3-Medical Extra Territorial Legislation.pdf

City of Lewisville

EXTRATERRITORIAL LEGISLATION

EFFECTIVE DATE: January 1, 2026

ETALLM26A

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 – California Residents CERTIFICATE RIDER – Delaware Residents CERTIFICATE RIDER – Florida Residents CERTIFICATE RIDER – Georgia Residents CERTIFICATE RIDER – Illinois Residents CERTIFICATE RIDER – Indiana Residents CERTIFICATE RIDER – Kansas Residents CERTIFICATE RIDER – Louisiana Residents CERTIFICATE RIDER – Michigan Residents CERTIFICATE RIDER – Minnesota Residents CERTIFICATE RIDER – Montana Residents CERTIFICATE RIDER – South Carolina Residents CERTIFICATE RIDER – South Dakota Residents CERTIFICATE RIDER – Utah Residents CERTIFICATE RIDER – Washington Residents CERTIFICATE RIDER – West Virginia 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 – 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.

HC-ETCARDR

Your Rights Under HIPAA If You Lose Group Coverage Federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects health insurance coverage for workers and their families when they change or lose their jobs. California law provides similar and additional protections. If you lose group health insurance coverage and meet certain criteria, you are entitled to purchase individual health coverage (non-group) from any health plan that sells individual coverage for hospital, medical or surgical benefits.

Every health plan that sells individual health coverage for these benefits must offer individual coverage to an eligible person under HIPAA. The health plan cannot reject your application if: you are an eligible person under HIPAA; you agree to pay the required premiums; and you live or work inside the plan's service area. To be considered an eligible person under HIPAA you must meet the following requirements:

• you have 18 or more months of creditable coverage without a break of 63 days or more between any of the periods of creditable coverage or since your most recent coverage was terminated;

• your most recent creditable coverage was a group, government or church plan that provided hospital, medical or surgical benefits. (COBRA and Cal-COBRA are considered group coverage);

• you were not terminated from your most recent creditable coverage due to nonpayment of premiums or fraud;

• you are not eligible for coverage under a group health plan, Medicare, or Medicaid (Medi-Cal);

• you have no other health insurance coverage; and

• you have elected and exhausted any continuation coverage you were offered under COBRA or Cal-COBRA.

There are important choices you need to make in a very short time frame regarding the options available to you following termination of your group health care coverage. You should read carefully all available information regarding HIPAA coverage so you can understand fully the special protections of HIPAA coverage and make an informed comparison and choice regarding available coverage. For more information, please call the number on your ID card.

If you believe your HIPAA rights have been violated, you should contact the CA Department of Insurance or visit the Department’s web site.

HC-IMP357 01-23

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The Schedule The introductory paragraph regarding “Contract Year” in The Schedule of your medical certificate is hereby amended to read as follows:

Contract Year Contract Year means a 12 month period beginning at 12:01 a.m. on 01/01/2026 or any renewal term and ending at 12:01 a.m. on the next anniversary of that date.

SCHED CA ET3

The Schedule The following paragraphs are added to, and replace any similar provision in The Schedule of your medical certificate:

Out-of-Network Charges for Certain Services Charges for services furnished by an Out-of-Network provider in an In-Network facility while you are receiving In-Network services at that In-Network facility: (i) are payable at the In-myCigna.com6

Network cost-sharing level; and (ii) the allowable amount used to determine the Plan’s benefit payment is the amount agreed to by the Out-of-Network provider and Cigna, or as required by applicable state or Federal law.

The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is not responsible for any charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card.

If services are rendered in California by a California-licensed non-Participating Provider as part of covered non-Emergency Services in an In-Network facility any In-Network cost-sharing will be apply to any In-Network Deductible and Out-of-Pocket Maximum.

In certain situations when services are rendered in California, you may voluntarily choose to pay the Out-of-Network cost share to a California-licensed non-Participating Provider who provides services as part of covered non-Emergency Services in an In-Network facility. If you and the non-Participating Provider agree to this arrangement, the non-Participating Provider must receive your written authorization at least 24 hours in advance of providing service. The non-Participating Provider must also provide you with a written estimate of your total out-of-pocket cost for the care prior to obtaining your consent. When submitting the claim, the non-Participating provide must include a copy of such authorization with the request for reimbursement. You may always seek care from a Participating Provider and you may call the number on the back of your ID card for assistance in finding a Participating Provider and arranging for services from a Participating Provider.

