Five Star Technology Solutions - High PPO - 10.1.26

Plan Identification & Status

Field	Details
Company Name	Five Star Technology Solutions
Plan Name	High PPO
Master Group Number	64800
Subgroup Numbers	64810 (Tier 1 / In-Network); 64811 (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	No
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

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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
Reference-Based Pricing (RBP)	Yes - Out-of-Network (Tier 2) claims
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 ($25 per consult)
Pace Program	Yes
A&G / Patient Defender / CareConnect	No
Benchmark State	Utah

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MEDICAL DEDUCTIBLES

Annual Calendar Year Deductibles

Coverage Level	In-Network Providers	Out-of-Network Providers
Per Person	$5,000	$10,000
Per Family	$10,000	$20,000

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	NO - Co-payments/Coinsurance apply

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COINSURANCE (PLAN PAYMENT PERCENTAGE)

Network	Plan Pays After Deductible	Applied To
In-Network Providers (Tier 1)	80%	Unless otherwise stated
Out-of-Network Providers (Tier 2)	50%	Unless otherwise stated

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OUT-OF-POCKET MAXIMUMS

Annual Calendar Year Out-of-Pocket Maximums

Coverage Level	In-Network Providers	Out-of-Network Providers
Per Person	$7,000	$14,000
Per Family	$14,000	$28,000

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

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MEDICAL CO-PAYMENTS

In-Network Co-payment Summary

Service Type	In-Network Co-payment	Deductible	How Applied
Primary Care Office Visit	$0	Waived	Per day / per provider
Specialist Office Visit	$50	Waived	Per day / per provider
Chiropractic, PT, OT, Speech Therapy	$50	Waived	Per visit
Other Rehabilitative/Habilitative Services (ABA, cardiac, pulmonary, cognitive rehab)	$50	Waived	Per visit
Major Diagnostic Imaging - Office/Freestanding Facility	$60	Waived	Per day / per provider
Ambulatory Surgical Center	$100 flat	Waived	Per day / per provider
Outpatient Hospital Surgery	$250, then 80%	Applies	Per day / per provider
Outpatient Hospital Lab, X-ray and Imaging (including MRI, CT, PET)	$250, then 80%	Applies	Per day / per provider
Urgent Care	$75, then 100%	Waived	Per day / per provider
Emergency Room (Facility)	$400, then 80%	Applies	Per visit; waived if admitted within 24 hours
Inpatient Hospital Admission	$500, then 80%	Applies	Per admission
Skilled Nursing / Extended Care Facility	$500, then 80%	Applies	Per admission
Mental Health/Substance Use Residential Treatment	$500, then 80%	Applies	Per admission
Transplant Facility (Recipient)	$500, then 80%	Applies	Per admission
Teladoc Consult	$25	N/A	Per consult

Note: Co-payments apply to In-Network (Tier 1) services only unless stated otherwise. Out-of-Network (Tier 2) services are generally subject to the Out-of-Network Deductible, then paid at 50%.

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PRESCRIPTION DRUG BENEFITS

Prescription Drug Structure

Feature	Details
Administrator (PBM)	DREXI
Prescription Drugs Covered Under	Drug Plan
Subject to Deductible	NO
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	$15 Co-payment per prescription
Preferred Brand Name Drug	$60 Co-payment per prescription
Non-Preferred Brand Name Drug	$100 Co-payment per prescription
Specialty Drug	25% Coinsurance up to a $300 maximum

Mail Order Pharmacy - Up to 90 Day Supply

Drug Type	Your Cost
Generic Drug	$37.50 Co-payment per prescription
Preferred Brand Name Drug	$150 Co-payment per prescription
Non-Preferred Brand Name Drug	$250 Co-payment per prescription
Specialty Drug	25% Coinsurance up to a $300 maximum (retail)

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

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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

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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)

