Exhibit 05c - Cal Yr 2025 City of Miami CIGNA Dental HMO Certificate Riders and Coverage for 7 States ETALLD25A Plan 3202272 HC-ETRDR.pdf

City of Miami

EXTRATERRITORIAL LEGISLATION

EFFECTIVE DATE: January 1, 2025

ETALLD25A

3202272

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

Printed in U.S.A.

EXHIBIT 05C

Table of Contents

IMPORTANT INFORMATION

CERTIFICATE RIDER – District of Columbia Residents CERTIFICATE RIDER – Indiana Residents CERTIFICATE RIDER – Louisiana Residents CERTIFICATE RIDER – Nevada Residents CERTIFICATE RIDER – Oregon Residents CERTIFICATE RIDER – South Carolina Residents CERTIFICATE RIDER – Washington Residents myCigna.com4

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

CERTIFICATE RIDER

Policyholder: City of Miami Rider Eligibility: Each Employee as noted within this certificate rider Policy No. or Nos.: 3202272 Effective Date: January 1, 2025

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

IMPORTANT INFORMATION

For Residents of States other than the State of New York:

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 – District of Columbia Residents

Rider Eligibility: Each Employee who is located in District of Columbia

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

HC-ETDCRDR

Definitions Dependent The term child means a child born to you or a child legally adopted by you. It also includes a stepchild, a grandchild who lives with you, a foster child, or a child for whom you are the legal guardian. If your Domestic Partner has a child who lives with you, that child will also be included as a Dependent. A child also includes a minor grandchild, niece or nephew for whom you provide food, clothing and shelter on a regular and continuous basis when the District of Columbia schools are in regular session, provided such child’s legal guardian, if not you, is not covered by an accident or Sickness policy.

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Indiana Residents

Rider Eligibility: Each Employee who is located in Indiana

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

HC-ETINRDR

Eligibility - Effective Date Eligibility for Coverage for Adopted Children Any child who is adopted by You, including a child who is placed with You for adoption, will be eligible for Dependent coverage, if otherwise eligible as a Dependent, upon the earlier of:

The date of the entry of an order granting the adoptive parent custody of the child for purposes of adoption; or The date of placement with You.

A child will be considered placed for adoption when You become legally obligated to support that child, totally or partially prior to that child’s adoption. If a child placed for adoption is not adopted, all dental coverage ceases when the placement ends, and will not be continued. The provisions in the Exception for Newborns provision that describe requirements for enrollment and Effective Date of insurance will also apply to an adopted child or a child placed with You for adoption.

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COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Louisiana Residents

Rider Eligibility: Each Employee who is located in Louisiana

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

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

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

HC-ETLARDR

Important Information If the following text regarding “If Cigna determines….required to pay.” is included in your 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 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.

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Eligibility - Effective Date Choice of Participating Dental Facility NOTE: For members receiving services from LA Providers:

The CDH managed dental care network has been carefully selected for your convenience. Under Louisiana law, you may choose to go to a non-plan LA dentist. If you want to make this choice and there is another dental plan for you to select, it is recommended that you select that plan and benefits. If you choose the in-network plan you can still go to a non-plan dentist. However, the non-plan dentist is not under contract with CDH and does not have to charge you in accordance with the CDH Patient Charge Schedule. Therefore, you will have to pay the dentist’s usual and customary fees for any procedures performed, minus a minimal payment from CDH representing the amount we would have paid to a dentist under contract with us. Please call CDH Member Services at 1-800-Cigna24 for further explanation and arrangement for payment.

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

90 days from the date your military service ends;

the last day for which you made any required contribution for the insurance; or the date the group policy cancels.

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

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

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Definitions Dependent Dependents include:

any unmarried child of yours who is less than 21 years old.

21 years but less than 24 years old, unmarried, enrolled in school as a full-time student and primarily supported by you. This enrollment may be at an accredited college or university, or at a vocational, technical, vocational-technical, trade school or institute.

21 or more years old and primarily supported by you and incapable of self-sustaining employment by reason of intellectual or physical disability. Proof of the child's condition and dependence must be submitted to Cigna within 31 days after the date the child ceases to qualify above. From time to time, but not more frequently than once a year after the two-year period following the child’s attainment of the limiting age, Cigna may require proof of the continuation of such condition and dependence. For full-time students under the age of 24 who develop a mental or nervous condition, problem or disorder which, in the opinion of a qualified psychiatrist prevents them from attending school as a full-time student, and from holding self-sustaining employment, coverage will be continued to age 24.

