2-Dental Extra Territorial Legislation.pdf

City of Lewisville

EXTRATERRITORIAL LEGISLATION

EFFECTIVE DATE: January 1, 2026

ETALLD26A

3328347

This document printed in December, 2025 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 – Florida Residents CERTIFICATE RIDER – Georgia Residents CERTIFICATE RIDER – Illinois Residents CERTIFICATE RIDER – Louisiana Residents CERTIFICATE RIDER – Montana Residents CERTIFICATE RIDER – South Dakota Residents CERTIFICATE RIDER – Utah Residents CERTIFICATE RIDER – Washington Residents myCigna.com4

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

CERTIFICATE RIDER

Policyholder: City of Lewisville Rider Eligibility: Each Employee as noted within this certificate rider Policy No. or Nos.: 3328347 Effective Date: January 1, 2026

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.

HC-ETRDR

myCigna.com5

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.

HC-ETFLRDR

Eligibility - Effective Date Foster Children, Adoptive Children and Children in Custodial Care Benefits applicable to children of the insured Employee also apply to adoptive children, foster children and children in custodial care. Coverage begins from birth or from the moment of placement in the home. Except in the case of foster children, coverage may not exclude any preexisting condition of the child.

In the case of a newborn adoptive child, coverage begins from the moment of birth if there is a written agreement to adopt the child, whether or not the agreement is enforceable.

Coverage does not extend to an adoptive child who is not ultimately placed in the home of the insured Employee.

If notice of the birth or placement of an adopted child is given to the company within 30 days there is no premium charge for the initial 30 day period. If timely notice is not given, the insurer may charge additional premium from the time of birth or placement.

If notice is given within 60 days of the birth or placement of an adopted child, the insurer may not deny coverage for the child due to the failure of the insured to timely notify the insurer of the birth or placement of the child.

If any family member of the insured Employee is covered as a dependent, then benefits applicable to children are covered with respect to a foster child or other child in court-ordered temporary custody or other custody of the insured Employee.

Newborn Children Coverage for newborn children of an insured employee or the employee’s covered family member begins from the moment of birth.

Coverage for a newborn child of a covered family member terminates when the child is 18 months old.

If notice of birth is given to the company within 30 days there is no premium charge for the initial 30 day period. If timely notice is not given, the insurer may charge additional premium from the time of birth.

If notice is given within 60 days of the birth of the child, the insurer may not deny coverage for a child due to the failure of the insured to timely notify the insurer of the birth of the child.

This policy covers newborn children for the necessary dental care or dental treatment of congenital defects or birth abnormalities of the teeth or gums.

HCDFB-ELG115 06-21

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Dental Benefits Extension – For Total Disability Upon Policy Discontinuation An expense incurred in connection with a Covered Dental Service that is completed after Your benefits cease, for any reason other than the person's failure to pay premiums, will be deemed to be incurred while You are insured if:

• the course of treatment was recommended in writing by the physician and began while the person was insured for dental benefits; and myCigna.com6

• the Covered Dental Service is other than a routine examination, prophylaxis, x-ray, or sealants or orthodontic services;

• for Orthodontic Services, the treatment commenced while the person was insured and the expenses are incurred within 60 days after his insurance ceases.

• and the Covered Dental Service is performed within 90 days after his insurance ceases.

The terms of this Dental Benefits Extension will not apply to a person who becomes insured under another group policy for similar dental benefits.

HCDFB-BEX13 06-21

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Definitions Dependent The term child means a child born to You or a child legally adopted by You, 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. A child also includes a foster child or a child placed in Your custody by a court order from the date of placement in the home. Coverage is not required if the adopted or foster child is ultimately not placed in Your home. It also includes:

• a stepchild;

• a child born to an insured Dependent child of Yours until such child is 18 months old, or a child supported pursuant to a court order imposed on You (including a Qualified Medical Child Support Order).

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Georgia Residents

Rider Eligibility: Each Employee who is located in Georgia

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 Georgia group insurance plans covering insureds located in Georgia. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETGARDR

Important Notices

CIGNA DENTAL PPO

IMPORTANT:

If You opt to receive dental services or procedures that are not covered benefits under this plan, a participating dental provider may charge You his or her usual and customary rate for such services or procedures. Prior to providing You with dental services or procedures that are not covered benefits, the dental provider should provide You with a treatment plan that includes each anticipated service or procedure to be provided and the estimated cost of each such service or procedure. To fully understand Your coverage, You may wish to review Your evidence of coverage document.

HCDFB-IMP84 06-21

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myCigna.com7

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

Expenses Not Covered

• charges for travel time or transportation costs;

HC-DEX1 04-10

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Louisiana Residents

Rider Eligibility: Each Employee who is located in Louisiana

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 Louisiana group insurance plans covering insureds located in Louisiana. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETLARDR

How To File Your Claim Payment of Claims All claims arising under the terms of this contract shall be paid not more than thirty days from the date upon which written notice and proof of loss are furnished to the insurer, unless just and reasonable grounds exist for delay.