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PHYSICIAN & OFFICE SERVICES

Office Visits and Office-Based Services

Service	In-Network Coverage	Out-of-Network Coverage	Special Notes
Medical Office Visit - Primary Care	$0 Co-payment per visit, then 100% (Deductible waived)	50% (after Deductible)	Co-pay applied per day / per provider
Medical Office Visit - Specialist	$50 Co-payment per visit, then 100% (Deductible waived)	50% (after Deductible)	Co-pay applied per day / per provider
Therapeutic Injections (Office)	Primary Care: $0 Co-payment; Specialist: $50 Co-payment; then 100% (Deductible waived)	50% (after Deductible)	Co-pay applied per day / per provider
Office X-ray & Professional Component	Primary Care: $0 Co-payment; Specialist: $50 Co-payment; then 100% (Deductible waived)	50% (after Deductible)	In-Network does NOT include high-cost imaging (MRI, CT, PET) - see Diagnostic Services
Office Laboratory & Professional Component	Primary Care: $0 Co-payment; Specialist: $50 Co-payment; then 100% (Deductible waived)	50% (after Deductible)	Co-pay applied per day / per provider
Office Diagnostic Testing	Primary Care: $0 Co-payment; Specialist: $50 Co-payment; then 100% (Deductible waived)	50% (after Deductible)	Co-pay applied per day / per provider
All Other Office Related Services	Primary Care: $0 Co-payment; Specialist: $50 Co-payment; then 100% (Deductible waived)	50% (after Deductible)	Co-pay applied per day / per provider
Office Surgery (includes related anesthesia)	80% (after Deductible)	50% (after Deductible)	None specified
Allergy Injections and Serum	80% (after Deductible)	50% (after Deductible)	None specified
Allergy Testing	80% (after Deductible)	50% (after Deductible)	None specified
Independent Laboratory & Professional Component	80% (after Deductible)	50% (after Deductible)	None specified
Second Surgical Opinion	100%	50% (after Deductible)	None specified

Telemedicine

Service	Coverage Status	Special Notes
Telemedicine - Patient to Physician (telephone and internet)	COVERED	Paid under Medical Office Visit benefit
Teladoc	COVERED	Separate benefit from medical; $25 per consult
Telemedicine - Physician to Physician	NOT COVERED	Excluded

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DIAGNOSTIC SERVICES

Service	In-Network Coverage	Out-of-Network Coverage
Major Diagnostic Procedures - Office / Freestanding Facility (MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans)	$60 Co-payment, then 100% (Deductible waived)	50% (after Deductible)
Major Diagnostic Procedures - Outpatient Hospital (MRI, PET, CT, Nuclear Medicine, Myelogram, Cardiac Stress Test, Bone Scans)	Deductible, then $250 Co-payment per visit, then 80%	50% (after Deductible)
Lab, X-ray, and Diagnostic Imaging including Ultrasound (Outpatient hospital facility setting)	Deductible, then $250 Co-payment per visit, then 80%	50% (after Deductible)
Sleep Studies	80% (after Deductible)	50% (after Deductible)

Note: High-cost imaging at a freestanding or office setting costs the member a $60 co-pay with the Deductible waived. The same imaging at an outpatient hospital is subject to the Deductible, then a $250 co-pay, then 80%.

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EMERGENCY & URGENT CARE

Service	In-Network Coverage	Out-of-Network Coverage	Special Notes
Emergency Room - Hospital Facility	Deductible, then $400 Co-payment per visit, then 80%	Deductible, then $400 Co-payment per visit, then 80% (In-Network level)	Co-pay waived if admitted within 24 hours; Out-of-Network claims apply to In-Network Deductible/OOPM accumulators
Emergency Room - Professional Services	80% (after Deductible)	80% (after In-Network Deductible)	All emergency services paid at In-Network level; Out-of-Network claims apply to In-Network accumulators
Ambulance (ground and air)	80% (after Deductible)	80% (after In-Network Deductible)	Includes facility-to-facility transport when medically necessary; Out-of-Network applies to In-Network accumulators
Urgent Care Services (includes all related services)	$75 Co-payment per visit, then 100% (Deductible waived)	50% (after Deductible)	Co-pay applied per day / per provider

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HOSPITAL SERVICES - INPATIENT