SCHED CA ET4

Covered Expenses

• charges made for or in connection with mammograms for breast cancer screenings or diagnostic purposes including, but not limited to: a baseline mammogram for women age 35, but less than 40; a mammogram for women age 40, but less than 50, every two years or more, if Medically Necessary and if recommended by a Physician, nurse practitioner or a nurse midwife; and a mammogram every year for women age 50 and over.

• charges for standard fertility preservation services when a covered treatment may directly or indirectly cause iatrogenic infertility. Iatrogenic is infertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment. As used here, ‘directly or indirectly’ means medical treatment with a possible side effect of infertility, as established by the American Society of Clinical Oncology or the American Society for Reproductive Medicine. As used here, ‘standard’ means fertility preservation services consistent with the established medical practices and professional guidelines published by the American Society of Clinical Oncology or the American Society for Reproductive Medicine.

HC-COV1019 01-23

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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). It also includes a stepchild, a grandchild who lives with you, or a child for whom you are the legal guardian. If your Domestic Partner has a child, that child will also be included as a Dependent.

HC-DFS1833 01-23

ET2

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.

HC-DFS167 04-10

V2-ET1

myCigna.com7

CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Delaware Residents

Rider Eligibility: Each Employee who is located in Delaware

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

HC-ETDERDR

The Schedule The pharmacy Schedule is amended to indicate the following:

You may receive coverage for up to a 90-day supply of a covered Prescription Drug Product dispensed by a Retail Network Pharmacy or a Home Delivery Network Pharmacy.

The amount you pay for a up to 90-day supply of a Prescription Drug Product at a Retail Network Pharmacy or a Home Delivery Network Pharmacy will be 3X the Copay for a 30-day supply at a Retail Network Pharmacy and the same Coinsurance as a Retail Network Pharmacy.

If Specialty Drugs are limited to a 30-day supply at a Home Delivery Network Pharmacy then the following will apply:

Specialty Prescription Drug Products are limited to up to a consecutive 30-day supply per Prescription Order or Refill and are subject to the same Copayment or Coinsurance that applies to Retail Pharmacies.

SCHED90EQ-deet

Prescription Drug Benefits Limitations Emergency Supplies of Prescription Drug Products Coverage includes immediate access, without prior authorization, to a 5-day emergency supply of covered, prescribed medications for the Medically Necessary treatment of serious mental illnesses and drug and alcohol dependencies, where an Emergency Medical Condition exists. The emergency supply requirement includes prescribed medications for opioid overdose reversal that are otherwise covered under the health benefit plan.

HC-PHR787 01-25

ET1

Definitions Drug and Alcohol Dependencies Drug and Alcohol Dependencies means Substance Abuse Disorder or the chronic, habitual, regular, or recurrent use of alcohol, inhalants, or controlled substances as identified in Delaware law.

HC-DFS1052 11-17

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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.

myCigna.com8

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

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.

As required by law, Cigna or its affiliates must use rebates or other remuneration from pharmaceutical manufacturers to either reduce your Deductible, Coinsurance, Copayment that you pay at the point-of-sale for Medical Pharmaceuticals covered under your plan and Prescription Drug Products or apply such amounts to reduce the cost of future premiums.

HC-IMP463 01-26

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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 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.

HC-ELG326 03-21

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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.

myCigna.com9

• 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.

HC-COV1498 01-25

ET1

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.

• 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 myCigna.com10 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

V1-ET

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 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-EXC600 01-25

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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;

myCigna.com11

• 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-DFS1978 01-25

V1-ET

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 Information “If Cigna determines… required to pay.” is included in the Important Information section of your certificate, it does not apply to you.

Coupons, Incentives and Other Communications 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 myCigna.com12 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.

HC-IMP408 01-25

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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 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 myCigna.com13

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

V1 ET

Covered Expenses

• charges for anesthesia and associated facility charges for dental care provided in a Hospital or ambulatory surgical facility to a covered person who is age 6 or younger; or has a medical condition that requires hospitalization or general anesthesia for dental care, or is a person with a disability.

