2-Attachment B 2025 McKinney Medical ET Rider Certificate.pdf

City of McKinney

EXTRATERRITORIAL LEGISLATION

EFFECTIVE DATE: January 1, 2025

ETALLM25A

3341054

This document printed in November, 2024 takes the place of any documents previously issued to you which described your benefits.

Printed in U.S.A.

Table of Contents

IMPORTANT INFORMATION

CERTIFICATE RIDER – Arkansas Residents CERTIFICATE RIDER – California Residents CERTIFICATE RIDER – Florida Residents CERTIFICATE RIDER – Illinois Residents CERTIFICATE RIDER – Kansas Residents CERTIFICATE RIDER – Kentucky Residents CERTIFICATE RIDER – Nevada Residents CERTIFICATE RIDER – New Mexico Residents CERTIFICATE RIDER – Oklahoma Residents CERTIFICATE RIDER – Pennsylvania Residents CERTIFICATE RIDER – Washington Residents myCigna.com4

CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER

Policyholder: City of McKinney Rider Eligibility: Each Employee as noted within this certificate rider Policy No. or Nos.: 3341054 Effective Date: January 1, 2025

This rider forms a part of the certificate issued to you by Cigna describing the benefits provided under the policy(ies) specified above. This rider replaces any other issued to you previously.

IMPORTANT INFORMATION

For Residents of States other than the State of Texas:

State-specific riders contain provisions that may add to or change your certificate provisions.

The provisions identified in your state-specific rider, attached, are ONLY applicable to Employees residing in that state. The state for which the rider is applicable is identified at the beginning of each state specific rider in the "Rider Eligibility" section.

Additionally, the provisions identified in each state-specific rider only apply to:

(a) Benefit plans made available to you and/or your Dependents by your Employer;

(b) Benefit plans for which you and/or your Dependents are eligible;

(c) Benefit plans which you have elected for you and/or your Dependents;

(d) Benefit plans which are currently effective for you and/or your Dependents.

Please refer to the Table of Contents for the state-specific rider that is applicable for your residence state.

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myCigna.com5

CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Arkansas Residents

Rider Eligibility: Each Employee who is located in Arkansas

You will become insured on the date you become eligible, including if you are not in Active Service on that date due to your health status.

This rider forms a part of the certificate issued to you by Cigna.

The provisions set forth in this rider comply with the legal requirements of Arkansas for group insurance plans covering insureds located in Arkansas. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

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Eligibility - Effective Date Dependent Insurance Exception for Newborns Any Dependent child born while you are insured will become insured on the date of his birth if you elect Dependent Insurance no later than 90 days after his birth or the next premium due date, whichever is later. If you do not elect to insure your newborn child within such 90 days or by the next premium due date, whichever is later, coverage for that child will end on the 90th day. No benefits for expenses incurred beyond the 90th day will be payable.

Exception for Adopted Children Any Dependent child adopted by you while you are insured will become insured from the date the adopted child is placed with you, or from the date you file the petition for adoption, if you elect Dependent Insurance no later than 90 days from the date of the petition for adoption, or from the date of placement, whichever is later. A newborn adopted child will become insured from the moment of birth, if the petition is filed and if you elect Dependent Insurance no later than 90 days from the child’s birth.

If you do not elect to insure your adopted child within such 90 days, or if your petition for adoption is dismissed or denied, no benefits for expenses incurred beyond the 90th day following placement or filing of the petition to adopt, whichever is later, will be payable.

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The Schedule The provision “Mammograms, PSA, Pap Smear” in your medical schedule for Colorectal Cancer Screenings is amended to indicate the following:

Mammograms, PSA, Pap Smear, Colorectal Cancer Screenings In-Network Preventive Care Related Services (i.e. “routine” services) will be covered at "100%".

The following note is hereby added to Diagnostic Related Services (i.e. “non-routine” services):

Note:

A follow-up colonoscopy is not subject to a cost share requirement if services are performed In-Network.

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The Schedule The provision “Mammograms, PSA, Pap Smear” in your medical schedule for PSA is amended to indicate In-Network and Out-of-Network Preventive Care Related Services (i.e.

“routine” services) will not be subject any plan deductible.

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Covered Expenses

• charges for screening for hepatitis C during pregnancy; not subject to Copay or Deductible.

• charges for the treatment of newborn children for congenital defects, spinal muscular atrophy, premature birth and tests for hypothyroidism, phenylketonuria and galactosemia and tests for sickle cell anemia and all other genetic disorders for which screening is performed by or for the State of Arkansas. Coverage will also include routine nursery care and pediatric charges for well newborn children for the myCigna.com6 earlier of 5 days in a Hospital nursery, or until the mother is discharged from the Hospital.

