Page 5 - 2022 Iodine Software Benefit Guide

Medical and pharmacy coverage

Medical Plan Provider Information
Cigna
Claims, Benefits: www.cigna.com
Network: Open Access Plus
Customer Service: 866-494-2111
Group No.: 0629062

HDHP w/HSA Base Plan Buy-Up Plan
Medical Plan Provisions In-Network Benefits In-Network Benefits In-Network Benefits

Company contribution to HSA
(Individual/Family) $1,200/$1,200 N/A N/A
Annual Deductible $3,000/$6,000 $1,000/$2,000 $500/$1,000
(Individual/Family)

Out-of-Pocket Maximum $3,000/$6,000 $4,000/$8,000 $4,000/$8,000
(Includes Deductible)
Preventive Care Covered at 100% Covered at 100% Covered at 100%

Primary Care Provider Office Visit 100% after deductible $25 copay $35 copay
Specialist Office Visit 100% after deductible $40 copay $60 copay
Telehealth / Virtual Visit 100% after deductible $25 copay $35 copay

Fertility $20,000 benefit $20,000 benefit $20,000 benefit
12 visits 12 visits 12 visits
Acupuncture
(covered under Specialty) (covered under Specialty) (covered under Specialty)
X-Ray and Lab 100% after deductible 100% 100%
Inpatient Hospital Services 100% after deductible 80% after deductible 80% after deductible
Outpatient Hospital Services 100% after deductible 80% after deductible 80% after deductible

Urgent Care 100% after deductible $100 copay $100 copay
Emergency Room 100% after deductible 80% after $400 copay 80% after $400 copay
Retail Pharmacy (up to a 31-day supply)

Level 1 100% after deductible $10 copay $10 copay
Level 2 100% after deductible $30 copay $30 copay

Level 3 100% after deductible $50 copay $50 copay
Level 4 100% after deductible 25% 25%

Specialty 100% after deductible 35% 35%
Mail Order (90-day supply) 2.5x retail copay 2.5x retail copay 2.5x retail copay

Please review your plan document for an exact description of the services and supplies that are covered, those which are excluded or limited,
and other terms and conditions of coverage.

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