Charges for anesthesia provided in a dentist or oral surgeon’s office for dental care provided to a covered person who is under age 26 and has been diagnosed with an autism spectrum disorder or a developmental disability are also covered.

• 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 delegated authority to provide breast examinations. Coverage shall include such an exam at least once every three years for women ages 20 to 40; and annually for women 40 years of age or older.

• charges for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome, including, but not limited to the use of intravenous immunoglobin therapy.

• charges for donated breast milk for a covered Dependent child age 12 months or younger, when prescribed by a licensed medical practitioner and all of the following conditions are met:

• the milk is obtained from a human milk bank licensed by the Department of Public Health or that meets Human Milk Banking Association quality guidelines; and

• the child’s mother is medically or physically unable to produce, or unable to produce sufficient quantities of, maternal breast milk, or the maternal breast milk is contraindicated; and

• the milk is Medically Necessary for the child; and

• one or more of the following applies to the child: birth weight is below 1,500 grams; congenital or acquired condition that places the child at high risk for development of necrotizing enterocolitis; hypoglycemia;

congenital heart disease; has had or will have an organ transplant; sepsis; or any other serious congenital or acquired condition for which the use of donated human breast milk is Medically Necessary and supports treatment or recovery of the child.

• charges for long-term antibiotic therapy, including necessary office visits and ongoing test, for a person with a tick-borne disease when determined to be Medically Necessary and ordered by a Physician licensed to practice medicine in all its branches after making a thorough evaluation of the person’s symptoms, diagnostic test results, or response to treatment. An experimental drug must be covered as a long-term antibiotic therapy if it is approved for an indication by the United States Food and Drug myCigna.com14

Administration. A drug, including an experimental drug, shall be covered for an off-label use in the treatment of a tick-borne disease if the drug has been approved by the United States Food and Drug Administration.

• charges for one annual office visit for a whole body skin examination for lesions suspicious for skin cancer.

Virtual Physician Services Includes charges for the delivery of real-time medical and health-related services and consultations as medically appropriate through audio, video and secure internet-based technologies that are similar to office visit services provided in a face-to-face setting.

Includes charges for the delivery of real-time mental health and Substance Use Disorder consultations and services, via secure telecommunications technologies that shall include video capability, telephone and internet, when such consultations and services are delivered by a behavioral provider and are similar to office visit services provided in a face-to-face setting.

HC-COV1582 01-24

ET3

Mental Health and Substance Use Disorder Services The plan covers charges for mental health and substance use disorder services.

Coverage includes:

• charges for one annual mental health prevention and wellness visit for a covered person regardless of age, not subject to any member cost share after Deductible is satisfied, when the visit is with a Participating Provider.

• charges for treatment of mental health and substance use disorder conditions related to pregnancy or postpartum complications. Medical Necessity for the first 48 hours of covered mental health and/or substance use disorder services must be determined solely by the provider.

• charges for evidence-based early treatment of a serious mental illness in a covered person under age 26:

• coordinated specialty care for first episode psychosis treatment based on the Recovery After an Initial Schizophrenia Episode (RAISE) treatment model, excluding education and employment support elements of the model.

• assertive community treatment (ACT) and community support team (CST) treatment. ACT and CST both mean bundled services delivered through a multi-disciplinary team of Mental Health professionals.

Medically Necessary treatment that is otherwise eligible for coverage under this plan cannot be limited or excluded on the basis that the treatment should be or is covered by a public entitlement program, including but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance.

Mental Health Disorders are conditions which consider the following factors as defined in the current version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM):

• a behavioral or psychological syndrome or pattern that occurs in an individual.

• reflects an underlying psychobiological dysfunction.

• the consequences of which are clinically significant distress

(such as a painful symptom) or disability (such as impairment in one or more important areas of functioning).

• must not be merely an expected response to common stressors and losses (such as loss of a loved one) or a culturally sanctioned response to a particular event (such as trance states in religious rituals).

• primarily a result of social deviance or conflicts with society.

Substance Use Disorders involve patterns of symptoms caused by using a substance that an individual continues taking despite its negative effects, considering the following factors as defined in the current version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM):

• using more of a substance than intended or using it for longer than a person is meant to use it.

