Five Star Technology Solutions - HDHP PPO - 10.1.26
This comprehensive guide contains the medical and prescription drug benefits for Five Star Technology Solutions employees enrolled in the HDHP PPO plan effective October 1, 2026. The plan is a Qualified High Deductible Health Plan administered by 90 Degree Benefits, with separate In-Network (Tier 1, CIGNA network) and Out-of-Network (Tier 2) coverage and prescription drug benefits administered by DREXI. After the In-Network Deductible is met, most In-Network services are paid at 100%.
lan Identification & Status
| Field | Details |
|---|---|
| Company Name | Five Star Technology Solutions |
| Plan Name | HDHP PPO |
| Master Group Number | 64800 |
| Subgroup Numbers | 64830 (Tier 1 / In-Network); 64831 (Tier 2 / Out-of-Network) |
| Effective Date | October 1, 2026 |
| Install Type | Initial |
| Plan Structure | 2 Tier (In-Network / Out-of-Network) |
| Qualified High Deductible Health Plan | Yes |
| Grandfathered Status | No |
| ERISA Plan | Yes |
| Benefit Period | Calendar Year (January 1 - December 31) |
| Fiscal Year (Plan Funding) | 01/01 - 12/31 |
| Dental / Vision Benefits | Excepted (unbundled) - not part of this medical plan |
| Number of Employees | 88 |
| Document Status | FINAL |
Plan Administration & Vendors
| Role/Function | Provider/Contact |
|---|---|
| Third Party Administrator (TPA) | 90 Degree Benefits |
| TPA Hours of Operation | 8:00 AM - 5:00 PM CST |
| PPO Network | CIGNA |
| Transplant Network | CIGNA LifeSOURCE Transplant Network |
| Precertification / Notification | CIGNA - 1-888-267-4445 |
| Out-of-Network Pricing | 130% of Medicare (professional); 150% of Medicare (facility, priced by Payer Compass) |
| Prescription Drug Administrator (PBM) | DREXI |
| Vision Vendor | Humana (separate from medical plan) |
| Telemedicine Vendor | Teladoc (consults subject to Deductible/Coinsurance) |
| Reference-Based Pricing (RBP) | No |
| Pace Program | Yes |
| A&G / Patient Defender / CareConnect | No |
| Benchmark State | Utah |
MEDICAL DEDUCTIBLES
Annual Calendar Year Deductibles
| Coverage Level | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Per Person | $5,500 | $11,000 |
| Per Family | $11,000 | $22,000 |
Deductible Structure
| Feature | Details |
|---|---|
| In-Network and Out-of-Network Deductibles | SEPARATE - Do not cross-apply |
| Deductible Applies to Out-of-Pocket Maximum | YES (In-Network and Out-of-Network) |
| 3-Month Deductible Carryover | NO |
| Prescription Drugs Subject to Deductible | YES |
COINSURANCE (PLAN PAYMENT PERCENTAGE)
| Network | Plan Pays After Deductible | Applied To |
|---|---|---|
| In-Network Providers (Tier 1) | 100% | Unless otherwise stated |
| Out-of-Network Providers (Tier 2) | 50% | Unless otherwise stated |
Note: Because the In-Network Deductible and In-Network Out-of-Pocket Maximum are the same amount, meeting the In-Network Deductible effectively means In-Network covered services are paid at 100% for the balance of the Calendar Year.
