Page 5 - Cytokinetics 2022 Benefits Guide

Medical and pharmacy coverage

Cigna OAP/PPO Cigna HDHP/HSA Kaiser HMO
Medical Plan Provisions In-Network Out-of-Network¹ In-Network Out-of-Network³ In-Network

Cytokinetics contribution to
HSA (Individual/Family) N/A $1,400/$2,800 N/A
Annual Deductible
(Individual/Family) $100/$200 $200/$400 $2,800/$5,600 $5,000/$10,000 None
Annual Out-of-Pocket
Maximum (Includes Deductible) $1,500/$3,000 $3,000/$6,000 $3,000/$6,000 $7,500/$15,000 $1,500/$3,000

Preventive Care Covered at 100% 30%* Covered at 100% 30%* Covered at 100%
Primary Care Provider $20 copay* 30%² 10%* 30%* $10 copay*
Office Visit

Specialist Office Visit $30 copay* 30%² 10%* 30%* $10 copay*
X-Ray and Lab 10%* 30%* 10%* 30%* Covered at 100%
Inpatient Hospital Services 10%* 30%* 10%* 30%* Covered at 100%
$10 copay*/
Outpatient Hospital Services 10%* 30%* 10%* 30%*
procedure
Urgent Care $35* 30%* 10%* 30%* 10%*
Emergency Room $150 copay + 10%* 10%* $50 copay*/visit
Retail Pharmacy (up to a 30-day supply)

Generic $10 copay* Not covered $10 copay* Not covered $10 copay*
Brand Preferred $30 copay* Not covered $30 copay* Not covered $20 copay*
Brand Non-Preferred $50 copay* Not covered $50 copay* Not covered $20 copay*

Specialty 20%* (up to $200) Not covered 20%* (up to $200) Not covered N/A
Mail Order Pharmacy (90-day supply)
Generic $20 copay* Not covered $20 copay* Not covered $10 copay*

Brand Preferred $60 copay* Not covered $60 copay* Not covered $20 copay*
Brand Non-Preferred $100 copay* Not covered $100 copay* Not covered $20 copay*
Specialty (30 days only) 20%* (up to $200) Not covered 20%* (up to $200) Not covered N/A
*After deductible
¹Out-of-Network services are paid at a percentage of Medicare – professional 180%, facility 225%
²Coinsurance applies after the calendar year deductible is satisfied
³HDHP HSA Out-of-Network services are paid at a percentage of Medicare – professional 105%, facility 140%
Pharmacy formularies are adjusted on a regular basis, please check the carriers’ websites for updates

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