Exhibit 06c - Cal Yr 2025 City of Miami CIGNA Dental PPO Certificate Riders and Coverage for other states ETALLD25B Plan 3202272 HC-IMP35.pdf

City of Miami

EXTRATERRITORIAL LEGISLATION

EFFECTIVE DATE: January 1, 2025

ETALLD25B

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 06c

Table of Contents

IMPORTANT INFORMATION

CERTIFICATE RIDER – Arizona Residents CERTIFICATE RIDER – California Residents CERTIFICATE RIDER – Colorado Residents CERTIFICATE RIDER – Connecticut Residents CERTIFICATE RIDER – Delaware Residents CERTIFICATE RIDER – District of Columbia Residents CERTIFICATE RIDER – Georgia Residents CERTIFICATE RIDER – Illinois Residents CERTIFICATE RIDER – Indiana Residents CERTIFICATE RIDER – Louisiana Residents CERTIFICATE RIDER – Maine Residents CERTIFICATE RIDER – Maryland Residents CERTIFICATE RIDER – Massachusetts Residents CERTIFICATE RIDER – Nevada Residents CERTIFICATE RIDER – New Jersey Residents CERTIFICATE RIDER – New York Residents CERTIFICATE RIDER – North Carolina Residents CERTIFICATE RIDER – Ohio Residents CERTIFICATE RIDER – Oregon Residents CERTIFICATE RIDER – South Carolina Residents CERTIFICATE RIDER – Utah Residents CERTIFICATE RIDER – Virginia 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 Florida:

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-ETRDR2

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Arizona Residents

Rider Eligibility: Each Employee who is located in Arizona

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

HC-ETAZRDR

Notice This Certificate of insurance may not provide all benefits and protections provided by law in Arizona. Please read this Certificate carefully.

HCDFB-IMP37 01-18

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Important Notice This notice is to advise You that You can obtain a replacement Appeals Process Information Packet by calling the Customer Service Department at the telephone number listed on Your identification card for "Claim Questions/Eligibility Verification" or for "Member Services" or by calling 1-800- 244-6224.

The Information Packet includes a description and explanation of the appeal process for Cigna.

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Eligibility - Effective Date Reinstatement of Benefits for Military Returnees If Your coverage ends when You are called to active duty and You are reemployed by Your current Employer, coverage for You and Your Dependents (including a Dependent born during the period of active military duty) may be reinstated if You applied for reinstatement within 90 days from the date of discharge or within one year of hospitalization continuing after discharge.

You and Your Dependents will be subject to only the balance of a Pre-existing Conditions Limitation (PCL) or waiting period, if any, that was not yet satisfied before the leave began. Any 63-day break in coverage rule regarding credit for time accrued toward a PCL waiting period will be waived.

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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

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Eligibility - Effective Date Eligibility for Coverage for Adopted Children Any child who is adopted by You, including a child who is placed with You for adoption, will be eligible for Dependent coverage, if otherwise eligible as a Dependent, upon the date of placement with You. A child will be considered placed for adoption from and after the moment the child is placed in the physical custody of the insured for adoption. If a child placed for adoption is not adopted, all dental coverage ceases when the placement ends, and will not be continued.

Exception for Newborns and Adopted Minors Any Dependent child born while You are insured will become insured on the date of the child’s birth, and any Dependent minor child placed for adoption while you are insured will become insured on the date the child is placed in your physical custody for adoption. If You do not elect to insure Your newborn child within such 31 days, coverage for that child will end on the 31st day. No benefits for expenses incurred beyond the 31st day will be payable.

Dual Eligibility If both You and Your Spouse, Your Domestic Partner, or Your Civil Union Partner are in an Eligible Class of the Employer, You may each enroll individually or as a Dependent of the other, but not as both. Any eligible Dependent child may also be enrolled by either You or Your Spouse, Your Domestic Partner, or Your Civil Union Partner.

If the Spouse, Your Domestic Partner, or Your Civil Union Partner who enrolls for Dependent coverage ceases to be eligible, notify Your plan administrator immediately for coverage to continue under the plan of the other Spouse, Domestic Partner, or Civil Union Partner.