OUT-OF-POCKET MAXIMUMS
Annual Calendar Year Out-of-Pocket Maximums
| Coverage Level | In-Network Providers | Out-of-Network Providers |
|---|---|---|
| Per Person | $5,500 | $11,000 |
| Per Family | $11,000 | $22,000 |
Out-of-Pocket Maximum Structure
| Feature | Details |
|---|---|
| In-Network and Out-of-Network OOPM | SEPARATE - Do not cross-apply |
| Integrated with Pharmacy | YES - Prescription drug costs count toward the medical OOPM |
| Co-payments Apply to OOPM | YES |
| 3-Month Carryover | NO |
| Benefit Maximums (visit/day limits) | COMBINED across In-Network and Out-of-Network |
PRESCRIPTION DRUG BENEFITS
Prescription Drug Structure
| Feature | Details |
|---|---|
| Administrator (PBM) | DREXI |
| Prescription Drugs Covered Under | Drug Plan |
| Subject to Deductible | YES |
| Out-of-Pocket Maximum | COMBINED with medical OOPM |
| New-to-Market Specialty Drugs | 6-month waiting period |
Retail Pharmacy - Up to 30 Day Supply
| Drug Type | Your Cost |
|---|---|
| Generic Drug | Deductible, then 0% |
| Preferred Brand Name Drug | Deductible, then 0% |
| Non-Preferred Brand Name Drug | Deductible, then 0% |
| Specialty Drug | Deductible, then 0% |
Mail Order Pharmacy - Up to 90 Day Supply
| Drug Type | Your Cost |
|---|---|
| Generic Drug | Deductible, then 0% |
| Preferred Brand Name Drug | Deductible, then 0% |
| Non-Preferred Brand Name Drug | Deductible, then 0% |
| Specialty Drug | Deductible, then 0% |
How Specific Items Are Covered
| Item | Covered Under |
|---|---|
| Diabetic Supplies | Drug Plan |
| Insulin | Drug Plan |
| Growth Hormones | NOT COVERED |
| Take-Home Medications | NOT COVERED |
| Contraceptive Patches, Oral Tablets, Vaginal Rings | Drug Plan |
| Contraceptive Injections (e.g., Depo-Provera) | Drug Plan |
| Contraceptives Administered in Office (IUDs, implants) | Medical Plan (In-Network and Out-of-Network) and Drug Plan |
| Smoking Cessation Drugs | Prescription Drug benefit |
| Botox | Medical Plan |
Specialty Pharmacy Injectable Drugs
| Feature | Details |
|---|---|
| Injectables Under Medical Plan | YES - Paid the same as other medical office services |
| Coordination Rule | Medications and supplies for administering injectable prescription medication may be covered under the Medical OR Pharmacy benefit, but not both |
PRECERTIFICATION REQUIREMENTS
| Requirement | Details |
|---|---|
| Precertification Provided By | CIGNA - 1-888-267-4445 |
| Services Requiring Precertification | See CIGNA Precertification list |
| Retroactive Precertification Allowed | YES |
| Penalty for Post-Service Precertification | NO |
| Precertification Penalty Waived for Emergency Inpatient Admissions | NO |
| Precertification Required When Medicare Is Primary | NO |
| Precertification Required When Other Coverage Is Primary | NO |
PREVENTIVE CARE SERVICES
Preventive Care General Information
| Information Type | Details |
|---|---|
| ACA Compliance | Non-grandfathered plan; follows US Preventive Services Task Force (USPSTF) recommendations |
| Cost Sharing | Preventive services are covered without cost sharing when rendered by a network provider |
| Additional Wellness Benefit | YES - Routine services beyond USPSTF recommendations are also covered (see below) |
ACA Preventive Care and Routine Wellness
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| ACA Preventive Care Services | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Physical Exams | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Immunizations | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Diagnostic Tests, Labs, and X-rays | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Mammograms | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Pap Smear / Test and Pelvic Exam | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Fecal Blood Culture | 100% (Deductible waived) | 50% (after Deductible) |
| Routine PSA Test and Prostate Exam | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Colonoscopy, Sigmoidoscopy and Similar Preventive Procedures | 100% (Deductible waived) | 50% (after Deductible) |
| Contraceptive Management | 100% (Deductible waived) | 50% (after Deductible) |
| Routine Hearing Exam | 100% (Deductible waived) | 50% (after Deductible) |
| Nutritional Counseling | 100% (Deductible waived) | 50% (after Deductible) |
PHYSICIAN & OFFICE SERVICES
Note: This plan has no office visit co-payments. Office services are subject to the Deductible, then paid at the coinsurance level shown. There is no separate co-pay for specialists.
