260125_Chapter_1A_-_Medical_Network_Plan_Booklet_FY25_(SPD)_-_Retiree.pdf

City of Tucson

NETWORK MEDICAL BENEFITS

Retiree Only Plan

EFFECTIVE DATE: July 1, 2024

ASO39

3342685

This document printed in July, 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 Special Plan Provisions Important Notices How To File Your Claim Eligibility - Effective Date

Employee Insurance Dependent Insurance

Important Information About Your Medical Plan Network Medical Benefits

The Schedule Prior Authorization/Pre-Authorized Covered Expenses

Prescription Drug Benefits The Schedule Covered Expenses Limitations Your Payments Exclusions Reimbursement/Filing a Claim

Exclusions, Expenses Not Covered and General Limitations Coordination of Benefits Expenses For Which A Third Party May Be Responsible Payment of Benefits Termination of Insurance

Employees Dependents

Federal Requirements Notice of Provider Directory/Networks Qualified Medical Child Support Order (QMCSO) Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) Eligibility for Coverage for Adopted Children Coverage for Maternity Hospital Stay Women’s Health and Cancer Rights Act (WHCRA) Group Plan Coverage Instead of Medicaid Claim Determination Procedures Appointment of Authorized Representative

Medical - When You Have a Complaint or an Appeal COBRA Continuation Rights Under Federal Law

Definitions

Important Information

THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR

ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY CITY OF TUCSON WHICH IS

RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY

(CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT

INSURE THE BENEFITS DESCRIBED.

THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE

THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO

INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA,"

"INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR

"EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND

"INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."

HC-NOT89

Explanation of Terms You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms are defined in the Definitions section of your certificate.

The Schedule The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents.

myCigna.com6

Special Plan Provisions Case Management Case Management is a service provided through a Review Organization, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a Hospital or specialized facility.

Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending Physician to determine appropriate treatment options which will best meet the patient's needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis.

Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, each trained in a clinical specialty area such as trauma, high risk pregnancy and neonates, oncology, mental health, rehabilitation or general medicine and surgery. A Case Manager trained in the appropriate clinical specialty area will be assigned to you or your dependent. In addition, Case Managers are supported by a panel of Physician advisors who offer guidance on up-to-date treatment programs and medical technology. While the Case Manager recommends alternate treatment programs and helps coordinate needed resources, the patient's attending Physician remains responsible for the actual medical care.

• You, your dependent or an attending Physician can request

Case Management services by calling the toll-free number shown on your ID card during normal business hours, Monday through Friday. In addition, your employer, a claim office or a utilization review program (see the PAC/CSR section of your certificate) may refer an individual for Case Management.

• The Review Organization assesses each case to determine whether Case Management is appropriate.

• You or your Dependent is contacted by an assigned Case Manager who explains in detail how the program works.

Participation in the program is voluntary - no penalty or benefit reduction is imposed if you do not wish to participate in Case Management.

• Following an initial assessment, the Case Manager works with you, your family and Physician to determine the needs of the patient and to identify what alternate treatment programs are available (for example, in-home medical care in lieu of an extended Hospital convalescence). You are not penalized if the alternate treatment program is not followed.

• The Case Manager arranges for alternate treatment services and supplies, as needed (for example, nursing services or a Hospital bed and other Durable Medical Equipment for the home).

• The Case Manager also acts as a liaison between the insurer, the patient, his or her family and Physician as needed (for example, by helping you to understand a complex medical diagnosis or treatment plan).

• Once the alternate treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient's needs.

While participation in Case Management is strictly voluntary, Case Management professionals can offer quality, cost-effective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need.

HC-SPP2 04-10

V1

Additional Programs We may, from time to time, offer or arrange for various entities to offer discounts, benefits, or other consideration to our members for the purpose of promoting the general health and well being of our members. We may also arrange for the reimbursement of all or a portion of the cost of services provided by other parties to the Policyholder. Contact us for details regarding any such arrangements.

HC-SPP3 04-10

V1

Incentives to Participating Providers Cigna continuously develops programs to help our customers access quality, cost-effective health care. Some programs include Participating Providers receiving financial incentives from Cigna for providing care to members in a way that meets or exceeds certain quality and/or cost-efficiency standards, when, in the Participating Provider’s professional judgment, it is appropriate to do so within the applicable standard of care.