A child includes:

any grandchild of yours provided such child is under 21 years of age, or in the case of full-time students, under 24 years of age, and is in your legal custody and resides with you;

any grandchild of yours who is in your legal custody and resides with you, and is incapable of self-sustaining employment by reason of intellectual or physical disability which existed prior to the child's 21st birthday.

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Nevada Residents

Rider Eligibility: Each Employee who is located in Nevada

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

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Important Notices Nevada Division of Insurance

You can contact the Nevada Division of Insurance at the following:

The Department of Business Industry, Division of Insurance

Toll free number: (888) 872-3234 Hours of operation of the division: Mondays through Fridays from 8:00 a.m. until 5:00 p.m., Pacific Standard Time (PST).

If you have local telephone access to the Carson City and Las Vegas offices of the Division of Insurance, you should call the local numbers.

Local telephone numbers are: Carson City, 702-687-4270 and Las Vegas, 702-486-4009

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Definitions If Domestic Partners are covered under the plan, then the following applies:

Domestic Partner A Domestic Partner is defined as a person of the same or opposite sex who:

shares your permanent residence;

has resided with you for no less than one year;

is no less than 18 years of age;

is financially interdependent with you and has proven such interdependence by providing documentation of at least two of the following arrangements: common ownership of real property or a common leasehold interest in such property;

community ownership of a motor vehicle; a joint bank account or a joint credit account; designation as a beneficiary for life insurance or retirement benefits or under your partner's will; assignment of a durable power of attorney or health care power of attorney; or such other proof as is considered by Cigna to be sufficient to establish financial interdependency under the circumstances of your particular case;

is not a blood relative any closer than would prohibit legal marriage; and has signed jointly with you, a notarized affidavit attesting to the above which can be made available to Cigna upon request.

In addition, you and your Domestic Partner will be considered to have met the terms of this definition as long as neither you nor your Domestic Partner:

has signed a Domestic Partner affidavit or declaration with any other person within twelve months prior to designating each other as Domestic Partners hereunder;

is currently legally married to another person; or has any other Domestic Partner, spouse or spouse equivalent of the same or opposite sex.

You and your Domestic Partner must have registered as Domestic Partners, if you reside in a state that provides for such registration.

The section of this certificate entitled "COBRA Continuation Rights Under Federal Law" will not apply to your Domestic Partner and his or her Dependents.

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Oregon Residents

Rider Eligibility: Each Employee who is located in Oregon

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

HC-ORCDC-04-10 HC-ETORRDR

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Definitions Dependent The term child means a child born to you. It also means:

a child legally adopted by you, including that child from the date of placement. Coverage for such child will include the necessary care and treatment of conditions existing prior to the date of placement including medically diagnosed congenital defects or birth abnormalities, regardless of any pre-existing condition limitation in the policy.

HC-DFS217 07-14

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – South Carolina Residents

Rider Eligibility: Each Employee who is located in South Carolina

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

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

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

HC-ETSCRDR

General Limitations And Expenses Not Covered Expenses Not Covered Covered Expenses will not include, and no payment will be made for:

cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance) which may include but is not limited to the following:

bleaching (tooth whitening), in office and/or at home, enamel microabrasion, odontoplasty, facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth will always be considered cosmetic, unless specifically covered by this plan under the Cosmetic Services Rider. However, for newborn children benefits will include coverage of an injury or illness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities;

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Definitions Dependent The term child means a child born to you, a child legally adopted by you or an adopted child of whom you have custody according to the decree of the court provided you have paid premiums. Adoption proceedings must be instituted by you, and completed within 31 days after the child’s birth date, and a decree of adoption must be entered within one year from the start of proceedings, unless extended by court order due to the child’s special needs. It also includes a stepchild who lives with you.

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COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Washington Residents

Rider Eligibility: Each Employee who is located in Washington

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

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

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

HC-ETWARDR

CIGNA HEALTH AND LIFE INSURANCE

COMPANY

a Cigna company (hereinafter referred to as “Cigna”, “We”, “Us”, or “Our”) certifies that it insures certain Employees for the benefits provided by the following Policy(ies).

HCDFB-CER63 06-21

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Important Notice Health Care Benefit Manager A health care benefit manager (“HCBM”) is any person or entity that provides services to or acts on behalf of a health carrier or employee benefits program. HCBMs directly or indirectly impact the determination or use of benefits for or patient access to health care services, drugs and supplies.

