Page 7 - 2018 MDHA Enrollment

Metropolitan Development and Housing Agency

Plan Details

In-Network Out-of-Network Semi-Monthly Pre-Tax
Calendar Year Deductible Contributions
Individual $2,000 $6,000 Employee Only $69.08*
Family $4,000 $12,000 Employee + Spouse $177.10*
MDHA Funded HRA Employee + Child or $160.60*
Individual $1,250 Children
Family $2,500 Family $251.34*
Out-of-Pocket Maximum * $6.10 semi-monthly discount given if
Individual $5,500 $16,500 your annual physical has been completed
(annual savings of $146.40)
Family $11,000 $33,000
Physician Ofice Visits
Primary Care 20% coinsurance after 40% coinsurance after
deductible deductible
Specialist 20% coinsurance after 40% coinsurance after
deductible deductible
Preventive
100% no deductible 40% coinsurance
Urgent Care
$50 copay $50 copay
Hospital Services
Inpatient 20% coinsurance after 40% coinsurance after
deductible deductible
Outpatient 20% coinsurance after 40% coinsurance after
deductible deductible
Emergency Room $250 copay $250 copay
Chiropractic Care
Limited to 20 Visits 20% coinsurance after 40% coinsurance after
per Calendar Year deductible deductible
Prescription Drugs*

Retail—30-Day Supply Home Delivery—90-Day
Supply
Preventive Generic No charge No charge
Generic $20 copay $60 copay
Preferred Brand $75 copay $225 copay
Non-Preferred $100 copay $300 copay
Brand

* Please refer to the Cigna 2018 formulary for step therapy, prior authorization, quantity limits,
and specialty drug requirements.
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.

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