• trying to cut down or stop using the substance, but unable to do so.

• experiencing intense cravings or urges to use the substance.

• needing more of the substance to get a desired effect, also referred to as tolerance.

• developing withdrawal symptoms when not using the substance.

• spending more time getting and using drugs and recovering from substance use.

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• neglecting responsibilities at home, work, or school because of substance use.

• continuing to use the substance despite the substance causing problems to physical or mental health.

• giving up important or desirable social and recreational activities due to substance use.

• using substances in risky settings that put you or your Dependent in danger.

Inpatient Mental Health Services (including Mental Health Acute Inpatient Services and Mental Health Residential Treatment Services) Mental Health Acute Inpatient Services are services provided by a Hospital while you or your Dependent are Confined in a Hospital for evaluation and treatment of an acute Mental Health Disorder.

Mental Health Residential Treatment Services are services provided by a Hospital or Mental Health Residential Treatment Center while you or your Dependent are Confined in a Hospital or Residential Treatment Center for the evaluation and treatment of a subacute Mental Health Disorder.

Mental Health Residential Treatment Center means an institution which specializes in the treatment of psychological and social disturbances that are the result of a Mental Health Disorder; provides a subacute, structured, psychotherapeutic treatment program, under the supervision of Physicians;

provides 24-hour care, in which a person lives in an open setting; and is licensed in accordance with the laws of the appropriate legally authorized agency as a Mental Health Residential Treatment Center.

Outpatient Mental Health Services (including Mental Health Partial Hospitalization and Mental Health Intensive Outpatient Services) Outpatient Mental Health Services are services provided by providers who are licensed or certified in accordance with the laws of the appropriate legally authorized agency and qualified to treat Mental Health Disorders when treatment is provided on an outpatient basis, while you or your Dependent are not Confined in a Hospital or Mental Health Residential Treatment Center, for evaluation and treatment of a Mental Health Disorder.

Mental Health Partial Hospitalization Services are active, time-limited, ambulatory mental health treatment programs that offer therapeutically intensive, structured, and coordinated clinical services for Mental Health Disorders, similar in intensity to that provided in an Inpatient Hospital or Mental

Health Residential Treatment Center, but for individuals who can maintain personal safety with support systems in the community.

Mental Health Intensive Outpatient Services are active, time-limited, ambulatory mental health treatment programs that offer structured and coordinated, multi-disciplinary clinical services for Mental Health Disorders for individuals who can maintain personal safety with support systems in the community, and who can maintain some ability to fulfill family, student or work activities.

Inpatient Substance Use Disorder Services (including Acute Inpatient Detoxification, Substance Use Disorder Inpatient Rehabilitation, Substance Use Disorder Residential Treatment Services) Acute Inpatient Detoxification Services are services provided by a Hospital or Substance Use Disorder Residential Treatment Center for around-the-clock, intensive management and monitoring of individuals requiring acute detoxification as the initial phase of evaluation and treatment for a Substance Use Disorder.

Substance Use Disorder Inpatient Treatment Services are services provided by a Hospital while you or your Dependent are Confined in a Hospital for evaluation and treatment of an acute Substance Use Disorder.

Substance Use Disorder Residential Treatment Services are services provided by a Hospital or Substance Use Disorder Residential Treatment Center while you or your Dependent are Confined in a Hospital or Residential Treatment Center for evaluation and treatment of a subacute Substance Use Disorder.

Substance Use Disorder Residential Treatment Center means an institution which specializes in the treatment of psychological and social disturbances that are the result of a Substance Use Disorder; provides a subacute, structured, psychotherapeutic treatment program, under the supervision of Physicians; provides 24-hour care, in which a person lives in an open setting; and is licensed in accordance with the laws of the appropriate legally authorized agency as a Substance Use Disorder Residential Treatment Center.

Outpatient Substance Use Disorder Rehabilitation Services (including Outpatient Detoxification, Substance Use Disorder Partial Hospitalization, and Substance Use Disorder Intensive Outpatient Services) Outpatient Substance Use Disorder Services are services provided by providers who are licensed or certified in accordance with the laws of the appropriate legally authorized myCigna.com16 agency and qualified to treat Substance Use Disorders when treatment is provided on an outpatient basis, while you or your Dependent are not Confined in a Hospital or Substance Use Disorder Residential Treatment Center, for evaluation and treatment of a Substance Use Disorder.

