Page 8 - Interior Architects-2022-23-Benefit Guide

Medical and Pharmacy Coverage (continued)

Cigna PPO Cigna HDHP
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network
Employee: $750
IA contribution to HSA N/A Employee + 1: $1,000
Employee + Family: $1,500
$1,500/$3,000 $3,000/$4,000
Calendar Year Deductible ($2,800 ($3,000
(Individual/Family) $250/$750 $500/$1,500 for individual in for individual in
family plan) family plan)
Calendar Year Out-of-Pocket Maximum
(Includes Deductible) $2,000/$4,000 $4,500/$9,000 $3,000/$6,000 $9,000/$18,000
Preventive Care Covered at 100% 30%* Covered at 100% 30%*
Primary Care Provider Office Visit $20 copay 30%* 10%* 30%*
Specialist Office Visit $40 copay 30%* 10%* 30%*
$40 copay before
deductible is met;
Telemedicine $20 copay Not covered Not covered
10% after deductible
is met
X-Ray and Lab $20 copay 30%* 30%* 30%*
Inpatient Hospital Services $250 copay + 10%* 30%* 30%* 30%*
Outpatient Hospital Services 10%* 30%* 30%* 30%*
Urgent Care $35 copay 30%* 30%* 30%*
$100 copay, then 10%
Emergency Room 10%*
(copay waived if admitted)
Chiropractic (20-40 visits per year) $20 copay 30%* 10%* 30%*
Acupuncture (20-40 visits per year) $20 copay 30%* 10%* 30%*
10%* up to 10%* up to
Hearing Aid Coverage Not covered Not covered
$5,000/year $5,000/year
Retail Pharmacy (up to a 90-day supply)
Tier 1 – Generic $15 copay Not covered $10 copay* Not covered
Tier 2 – Brand Preferred $30 copay Not covered $20 copay* Not covered
Tier 3 – Brand Non-Preferred $50 copay Not covered $35 copay* Not covered
20% up to a 20% up to a
Tier 4 – Specialty Not covered Not covered
maximum of $200 maximum of $200*
Mail Order Pharmacy (90-day supply)
Tier 1 – Generic $30 copay Not covered $20 copay* Not covered

Tier 2 – Brand Preferred $60 copay Not covered $40 copay* Not covered
Tier 3 – Brand Non-Preferred $100 copay Not covered $70 copay* Not covered
20% up to a 20% up to a
Tier 4 – Specialty Not covered Not covered
maximum of $200 maximum of $200*
*After deductible

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