• charges made for anesthesia, hospitalization services or ambulatory surgical facility charges performed in connection with dental procedures when such services are required to effectively perform the procedures and the patient is:

• under seven years of age and it is determined by two dentists that treatment in a Hospital or ambulatory surgical center is required without delay due to a significantly complex dental condition; or

• a person with a serious diagnosed mental or physical condition; or

• a person with a significant behavioral problem as determined by their Physician.

• charges for colorectal cancer examinations and laboratory tests for individuals who:

• are 45 years of age or older.

• less than 45 years of age and at high risk for colorectal cancer. Individuals defined to be “high risk” include:

• the presence of one (1) or more adenomatous polyps on a previous colonoscopy, or flexible sigmoidoscopy;

• have a family history of colorectal cancer;

• have genetic alterations of hereditary nonpolyposis;

• have colon cancer or familial adenomatous polyposis;

• a personal history of colorectal cancer, ulcerative colitis, or Crohn’s disease; or the presence of any appropriate recognized gene markers for colorectal cancer or other predisposing factors; and

• any additional or expanded definition of "high risk" as recognized by medical science and determined by the Secretary of the Department of Health in consultation with the University of Arkansas for Medical Sciences and consistent with guidelines issued by the United States Preventive Services Task Force.

• individuals experiencing the following symptoms of colorectal cancer as determined by a Physician: bleeding from the rectum or blood in the stool; or a change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts more than five (5) days.

The colorectal screening shall involve an examination of the entire colon, including:

• all examinations, lab tests, or preventive screening tests assigned either a grade of "A" or a grade of "B" by the United States Preventive Services Task Force.

• any additional medically recognized screening tests determined by the United States Preventive Services Task Force for colorectal cancer.

Benefits for follow-up screening shall be limited to the following guidelines for the management or subsequent need for follow-up colonoscopy:

• a colonoscopy performed as a result of a positive result on a non-colonoscopy preventive screening test; or

• any additional non-colonoscopy preventive screening tests for colorectal cancer required by the Secretary of the Department of Health in consultation with the University of Arkansas for Medical Sciences and consistent with guidelines issued by the United States Preventive Services Task Force.

• charges for prostate cancer examinations and laboratory tests once a year for non-symptomatic men who are forty years of age or older in accordance with the National Comprehensive Cancer Guidelines.

• expenses incurred at any of the Approximate Age Intervals shown below for a Dependent child who is age 18 or less, for charges made for Child Preventive Care Services consisting of the following services delivered or supervised by a Physician, in keeping with prevailing medical standards:

• a history;

• physical examination;

• development assessment;

• anticipatory guidance;

• appropriate immunizations, which are not subject to any

Copay, Coinsurance, Deductible, or dollar limit; and laboratory tests, excluding any charges for:

• more than one visit to one provider for Child

Preventive Care Services at each of the Approximate Age Intervals up to a total of 20 visits for each Dependent child;

• services for which benefits are otherwise provided under this Covered Expenses section; and

• services for which benefits are not payable according to the Expenses Not Covered section.

Approximate Age Intervals are: Birth, 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years, 8 years, 10 years, 12 years, 14 years, 16 years, and 18 years.

• charges made for corrective surgery and related medical care for individuals of any age diagnosed as having a craniofacial anomaly, if the surgery and treatment are Medically Necessary to improve a functional impairment, as myCigna.com7 determined by a surgical member of a nationally accredited cleft-craniofacial team of the American Cleft Palate- Craniofacial Association. “Craniofacial anomaly” means the abnormal development of the skull and face.

Required medical care coverage includes reconstructive surgery, dental care, and vision care. Coverage for the following is included, if Medically Necessary;

• on an annual basis:

• sclera contact lenses, including coatings;

• office visits;

• an ocular impression of each eye;

• autologous serum eye drops;

• eye weights, either surgically and/or external eye weights in one or both eyes, as directed by an eye specialist; and

• any additional tests or procedures that are Medically Necessary for a craniofacial patient.

• every two (2) years, two (2) hearing aids and two (2) hearing aid molds for each ear; and

• every four (4) years, a dehumidifier.

• charges for prescription drugs or devices approved by the

United States Food and Drug Administration for use as a contraceptive. Cost share levels are the same as for other covered prescription drugs. Covered contraceptives include oral, implantable, and injectable contraceptive drugs, intrauterine devices, and prescription barrier methods for contraception.

• charges for positron emission tomography to screen for or to diagnose cancer in a patient upon the recommendation of the patient's Physician when the patient has a prior history of cancer.

• charges for a gastric pacemaker to treat gastroparesis, a neuromuscular stomach disorder in which food empties into the stomach more slowly than normal.