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

procedures performed by a Dentist who is a member of the Covered Person’s family except in the case of a dental emergency when no other Dentist is available. (Covered Person’s family is limited to a Spouse, Domestic Partner, Civil Union Partner, siblings, parents, children, grandparents, and the Spouse’s, Domestic Partner’s, Civil Union Partner’s siblings and parents).

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Coordination of Benefits For the Dependent of divorced or separated parents, benefits for the Dependent shall be determined in the following order:

first, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge;

then, the Plan of the parent with custody of the child;

then, the Plan of the Spouse, Domestic Partner, or Civil Union Partner of the parent with custody of the child;

then, the Plan of the noncustodial parent of the child;

and finally, the Plan of the Spouse, Domestic Partner, or Civil Union Partner of the parent not having custody of the child.

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Definitions Dependent The term Dependent means:

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

less than 26 years old.

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.

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The term child means a child born to You or 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.

If Your Domestic Partner or Civil Union 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: Your Domestic Partner who has registered the domestic partnership by filing a Declaration of Domestic Partnership with the California Secretary of state pursuant to Section 298 of the Family Code or an equivalent document issued by a local agency of California, another state, or a local agency of another state under which the partnership was created.

The term Domestic Partner means a person of the same or opposite sex who has not registered the domestic partnership as stated above and:

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 Us 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 Us 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, Civil Union Partner, or Spouse equivalent of the same or opposite sex.

The section of this Certificate entitled "COBRA Continuation Rights Under Federal Law" will not apply to Your Domestic Partner and Your Domestic Partner’s Dependents.

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Colorado Residents

Rider Eligibility: Each Employee who is located in Colorado

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

HC-ETCORDR

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

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COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Connecticut Residents

Rider Eligibility: Each Employee who is located in Connecticut

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

HC-ETCTRDR

Definitions Civil Union The term Civil Union means a state sanctioned or legally recognized union of two eligible individuals of the same or opposite sex.

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Dependent The term Dependent means:

Your lawful Spouse, including Your Civil Union partner; or Your Domestic Partner; and

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Spouse The term Spouse means Your legally recognized Spouse, lawful Domestic Partner or Civil Union Partner in the state where You reside.

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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

Definitions Civil Union The term Civil Union means a state sanctioned or legally recognized union of two eligible individuals of the same or opposite sex.

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Dependent The term Dependent means:

Your lawful Spouse, including Your Civil Union partner; or myCigna.com9

Your Domestic Partner.

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Spouse The term Spouse means Your legally recognized Spouse, lawful Domestic Partner or Civil Union Partner in the state where You reside.

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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. A child also includes a minor grandchild, niece or nephew, if the legal guardian of the 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 – 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

HC-ETGARDR

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Important Notices

CIGNA DENTAL PPO

IMPORTANT:

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

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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

Expenses Not Covered charges for travel time or transportation costs;

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Definitions Civil Union The term Civil Union means a state sanctioned or legally recognized union of two eligible individuals of the same or opposite sex.

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Dependent The term Dependent means:

Your lawful Spouse, including Your Civil Union partner (The Religious Freedom Protection Act and Civil Union Act, 750 ILCS 75, allows both same-sex and different-sex couples to enter into a Civil Union with all of the obligations, protections, and legal rights that Illinois provides to married heterosexual couples); or Your Domestic Partner; and

The term child means a child born to You or a child legally adopted by You. It also includes a stepchild and child acquired through a Civil Union, a grandchild who lives with You, a foster child, or a child for whom You are the legal guardian, or a child supported pursuant to a court order imposed on You (including a Qualified Medical Child Support Order).

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Spouse The term Spouse means Your legally recognized Spouse, lawful Domestic Partner or Civil Union partner in the state where You reside.

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myCigna.com11

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

Definitions Dependent The term child means a legally adopted child including: a child who has been placed with you for adoption provided the child is not removed from placement prior to legal adoption or a child for whom entry of an order granting custody to you has been made.

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Louisiana Residents

Rider Eligibility: Each Employee who is located in Louisiana

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

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

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

HC-ETLARDR

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.

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

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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 The term Dependent means:

any child of Yours who is:

less than 26 years old.