Inpatient Requirements and Co-payments

Requirement/Feature	Details
Inpatient Hospital Co-payment	In-Network: Deductible, then $500 per admission, then 80%
Precertification Penalty Waived for Emergency Admissions	NO
ER Co-pay Waived if Admitted Through ER	YES
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.)	Deductible, then $500 Co-payment per admission, then 80%	50% (after Deductible)	None specified
Ancillary (All Other Inpatient) Services	80% (after Deductible)	50% (after Deductible)	None specified
Anesthesia	80% (after Deductible)	50% (after Deductible)	None specified
Surgeon / Assistant Surgeon / Co-Surgeon	80% (after Deductible)	50% (after Deductible)	Assistant Surgeon limited to 25% of the Usual and Customary fee for the procedure
Maternity Surgery (includes physician attendance)	80% (after Deductible)	50% (after Deductible)	See Maternity section

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HOSPITAL SERVICES - OUTPATIENT

Service	In-Network Coverage	Out-of-Network Coverage	Special Notes
Ambulatory Surgical Center	$100 Co-payment, then 100% (Deductible waived)	50% (after Deductible)	$100 flat co-pay per day / per provider
Outpatient Hospital Surgery	Deductible, then $250 Co-payment per visit, then 80%	50% (after Deductible)	Co-pay applied per day / per provider
Outpatient Hospital Services (unless otherwise specified)	80% (after Deductible)	50% (after Deductible)	None specified
Outpatient Physician Services (unless otherwise specified)	80% (after Deductible)	50% (after Deductible)	None specified
Infusion Therapy	80% (after Deductible)	50% (after Deductible)	None specified
Dialysis	80% (after Deductible)	50% (after Deductible)	None specified
Chemotherapy / Radiation Therapy (Professional and Facility)	80% (after Deductible)	50% (after Deductible)	None specified

Note: Outpatient surgery at an Ambulatory Surgical Center is a $100 flat co-pay with the Deductible waived. The same surgery at an outpatient hospital is subject to the Deductible, then a $250 co-pay, then 80%.

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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

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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	Special Notes
Office Visits	Paid under Medical Office Visit benefit	50% (after Deductible)	See Physician & Office Services
Inpatient Hospitalization	Deductible, then $500 Co-payment per admission, then 80%	50% (after Deductible)	Paid as Inpatient Facility Services
Residential Treatment Center	Deductible, then $500 Co-payment per admission, then 80%	50% (after Deductible)	None specified
Outpatient Facility Treatment (Partial Hospitalization, Day Treatment, Intensive Outpatient)	100% (Deductible waived) - no charge	50% (after Deductible)	None specified

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

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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	Listed as EXCLUDED in the plan's miscellaneous exclusions; the maternity section states abortion coverage (elective, rape/incest, life of mother) is based on applicable state law
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

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THERAPY & REHABILITATION SERVICES

Service	In-Network Coverage	Out-of-Network Coverage	Visit Limits	Special Notes
Physical Therapy	$50 Co-payment per visit, then 100% (Deductible waived)	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	$50 Co-payment per visit, then 100% (Deductible waived)	50% (after Deductible)	Up to 20 visits per Calendar Year	Includes massage therapy performed by a covered provider; separate from PT limit
Speech Therapy	$50 Co-payment per visit, then 100% (Deductible waived)	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)	$50 Co-payment per visit, then 100% (Deductible waived)	50% (after Deductible)	No maximum indicated	None specified
Chiropractic Services	$50 Co-payment per visit, then 100% (Deductible waived)	50% (after Deductible)	Up to 20 visits per Calendar Year	Co-pay applied per day / per provider

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.

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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)	Deductible, then $500 Co-payment per admission, then 80%	50% (after Deductible)	Up to 60 days per Calendar Year	None specified
Home Health Care	80% (after Deductible)	50% (after Deductible)	Up to 60 visits per Calendar Year	None specified
Hospice Care	80% (after Deductible)	50% (after Deductible)	No day maximum	Custodial/respite care allowed and included in Hospice benefit
Bereavement Counseling	80%	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: 80% (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: 80% (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: Deductible, then $500 Co-payment per admission, then 80%; 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	80% (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

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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

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VISION & HEARING

Service	Coverage Status	Special Notes
Medical Eye Exams and Glaucoma Testing	COVERED under medical	Paid under applicable medical benefit
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

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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 (see Maternity section regarding state law)	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.

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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.

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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

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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

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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

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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

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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
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

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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 High 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