For example, some Participating Providers could receive financial incentives for utilizing or referring you to alternative sites of care as determined by your plan rather than in a more expensive setting, or achieving particular outcomes for certain health conditions. Participating Providers may also receive myCigna.com7 purchasing discounts when purchasing certain prescription drugs from Cigna affiliates. Such programs can help make you healthier, decrease your health care costs, or both. These programs are not intended to affect your access to the health care that you need. We encourage you to talk to your Participating Provider if you have questions about whether they receive financial incentives from Cigna and whether those incentives apply to your care.

HC-SPP85 01-24

Notice Regarding Emergency Services and Urgent Care In the event of an Emergency, get help immediately. Go to the nearest emergency room, the nearest Hospital or call or ask someone to call 911 or your local emergency service, police or fire department for help. You do not need a referral from your PCP for Emergency Services, but you need to call your PCP as soon as possible for further assistance and advice on follow-up care. If you require specialty care or a Hospital admission, your PCP will coordinate it and handle the necessary authorizations for care or hospitalization.

Participating Providers are on call 24 hours a day, seven days a week to assist you when you need Emergency Services.

If you receive Emergency Services outside the service area, you must notify the Review Organization as soon as reasonably possible. The Review Organization may arrange to have you transferred to a Participating Provider for continuing or follow-up care, if it is determined to be medically safe to do so.

Urgent Care Inside the Service Area For Urgent Care inside the service area, you must take all reasonable steps to contact your PCP for direction and you must receive care from a Participating Provider, unless otherwise authorized by your PCP or the Review Organization.

Urgent Care Outside the Service Area In the event you need Urgent Care while outside the service area, you should, whenever possible, contact your PCP for direction and authorization prior to receiving services.

Continuing or Follow-up Treatment Continuing or follow-up treatment, whether in or out of the service area is not covered unless it is provided or arranged for by your PCP or upon prior authorization by the Review Organization.

HC-SPP5 04-10

V1

Care Management and Care Coordination Services Your plan may enter into specific collaborative arrangements with health care professionals committed to improving quality care, patient satisfaction and affordability. Through these collaborative arrangements, health care professionals commit to proactively providing participants with certain care management and care coordination services to facilitate achievement of these goals. Reimbursement is provided at 100% for these services when rendered by designated health care professionals in these collaborative arrangements.

HC-SPP27 06-15

V1

Important Notices Important Information Rebates and Other Payments Cigna or its affiliates may receive rebates or other remuneration from pharmaceutical manufacturers in connection with certain Medical Pharmaceuticals covered under your plan and Prescription Drug Products included on the Prescription Drug List. These rebates or remuneration are not obtained on you or your Employer’s or plan’s behalf or for your benefit.

Cigna, its affiliates and the plan are not obligated to pass these rebates on to you, or apply them to your plan’s Deductible if any or take them into account in determining your Copayments and/or Coinsurance. Cigna and its affiliates or designees, conduct business with various pharmaceutical manufacturers separate and apart from this plan’s Medical Pharmaceutical and Prescription Drug Product benefits. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this plan. Cigna and its affiliates are not required to pass on to you, and do not pass on to you, such amounts.

Coupons, Incentives and Other Communications At various times, Cigna or its designee may send mailings to you or your Dependents or to your Physician that communicate a variety of messages, including information about Medical Pharmaceuticals and Prescription Drug Products. These mailings may contain coupons or offers from pharmaceutical manufacturers that enable you or your Dependents, at your discretion, to purchase the described Medical Pharmaceutical and Prescription Drug Product at a discount or to obtain it at no charge. Pharmaceutical manufacturers may pay for and/or provide the content for these mailings. Cigna, its affiliates and the plan are not myCigna.com8 responsible in any way for any decision you make in connection with any coupon, incentive, or other offer you may receive from a pharmaceutical manufacturer or Physician.

If Cigna determines that a Pharmacy, pharmaceutical manufacturer or other third party is or has waived, reduced, or forgiven any portion of the charges and/or any portion of Copayment, Deductible, and/or Coinsurance amount(s) you are required to pay for a Prescription Drug Product without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny the payment of plan benefits in connection with the Prescription Drug Product, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the Pharmacy, pharmaceutical manufacturer or other third party represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by the plan.