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

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

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Maine Residents

Rider Eligibility: Each Employee who is located in Maine myCigna.com13

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

HC-ETMERDR

Covered Dental Expense Covered Dental Expense means that portion of a Dentist’s or Independent Practice Dental Hygienist’s charge that is payable for a service delivered to a covered person provided:

the service is ordered or prescribed by a Dentist or Independent Practice Dental Hygienist;

is essential for the Necessary care of teeth;

the service is within the scope of coverage limitations;

the deductible amount in The Schedule has been met;

the maximum benefit in The Schedule has not been exceeded;

the charge does not exceed the amount allowed under the Alternate Benefit Provision;

for Class I, II or III the service is started and completed while coverage is in effect.

Predetermination of Benefits Predetermination of Benefits is a voluntary review of a Dentist’s or Independent Practice Dental Hygienist’s proposed treatment plan and expected charges. It is not preauthorization of service and is not required.

The treatment plan should include supporting pre-operative x-rays and other diagnostic materials as requested by Cigna's dental consultant. If there is a change in the treatment plan, a revised plan should be submitted.

Cigna will determine covered dental expenses for the proposed treatment plan. If there is no Predetermination of Benefits, Cigna will determine covered dental expenses when it receives a claim.

Review of proposed treatment is advised whenever extensive dental work is recommended when charges exceed $200.

Predetermination of Benefits is not a guarantee of a set payment. Payment is based on the services that are actually delivered and the coverage in force at the time services are completed.

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Definitions Independent Practice Dental Hygienist The term Independent Practice Dental Hygienist means a dental hygienist licensed to perform certain hygienist duties without supervision of a Dentist.

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Maryland Residents

Rider Eligibility: Each Employee who is located in Maryland

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 Maryland group insurance plans covering insureds located in Maryland. These provisions supersede any provisions in your certificate to the contrary unless the

HC-ETMDRDR

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Important Notices Qualified Medical Child Support Order (QMCSO) Eligibility for Coverage Under a QMCSO If a Qualified Medical Child Support Order (QMCSO) is issued for Your child, that child will be eligible for coverage as required by the order and You will not be considered a Late Entrant for Dependent Insurance.

You, Your child’s non-insuring parent, a state child support enforcement agency or the Maryland Department of Health and Mental Hygiene must notify Your Employer and elect coverage for that child. If You yourself are not already enrolled, You must elect coverage for both Yourself and Your child. We will enroll both You and Your child within 20 business days of our receipt of the QMCSO from Your Employer.

Eligibility for coverage will not be denied on the grounds that the child: was born out of wedlock; is not claimed as a dependent on the Employee’s federal income tax return; or does not reside with the Employee or within the plan’s service area; or is receiving benefits or is eligible to receive benefits under the Maryland Medical Assistance Program.

Continuity of Care Notice You have special rights in Maryland when You are a new enrollee and may be moving from Maryland Medical Assistance or another company’s dental plan to Cigna Health and Life Insurance Company coverage and if You currently are receiving treatment.

Right to use non-network providers. If You have been receiving services from a health care provider, and that provider is a non- network provider under Your new health plan with Us, You may be able to continue to see Your provider as though the provider were an in-network provider.

You or Your parent, guardian, designee, or health care provider may also contact Us on Your behalf at 1-800- Cigna24 to request the right to continue to see the non-network provider as if the provider were an in-network provider with Us.

This right applies only if You are being treated by the non-network provider for covered services for one or more of the following types of conditions:

Acute dental conditions;

Serious chronic dental conditions;

Any other condition upon which we and the out-of-network provider agree.

Any other condition on which the Non-Participating provider and the receiving carrier or managed care organization reach agreement

There is a time limit for how long You can continue to see a non-network provider and only need to pay cost-sharing as though the provider were an in-network provider. For all conditions the time limit is 90 days or until the course of treatment is completed, whichever is sooner. The 90-day limit is measured from the date your coverage starts under the new plan.

You or Your representative need to contact Us so that We can pay Your claim as if You are still receiving care from a network dentist. If the non-network Dentist accepts Cigna’s rate of payment, the Dentist is only permitted to bill You for the in-network cost-sharing amounts that apply to the service, such as copayments, coinsurance and deductible.