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Medical Office Visit (Primary Care and Specialist) | 100% (after Deductible) | 50% (after Deductible) |
| Office Surgery (includes related anesthesia) | 100% (after Deductible) | 50% (after Deductible) |
| Therapeutic Injections (Office) | 100% (after Deductible) | 50% (after Deductible) |
| Allergy Injections and Serum | 100% (after Deductible) | 50% (after Deductible) |
| Allergy Testing | 100% (after Deductible) | 50% (after Deductible) |
| Office X-ray & Professional Component (includes MRI, CT, PET) | 100% (after Deductible) | 50% (after Deductible) |
| Office Laboratory & Professional Component | 100% (after Deductible) | 50% (after Deductible) |
| Office Diagnostic Testing | 100% (after Deductible) | 50% (after Deductible) |
| All Other Office Related Services | 100% (after Deductible) | 50% (after Deductible) |
| Independent Laboratory & Professional Component | 100% (after Deductible) | 50% (after Deductible) |
| Second Surgical Opinion | 100% (after Deductible) | 50% (after Deductible) |
Telemedicine
| Service | Coverage Status | Special Notes |
|---|---|---|
| Telemedicine - Patient to Physician (telephone and internet) | COVERED | Subject to Deductible/Coinsurance |
| Teladoc | COVERED | Separate benefit from medical; consults subject to Deductible/Coinsurance |
| Telemedicine - Physician to Physician | NOT COVERED | Excluded |
DIAGNOSTIC SERVICES
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Lab, X-ray, and Diagnostic Imaging including Ultrasound (Outpatient testing and/or facility fee) | 100% (after Deductible) | 50% (after Deductible) |
| Major Diagnostic Procedures - Freestanding Facility (MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans) | 100% (after Deductible) | 50% (after Deductible) |
| Major Diagnostic Procedures - Outpatient (MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans) | 100% (after Deductible) | 50% (after Deductible) |
| Sleep Studies | 100% (after Deductible) | 50% (after Deductible) |
EMERGENCY & URGENT CARE
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Emergency Room - Hospital Facility | 100% (after Deductible) | 100% (after Deductible) | All emergency services paid at In-Network level; Out-of-Network claims apply to In-Network Deductible/OOPM accumulators |
| Emergency Room - Professional Services | 100% (after Deductible) | 100% (after Deductible) | All emergency services paid at In-Network level; Out-of-Network claims apply to In-Network Deductible/OOPM accumulators |
| Ambulance (ground and air) | 100% (after Deductible) | 100% (after Deductible) | Includes facility-to-facility transport when medically necessary; Out-of-Network applies In-Network Deductible and OOPM |
| Urgent Care Services (includes all related services) | 100% (after Deductible) | 50% (after Deductible) | None specified |
HOSPITAL SERVICES - INPATIENT
Inpatient Requirements
| Requirement/Feature | Details |
|---|---|
| Precertification Penalty Waived for Emergency Admissions | NO |
| ER Co-pay Waived if Admitted Through ER | Not applicable - no ER co-pay |
| Reduced to Semi-Private Room Rate | NO |
Inpatient Hospital Services
| Service | In-Network Coverage | Out-of-Network Coverage | Special Notes |
|---|---|---|---|
| Inpatient Facility Services (room & board, ICU, etc.) | 100% (after Deductible) | 50% (after Deductible) | None specified |
| Ancillary (All Other Inpatient) Services | 100% (after Deductible) | 50% (after Deductible) | None specified |
| Anesthesia | 100% (after Deductible) | 50% (after Deductible) | None specified |
| Surgeon / Assistant Surgeon / Co-Surgeon | 100% (after Deductible) | 50% (after Deductible) | Assistant Surgeon limited to 25% of the Usual and Customary fee for the procedure |
| Maternity Surgery (includes physician attendance) | 100% (after Deductible) | 50% (after Deductible) | See Maternity section |
HOSPITAL SERVICES - OUTPATIENT
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Outpatient Hospital Surgery | 100% (after Deductible) | 50% (after Deductible) |
| Ambulatory Surgical Center | 100% (after Deductible) | 50% (after Deductible) |
| Outpatient Hospital Services (unless otherwise specified) | 100% (after Deductible) | 50% (after Deductible) |
| Outpatient Physician Services (unless otherwise specified) | 100% (after Deductible) | 50% (after Deductible) |
| Infusion Therapy | 100% (after Deductible) | 50% (after Deductible) |
| Dialysis | 100% (after Deductible) | 50% (after Deductible) |
| Chemotherapy / Radiation Therapy (Professional and Facility) | 100% (after Deductible) | 50% (after Deductible) |
OUT-OF-NETWORK PROVIDERS PAID AT IN-NETWORK LEVEL
| Scenario | Paid as In-Network? |
|---|---|
| Hospitalists, Radiology, Pathology and Anesthesiology at a participating facility | YES |
| Emergency Room Physicians | YES |
| Referred by a participating physician | NO |
| Services outside the service area (more than 50 miles from residence) | YES |
| Services unable to be provided by a network provider | YES |
| Emergency care out of area or at a non-network hospital (accidental injury or emergency) | YES |
MENTAL HEALTH & SUBSTANCE USE SERVICES
Note: When covered, all Mental/Nervous and Substance Abuse benefits are paid the same as any other illness.