• charges for screening for depression of the birth mother by a healthcare professional within the first six (6) weeks of giving birth.

• charges for biomarker testing for the purpose of diagnosis, treatment, appropriate management or ongoing monitoring of an individual’s disease or condition to guide treatment decisions when supported by medical and scientific evidence.

Pediatric Autoimmune Neuropsychiatric Disorders

(PANS) (PANDAS)

Coverage for off-label use of intravenous immunoglobulin, also known as "IVIG", to treat individuals diagnosed with pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS), or both, if the pediatric patient’s Primary Care Physician, in consultation with a Arkansas licensed pediatric psychiatrist and licensed physician practicing in at least one pediatric subspecialty, determines and agrees that the treatment is necessary and follows a patient-specific treatment plan consistent with established protocols and rules developed by the Insurance Commissioner, in consultation with the Childhood Post-infectious Autoimmune Encephalopathy Center of Excellence.

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Covered Expenses Prostheses/Prosthetic Appliances and Devices Prostheses/prosthetic appliances and devices are defined as fabricated replacements for missing body parts.

Prostheses/prosthetic appliances and devices include, but are not limited to:

• limb prostheses;

• terminal devices such as hands or hooks;

• speech prostheses;

• facial prostheses;

• devices for athletics or recreation; and

• devices for showering or bathing.

Orthoses and Orthotic Devices Orthoses and orthotic devices are defined as orthopedic appliances or apparatuses used to support, align, prevent or correct deformities. Coverage is provided for custom foot orthoses and other orthoses as follows:

• Non-foot orthoses – only the following non-foot orthoses are covered:

• rigid and semi-rigid custom fabricated orthoses;

• semi-rigid prefabricated and flexible orthoses; and

• rigid prefabricated orthoses including preparation, fitting and basic additions, such as bars and joints.

• Custom foot orthoses – custom foot orthoses are only covered as follows:

• for persons with impaired peripheral sensation and/or altered peripheral circulation (e.g. diabetic neuropathy and peripheral vascular disease);

• when the foot orthosis is an integral part of a leg brace and is necessary for the proper functioning of the brace;

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• when the foot orthosis is for use as a replacement or substitute for missing parts of the foot (e.g. amputated toes) and is necessary for the alleviation or correction of Injury, Sickness or congenital defect; and

• for persons with neurologic or neuromuscular condition (e.g. cerebral palsy, hemiplegia, spina bifida) producing spasticity, malalignment, or pathological positioning of the foot and there is reasonable expectation of improvement.

The following are specifically excluded orthoses and orthotic devices:

• prefabricated foot orthoses;

• cranial banding and/or cranial orthoses. Other similar devices are excluded except when used postoperatively for synostotic plagiocephaly. When used for this indication, the cranial orthosis will be subject to the limitations and maximums of the External Prosthetic Appliances and Devices benefit;

• orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers;

• orthoses primarily used for cosmetic rather than functional reasons; and

• orthoses primarily for improved athletic performance or sports participation.

Braces A Brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part.

The following braces are specifically excluded: Copes scoliosis braces.

Splints A Splint is defined as an appliance for preventing movement of a joint or for the fixation of displaced or movable parts.

Coverage for replacement of external prosthetic appliances and devices is limited to the following:

• replacement due to regular wear. Replacement for damage due to abuse or misuse by the person will not be covered.

• replacement required because anatomic change has rendered the external prosthetic appliance or device ineffective.

Anatomic change includes significant weight gain or loss, atrophy and/or growth.

• replacement due to a surgical alteration or revision of the impacted site.

Coverage for replacement is limited as follows, unless Medically Necessary or indicated by other coverage criteria:

• no more than once every 24 months for persons 19 years of age and older; and

• no more than once every 12 months for persons 18 years of age and under.

The following are specifically excluded external prosthetic appliances and devices:

• external and internal power enhancements for external prosthetic devices;

• microprocessor controlled prostheses and orthoses; and

• myoelectric prostheses and orthoses.

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The Schedule The Pharmacy Schedule is amended to indicate that for plans subject to the Affordable Care Act (ACA) contraceptives are covered at no cost share, when purchased from a Network or home delivery Pharmacy, if applicable. A written prescription is required. Otherwise, Contraceptive devices and oral contraceptives are payable as shown in The Schedule, unless your plan qualifies for a religious exemption.

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Prescription Drug Benefits Limitations Prior Authorization Requirements Coverage for certain Prescription Drug Products prescribed to you requires your Physician to obtain prior authorization from Cigna or its Review Organization. The reason for obtaining prior authorization from Cigna is to determine whether the Prescription Drug Product is Medically Necessary in accordance with Cigna's coverage criteria. Coverage criteria for a Prescription Drug Product may vary based on the clinical use for which the Prescription Order or Refill is submitted, and may change periodically based on changes in, without limitation, clinical guidelines or practice standards, or market factors.

