Page 6 - 2022 Intapp Benefits Guide

Medical and pharmacy coverage

Kaiser Cigna OAP Cigna HDHP Kaiser HDHP
HMO 30 (PPO) w/HSA w/HSA 2
Medical Plan Provisions In-Network In-Network Out-of-Network In-Network Out-of-Network In-Network
Only CA
Only CA
Company contribution to HSA N/A N/A $2,000/$3,000 $2,000/$3,000
(Individual/Family)
Annual Deductible $2,000/$2,800/ $5,000/$7,000/
(Individual/Individual in a family/ None $300/$600 $600/$1,200 $2,800 $7,000 $2,800/$5,600
Family)
Out-of-Pocket Maximum $1,500/$3,000 $3,000/$6,000 $6,000/$12,000 $3,275/$5,600/ $6,550/$11,200/ $2,800/$5,600
(Includes Deductible) $6,550 $13,100
You pay You pay You pay You pay
Preventive Care Covered in full Covered in full 30% 3 Covered in full 40% 3 Covered in full
Primary Care Provider $30 copay $20 copay 30% 3 10% 3 40% 3 0% 3
Office Visit

Specialist Office Visit $30 copay $20 copay 30% 3 10% 3 40% 3 0% 3
Covered
X-Ray and Lab 10% 3 30% 3 10% 3 40% 3 0% 3
in full
Inpatient Hospital Services $500 per admit 10% 3 30% 3 10% 3 40% 3 0% 3
$30 per
Outpatient Hospital Services 10% 3 30% 3 10% 3 40% 3 0% 3
procedure
$75 per visit
Urgent Care $30 copay 30% 3 10% 3 40% 3 0% 3
and 10%
Emergency Room $100 copay $150 copay 10% 3 0% 3
(copay waived if admitted)
Chiropractic Not covered $20 copay 30% 3 10% 3 40% 3 Not covered
(25 visits per year)
Prescription Drug Coverage
Retail Pharmacy (up to a 30-day supply)
Generic $15 copay $10 copay Not covered $10 copay 3 Not covered No charge 3
Brand Preferred $35 copay $30 copay Not covered $30 copay 3 Not covered No charge 3
Brand Non-Preferred $50 copay Not covered $50 copay 3 Not covered
Specialty $35 copay NA Not covered NA Not covered No charge 3

Mail Order Pharmacy (90-day supply)
Generic $15 copay $30 copay Not covered $30 copay 3 Not covered No charge 3
Brand Preferred $35 copay $90 copay Not covered $90 copay 3 Not covered No charge 3

Brand Non-Preferred $150 copay Not covered $150 copay 3 Not covered
Specialty $35 copay N/A Not covered N/A Not covered No charge 3
2 Kaiser has an embedded deductible which means once a single member in a family meets the individual deductible of $2,800, insurance covers at a 100% for that person.
3 Subject to the calendar year deductible
*Out-of-Network benefits are paid based on 110% of Medicare

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