| Service | In-Network Coverage | Out-of-Network Coverage |
|---|---|---|
| Office and Outpatient Physician Services | 100% (after Deductible) | 50% (after Deductible) |
| Inpatient Hospitalization | 100% (after Deductible) | 50% (after Deductible) |
| Residential Treatment Center | 100% (after Deductible) | 50% (after Deductible) |
| Outpatient Facility Treatment (Partial Hospitalization, Day Treatment, Intensive Outpatient) | 100% (after Deductible) | 50% (after Deductible) |
Covered Mental Health Providers
| Provider Type | Covered? |
|---|---|
| PsyD - Therapist with a PhD or master's degree in psychiatry or related field | YES |
| State Licensed Psychologist | YES |
| State Licensed or Certified Social Worker | YES |
| Licensed Professional Counselor | YES |
| Certified Addiction Counselor (substance abuse) | YES |
| MSW - Masters in Social Work | YES |
MATERNITY & NEWBORN CARE
| Feature | Details |
|---|---|
| Office Services | Paid according to Medical Office Visit benefits |
| Hospital Services | Paid according to Hospital benefits |
| Dependent Daughter Pregnancies | NOT COVERED (PPACA-required services are covered) |
| Outpatient Birthing Centers | COVERED |
| Home Deliveries | NOT COVERED |
| Elective Abortion | NOT COVERED |
| Abortion Coverage Applies To | Employee/Spouse only |
| Sick Newborn | Normal plan benefits apply; newborn must be enrolled within 31 days |
| Well Newborn | All newborn charges processed under the mother |
THERAPY & REHABILITATION SERVICES
| Service | In-Network Coverage | Out-of-Network Coverage | Visit Limits | Special Notes |
|---|---|---|---|---|
| Physical Therapy | 100% (after Deductible) | 50% (after Deductible) | Up to 20 visits per Calendar Year | Includes aquatic therapy performed with PT and massage therapy performed by a covered provider |
| Occupational Therapy | 100% (after Deductible) | 50% (after Deductible) | Up to 20 visits per Calendar Year | Includes massage therapy performed by a covered provider; separate from PT limit |
| Speech Therapy | 100% (after Deductible) | 50% (after Deductible) | Up to 20 visits per Calendar Year | None specified |
| Other Rehabilitative and Habilitative Services (ABA therapy, cognitive rehab, cardiac rehab, pulmonary rehab) | 100% (after Deductible) | 50% (after Deductible) | Calendar Year maximum indicated; amount not specified | None specified |
| Chiropractic Services | 100% (after Deductible) | 50% (after Deductible) | Up to 20 visits per Calendar Year | None specified |
Note: Physical Therapy and Occupational Therapy are NOT a combined benefit; each has its own 20-visit limit. All visit limits are combined across In-Network and Out-of-Network.