Prior authorization will not be required for antiretroviral drugs that are Medically Necessary for the prevention of HIV or AIDS, including HIV preexposure prophylaxis and HIV postexposure prophylaxis.

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Prior authorization will not be required for medication-assisted treatment for opioid and alcohol addiction, other than a valid prescription and compliance with the medication-assisted treatment guidelines issued by the SAMH Services Administration under the U.S. Department of Health and Human Services. If a new medication becomes available and is more expensive or not shown to be more effective than current medications, prior authorization may be applied.

Step Therapy Certain Prescription Drug Products are subject to step therapy requirements. This means that in order to receive Benefits for such Prescription Drug Products you are required to try a different Prescription Drug Product(s) first unless you satisfy the plan’s exception criteria. You may identify whether a particular Prescription Drug Product is subject to step therapy requirements at the website shown on your ID card or by calling member services at the telephone number on your ID card.

Step therapy will not be required for antiretroviral drugs that are Medically Necessary for the prevention of HIV or AIDS, including HIV preexposure prophylaxis and HIV postexposure prophylaxis.

A step therapy protocol exception shall be granted if the required prescription drug is:

• contraindicated or will likely cause an adverse reaction or physical or mental harm to the patient;

• expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen;

• a patient has tried the required prescription drug while under the patient's current or previous health benefit plan, or another prescription drug in the same pharmacologic class or with the same mechanism of action and the prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event;

• not in the best interest of the patient, based on Medical Necessity;

• a patient is stable on a prescription drug selected by the patient's healthcare provider for the medical condition under consideration while on a current or previous health benefit plan.

A request for a step therapy protocol exception shall be granted or denied within seventy-two (72) hours of receiving the request and twenty-four (24) hours of receiving the request for urgent cases.

You may appeal the denial of a request for a step therapy protocol exception. The health benefit plan shall grant or deny the appeal within seventy-two (72) hours of receiving the appeal and within twenty-four (24) hours of receiving the appeal for urgent cases.

If a response is not received within seventy-two (72) hours of receiving the initial request or appeal and within twenty-four

(24) hours of receiving the initial request or appeal for urgent cases, then such a request shall be deemed granted.

Step therapy may not be applied for a drug approved by the United States Food and Drug Administration when coverage is provided for the treatment of psychosis and serious mental illness through antipsychotic prescription drugs and metastatic cancer.

Prescription Eye Drops Charges for early refills of prescription eye drops if:

• For a thirty-day supply:

• The amount of time has passed after which a covered person should have used seventy percent (70%) of the dosage of the prescription eye drops according to a healthcare professional's instructions on the prescription;

or

• Twenty-two (22) days have passed from the original date the prescription eye drops were distributed to a covered person; or the date the most recent refill of the prescription eye drops was distributed to a covered person;

• The healthcare professional indicates on the original prescription that additional quantities of the prescription eye drops are needed;

• A refill request of a covered person for prescription eye drops does not exceed the number of additional quantities needed as described above; and

• The prescription eye drops prescribed by a healthcare professional are a covered benefit under the health benefit plan of the covered person.

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Exclusions

• for or in connection with experimental, investigational or unproven services.

Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be:

• not approved by the U.S. Food and Drug Administration

(FDA) or other appropriate regulatory agency to be lawfully marketed;

• not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed;

• the subject of review or approval by an Institutional Review Board for the proposed use except as provided in the “Clinical Trials” section(s) of this plan; or

• the subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the “Clinical Trials” section(s) of this plan.

In determining whether any such technologies, supplies, treatments, drug or Biologic therapies, or devices are experimental, investigational, and/or unproven, the utilization review Physician may rely on the clinical coverage policies maintained by Cigna or the Review Organization. Clinical coverage policies may incorporate, without limitation and as applicable, criteria relating to U.S. Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scientific literature or guidelines. The plan or policy shall not deny coverage for a drug or Biologic therapy as experimental, investigational and unproven if the drug or Biologic therapy is otherwise approved by the FDA to be lawfully marketed and is recognized for the treatment of the prescribed indication in any one of the following: The American Hospital Formulary Service Drug Information; The National Comprehensive Cancer Network Drugs and Biologics Compendium; and The Elsevier Gold Standard’s Clinical Pharmacology; or the drug has been recognized as safe and effective for treatment of that specific type of cancer in two articles from medical literature not otherwise contradicted by any one article in a similar publication; or other authoritative compendia as identified by the Secretary of the United States Department of Health and Human Services or the commissioner.

