of-network maximums are double: $11,000 single/$22,000 family. These are separate and don't combine.
Q: Are there any co-payments for doctor visits? A: No, this plan has no co-payments. You pay 100% until you meet your deductible, then in-network services are covered at 100% and out-of-network at 50%.
Q: Can I use mail order for my prescriptions? A: Yes, mail order pharmacy is available through TrueScripts for up to a 90-day supply with $0 co-payment after you meet your deductible.