OTHER SERVICES & SUPPLIES
Extended and Home-Based Care
| Service | In-Network Coverage | Out-of-Network Coverage | Limits | Special Notes |
|---|---|---|---|---|
| Extended Care Facility (skilled nursing, subacute) | 100% (after Deductible) | 50% (after Deductible) | Up to 60 days per Calendar Year | None specified |
| Home Health Care | 100% (after Deductible) | 50% (after Deductible) | Up to 60 visits per Calendar Year | None specified |
| Hospice Care | 100% (after Deductible) | 50% (after Deductible) | No day maximum | Custodial/respite care allowed and included in Hospice benefit |
| Bereavement Counseling | 100% | 50% | No visit maximum | Included in Hospice benefit; services must be furnished within 6 months of death |
Durable Medical Equipment
| Feature | Details |
|---|---|
| Coverage | In-Network: 100% (after Deductible); Out-of-Network: 50% (after Deductible) |
| Insulin Pumps and Pump Supplies | COVERED as DME |
| Repairs (not due to misuse) | COVERED |
| Replacement (non-functioning, outside warranty, unrepairable) | COVERED |
| Batteries for Covered Equipment | COVERED |
| Sales Tax and Shipping | NOT COVERED |
| Rental | Covered up to the purchase price of the equipment |
Orthotics and Prosthetics
| Feature | Details |
|---|---|
| Coverage | In-Network: 100% (after Deductible); Out-of-Network: 50% (after Deductible) |
| Initial Purchase, Fitting, Repair and Replacement | COVERED |
| Custom-Molded Foot Orthotics | COVERED |
| Non-Custom Molded Shoe Inserts | NOT COVERED |
| Diabetic Shoes | COVERED - limited to 2 pair per Calendar Year |
Transplant Services
| Feature | Details |
|---|---|
| Recipient Facility Benefits | In-Network: 100% (after Deductible); Out-of-Network: 50% (after Deductible); managed through CIGNA LifeSOURCE Transplant Network |
| Living Donor Facility Benefits | COVERED; managed through CIGNA LifeSOURCE Transplant Network |
| Separate Transplant Policy | NO |
| Donor Covered When Recipient Is Not Covered Under the Plan | NO |
Transplant Travel and Lodging
| Expense | Covered? |
|---|---|
| Airfare | YES |
| Meals | YES |
| Tolls | YES |
| Parking Fees | YES |
| Hotel / Motel | YES |
| Apartment Rental | NO |
| Relocation Fees | NO |
| Taxes | NO |
Note: Travel and lodging is managed through CIGNA LifeSOURCE Transplant Network, covered only if the facility is more than 60 miles from the residence, and limited to $10,000 per transplant.
Wigs
| Service | In-Network Coverage | Out-of-Network Coverage | Limits |
|---|---|---|---|
| Wigs | 100% (after Deductible) | 50% (after Deductible) | Covered when due to treatment of cancer; 1 wig per Calendar Year, up to $300 per wig |
Infertility Services
| Service | Covered? |
|---|---|
| Diagnostic Services Only (to determine diagnosis) | YES |
| Hormone or Therapy Drugs | YES |
| Genetic Testing to Diagnose Infertility | NO |
| Fertility Tests; Tests to Prepare for Induced Conception | NO |
| Surgical Reversal of Sterilization | NO |
| Sperm Enhancement Procedures | NO |
| Artificial Insemination, IVF, GIFT, ZIFT, Embryo Transfer | NO |
| Freezing or Storage of Embryos, Eggs or Semen | NO |
DENTAL, ORAL & TMJ SERVICES UNDER MEDICAL
Oral Surgery Covered Under Medical
| Procedure | Covered? |
|---|---|
| Excision of tumors and cysts of the jaw, cheeks, lips, tongue, roof and floor of mouth (when pathological exam required) | YES |
| Surgical correction of accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of mouth | YES |
| Reduction of fractures and dislocations of the jaw | YES |
| External incision and drainage of cellulitis | YES |
| Incision of accessory sinuses, salivary glands or ducts | YES |
| Excision of exostosis of jaws and hard palate | YES |
| Excision of partially or completely impacted teeth | NO |
| Frenectomy | NO |
| Gingival mucosal surgery (gingivectomy, osseous, periodontal surgery and grafting) | NO |
| Apicoectomy | NO |
| Root canal therapy with an Apicoectomy | NO |
| Alveolectomy | NO |
Other Dental Services
| Service | Covered? |
|---|---|
| Dental Implants | NO |
| Anesthesia, X-ray and Lab for medically appropriate hospital dental services | YES |
| Any Other Dental Services Under Medical | NO |
| Temporomandibular Joint Disorder (TMJ) - all services including diagnosis, non-surgical treatment and surgery | NO |
VISION & HEARING
| Service | Coverage Status | Special Notes |