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Prescription Drug Benefits Your Payments Covered Prescription Drug Products purchased at a Pharmacy are subject to any applicable Deductible, Copayments or Coinsurance shown in The Schedule. Please refer to The Schedule for any required Copayments, Coinsurance, Deductibles or Out-of-Pocket Maximums.

After satisfying the plan Deductible, if any, your responsibility for a covered Prescription Drug Product subject to a Copayment requirement will always be the lowest of:

• the Copayment for the Prescription Drug Product; or

• the Prescription Drug Charge for the Prescription Drug

Product; or

• the Pharmacy’s Usual and Customary (U&C) Charge for the

Prescription Drug Product.

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Exclusions, Expenses Not Covered and General Limitations Exclusions and Expenses Not Covered

• for or in connection with experimental, investigational or unproven services.

Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be:

• not approved by the U.S. Food and Drug Administration

(FDA) or other appropriate regulatory agency to be lawfully marketed;

• not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed;

• the subject of review or approval by an Institutional Review Board for the proposed use except as provided in the “Clinical Trials” sections of this plan; or

• the subject of an ongoing phase I, II, or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the “Clinical Trials” sections of this plan.

In determining whether any such technologies, supplies, treatments, drug or Biologic therapies or devices are experimental, investigational and/or unproven, the utilization review Physician may rely on the clinical coverage policies maintained by Cigna or the Review Organization. Clinical coverage policies may incorporate, without limitation and as applicable, criteria relating to U.S.

Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scientific literature or guidelines.

The plan or policy shall not deny coverage for a drug or Biologic therapy as experimental, investigational and unproven if the drug or Biologic therapy is otherwise approved by the FDA to be lawfully marketed and is recognized for the treatment of the prescribed indication in any one of the following: The American Hospital Formulary Service Drug Information; The National Comprehensive Cancer Network Drugs and Biologics Compendium; and The Elsevier Gold Standard’s Clinical Pharmacology; or the drug has been recognized as safe and effective treatment of that specific type of cancer in two articles from medical literature not otherwise contradicted by any one article in a similar publication; or other authoritative compendia as identified by the Secretary of the United States Department of Health and Human Services or the commissioner.

• surgical and non-surgical treatment of Temporomandibular Joint Dysfunction (TMJ) and craniofacial muscle disorders, except as described in Covered Expenses.

• except as specified in the Covered Expenses section, hearing aids, including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs). A hearing aid is any device that amplifies sound.

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Definitions Dependent The term child means a child born to you or a child legally adopted by you from the date you file a petition for adoption.

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Prescription Drug Charge The amount Cigna charges to the Plan, including the applicable dispensing fee and any applicable sales tax and prior to application of any Deductible, Copayment or Coinsurance amounts, for a Prescription Drug Product dispensed at a Network Pharmacy. Cigna may pay a Network Pharmacy a different amount for a Prescription Drug Product than the Plan pays to Cigna. You are not entitled to the difference between the rate Cigna charges to the Plan and the rate Cigna pays to the Pharmacy for a Prescription Drug Product. For the purposes of Prescription Drug benefit payments, the “Plan” is the entity or business unit responsible for funding benefits in accordance with the terms and conditions outlined in this booklet/certificate.

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COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – California Residents

Rider Eligibility: Each Employee who is located in California

You will become insured on the date you become eligible, including if you are not in Active Service on that date due to your health status.

This rider forms a part of the certificate issued to you by Cigna.

The provisions set forth in this rider comply with the legal requirements of California for group insurance plans covering insureds located in California. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

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Definitions Dependent The term child means a child born to you, a child legally adopted by you from the date the child is placed in your physical custody prior to the finalization of the child's adoption, or a child supported by you pursuant to a court order (including a qualified medical child support order).

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Primary Care Physician The term Primary Care Physician means a Physician who qualifies as a Participating Provider in general practice, internal medicine, family practice, obstetrics/gynecology or pediatrics; and who has been selected by you, as authorized by Cigna, to provide or arrange for medical care for you or any of your insured Dependents.

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Florida Residents

Rider Eligibility: Each Employee who is located in Florida

The benefits of the policy providing your coverage are primarily governed by the law of a state other than Florida.

You will become insured on the date you become eligible, including if you are not in Active Service on that date due to your health status.

This rider forms a part of the certificate issued to you by Cigna.

The provisions set forth in this rider comply with the legal requirements of Florida group insurance plans covering insureds located in Florida. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

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Eligibility - Effective Date Dependent Insurance Effective Date of Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by signing an approved payroll deduction form, but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included. For your Dependents to be insured for these benefits, you must elect the Dependent insurance for yourself no later than 30 days after you become eligible.

