Page 7 - QSC Benefits Guide 7-17 SLO

MEDICAL INSURANCE

Option 1 - HMO

With the Maintenance Organization (HMO) plan, you must choose a Primary Care Physician (PCP) or medical group within
the Cigna So CA HMO Network for all of your covered family members. All of your care must be directed through your PCP
or medical group. Any specialty care you need will be coordinated through your PCP and will generally require a referral or
authorization. You will receive benefits only if you use the doctors, clinics, and hospitals that belong to the medical group in
which you are enrolled, except in the case of an emergency.

Option 2 - PPO (OAP)
With the Preferred Provider Organization (PPO) option through Cigna, you have the freedom to choose your doctor without using a
primary care physician (PCP) and you may self-refer to specialists. You may use a PPO provider whose negotiated rates provide richer
levels of benefits with claim forms filed by the providers. You may also obtain services using a non-network provider; however, you will
be responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims.

Option 3 - HSA PPO (Choice Fund OAP)
The Health Savings Account (HSA) plan through Cigna combines a high deductible health plan (HDHP) with a special, tax-qualified
savings account. You may use your HSA funds to pay for current medical expenses or save toward future medical expenses.
Similar to the PPO plan, you have the freedom to choose your doctor without the requirement of selecting a PCP and you may
self-refer to specialists. You may use a PPO provider whose negotiated rates provide richer levels of benefits with claim forms filed
by the providers. You may also obtain services using a non-network provider; however, you will be responsible for the difference
between the covered amount and the actual charges and you may be responsible for filing claims. QSC will make an annual
contribution toward your employee/family health savings account, funded biweekly. In addition to the company contributions,
you may elect to make contributions into your account up to the IRS maximums. See page 10 for additional information.

Plan Features HMO OAP PPO HSA PPO

Employee Premiums $$ $$$ $
Health Savings Account
Employer Funding P
Employee Funding P
Cost Sharing Contribution, Copay Contribution, Copay, Contribution, Copay,
Deductible, Coinsurance Deductible, Coinsurance
Network Size AA AAA AAA
In-Network Benefits P P P
Non-Network Benefits P P
Preventive Care 100% 100% (Ded Waived) 100% (Ded Waived)
(in-network)
Access to Providers Managed by Your PCP Managed by You Managed by You
Primary Care Physician Required Not Required Not Required
Referral for Specialist Required Not Required Not Required

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