|---|---|---|
| Medical Eye Exams and Glaucoma Testing | COVERED under medical | Subject to medical Deductible/Coinsurance |
| Glaucoma and Cataracts | COVERED under medical | None specified |
| Routine Eye Exams and Refractions | NOT COVERED | Routine vision provided through separate vendor (Humana) |
| Lenses, Frames, Contacts, Safety Glasses, Sunglasses | NOT COVERED | None specified |
| Refractive Eye Surgery (Lasik, radial keratotomy) | NOT COVERED | None specified |
| Vision Therapy including Orthoptics | NOT COVERED | None specified |
| Routine Hearing Exam | COVERED | In-Network: 100% (Deductible waived); Out-of-Network: 50% (after Deductible) |
| Hearing Aids | NOT COVERED | None specified |
COMPLETE EXCLUSIONS LIST
Services NOT COVERED
| Service Category | Specific Service | Coverage Status |
|---|---|---|
| Alternative/Complementary | Acupuncture | NOT COVERED |
| Alternative/Complementary | Holistic or Homeopathic Medicine | NOT COVERED |
| Alternative/Complementary | Hypnosis | NOT COVERED |
| Alternative/Complementary | Other alternative treatment not accepted medical practice | NOT COVERED |
| Alternative/Complementary | Biofeedback | NOT COVERED |
| Devices/Equipment | Hearing Aids | NOT COVERED |
| Devices/Equipment | Blood Pressure Cuffs/Monitors | NOT COVERED |
| Devices/Equipment | Non-Custom Molded Shoe Inserts | NOT COVERED |
| Surgical | Weight Control / Bariatric Surgery (gastric bypass, gastric sleeve) | NOT COVERED |
| Surgical | Panniculectomy/Abdominoplasty | NOT COVERED |
| Weight Control | Weight loss medications, physician-supervised weight loss programs, diet supplements | NOT COVERED |
| Sexual/Reproductive | Sexual Function treatment (diagnostic, non-surgical, surgical, prescription drugs) | NOT COVERED |
| Sexual/Reproductive | Infertility treatment beyond diagnosis and hormone/therapy drugs | NOT COVERED |
| Sexual/Reproductive | Elective Abortion | NOT COVERED |
| Maternity | Home Deliveries | NOT COVERED |
| Maternity | Dependent Daughter Pregnancies (PPACA-required services are covered) | NOT COVERED |
| Genetic | Gene Therapy (medical and prescription drug charges) | NOT COVERED |
| Medications | Orphan Drugs (medical and prescription drug charges) | NOT COVERED |
| Medications | Growth Hormones | NOT COVERED |
| Medications | Take-Home Medications | NOT COVERED |
| Counseling | Marriage Counseling | NOT COVERED |
| Dental | TMJ Treatment | NOT COVERED |
| Dental | Dental Implants; excision of impacted teeth; periodontal surgery | NOT COVERED |
| Vision | Routine Eye Exams, Eyewear, and Refractive Surgery | NOT COVERED |
| Foot Care | Treatment of bunions, corns, calluses and toenails (unless medically necessary) | NOT COVERED |
| Telemedicine | Physician-to-Physician Telemedicine | NOT COVERED |
| Administrative | Sales Tax, Shipping and Handling | NOT COVERED |
| Administrative | Complications from a Non-Covered Service | NOT COVERED |
Notable Services That ARE Covered
| Service | Coverage Details |
|---|---|
| Transgender Services | COVERED - see appropriate benefit section |
| Genetic Counseling or Testing | COVERED based on medical appropriateness or family history (ACA-mandated genetic testing covered) |
| Breast Reductions | COVERED - see appropriate benefit section |
| Botox | COVERED through the Medical plan |
| Massage Therapy | COVERED only when performed by a covered provider as part of PT or OT (massage therapists are not covered providers) |
| Contraceptives Administered in Office (IUDs, implants) | COVERED under Medical and Drug Plan |
Important Note: This is not a complete listing of all Plan exclusions. Refer to the Plan Document/Summary Plan Description for complete benefit and exclusion language.
COMBINED IN-NETWORK AND OUT-OF-NETWORK MAXIMUMS
| Service | Combined Maximum | Time Period |
|---|---|---|
| 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 |
| Extended Care Facility (skilled nursing, subacute) | 60 days | Per Calendar Year |
| Home Health Care | 60 visits | Per Calendar Year |
| Diabetic Shoes | 2 pair | Per Calendar Year |
| Wigs (cancer treatment) | 1 wig (up to $300) | Per Calendar Year |
| Transplant Travel and Lodging | $10,000 | Per transplant |
Note: All benefit maximums are a combination of services received from In-Network and Out-of-Network providers or facilities.