Substance Use Disorder Partial Hospitalization Services are active, time-limited, ambulatory substance use disorder treatment programs that offer therapeutically intensive, structured, and coordinated clinical services for Substance Use Disorders, similar in intensity to that provided in an Inpatient Hospital or Substance Use Disorder Residential Treatment Center, but for individuals who can maintain personal safety with support systems in the community.

Substance Use Disorder Intensive Outpatient Services are active, time-limited, ambulatory substance use disorder treatment programs that offer structured and coordinated, multi-disciplinary clinical services for Substance Use Disorders for individuals who can maintain personal safety with support systems in the community, and who can maintain some ability to fulfill family, student or work activities.

Substance Use Disorder Detoxification Services are services provided for daily, active comprehensive management and monitoring of individuals requiring detoxification as part of evaluation and treatment of a Substance Use Disorder, but that do not require a person to be Confined in a Hospital or Substance Use Disorder Residential Treatment Center.

Detoxification and related medical ancillary services are provided when required for the diagnosis and treatment of addiction to alcohol and/or drugs.

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Durable Medical Equipment Illinois requires coverage for cardiopulmonary monitors determined to be Medically Necessary for a person 18 years old or younger who has had a cardiopulmonary event.

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Prescription Drug Benefits Covered Expenses

• charges for Medically Necessary epinephrine injectors for persons age 18 and younger.

Prescription Drug List Exceptions Cigna maintains a medical exceptions process which allows for the request of any clinically appropriate Prescription Drug Product when the:

• drug is not covered based on the plan's Prescription Drug

List;

• plan is discontinuing coverage of the drug on the plan's

Prescription Drug List for reasons other than safety or other than because the Prescription Drug Product has been withdrawn from the market by the drug's manufacturer;

• prescription drug alternatives required to be used in accordance with a step therapy requirement has been ineffective in the treatment of your disease or medical condition or, based on both sound clinical evidence and medical and scientific evidence, the known relevant physical or mental characteristics, and the known characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug's effectiveness or patient compliance or has caused or, based on sound medical evidence, is likely to cause an adverse reaction or harm to you or your Dependent; or

• number of doses available under a dose restriction for the Prescription Drug Product has been ineffective in the treatment of your disease or medical condition or based on both sound clinical evidence and medical and scientific evidence, the known relevant physical and mental characteristics, and known characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug's effectiveness or patient compliance.

Such medical exceptions procedures require, at a minimum, the following:

• any request for approval of coverage made verbally or in writing (regardless of whether made using a paper or electronic form or some other writing) at any time shall be reviewed by appropriate health care professionals.

• within 72 hours after receipt of a request either approve or deny the request. In the case of a denial, Cigna shall provide you or your authorized representative and your Physician with the reason for the denial, an alternative covered medication, if applicable, and information myCigna.com17 regarding the procedure for submitting an appeal to the denial.

• an expedited coverage determination request must either be approved or denied within 24 hours after receipt of the request. In the case of a denial, Cigna shall provide you or your authorized representative and your Physician with the reason for the denial, an alternative covered medication, submitting an appeal to the denial.

Should your request for an exception be denied, you may refer to the “When You Have a Complaint or Appeal” section of this certificate which outlines the process to request that the original external exception request and the subsequent denial of that request be reviewed by an independent review organization.

A step therapy requirement exception request shall be approved if the: required Prescription Drug Product is contraindicated; you have tried the required Prescription Drug Product while under your current or previous health insurance or health benefit plan and the prescribing Physician submits evidence of failure or intolerance; or you are stable on a Prescription Drug Product selected by your Physician for the medical condition under consideration while on a current or previous health insurance or health benefit plan.

Once the exception request has been approved, the authorization for the coverage for the drug prescribed by your treating Physician, to the extent the prescribed drug is a covered drug under the plan up to the quantity covered and be made for 12 months following the approval or until renewal of the plan.

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Limitations Step Therapy Step therapy is not required for medications used in the treatment of substance use disorders. Cigna will process these medications in compliance with the requirements of the law.

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Exclusions, Expenses Not Covered and General…