For example, if you use a coupon provided by a pharmaceutical manufacturer or other third party that discounts the cost of a Prescription Drug 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.

Specialty Prescription Drug Manufacturer Assistance and Support Benefit Certain Specialty Prescription Drugs on the Prescription Drug List will not have their cost applied toward satisfying the Out-of-Pocket Maximum. A list of these Specialty Prescription Drugs and the applicable Coinsurance for each Specialty Prescription Drug can be accessed at www.saveonsp.com/cigna.

This list will change from time to time.

If you are prescribed one of these Specialty Prescription Drugs, you will be contacted by SaveOn SP, LLC ("SaveOnSP") and required to enroll in the applicable prescription drug manufacturer assistance or support program.

Once enrolled, you provide SaveOn SP with consent to monitor your account. Any Coinsurance required for Specialty Prescription Drugs and/or any Coinsurance remaining after the available prescription drug manufacturer assistance is applied or is exhausted will be credited, and your Out-of-Pocket cost share will be reduced to $0.00. In the event you fail to enroll in the applicable prescription drug manufacturer assistance or support program, or you do not provide consent to SaveOnSP to monitor your account, you will be responsible for the full required Coinsurance for the Specialty Prescription Drug without such payment applying to the Out-of-Pocket Maximum.

In the event you enroll, or attempt to enroll, in the applicable/available prescription drug manufacturer assistance or support program and are denied any and all prescription drug manufacturer assistance or support due to a prescription drug manufacturer and/or legal restriction, the required Coinsurance for the Specialty Prescription Drugs will be credited and your Out-of-Pocket cost share will be reduced to $0.00, so long as you have given SaveOnSP consent to monitor your account.

HC-IMP331 12-22

Discrimination is Against the Law Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Cigna:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters

• Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as

• Qualified interpreters

• Information written in other languages

If you need these services, contact customer service at the toll-free phone number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by writing to the following address:

Cigna Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human myCigna.com9

Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

HC-NOT96 07-17

Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call

1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。

對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。

其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원

서비스를 무료로 이용하실 수 있습니다. 현재 Cigna

가입자님들께서는 ID 카드 뒷면에 있는 전화번호로

연락해주십시오. 기타 다른 경우에는 1.800.244.6224

(TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224

(TTY: 711).

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro

1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para

1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サー

ビスをご利用いただけます。現在のCignaの

お客様は、IDカード裏面の電話番号まで、お電話にてご

連絡ください。その他の方は、1.800.244.6224（TTY:

711）まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione.

In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung.

Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte

an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

myCigna.com10

HC-NOT97 07-17

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) - Non-Quantitative Treatment Limitations (NQTLs) Federal MHPAEA regulations provide that a plan cannot impose a Non-Quantitative Treatment Limitation (NQTL) on mental health or substance use disorder (MH/SUD) benefits in any classification unless the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits are comparable to, and are applied no more stringently than, those used in applying the NQTL to medical/surgical benefits in the same classification of benefits as written and in operation under the terms of the plan.

A description of your plan’s NQTL methodologies and processes applied to medical/surgical benefits and MH/SUD benefits is available by accessing the link at www.cigna.com/sp.

To determine which document applies to your plan, select the relevant health plan product; medical management model (inpatient only or inpatient and outpatient) which can be located in this booklet immediately following The Schedule;

and pharmacy coverage (whether or not your plan includes pharmacy coverage).

HC-NOT137 01-24

How To File Your Claim If your plan provides coverage when care is received only from In-Network providers, you may still have Out-of- Network claims (for example, when Emergency Services are received from an Out-of-Network provider) and should follow the claim submission instructions for those claims. Claims can be submitted by the provider if the provider is able and willing to file on your behalf. If the provider is not submitting on your behalf, you must send your completed claim form and itemized bills to the claims address listed on the claim form.

You may get the required claim forms from the website listed on your identification card or by using the toll-free number on your identification card.

CLAIM REMINDERS

• BE SURE TO USE YOUR MEMBER ID AND

ACCOUNT/GROUP NUMBER WHEN YOU FILE

CIGNA’S CLAIM FORMS, OR WHEN YOU CALL

YOUR CIGNA CLAIM OFFICE.

YOUR MEMBER ID IS THE ID SHOWN ON YOUR

BENEFIT IDENTIFICATION CARD.