A newborn child will be covered for the first 31 days of life even if you fail to enroll the child. If you enroll the child after the first 31 days and by the 60th day after his birth, coverage will be offered at an additional premium. Coverage for an adopted child will become effective from the date of placement in your home or from birth for the first 31 days myCigna.com13 even if you fail to enroll the child. However, if you enroll the adopted child between the 31st and 60th days after his birth or placement in your home, coverage will be offered at an additional premium.

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Covered Expenses

• charges made for or in connection with mammograms for breast cancer screening or diagnostic purposes, including, but not limited to: a baseline mammogram for women ages 35 through 39; a mammogram for women ages 40 through 49, every two years or more frequently based on the attending Physician's recommendations; a mammogram every year for women age 50 and over; and one or more mammograms upon the recommendation of a Physician for any woman who is at risk for breast cancer due to her family history; has biopsy proven benign breast disease; or has not given birth before age 30. A mammogram will be covered with or without a Physician’s recommendation, provided the mammogram is performed at an approved facility for breast cancer screening.

• charges made for diagnosis and Medically Necessary surgical procedures to treat dysfunction of the temporomandibular joint. Appliances and non-surgical treatment including for orthodontia are not covered.

• charges for the treatment of cleft lip and cleft palate including medical, dental, speech therapy, audiology and nutrition services, when prescribed by a Physician.

• charges for general anesthesia and hospitalization services for dental procedures for an individual who is under age 8 and for whom it is determined by a licensed Dentist and the child's Physician that treatment in a Hospital or ambulatory surgical center is necessary due to a significantly complex dental condition or developmental disability in which patient management in the dental office has proven to be ineffective; or has one or more medical conditions that would create significant or undue medical risk if the procedure were not rendered in a Hospital or ambulatory surgical center.

• charges for the services of certified nurse-midwives, licensed midwives, and licensed birth centers regardless of whether or not such services are received in a home birth setting.

• charges for or in connection with Medically Necessary diagnosis and treatment of osteoporosis for high risk individuals. This includes, but is not limited to individuals who: have vertebral abnormalities; are receiving long-term glucocorticoid (steroid) therapy; have primary hyperparathyroidism; have a family history of osteoporosis;

and/or are estrogen-deficient individuals who are at clinical risk for osteoporosis.

• charges for an inpatient Hospital stay following a mastectomy will be covered for a period determined to be Medically Necessary by the Physician and in consultation with the patient. Postsurgical follow-up care may be provided at the Hospital, Physician's office, outpatient center, or at the home of the patient.

• charges for newborn and infant hearing screening as well as any medically necessary follow-up evaluations leading to diagnosis and subsequent medically necessary treatment of a diagnosed hearing impairment.

• charges for the coverage of child health supervision services from birth to age 16. Child health supervision services are physician-delivered or supervised services that include periodic visits which include a history, physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests.

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Medical Conversion Privilege For You and Your Dependents When a person's Medical Expense Insurance ceases, he may be eligible to be insured under an individual policy of medical care benefits (called the Converted Policy).

A Converted Policy will be issued by Cigna only to a person who:

• resides in a state that requires offering a conversion policy,

• is Entitled to Convert, and

• applies in writing and pays the first premium for the

Converted Policy to Cigna within 31 days after the date his insurance ceases. Evidence of good health is not needed.

Employees Entitled to Convert You are Entitled to Convert Medical Expense Insurance for yourself and all of your Dependents who were insured when your insurance ceased but only if:

• you are not eligible for other individual insurance coverage on a guaranteed issue basis.

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• you have been insured for at least three consecutive months under the policy or under it and a prior policy issued to the Policyholder.

• your insurance ceased because you were no longer in Active Service or no longer eligible for Medical Expense Insurance.

• you are not eligible for Medicare.

• you would not be Overinsured.

• you have paid all required premium or contribution.

• you have not performed an act or practice that constitutes fraud in connection with the coverage.

• you have not made an intentional misrepresentation of a material fact under the terms of the coverage.

• your insurance did not cease because the policy in its entirety canceled.

If you retire, you may apply for a Converted Policy within 31 days after your retirement date in place of any continuation of your insurance that may be available under this plan when you retire, if you are otherwise Entitled to Convert.

