Medical Benefits

Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family.

Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please www.cigna.com.

Cigna Network	Buy-Up PPO $250	HSA $3,400	Base PPO $3,250
HSA Eligible?	NO	YES and Employer Contribution	NO
Deductible (Individual/Family)	$250 / $500	$3,400 / $6,800	$3,250 / $6,500
Member Coinsurance (Your Share)	20%	0%	0%
Out-of-Pocket Max (Individual/Family)	$1,250 / $2,500	$3,400 / $6,800	$3,250 / $6,500
Physician Visits
Primary Care Office Visit	$25 Copay	0% after Deductible	$30 Copay
Preventive Care	100%	100%	100%
Specialist Visit	$45 Copay	0% after Deductible	$50 Copay
Hospital Services
Inpatient/Outpatient Services	20% after Deductible	0% after Deductible	0% after Deductible
Basic Outpatient Diagnostics	20% after Deductible	0% after Deductible	0% after Deductible
Urgent Care	$45 Copay	0% after Deductible	$50 Copay
Emergency Room	20% after Deductible	0% after Deductible	$400 Copay
Prescriptions
Retail	$10 / $35 / $75	0% after Deductible	$10 / $35 / $75
Specialty Rx	MAM (Manufacturer Assistance Program) PAP (Patient Assistance Program) ASP (Average Sales Price)	MAM (Manufacturer Assistance Program) PAP (Patient Assistance Program) ASP (Average Sales Price)	MAM (Manufacturer Assistance Program) PAP (Patient Assistance Program) ASP (Average Sales Price)


*HSA plan participants are responsible for paying 100% of medical costs until the plan’s deductible is met. Once the deductible is met, all subsequent expenses will be covered in full by Cigna.


Participants in an HSA plan will receive a $50 per month contribution from DCA into a Health Savings Account (HSA).

Full-Time Employee Rates Per Pay Period (26)	Buy-Up PPO $250	HSA $3,400	Base PPO $3,250
Employee Only	$141.90	$54.67	$98.52
Employee + Spouse	$417.25	$294.57	$355.32
Employee + Child(ren)	$390.23	$260.91	$305.10
Family	$723.10	$570.45	$680.76


This is a brief outline of your benefits, showing *in-network benefits only.*
Dependents are covered until the end of the calendar year in which they turn age 26.
Employees who are or reach the age of 65 may continue to be enrolled in benefits. See “Miller Milestones” on page 16 of your brochure for more information.