YOUR ACCOUNT/GROUP NUMBER IS SHOWN ON

YOUR BENEFIT IDENTIFICATION CARD.

• BE SURE TO FOLLOW THE INSTRUCTIONS LISTED

ON THE BACK OF THE CLAIM FORM CAREFULLY

WHEN SUBMITTING A CLAIM TO CIGNA.

Timely Filing of Out-of-Network Claims Cigna will consider claims for coverage under our plans when proof of loss (a claim) is submitted within 180 days for Out-of-Network benefits after services are rendered. If services are rendered on consecutive days, such as for a Hospital Confinement, the limit will be counted from the last date of service. If claims are not submitted within 180 days for Out-of-Network benefits, the claim will not be considered valid and will be denied.

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information; or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.

HC-CLM25 01-11

V11

Eligibility - Effective Date

Employee Insurance This plan is offered to you as a retired Employee.

Eligibility for Employee Insurance You will become eligible for insurance on the date you retire if you are in a Class of Eligible Employees.

Eligibility for Dependent Insurance You will become eligible for Dependent Insurance on the later of:

• the day you become eligible for yourself; or

• the day you acquire your first Dependent.

myCigna.com11

Classes of Eligible Employees Each retired Employee as reported to the insurance company by your former Employer.

Effective Date of Employee Insurance You will become insured on the date you elect the insurance by signing a written agreement with the Policyholder to make the required contribution, but no earlier than the date you become eligible. To be insured for these benefits, you must elect the insurance for yourself no later than 30 days after your retirement.

Dependent Insurance For your Dependents to be insured, you will have to pay the required contribution, if any, toward the cost of Dependent Insurance.

Effective Date of Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by signing a written agreement with the Policyholder to make the required contribution, 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.

Your Dependents will be insured only if you are insured.

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 60 days after his birth. If you do not elect to insure your newborn child within such 60 days, coverage for that child will end on the 60th day. No benefits for expenses incurred beyond the 60th day will be payable.

HC-ELG274M 01-19

Important Information About Your Medical Plan Details of your medical benefits are described on the following pages.

Primary Care Physician This medical plan does not require that you select a Primary Care Physician or obtain a referral from a Primary Care Physician in order to receive all benefits available to you under this medical plan. Notwithstanding, a Primary Care Physician may serve an important role in meeting your health care needs by providing or arranging for medical care for you and your Dependents. For this reason, we encourage the use of Primary Care Physicians and provide you with the Primary Care Physician from a list provided by Cigna for yourself and your Dependents. If you choose to select a Primary Care Physician, the Primary Care Physician you select for yourself may be different from the Primary Care Physician you select for each of your Dependents. If you need assistance selecting your Primary Care Physician, please visit our website at www.cigna.com or call the number on the back of your ID Card.

The Primary Care Physician's role is to provide or arrange for medical care for you and any of your Dependents.

Referrals to Specialists You must obtain a referral from your Primary Care Physician before visiting any provider other than your Primary Care Physician. The referral authorizes the specific number of visits that you may make to the provider within a specified period of time.

Changing Primary Care Physicians You may request a transfer from one Primary Care Physician to another by visiting our website at www.cigna.com or calling the number on the back of your ID Card. Any such transfer will be effective on the first day of the month following the month in which the processing of the change request is completed.

In addition, if at any time a Primary Care Physician ceases to be a Participating Provider, you or your Dependent will be notified.

Selection of a Primary Care Physician This plan requires the designation of a Primary Care Physician for yourself and your Dependents. You have the right to designate any Primary Care Physician who participates in the network and who is available to accept you or your family members. The Primary Care Physician you select for yourself may be different from the Primary Care Physician you select for each of your Dependents. Until you make this designation, Cigna designates one for you. For information on how to select a Primary Care Physician, and for a list of participating Primary Care Physicians, visit our website at www.cigna.com or call the number on the back of your ID Card. For children, you may designate a pediatrician as the Primary Care Physician.

Direct Access For Mental Health and Substance Use Disorder Services You are allowed direct access to a licensed/certified Participating Provider for covered Mental Health and Substance Use Disorder Services. There is no requirement to obtain an authorization of care from your Primary Care Physician for individual or group therapy visits to the myCigna.com12

Participating Provider of your choice for Mental Health and Substance Use Disorder.