Dependents Entitled to Convert The following Dependents are also Entitled to Convert:

• a child who is not eligible for other individual insurance coverage on a guaranteed issue basis, and whose insurance under this plan ceases because he no longer qualifies as a Dependent or because of your death;

• a spouse who is not eligible for other individual insurance coverage on a guaranteed issue basis, and whose insurance under this plan ceases due to divorce, annulment of marriage or your death;

• your Dependents whose insurance under this plan ceases because your insurance ceased solely because you are eligible for Medicare;

but only if that Dependent: is not eligible for other individual insurance coverage on a guaranteed issue basis, is not eligible for Medicare, would not be Overinsured, has paid all required premium or contribution, has not performed an act or practice that constitutes fraud in connection with the coverage, and has not made an intentional misrepresentation of a material fact under the terms of the coverage.

Overinsured A person will be considered Overinsured if either of the following occurs:

• his insurance under this plan is replaced by similar group coverage within 31 days.

• the benefits under the Converted Policy, combined with Similar Benefits, result in an excess of insurance based on Cigna's underwriting standards for individual policies.

Similar Benefits are: those for which the person is covered by another hospital, surgical or medical expense insurance policy, or a hospital, or medical service subscriber contract, or a medical practice or other prepayment plan or by any other plan or program; those for which the person is eligible, whether or not covered, under any plan of group coverage on an insured or uninsured basis; or those available for the person by or through any state, provincial or federal law.

Converted Policy If you reside in a state that requires the offering of a conversion policy, the Converted Policy will be one of Cigna's current conversion policy offerings available in the state where you reside, as determined based upon Cigna's rules.

The Converted Policy will be issued to you if you are Entitled to Convert, insuring you and those Dependents for whom you may convert. If you are not Entitled to Convert and your spouse and children are Entitled to Convert, it will be issued to the spouse, covering all such Dependents. Otherwise, a Converted Policy will be issued to each Dependent who is Entitled to Convert. The Converted Policy will take effect on the day after the person's insurance under this plan ceases. The premium on its effective date will be based on: class of risk and age; and benefits.

During the first 12 months the Converted Policy is in effect, the amount payable under it will be reduced so that the total amount payable under the Converted Policy and the Medical Benefits Extension of this plan (if any) will not be more than the amount that would have been payable under this plan if the person's insurance had not ceased. After that, the amount payable under the Converted Policy will be reduced by any amount still payable under the Medical Benefits Extension of this plan (if any). Cigna or the Policyholder will give you, on request, further details of the Converted Policy.

HC-CNV28 04-14

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Exclusions, Expenses Not Covered and General Limitations If the following text “Provided further,….required to pay.” is included in your certificate, it does not apply to you.

Provided further, if you use a coupon provided by a pharmaceutical manufacturer or other third party that discounts the cost of a prescription medication or other myCigna.com15 product, Cigna may, in its sole discretion, reduce the benefits provided under the plan in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts to which the value of the coupon has been applied by the Pharmacy or other third party, and/or exclude from accumulation toward any plan Deductible or Out-of-Pocket Maximum the value of any coupon applied to any Copayment, Deductible and/or Coinsurance you are required to pay.

HC-EXC528 01-24

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Medical Benefits Extension Upon Policy Cancellation If the Medical Benefits under this plan cease for you or your Dependent due to cancellation of the policy, and you or your Dependent is Totally Disabled on that date due to an Injury, Sickness or pregnancy, Medical Benefits will be paid for Covered Expenses incurred in connection with that Injury, Sickness or pregnancy. However, no benefits will be paid after the earliest of:

• the date you exceed the Maximum Benefit, if any, shown in the Schedule;

• the date a succeeding carrier agrees to provide coverage without limitation for the disabling condition;

• the date you are no longer Totally Disabled;

• 12 months from the date the policy is canceled; or

• for pregnancy, until delivery.

Totally Disabled You will be considered Totally Disabled if, because of an Injury or a Sickness:

• you are unable to perform the basic duties of your occupation; and

• you are not performing any other work or engaging in any other occupation for wage or profit.

Your Dependent will be considered Totally Disabled if, because of an Injury or a Sickness:

• he is unable to engage in the normal activities of a person of the same age, sex and ability; or

• in the case of a Dependent who normally works for wage or profit, he is not performing such work.

HC-BEX42 04-11

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Definitions Dependent – For Medical Insurance A child includes a legally adopted child, including that child from the date of placement in the home or from birth provided that a written agreement to adopt such child has been entered into prior to the birth of such child. Coverage for a legally adopted child will include the necessary care and treatment of an Injury or a Sickness existing prior to the date of placement or adoption. Coverage is not required if the adopted child is ultimately not placed in your home.

A child includes a child born to an insured Dependent child of yours until such child is 18 months old.

HC-DFS1685 01-23

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Illinois Residents

Rider Eligibility: Each Employee who is located in Illinois

You will become insured on the date you become eligible, including if you are not in Active Service on that date due to your health status.

This rider forms a part of the certificate issued to you by Cigna.

