Page 7 - Interior Architects-2022-23-Benefit Guide

Medical and Pharmacy Coverage

Cigna EPO Kaiser CA HMO
Medical Plan Provisions In-Network Only In-Network Only

Calendar Year Deductible None None
(Individual/Family)
Calendar Year Out-of-Pocket Maximum
(Includes Deductible) $3,000/$6,000 $1,500/$3,000
Preventive Care Covered at 100% Covered at 100%
Primary Care Provider Office Visit $20 copay $20 copay
Specialist Office Visit $40 copay $20 copay
Telemedicine $20 copay Covered at 100%
X-Ray and Lab $20 copay Covered at 100%

Inpatient Hospital Services $250 copay $250 copay
Outpatient Hospital Services $125 copay $20 copay
Urgent Care $35 copay $20 copay
$100 per visit $150 copay
Emergency Room
(copay waived if admitted) (copay waived if admitted)
Chiropractic (20-40 visits per year) $15 copay $15 copay
Acupuncture (20-40 visits per year) $15 copay $15 copay
Hearing Aid Coverage Covered at 100% up to $5,000/year Covered at 100% up to $5,000/year
Retail Pharmacy (up to a 30-day supply with Kaiser & a 90-day supply with Cigna)

Tier 1 – Generic $15 copay $15 copay
Tier 2 – Brand Preferred $30 copay $35 copay
Tier 3 – Brand Non-Preferred $50 copay $35 copay
Tier 4 – Specialty 20% up to a maximum of $200 $35 copay
Mail Order Pharmacy (90-day supply)

Tier 1 – Generic $30 copay $30 copay
Tier 2 – Brand Preferred $60 copay $70 copay
Tier 3 – Brand Non-Preferred $100 copay $70 copay
Tier 4 – Specialty 20% up to a maximum of $200 Not covered

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