HC-IMP361 01-24

myCigna.com13

Network Medical Benefits

The Schedule For You and Your Dependents

Network Medical Benefits provide coverage for care In-Network. To receive Network Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services and supplies. That portion is the Copayment, Deductible or Coinsurance.

When you receive services from an In-Network Provider, remind your provider to utilize In-Network Providers for x-rays, lab tests and other services to ensure the cost may be considered at the In-Network level.

If you are unable to locate an In-Network Provider in your area who can provide you with a service or supply that is covered under this plan, you must call the number on the back of your I.D. card to obtain authorization for Out-of- Network Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, benefits for those services will be covered at the In-Network benefit level.

Important Notice on Mental Health and Substance Use Disorder Coverage Covered medical services received to diagnose or treat a Mental Health or Substance Use Disorder condition will be payable according to the Mental Health and Substance Use Disorder sections of The Schedule.

Coinsurance The term Coinsurance means the percentage of Covered Expenses that an insured person is required to pay under the plan in addition to the Deductible, if any.

Copayments/Deductibles Copayments are amounts to be paid by you or your Dependent for covered services. Deductibles are Covered Expenses to be paid by you or your Dependent before benefits are payable under this plan. Deductible amounts are separate from and not reduced by Copayments. Copayments and Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached, you and your family need not satisfy any further medical deductible for the rest of that year.

Contract Year Contract Year means a 12 month period beginning on each 07/01.

Out-of-Pocket Expenses

Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan. The following Expenses contribute to the Out-of-Pocket Maximum, and when the Out-of-Pocket Maximum shown in The Schedule is reached, they are payable by the benefit plan at 100%:

• Coinsurance.

• Plan Deductible.

• Copays The following Out-of-Pocket Expenses and charges do not contribute to the Out-of-Pocket Maximum, and they are not payable by the benefit plan at 100% when the Out-of-Pocket Maximum shown in The Schedule is reached:

• Non-compliance penalties..

myCigna.com14

The Schedule Guest Privileges If you or one of your Dependents will be residing temporarily in another location where there are In-Network Providers, you may be eligible for Point of Service Medical Benefits at that location. However, the benefits available at the host location may differ from those described in this certificate. Refer to your Benefit Summary from the host location or contact your Employer for more information.

Assistant Surgeon and Co-Surgeon Charges

Assistant Surgeon The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed a percentage of the surgeon's allowable charge as specified in Cigna Reimbursement Policies. (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.)

Co-Surgeon The maximum amount payable for charges made by co-surgeons will be limited to the amount specified in Cigna Reimbursement Policies.

BENEFIT HIGHLIGHTS IN-NETWORK

Lifetime Maximum Unlimited

The Percentage of Covered Expenses the Plan Pays

100%

See Definitions section for an explanation of Maximum Reimbursable Charge.

Note:

"No charge" means an insured person is not required to pay Coinsurance.

Contract Year Deductible Individual $500 per person Family Maximum $1,000 per family Family Maximum Calculation Individual Calculation:

Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance.

myCigna.com15

BENEFIT HIGHLIGHTS IN-NETWORK

Out-of-Pocket Maximum

Individual $6,350 per person Family Maximum $12,700 per family Family Maximum Calculation Individual Calculation:

Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%.

Combined Medical/Pharmacy Out-of-Pocket Maximum

Combined Medical/Pharmacy Out-of-Pocket:

includes retail and home delivery drugs

Yes

Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Out-of-Pocket Maximum

Yes

Physician’s Services Primary Care Physician’s Office Visit No charge after $40 per office visit copay

Specialty Care Physician’s Office Visits Consultant and Referral Physician’s Services

No charge after $60 per office visit copay

Note:

OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company.

Surgery Performed in the Physician’s Office No charge after the $40 PCP or $60 Specialist per office visit copay Second Opinion Consultations (provided on a voluntary basis)

No charge after the $40 PCP or $60 Specialist per office visit copay

Allergy Treatment/Injections No charge Allergy Serum (dispensed by the Physician in the office)

No charge myCigna.com16

Convenience Care Clinic No charge after the $40 per office visit copay Virtual Care

Dedicated Virtual Providers Services available through contracted virtual providers as medically appropriate.