IN-NETWORK VS OUT-OF-NETWORK ACCUMULATION
| Feature | Status |
|---|---|
| In-Network and Out-of-Network Deductibles | SEPARATE - Do not accumulate together |
| In-Network and Out-of-Network Out-of-Pocket Maximums | SEPARATE - Do not accumulate together |
| Emergency Room and Ambulance Exception | Out-of-Network emergency and ambulance claims apply to the In-Network Deductible and OOPM |
ELIGIBILITY
Who Can Be Covered
| Category | Eligible? |
|---|---|
| Full-Time Employees Only | YES - benefits limited to full-time employees |
| Dependents (to age 26) | YES |
| Domestic Partners | YES |
| Common Law Spouse | YES |
| Adopted Children | YES |
| Foster Children | YES |
| Children Under Legal Guardianship | YES |
| Grandchildren | NO |
| Spouse Eligible for Other Coverage | YES - may still be covered |
Continuation and Reinstatement
| Scenario | Details |
|---|---|
| Standard FMLA | YES |
| Continuation for Disability Outside FMLA | NO |
| Continuation for Layoff | NO |
| Leave of Absence Not Meeting FMLA Requirements | NO |
| Reinstatement of Coverage | Rehired employee is not treated as a new hire; waiting period waived if rehired within 91 days |
Continuity of Care
| Feature | Details |
|---|---|
| Continuity of Care Offered | YES - standard 90 days |
| Applies To | Persons under care for a serious illness or pregnancy; network benefits continue for a limited period if the physician leaves the network |
CLAIMS, APPEALS & COORDINATION OF BENEFITS
| Feature | Details |
|---|---|
| Timely Filing Period | 12 months |
| Levels of Appeal Before Independent Review (IRO) | 2 |
| Out-of-Network Reimbursement Basis | Percentage of Medicare (130% professional / 150% facility) |
| COB Same for Medicare-Eligible Employees | YES |
| Reduce Benefits as if Medicare Part B Elected | NO |
| Dependent COB Rule | Birthday Rule |
| Question Primary Carrier's Rule | NO |
| COB Method | Carve Out COB - savings do not satisfy member deductible or reduce co-payments |
| Medicare Note | Special COB rules may apply for employees with Medicare because the employer has fewer than 100 employees |
Other Covered Medical Providers
| Provider Type | Covered? |
|---|---|
| Certified Nurse Midwife (within scope of license) | YES |
| Chiropractor | YES |
| Massage Therapist | NO |
CONTACT INFORMATION
| Service Need | Contact |
|---|---|
| Plan Administration / Claims | 90 Degree Benefits (8:00 AM - 5:00 PM CST) |
| Precertification | CIGNA - 1-888-267-4445 |
| Network Provider Information | CIGNA |
| Transplant Services | CIGNA LifeSOURCE Transplant Network |
| Prescription Drug Questions | DREXI |
| Routine Vision | Humana |
| Telemedicine | Teladoc |
GLOSSARY OF KEY TERMS USED IN THIS DOCUMENT
| Term | Meaning in This Document |
|---|---|
| ABA | Applied Behavior Analysis |
| ACA / PPACA | Patient Protection and Affordable Care Act |
| Calendar Year | January 1 through December 31 |
| COB | Coordination of Benefits |
| DME | Durable Medical Equipment |
| ERISA | Employee Retirement Income Security Act |
| FMLA | Family and Medical Leave Act |
| HDHP | High Deductible Health Plan |
| IOP | Intensive Outpatient Program |
| IRO | Independent Review Organization |
| OOPM | Out-of-Pocket Maximum |
| PBM | Pharmacy Benefit Manager |
| PHP | Partial Hospitalization Program |
| PPO | Preferred Provider Organization |
| RBP | Reference-Based Pricing |
| TMJ | Temporomandibular Joint |
| TPA | Third Party Administrator |
| Tier 1 | In-Network (CIGNA) benefit level |
| Tier 2 | Out-of-Network benefit level |
| USPSTF | U.S. Preventive Services Task Force |
DOCUMENT REFERENCES
| Field | Information |
|---|---|
| Source Document | 90 Degree Benefits 2 Tier Install Plan Document |
| Effective Date | October 1, 2026 |
| Complete Plan Information | See Plan Document/Summary Plan Description |
| Precertification List | See CIGNA Precertification list |
END OF BENEFITS GUIDE
This document summarizes the Five Star Technology Solutions HDHP PPO Install Plan Document. For official plan administration, claims processing, appeals, and complete legal language, refer to the official Plan Document/Summary Plan Description.
Document prepared for: HubSpot Knowledge Base
For use by: Support Team and AI Assistant
Last updated: Based on Install Plan Document effective October 1, 2026