Attachment_1A_-_ASO46_2025_SPD_Network.pdf

City of Tucson

NETWORK MEDICAL BENEFITS

EFFECTIVE DATE: July 1, 2025

ASO46

3342685

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

Employee Insurance Waiting Period 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 Rescissions

Federal Requirements Notice of Provider Directory/Networks Qualified Medical Child Support Order (QMCSO) Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) Effect of Section 125 Tax Regulations on This Plan 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

Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) 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.com7

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 myCigna.com8 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 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 myCigna.com9

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 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 have been classified as non-essential health benefits (NEHBs) and the cost of such NEHB Specialty Prescription Drugs will not be applied toward satisfying the Deductible and/or Out-of-Pocket Maximum. A list of these NEHB Specialty Prescription Drugs and the applicable Coinsurance for each NEHB 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 NEHB 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 SaveOnSP with consent to monitor your account. Any Coinsurance required for NEHB 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. As a result of certain Specialty Prescription Drugs being classified as NEHB, your Coinsurance will continue to apply even after you have satisfied your plan’s Deductible and/or Out-of- Pocket Maximum. 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 NEHB Specialty Prescription Drug without such payment applying to the Deductible and/or Out-of-Pocket Maximum. Your Coinsurance will continue to apply even after your Deductible and/or Out-of-Pocket Maximum has been satisfied.

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 NEHB 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-IMP385 01-25

myCigna.com10

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 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).

myCigna.com11

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).

HC-NOT97 07-17

Federal CAA - Consolidated Appropriations Act and TIC

- Transparency in Coverage Notice Cigna will make available an internet-based self-service tool for use by individual customers, as well as certain data in machine-readable file format on a public website, as required under the Transparency in Coverage rule. Customers can access the cost estimator tool on myCigna.com. Updated machine-readable files can be found on Cigna.com and/or CignaForEmployers.com on a monthly basis.

Pursuant to Consolidated Appropriations Act (CAA), Section 106, Cigna will submit certain air ambulance claim information to the Department of Health and Human Services (HHS) in accordance with guidance issued by HHS.

Subject to change based on government guidance for CAA Section 204, Cigna will submit certain prescription drug and health care spending information to HHS through Plan Lists Files (P1-P3) and Data Files (D1-D8) (D1-D2) for an Employer without an integrated pharmacy product aggregated at the market segment and state level, as outlined in guidance.

HC-IMP353 01-24

Federal CAA - Consolidated Appropriations Act Continuity of Care In certain circumstances, if you are receiving continued care from an in-network provider or facility, and that provider’s network status changes from in-network to out-of-network, you may be eligible to continue to receive care from the provider at the in-network cost-sharing amount for up to 90 days from the date you are notified of your provider’s termination. A continuing care patient is an individual who is:

• undergoing a course of treatment for a serious and complex condition from the provider or facility.

• pregnant and undergoing treatment for the pregnancy from the provider or facility.

myCigna.com12

• undergoing a course of institutional or inpatient care from the provider or facility.

• scheduled to undergo non-elective surgery, including receipt of post-operative care with respect to such a surgery.

• determined to be terminally ill and is receiving treatment for such illness from the provider or facility.

If applicable, Cigna will notify you of your continuity of care options.

Appeals Any external review process available under the plan will apply to any adverse determination regarding claims subject to the No Surprises Act.

Provider Directories and Provider Networks A list of network providers is available to you, without charge, by visiting the website or calling the phone number on your ID card. The network consists of providers, including Hospitals, of varied specialties as well as generic practice, affiliated or contracted with Cigna or an organization contracting on its behalf.

A list of network pharmacies is available to you, without charge, by visiting the website or calling the phone number on your ID card. The network consists of pharmacies affiliated or contracted with Cigna or an organization contracting on its behalf.

Provider directory content is verified and updated, and processes are established for responding to provider network status inquiries, in accordance with applicable requirements of the No Surprises Act.

If you rely on a provider’s in-network status in the provider directory or by contacting Cigna at the website or phone number on your ID card to receive covered services from that provider, and that network status is incorrect, then your plan cannot impose out-of-network cost shares to that covered service. In-network cost share must be applied as if the covered service were provided by an in-network provider.

Direct Access to Obstetricians and Gynecologists You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, access the website or call the phone number on your ID card.

Selection of a Primary Care Provider This plan generally requires the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. Until you make this designation, Cigna designates one for you. For children, you may designate a pediatrician as the primary care provider. For information on how to select a primary care provider, and for a list of the participating primary care providers, access the website or call the phone number on your ID card.

Your Rights and Protections Against Surprise Medical Bills When you get emergency care or are treated by an out-of-network provider at an in-network Hospital or ambulatory surgical center, you are protected from balance billing. In these situations, you should not be charged more than your plan’s copayments, coinsurance, and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that is not in your health plan’s network.

“Out-of-network” means providers and facilities that have not signed a contract with your health plan to provide services.

Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing”. This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care

– such as when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for:

• Emergency services – If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as a copayments, coinsurance, and deductibles). You cannot be myCigna.com13 balanced billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

• Certain non-emergency services at an in-network Hospital or ambulatory surgical center – When you get services from an in-network Hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balanced billed.

If you get other types of services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing is not allowed, you have these protections:

• You are only responsible for paying your share of the cost

(such as copayments, coinsurance, and deductibles that you would pay if the provider were in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

• Generally, your health plan must:

• Cover emergency services without requiring you to get approval in advance for services (also known as prior authorization).

• Cover emergency services provided by out-of-network providers.

• Base what you owe the provider or facility (cost sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits

(EOB).

• Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you have been wrongly billed, contact Cigna at the phone number on your ID card. You can also contact No

Surprises Help Desk at 1-800-985-3059 or www.cms.gov/nosurprises for more information about your rights under federal law.

HC-IMP383 01-25

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.

myCigna.com14

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.

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V11

Eligibility - Effective Date

Employee Insurance This plan is offered to you as an Employee.

Eligibility for Employee Insurance You will become eligible for insurance on the day you complete the waiting period if:

• you are in a Class of Eligible Employees; and

• you are an eligible, Active permanent or appointed employee who has met the policyholder's eligibility requirements and are scheduled by the Policyholder to work in the United States 30 or more hours per week; or

• you are an eligible, Active permanent or appointed employee who has met the policyholder's eligibility requirements and are scheduled by the Policyholder to work in the United States 20 - 29 hours per week as of June 30, 2017; or

• Elected Official; or

• non-permanent employees, who over the course of the

City’s designated 12-month look-back period, worked or were credited with, on average, the requisite number of hours as defined by the ACA; and

• you pay any required contribution.

If your insurance ceased because you were no longer employed in a Class of Eligible Employees, you are required to satisfy the Waiting Period to become insured again if you again become a member of 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.

Waiting Period First day of the month following 30 days of employment.

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

Effective Date of Employee Insurance You will become insured on the date you elect the insurance by signing an approved payroll deduction or enrollment form, as applicable, but no earlier than the date you become eligible.

You will become insured on your first day of eligibility, following your election, if you are in Active Service on that date, or if you are not in Active Service on that date due to your health status.

Late Entrant - Employee You are a Late Entrant if:

• you elect the insurance more than 31 days after you become eligible; or

• you again elect it after you cancel your payroll deduction (if required).

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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 an approved payroll deduction form (if required), but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included.

Your Dependents will be insured only if you are insured.

Late Entrant – Dependent You are a Late Entrant for Dependent Insurance if:

• you elect that insurance more than 31 days after you become eligible for it; or

• you again elect it after you cancel your payroll deduction (if required).

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.

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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.com16

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

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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.

Important Notice on Ambulance Services for Mental Health and Substance Use Disorders Covered medical services received for Ambulance charges provided for Mental Health and Substance Use Disorders will be payable according to the Hospital Emergency Room section 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 07/01/2025.

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The Schedule Out-of-Pocket Expenses Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan because of any Deductibles, Copayments or Coinsurance. Such Covered Expenses accumulate to the Out-of-Pocket Maximum shown in The Schedule. When the Out-of-Pocket Maximum is reached, all Covered Expenses, except charges for non-compliance penalties, are payable by the benefit plan at 100%.

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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.

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-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.

Out-of-Network Emergency Services Charges

1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-Participating (Out-of-Network) provider.

2. The allowable amount used to determine the Plan's benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-of-Network provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or as required by applicable state or Federal law.

3. The allowable amount used to determine the Plan’s benefit payment when Out-of-Network Emergency Services result in an inpatient admission is the median amount negotiated with In-Network facilities.

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.

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The Schedule Out-of-Network Air Ambulance Services Charges

1. Covered air ambulance services are payable at the In-Network cost-sharing level if services are received from a non- Participating (Out-of-Network) provider.

2. The allowable amount used to determine the Plan’s benefit payment for covered air ambulance services rendered by an Out-of-Network provider 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.

BENEFIT HIGHLIGHTS IN-NETWORK

Lifetime Maximum Unlimited

The Percentage of Covered Expenses the Plan Pays

90%

Note:

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

Contract Year Deductible Individual $750 per person Family Maximum $1,500 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.

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BENEFIT HIGHLIGHTS IN-NETWORK

Combined Out-of-Pocket Maximum for Medical and Pharmacy expenses

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.com22

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

Preventive Care

Note:

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

Other Services Supplemental services, such as other common laboratory panel tests, when provided during a preventive visit.

Routine Preventive Care - all ages No charge Immunizations - all ages No charge .

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Mammograms, PSA, PAP Smear

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

No charge

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

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

Inpatient Hospital - Facility Services 90% after plan deductible

Semi-Private Room and Board Limited to the semi-private negotiated rate Private Room Limited to the semi-private…