Urgent Virtual Care Services No charge after the $40 PCP per office visit copay

Notes:

Dedicated Virtual Providers may deliver services that are payable under other benefits (e.g., Preventive Care, Primary Care Physician, Behavioral; Dermatology/Specialty Care Physician).

Lab services supporting a virtual visit must be obtained through dedicated labs.

Virtual Physician Services Services available through Physicians as medically appropriate.

Note:

Physicians may deliver services virtually that are payable under other benefits (e.g., Preventive Care, Outpatient Therapy Services).

Physician Virtual Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay myCigna.com17

Preventive Care

Note:

Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit.

Routine Preventive Care: Well-Baby, Well-Child, Adult and Well-Woman (including immunizations)

No charge

Note:

Well-Woman OB/GYN visits will be considered either as a PCP or Specialist depending on how the provider contracts with the Insurance Company.

Immunizations No charge

Mammograms, PSA, PAP Smear

Preventive Care Related Services (i.e. “routine” services)

100% after plan deductible

Diagnostic Related Services (i.e. “non-routine” services)

Subject to the plan’s x-ray & lab benefit; based on place of service

Note:

The associated wellness exam is subject to the $40 PCP or $60 Specialist per office visit copay.

Inpatient Hospital - Facility Services No charge after plan deductible

Semi-Private Room and Board Limited to the semi-private negotiated rate Private Room Limited to the semi-private negotiated rate Special Care Units (ICU/CCU) Limited to the negotiated rate

Outpatient Facility Services

Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room

No charge after plan deductible

Inpatient Hospital Physician’s Visits/Consultations

No charge

Inpatient Hospital Professional Services No charge

Surgeon

Radiologist Pathologist Anesthesiologist myCigna.com18

Outpatient Professional Services No charge

Surgeon Radiologist Pathologist Anesthesiologist

Urgent Care Services Physician’s Office Visit

No charge after the $40 PCP or $60 Specialist per office visit copay

Urgent Care Facility or Outpatient Facility No charge after $80 per visit copay (Copay waived if admitted)

Outpatient Professional Services (radiology, pathology, physician)

No charge

X-ray and/or Lab performed at the Urgent Care Facility (billed by the facility as part of the UC visit)

No charge

Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.)

No charge

Emergency Services Physician’s Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Hospital Emergency Room No charge after $300 per visit copay (Copay waived if admitted)

Outpatient Professional Services (radiology, pathology, ER physician)

No charge

X-ray and/or Lab performed at the Emergency Room Facility (billed by the facility as part of the ER visit)

No charge

Independent X-ray and/or Lab Facility in conjunction with an ER visit

No charge

Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.)

No charge

Air Ambulance No charge

Ambulance No charge myCigna.com19

Inpatient Services at Other Health Care Facilities Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub-Acute Facilities

No charge after plan deductible

Contract Year Maximum:

60 days combined No prior hospitalization required.

Laboratory and Radiology Services (includes pre-admission testing)

Physician’s Office Visit

Outpatient Hospital Facility No charge after plan deductible for facility charges; no charge for outpatient professional charges

Independent X-ray and/or Lab Facility

Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans and PET Scans)

Physician’s Office Visit No charge

Inpatient Facility No charge after plan deductible

Outpatient Facility No charge after plan deductible

Outpatient Therapy Services and Chiropractic Services

Contract Year Maximum:

60 days for all therapies combined

No charge after the $40 per office visit copay

(The limit is not applicable to mental health conditions.)

Includes:

Physical Therapy Speech Therapy Occupational Therapy Pulmonary Rehab Cognitive Therapy Chiropractic Therapy (includes Chiropractors)

Note:

The Outpatient Therapy Services copay does not apply to services provided as part of a Home Health Care Services visit.

Outpatient Cardiac Rehabilitation

Contract Year Maximum:

Unlimited

No charge after the $40 per office visit copay

Home Health Care Services Contract Year Maximum:

Unlimited (includes outpatient private nursing when approved as Medically Necessary) myCigna.com20

Hospice Inpatient Services No charge after plan deductible Outpatient Services (same coinsurance level as Home Health Care Services)

No charge

Bereavement Counseling Services Provided as part of Hospice Care

Inpatient No charge after plan deductible Outpatient No charge Services Provided by Mental Health Professional Covered under Mental Health benefit .

