Page 3 - Artemis 2021 Employee Benefits

Artemis Health
2021 Employee Benefits Brochure

Medical Plans

Cigna H.S.A. High Deductible Medical Plan

In- Network Out-of-Network
Deductible:
Individual
$2,000 $4,000
Family
$4,000 $8,000
(Combined Medical and Pharmacy)
Out-of-Pocket Limit:
Individual $4,000
Family $8,000
(Combined Medical and Pharmacy) $7,350 $16,000

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

Physician Services:
Office Visit (PCP/Specialist) 20% after deductible 50% after deductible
Pre-Natal Maternity See Benefit Summary See Benefit Summary
Diagnostic Lab & X-Ray 20% after deductible 50% after deductible
Imaging (CT/PET scans, MRIs) 20% after deductible 50% after deductible
Urgent Care 20% after deductible 50% after deductible
Chiropractic Care (20 visits) 20% after deductible 50% after deductible

Routine Care:
Preventative Checkups No Charge 50% after deductible

Prescription Drugs: (after deductible)

Retail / Mail Order
Generic $25 / $63 Retail / Mail Order
Not covered
Preferred Brand $50 / $125
Not covered
Non-Preferred Brand $100/ $250 Not covered
Specialty 50% up to $400 max/ 50% up to $400 max 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 Oder Rx: Up to a 90-day supply from Cigna 90 Now Program RX Home Delivery
(except Specialty up to 30-day supply)

Only certain Prescription Drugs available through mail order, please visit www.myCigna.com or call Customer Care.
H.S.A- Health savings account is a tax-exempt savings account that, when paired with a qualified high-
deductible plan (HDHP), can be used to pay for certain medical expenses.

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