The provisions set forth in this rider comply with the legal requirements of Illinois group insurance plans covering insureds located in Illinois. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETILRDR

The Schedule The provision “Mammograms, PSA, Pap Smear” in your medical schedule is amended to indicate the following:

If your medical plan is subject to a Lifetime Maximum or Preventive Care Maximum, Mammogram charges do not myCigna.com16 accumulate towards those maximums. In addition, In-Network Preventive Care Related (i.e. “routine”) Mammograms will be covered at “No charge”.

SCHEDIL-ETC

The Schedule The provision “Mammograms, PSA, Pap Smear” in your medical schedule is amended to indicate the following:

In-Network Diagnostic Related Services (i.e. “non-routine” services) for Mammograms will be covered at 100% without application of any deductible, except if you’re covered under a Qualified High Deductible Health Savings plan then the plan deductible will apply.

SCHED IL ET-1

The Schedule The provision “Skin Cancer Screening – one annual office visit for a whole body skin cancer screening examination” is hereby added to your medical schedule and is paid as follows:

In-Network Skin Cancer Screening will be covered at 100% without application of any deductible, except if you’re covered under a Qualified High Deductible Health Savings plan then the plan deductible will apply.

If your plan includes Out-of-Network coverage, Out-of- Network Skin Cancer Screening will be covered the same as any other Out-of-Network office visit.

SCHED IL ET-2

Certification Requirements - Out-of-Network For You and Your Dependents Pre-Admission Certification/Continued Stay Review for Hospital Confinement Pre-Admission Certification (PAC) and Continued Stay Review (CSR) refer to the process used to certify the Medical Necessity and length of a Hospital Confinement when you or your Dependent require treatment in a Hospital:

• as a registered bed patient, except for 48/96 hour maternity stays;

• for Mental Health Residential Treatment Services.

HC-PAC111 01-20

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Covered Expenses

• charges for ambulatory surgical facilities and associated anesthesia charges for dental care that is provided to a covered individual who: is a child age 6 or under; has a medical condition that requires hospitalization or general anesthesia for dental care; or is disabled.

• charges made, and anesthetics provided by a dentist with a permit by the IL Department of Financial and Professional Regulation to administer general anesthesia, deep sedation, or conscious sedation in conjunction with care that is covered under this plan and provided to an insured in a dental office, oral surgeon's office, Hospital or ambulatory surgical treatment center if the individual is under age 26 and has been diagnosed with an Autism Spectrum Disorder or a Developmental Disability and has made 2 visits to the dental care provider prior to accessing this coverage.

A person who is disabled refers to a person, regardless of age, with a chronic disability if the chronic disability meets all of the following conditions:

• it is attributable to a mental or physical impairment or a combination of such impairments; and

• it is likely to continue; and

• it results in substantial functional limitations in one or more of the following areas of major life activity: self-care; receptive and expressive language, learning;

mobility; capacity for independent living; or economic self-sufficiency.

Autism Spectrum Disorders means as defined in Section 10 of the Autism Spectrum Disorders Reporting Act.

Developmental Disability means a disability that is attributable to an intellectual disability or a related myCigna.com17 condition, if the related condition meets all of the following conditions:

• it is attributable to cerebral palsy, epilepsy, or any other condition, other than mental illness, found to be closely related to an intellectual disability because that condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with an intellectual disability and requires treatment or services similar to those required for those individuals; for purposes of this definition, autism is considered a related condition;

• it is manifested before the individual reaches age 22;

• it is likely to continue indefinitely; and

• it results in substantial functional limitations in 3 or more of the following areas of major life activity: self-care, language, learning, mobility, self-direction, and capacity for independent living.

• charges made for or in connection with low-dose mammography screening including breast tomosynthesis for detecting the presence of breast cancer. Coverage shall include: a baseline mammogram for women ages 35 to 39;

an annual mammogram for women age 40 and older; and mammograms at intervals considered Medically Necessary for women less than age 40 who have a family history of breast cancer, prior personal history of breast cancer, positive genetic testing or other risk factors. Coverage also includes a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when Medically Necessary as determined by a Physician licensed to practice medicine in all of its branches as well as a screening MRI when Medically Necessary as determined by a Physician licensed to practice medicine in all of its branches. Low dose mammography means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device and image receptor, with radiation exposure delivery of less than one rad per breast for two views of an average sized breast. This term also includes digital mammography and includes breast tomosynthesis. The term "breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.

• charges made for complete and thorough clinical breast exams performed by a Physician licensed to practice medicine in all its branches, an advanced practice nurse who has a collaborative agreement with a collaborating Physician that authorizes breast examinations, or a Physician assistant who has been…