DPS MEDICAL PLAN BENEFIT SUMMARIES

FOR 2011-12

Changes in coverage from 2010-11 plans. The following charts provide only a brief description of services covered under your plan and does not list those services which are limited or excluded from coverage. Your Employee Benefit Booklet provides a more complete explanation of your coverage, including limitations and exclusions. If differences exist between this Summary of Benefits and your Employee Benefit Booklet, the Benefit Booklet will govern.

Benefit Component / Kaiser DHMO
Low Plan / Kaiser HMO
High Plan / CIGNA Select
Low Plan / CIGNA Select
High Plan / CIGNA POS Plan
In-Network Out-Of-Network
PCP Required? / Yes / Yes / Yes / Yes / Yes / No
Hospitals & Pharmacies Available / Network Only / Network Only / Network Only (Colorado Select) Limited Specialist Network / Network Only
(Colorado Select) Limited Specialist Network / Network Only
(Colorado Network) / Any
Deductible (plan year 7/1 – 6/30) / $1,000 individual
$2,000 family / N/A / $1,500 individual
$3,000 family / $500 individual
$1,000 family / $1,000 individual
$2,000 family
Out-of-Pocket Maximum – there are limitations on which services count towards the OOP, please refer to your actual plan documents for details / $3,000individual
$6,000 family
(Deductible/Copay not included in OOP maximum) / $2,500 individual
$5,000 family / $3,000 individual
$6,000 family
(Deductible/Copay not included in OOP maximum) / $2,500 individual $7,500 family / $2,500 individual $5,000 family / $6,500 individual $13,000 family
Physician Services
PCP
Specialist
Child/Adult
Preventative
Maternity Care / $25 copay
$50 copay
No charge
$25 copay / $25 copay
$45 copay
$15 copay
$25 copay / $25 copay
$50 copay
Covered at 100%
$25 copay / $25 copay
$45 copay
Covered at 100%
$25 copay / $25 copay
$25 copay
Covered at 100%
$25 copay / Ded., 40%
Ded., 40%
Child: ded., 40%
Adult: Not covered
40% after deductible
Hospital Services
Inpatient
Outpatient
Emergency Room
Urgent Care / Ded., 30%
Ded., 30%
$150 copay per visit
$75 copay / $500 copay
$250 copay
$250 copay per visit
$75 copay / Ded., 30%
Ded., 30%
$150 copay per visit
$50 copay / Ded., $500 copay
Ded., $250 copay
$250 copay per visit
$50 copay / Ded., 20%
Ded., 20%
$100 copay per visit
$50 copay / Ded., 40%
Ded., 40%
$100 copay per visit
$50 copay
Diagnostics
Lab/X-Ray
High Tech Svcs. (MRI, CT scans,
etc.) / No charge
$100 copay / No charge
$100 copay / No charge
$100 copay / No charge
$100 copay / No charge
Inpat: Ded., 20%
Outpat: $75 copay then Ded., 20% / Ded., 40%
$150 copay then Ded.. 40%
Prescriptions (30 day)
Generic
Brand (Formulary, 3-tier)
Non-formulary Brand
Specialty Drugs
Mail Order (90-day supply) / $20 copay
$40 copay
$60 copay
20%; up to $250/script
2x retail copay / $10 copay
$30 copay
$50 copay
20%; up to $250/script
2x retail copay / $15 copay
$40 copay
$80 copay
20%; up to $100/script
2x retail copay / $15 copay
$30 copay
$80 copay
20%; up to $100/script
2x retail copay / $15 copay
$40 copay
$60 copay
N/A
2x retail copay / Not covered
Not covered
Not covered
Benefit Component / Kaiser HMO
Low Plan / Kaiser HMO
High Plan / CIGNA Select
Low Plan / CIGNA Select
High Plan / CIGNA POS Plan
In-Network Out-Of-Network
Therapies
Mental Health Outpatient,
Physical, Occupational & Speech
Therapy (outpatient)
Chiropractic Care / $25 copay; 20 visit max for each type of therapy
Not Covered / $25 copay; 20 visit max for each type of therapy per plan year
$25 copay; 20 visit max for each type of therapy per plan year / $25/$50 copay; 60 visit max for all therapies combined
$25/50 copay; 60 visit max for all therapies combined / $25/$45 copay; 60 visit max for all therapies combined
$25/$45 copay; 60 visits max for all therapies combined / $25 copay; 60 visit max for all therapies combined
$25 copay; 60 visit max for all therapies combined / Ded., 40%, 60 visit max for all therapies combined in and out-of-network
Ded., 40%, 60 visit max for all therapies combined in and out-of-network
Vision
Refractive Exam / $25 copay / $25 copay / Not covered / Not covered / Not covered / Not covered
Lifetime Maximum / Unlimited / Unlimited / Unlimited / Unlimited / Unlimited / Unlimited