HC-CLM11 04-10

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Termination of Insurance Continuation of Dental Insurance during Active Military Duty If your coverage would otherwise cease because you are a Reservist in the United States Armed Forces and are called to active duty, the insurance for you and your Dependents will be continued during your active duty only if you elect it in myCigna.com8 writing, and will continue until the earliest of the following dates:

• 90 days from the date your military service ends;

• the last day for which you made any required contribution for the insurance; or

• the date the group policy cancels.

Reinstatement of Dental Insurance If your coverage ceases because you are a Reservist in the United States Armed Forces and are called to active duty, the insurance for you and your Dependents will be automatically reinstated after your deactivation, provided that you return to Active Service within 90 days.

Such reinstatement will be without the application of: a new waiting period, or a new Pre-existing Condition Limitation. A new Pre-existing Condition Limitation will not be applied to any condition that you or your Dependent developed while coverage was interrupted. The remainder of a Pre-existing Condition Limitation which existed prior to interruption of coverage may still be applied.

HC-TRM71 04-10

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Definitions Dependent The term Dependent means:

• any child of Yours who is:

• less than 26 years old.

• For full-time students under the age of 24 who develop an intellectual or nervous condition, problem or disorder which, in the opinion of a qualified psychiatrist prevents them from attending school as a full-time student, and from holding self-sustaining employment, coverage will be continued to age 24.

The term child means a child born to You or a child legally adopted by You, including an unmarried child who is placed in Your home according to the adoption placement agreement executed with a licensed adoption agency effective from the date of placement in Your home, or any unmarried child, following execution of an act of voluntary surrender in favor of You or Your legal representative effective from the date on which the act of voluntary surrender becomes irrevocable. It also includes a stepchild, a grandchild who lives with You, or a child for whom You are the legal guardian, or a child supported pursuant to a court order imposed on You (including a Qualified Medical Child Support Order).

HCDFB-DFS558 06-21

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Montana Residents

Rider Eligibility: Each Employee who is located in Montana

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 Montana group insurance plans covering insureds located in Montana. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETMTRDR

Definitions Dependent The term Dependent means:

• any child of Yours who is:

• less than 26 years old.

myCigna.com9

• 26 or more years old, unmarried, and primarily supported by You and incapable of self-sustaining employment by reason of intellectual or physical disabilities. Proof of the child's condition and dependence may be required to be submitted to Us within 31 days after the date the child ceases to qualify above.

HCDFB-DFS520 06-21

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – South Dakota Residents

Rider Eligibility: Each Employee who is located in South Dakota

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 South Dakota group insurance plans covering insureds located in South Dakota. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETSDRDR

Covered Dental Services Teledentistry services are covered only when administered in conjunction with procedures and services which are covered under this plan. Covered Dental Services delivered through teledentistry are covered to the same extent We cover services rendered through in-person contact including the same cost-share, frequency limitations or any applicable benefit maximums or lack thereof.

HC-DEN330 06-21

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Utah Residents

Rider Eligibility: Each Employee who is located in Utah

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 Utah group insurance plans covering insureds located in Utah. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETUTRDR

Eligibility - Effective Date Eligibility for Coverage for Adopted Children Any child who is adopted by You, including a child who is placed with You for adoption, will be eligible for Dependent coverage, if otherwise eligible as a Dependent, upon the date of placement with You. An adopted child placed within 30 days of birth will be eligible from the moment of birth. A child myCigna.com10 will be considered placed for adoption when You become legally obligated to support that child, totally or partially prior to that child’s adoption. If a child placed for adoption is not adopted, all dental coverage ceases when the placement ends, and will not be continued. The provisions in the Exception for Newborns provision that describe requirements for enrollment and Effective Date of insurance will also apply to an adopted child or a child placed with You for adoption.

Exception for Newborns Any Dependent child born while You are insured will become insured on the date of the child’s birth if You elect Dependent Insurance no later than 31 days after birth. If You do not elect to insure Your newborn child within such 31 days, coverage for that child will end on the 31st day. No benefits for expenses incurred beyond the 31st day will be payable.

HCDFB-ELG87 06-21

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Definitions Dependent The term Dependent means:

• any child of Yours who is:

• 26 or more years old, unmarried and primarily supported by You and incapable of self-sustaining employment by reason of mental or physical impairment which arose while the child was covered as a Dependent under this Plan, or while covered as a Dependent under a prior plan with no break in coverage of more than 63 days. Proof of the child's condition and dependence may be required to be submitted to Us within 31 days after the date the child ceases to qualify above.

HCDFB-DFS388 06-21

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Washington Residents

Rider Eligibility: Each Employee who is located in Washington

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 Washington group insurance plans covering insureds located in Washington. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETWARDR

Definitions Dependent Dependents include:

• any child of yours who is

• 26 or more years old and primarily supported by you and incapable of self-sustaining employment by reason of mental or physical disability.

Proof of the child's condition and dependence may be required to be submitted to Cigna within 31 days after the date the child ceases to qualify above. Cigna may require proof not more frequently than annually after the two year period following the child’s attainment of the limiting age.

HC-DFS1399 01-19

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