Gene Therapy Includes prior authorized gene therapy products and services directly related to their administration, when Medically Necessary.

Gene therapy must be received at an In-Network facility specifically contracted with Cigna to provide the specific gene therapy. Gene therapy at other In- Network facilities is not covered.

Gene Therapy Product Subject to In-Network facility cost share based on place of service; separate from facility charges

Inpatient Facility No charge after plan deductible

Outpatient Facility No charge after plan deductible

Physician’s Services No charge

Travel Maximum:

$10,000 per episode of gene therapy

No charge (available only for travel when prior authorized to receive gene therapy at a participating In-Network facility specifically contracted with Cigna to provide the specific gene therapy) myCigna.com21

Advanced Cellular Therapy Includes prior authorized advanced cellular therapy products and related services when Medically Necessary.

Advanced Cellular Therapy Product 100% after plan deductible

Inpatient Facility No charge after plan deductible

Outpatient Facility No charge after plan deductible

Physician’s Services No charge

Advanced Cellular Therapy Travel Maximum:

$10,000 per episode of advanced cellular therapy (Available only for travel when prior authorized to receive advanced cellular therapy from a provider located more than 60 miles of your primary residence and is contracted with Cigna for the specific advanced cellular therapy product and related services.)

No charge

Maternity Care Services Initial Visit to Confirm Pregnancy No charge after the $40 PCP or $60 Specialist per office visit copay

Note:

OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company.

All subsequent Prenatal Visits, Postnatal Visits and Physician’s Delivery Charges (i.e. global maternity fee)

No charge

Physician’s Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist

No charge after the $40 PCP or $60 Specialist per office visit copay

Delivery - Facility (Inpatient Hospital, Birthing Center)

No charge after plan deductible

Abortion Includes only non-elective procedures

Physician’s Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Inpatient Facility No charge after plan deductible

Outpatient Facility No charge after plan deductible

Physician’s Services No charge myCigna.com22

Women’s Family Planning Services Physician’s Office Visit (tests, counseling) No charge

Note:

Includes coverage for contraceptive devices (e.g., Depo-Provera and Intrauterine Devices (IUDs)) as ordered or prescribed by a physician. Diaphragms also are covered when services are provided in the physician’s office.

Surgical Sterilization Procedures for Tubal Ligation (excludes reversals)

Physician’s Office Visit No charge Inpatient Facility No charge Outpatient Facility No charge Physician’s Services No charge

Men’s Family Planning Services Physician’s Office Visit (tests, counseling) No charge after the $40 PCP or $60 Specialist per office visit copay

Surgical Sterilization Procedures for Vasectomy (excludes reversals)

Physician’s Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Inpatient Facility No charge after plan deductible Outpatient Facility No charge after plan deductible Physician’s Services No charge

Infertility Services Services Not Covered include:

• Testing performed specifically to determine the cause of infertility.

• Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility condition).

• Artificial means of becoming pregnant (e.g.

Artificial Insemination, In-vitro, GIFT, ZIFT, etc).

Note:

Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness.

Not Covered myCigna.com23

Transplant Services and Related Specialty Care

Includes all medically appropriate, non-experimental transplants

Physician’s Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Inpatient Facility No charge after plan deductible

Inpatient Physician’s Services No charge

Lifetime Travel Maximum:

Unlimited

No charge (only available when using LifeSOURCE facility)

Durable Medical Equipment Contract Year Maximum:

Unlimited

No charge

Outpatient Dialysis Services

Physician's Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Outpatient Facility No charge after plan deductible

Physician's Services No charge

Home Setting No charge

Breast Feeding Equipment and Supplies Note:

Includes the rental of one breast pump per birth as ordered or prescribed by a physician. Includes related supplies.

No charge

External Prosthetic Appliances

Contract Year Maximum:

Unlimited myCigna.com24

Hearing Services Contract Year Maximum:

1 Hearing Exam

No charge after the $60 per office visit copay

Nutritional Counseling

Contract Year Maximum:

3 visits per person however, the 3 visit limit will not apply to treatment of mental health and substance use disorder conditions.

Physician’s Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Inpatient Facility No charge after plan deductible

Genetic Counseling Contract Year Maximum:

3 visits per person for Genetic Counseling for both pre- and post-genetic testing; however, the 3 visit limit will not apply to Mental Health and Substance Use Disorder conditions.