DPS DENTAL PLAN SUMMARIES

FOR 2011-12

No coverage changes

The following charts provide only a brief description of services covered under your plan and does not list those services which are limited or excluded from coverage. Your Employee Benefit Booklet provides a more complete explanation of your coverage, including limitations and exclusions. If differences exist between this Summary of Benefits and your Employee Benefit Booklet, the Benefit Booklet will govern.

Benefit Component / Delta Dental
PPO Plus Premier Plan (added PPO network to the Premier plan) / Delta Dental
EPO Plan /
Network Dentist Selection Required? / No, but less out-of-pocket costs when using a Delta Dental PPO or Premier participating dentist. Patients receiving services of a dentist not participating with Delta will be responsible for charges in excess of Maximum Plan Allowances / Yes, to receive the benefits.
No benefits outside the PPO network.
Deductible / $50 per person/Maximum of 3 per family per calendar year / No
Maximum Annual Benefits / $1500 / None
Orthodontic Max. Benefit / $1000 lifetime / N/A
Diagnostic and Preventative Services / 0%, deductible waived, includes exams, cleanings, X-Rays, Sealants, Fluoride Treatment / Exam: $10
Cleaning: No Cost
X-Rays: No Cost
Restorative Services / 20% after deductible (includes fillings) / Fillings: $21 to $73
Root Canals: $110 to $297
Oral Surgery: $22 to $100
Gum Surgery: $24 - $284
Major Services / 50% after deductible (includes bridges, crowns, dentures, extractions, root canals, gum surgery, dental implants). Patients receiving services of a dentist not participating with Delta will be responsible for charges in excess of Maximum Plan Allowances. / Crowns: $161 to $280
Dentures: $349 to $377
Orthodontics / 50% / Orthodontics Adult:
$935 to $2230
Orthodontics Child:
$600 to $2030


DPS VISION PLAN SUMMARY FOR 2011-12

No coverage changes

The following charts provide only a brief description of services covered under your plan and does not list those services which are limited or excluded from coverage. Your Employee Benefit Booklet provides a more complete explanation of your coverage, including limitations and exclusions. If differences exist between this Summary of Benefits and your Employee Benefit Booklet, the Benefit Booklet will govern.

Benefit Component / In Network / Out of Network
Benefit Frequency
(Exam, Lenses, Frames / Once every 12 months / Once every 12 months
Exams / Employee – Covered in full
Dependent – Covered in full / Up to $30
Lenses / All single, lined bifocal, lined trifocal lenses covered in full / Single: Up to $30, Bifocal: Up to $40, Trifocal: Up to $50
Frames / $120 retail allowance / Up to $30
Elective Contacts / Up to $120 in lieu of glasses
Allowance includes contacts, contact lens exam (evaluation & fitting) / Up to $105 in lieu of glasses
Comments / 20% discount off of frame overages
30% discount on cosmetic options such as tints, coats and progressive lenses. 15% discount off of Doctors contact lens exam fees. / Patients receiving services from a non-participating vision provider will be responsible for charges in excess of plan allowances.

B:\Open Enrollment\Open Enrollment Actives 2010-11\DPS Plan Summaries for 2010-2011 All plans.doc Revised 4/2010