Page 4 - Artemis Brochure 2021_Updated Feb 2021

Artemis Health

2021 Employee Benefits Brochure

Medical Plans

Cigna PPO Medical Plan

In-Network Out-of-Network

Deductible:
Individual $500 $5,000
Family $1,000 $10,000

Out-of-Pocket Limit:
Individual $5,500 $10,000
Family $11,000 $20,000

Hospital Services:
Inpatient 20% after deductible 50% after deductible
Outpatient Surgery 20% after deductible 50% after deductible
Emergency Room $300 $300

Physician Services:
Office Visit (PCP/Specialist) $30 / $60 50% after deductible
Pre-Natal Maternity See Benefit See Benefit
Diagnostic Lab & X-Ray Summary No Charge Summary 50% after
Imaging (CT/PET scans, $250 deductible
MRIs) Urgent Care $75 50% after deductible
Chiropractic Care (20 visits) $30 50% after deductible

Routine Care:
Preventative Checkups No Charge 50% after

Prescription Drugs: Retail / Mail Order Retail / Mail Order
Generic $15 / $38 Not covered
Preferred Brand $35 / $88 Not covered
Non-Preferred Brand $65 / $163 Not covered
Specialty $100 / $100 Not covered
DME (Durable Medical Equipment) 20% after deductible 50% after deductible

Retail Rx: Up to a 30-day supply from In-Network Retail Pharmacies
Mail Order Up to a 90-day supply from Cigna 90 Now Program RX Home Delivery
(except Specialty up to 30-day supply)

Only certain Prescription Drug Products are available through mail order, please visit www.myCigna.com or call Customer

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