Physician’s Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Inpatient Facility No charge after plan deductible

Outpatient Facility No charge after plan deductible

Physician’s Services No charge

Dental Care Limited to charges made for a continuous course of dental treatment for an Injury to teeth.

Physician’s Office Visit No charge after the $40 PCP or $60 Specialist per office visit copay

Inpatient Facility No charge after plan deductible myCigna.com25

Routine Foot Disorders Not covered except for services associated with foot care for diabetes, peripheral neuropathies and peripheral vascular disease when Medically Necessary.

Mental Health Inpatient Includes Acute Inpatient and Residential Treatment

Contract Year Maximum:

Unlimited

No charge after plan deductible

Outpatient Outpatient - Office Visits

Includes individual, family and group psychotherapy; medication management, virtual care, etc.

Contract Year Maximum:

Unlimited

$40 per visit copay

Outpatient - All Other Services Includes Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy), Transcranial Magnetic Stimulation (TMS), etc.

Contract Year Maximum:

Unlimited

100% myCigna.com26

Substance Use Disorder Inpatient Includes Acute Inpatient Detoxification, Acute Inpatient Rehabilitation and Residential Treatment

Contract Year Maximum:

Unlimited

No charge after plan deductible

Outpatient Outpatient - Office Visits

Includes individual, family and group psychotherapy; medication management, virtual care, etc.

Contract Year Maximum:

Unlimited

$40 per visit copay

Outpatient - All Other Services Includes Outpatient Detoxification, Partial Hospitalization, Intensive Outpatient Services, etc.

Contract Year Maximum:

Unlimited

100% myCigna.com27

Prior Authorization/Pre-Authorized The term Prior Authorization means the approval that a Participating Provider must receive from the Review Organization, prior to services being rendered, in order for certain services and benefits to be covered under this policy.

Services that require Prior Authorization include, but are not limited to:

• inpatient Hospital services, except for 48/96 hour maternity stays.

• inpatient services at any participating Other Health Care

Facility.

• residential treatment.

• outpatient facility services.

• partial hospitalization.

• advanced radiological imaging.

• non-emergency Ambulance.

• certain Medical Pharmaceuticals.

• home health care services.

• radiation therapy.

• transplant services.

HC-PRA55 01-22

V1

Covered Expenses The term Covered Expenses means expenses incurred by a person while covered under this plan for the charges listed below for:

• preventive care services; and

• services or supplies that are Medically Necessary for the care and treatment of an Injury or a Sickness, as determined by Cigna.

As determined by Cigna, Covered Expenses may also include all charges made by an entity that has directly or indirectly contracted with Cigna to arrange, through contracts with providers of services and/or supplies, for the provision of any services and/or supplies listed below. Any applicable Copayments, Deductibles or limits are shown in The Schedule.

Covered Expenses

• charges for inpatient Room and Board and other Necessary

Services and Supplies made by a Hospital, subject to the limits as shown in The Schedule.

• charges for inpatient Room and Board and other Necessary Services and Supplies made by an Other Health Care Facility, including a Skilled Nursing Facility, a Rehabilitation Hospital or a subacute facility as shown in The Schedule.

• charges for licensed Ambulance service to the nearest Hospital where the needed medical care and treatment can be provided.

• charges for outpatient medical care and treatment received at a Hospital.

• charges for outpatient medical care and treatment received at a Free-Standing Surgical Facility.

• charges for Emergency Services.

• charges for Urgent Care.

• charges by a Physician or a Psychologist for professional services.

• charges by a Nurse for professional nursing service.

• charges for anesthetics, including, but not limited to supplies and their administration.

• charges for diagnostic x-ray.

• charges for advanced radiological imaging, including for example CT Scans, MRI, MRA and PET scans and laboratory examinations, x-ray, radiation therapy and radium and radioactive isotope treatment and other therapeutic radiological procedures.

• charges for chemotherapy.

• charges for blood transfusions.

• charges for oxygen and other gases and their administration.

• charges for Medically Necessary foot care for diabetes, peripheral neuropathies, and peripheral vascular disease.

• charges for screening prostate-specific antigen (PSA) testing.

• charges for laboratory services, radiation therapy and other diagnostic and therapeutic radiological procedures.

• charges made for Family Planning, including medical history, physical exam, related laboratory…