HCBMs include, but are not limited to, specialized benefit types such as pharmacy, radiology, laboratory and mental health. The services of an HCBM also include: Prior authorization or preauthorization of benefits or care, certification of benefits or care, medical necessity determinations, utilization review, benefit determinations, claims processing and repricing for services and procedures, outcome management, provider credentialing and re-credentialing, payment or authorization of payment to providers and facilities for services or procedures, dispute resolution, grievances or appeals relating to determinations or utilization of benefits, provider network management and disease management.

A current list of HCBMs for Your plan is available at www.cigna.com/product-disclosures.

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Notice - Cigna Dental Care Coordination of Benefits Included – See Table of Contents for Location of Coordination of Benefits Section. Your Benefits may be affected by other Insurance.

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Important Notices Notice regarding Coordination of Benefits If you are covered by more than one health benefit plan, and you do not know which is your primary plan, you or your provider should contact any one of the health plans to verify which plan is primary. The health plan you contact is responsible for working with the other plan to determine which is primary and will let you know within thirty calendar days.

CAUTION: All health plans have timely claim filing requirements. If you or your provider fail to submit your claim to a secondary health plan within that plan's claim filing time limit, the plan can deny the claim. If you experience delays in the processing of your claim by the primary health plan, you or your provider will need to submit your claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim.

To avoid delays in claims processing, if you are covered by more than one plan you should promptly report to your providers and plans any changes in your coverage.

Health Care Benefit Manager A health care benefit manager (“HCBM”) is any person or entity that provides services to or acts on behalf of a health myCigna.com11 carrier or employee benefits program. HCBMs directly or indirectly impact the determination or use of benefits for or patient access to health care services, drugs and supplies.

HCBMs include, but are not limited to, specialized benefit types such as pharmacy, radiology, laboratory and mental health. The services of an HCBM also include: Prior authorization or preauthorization of benefits or care, certification of benefits or care, medical necessity determinations, utilization review, benefit determinations, claims processing and repricing for services and procedures, outcome management, provider credentialing and re-credentialing, payment or authorization of payment to providers and facilities for services or procedures, dispute resolution, grievances or appeals relating to determinations or utilization of benefits, provider network management and disease management.

A current list of HCBMs for your plan is available at www.cigna.com/product-disclosures.

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Eligibility – Effective Date Dependent Insurance Dental Insurance – Newborn, Adopted Children

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 31 days after his birth. If payment of an additional premium is required to provide coverage for a child, to continue coverage beyond 31days, you must elect Dependent Insurance for your newborn child within the 60 day enrollment period which begins on the first day of birth. If Dependent Insurance is not elected within the 60 day enrollment period, you may be required to wait until the next plan enrollment period to enroll the child for coverage under the plan. Coverage shall include, but not be limited to, coverage for congenital anomalies of such infant children from the moment of birth.

Adoptive children are covered from the date the obligation for total or partial support begins. Waiting periods do not apply to these categories of Dependents.

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Dental Benefits – Cigna Dental Care Services Not Covered Under Your Dental Plan Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility at the dentist’s Usual Fees. There is no coverage for:

general anesthesia, sedation and nitrous oxide, unless specifically listed on your Patient Charge Schedule. When listed on your Patient Charge Schedule, general anesthesia and IV Sedation are covered when medically necessary and provided in conjunction with Covered Services performed by an Oral Surgeon or Periodontist. There is no coverage for general anesthesia or intravenous sedation when used for the purposes of anxiety control or patient management.

However, general anesthesia is covered when medically necessary and authorized by your physician because the covered person is under the age of 7 or physically or developmentally disabled.

services for or in connection with experimental procedures or treatment methods. In determining whether services are experimental, Cigna in consultation with our dental consultant, will consider if such services: are approved by the American Dental Association or the appropriate dental specialty society; are in general use in the medical/dental field in the state of Washington; are under continued scientific testing and research; have shown a demonstrable benefit for a particular dental condition or disease; and are proven to be safe and effective.

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Definitions Domestic Partner The term Domestic Partner means a person who has a valid Domestic Partner registration in Washington.

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Dependent The term Dependent means:

Your Domestic Partner; and any child of Yours who is:

less than 26 years old.

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

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

It also includes a stepchild, a grandchild who lives with You, a foster child, a child for whom You are the legal guardian or a child supported pursuant to a court order imposed on You (including a Qualified Medical Child Support Order).

If Your Domestic Partner has a child, that child will also be included as a Dependent.

Benefits for a Dependent child will continue until the last day of the calendar month in which the limiting age is reached.

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Dependent Dependents include:

your Domestic Partner; and any child of yours who is less than 26 years old.

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

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

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

If your Domestic Partner has a child, that child will also be included as a Dependent.

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Domestic Partner A Domestic Partner is defined as a person who has a valid domestic partner registration in Washington.

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