If the non-network dentist will not accept Cigna’s rate of payment, the dentist may decide not to provide services to You, or may continue to provide services to You and bill You not only for any Copayment, Coinsurance or Deductible that applies, but also bill You for the difference between the Dentist’s fee and the allowable charge determined by Us.

If You have any questions please contact us at 1-800-Cigna24.

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Dental Benefits Extension Benefits for Covered Dental Expenses incurred in connection with a Covered Dental Service, except orthodontia, will be extended for 90 days after the date Your coverage terminates.

Covered Dental Expenses will be deemed to be incurred while You are insured if the treatment:

begins before the date coverage terminates; and requires two or more visits on separate days to a Dentist’s office.

If the plan covers orthodontia, benefits will be extended for 60 days after the date coverage terminates if the orthodontist has agreed to or is receiving monthly payments; or until the later of 60 days after the date coverage terminates or the end of the quarter in progress, if the orthodontist has agreed to accept or is receiving payments on a quarterly basis.

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Eligibility - Effective Date Effective Date of Dependent Insurance Insurance for Your Dependents will become effective on the date You elect it, by signing a written agreement with the Employer Policyholder to make the required contribution, but no earlier than the day You become eligible for Dependent Insurance. All of Your Dependents as defined will be included.

Your Dependents will be insured only if You are insured.

Enrollment of Your child may not be denied by Us under Your dental insurance for the following reasons, that Your child:

was born out of wedlock;

is not claimed as a Dependent on Your federal income tax return; or does not reside:

with You; or in Our service area; or is receiving benefits or is eligible to receive benefits under the Maryland Medical Assistance Program.

If You are required under an order to provide dental insurance coverage for Your child and You are eligible for Dependent dental insurance:

regardless of enrollment period restrictions, We will allow the insured to enroll in Dependent coverage and include the insured’s child in that coverage specified in the enrollment form;

if the insured is enrolled in dental insurance but does not include their child in the enrollment, We will allow either the noninsuring parent, the Child Support Enforcement Agency, or the Department of Health to apply for the enrollment on behalf of such child and include such child in dental insurance under the enrollment regardless of enrollment period restrictions; and We may not disenroll or eliminate dental insurance for the child, unless written evidence is provided to Us that:

the order is no longer in effect;

the child has been or will be enrolled under other reasonable dental insurance which will take effect no later than the effective date of the disenrollment;

the Employer has eliminated Dependent dental insurance from the plan for all Employees; or the Employer no longer employs the parent under whose name the child has been enrolled for coverage except to the extent that if the parent elects to exercise the provisions of the Consolidated Omnibus Budget Reconciliation Act of

1985 (COBRA) then the dental insurance coverage must be provided for the child consistent with the Employer's plan relating to post-employment dental insurance coverage for Dependents.

For a child who has dental insurance through Us which insures the insured parent, We will:

provide membership cards to the noninsuring parent;

provide the claim forms to the noninsuring parent;

provide any other information necessary for the child to obtain benefits through the dental coverage, to the noninsuring parent; and process the claim forms and make appropriate payment to the noninsuring parent, the dental provider, or the Department of Health when the noninsuring parent has incurred dental expenses relating to the dental care provided to the dependent child.

HCDFB-ELG105 06-21

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Definitions Dependent The term grandchild means Your unmarried grandchild who is in Your legal custody and resides with You. Coverage for Your mentally or physically incapacitated grandchild who reaches age 26, or if a student, age 26 will continue until the grandchild marries or is no longer mentally or physically incapacitated.

Coverage is provided for a newly born or newly adopted Dependent child or grandchild (as defined) from the moment of birth or date of adoption of the child or grandchild.

Coverage for a minor for whom guardianship is granted by court or testamentary appointment is payable from the date of appointment.

HCDFB-DFS544 06-21

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myCigna.com16

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Massachusetts Residents

Rider Eligibility: Each Employee who is located in Massachusetts

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

HC-ETMARDR

Eligibility - Effective Date Exception for Newborns Any Dependent child, including the newborn infant of a Dependent, an adopted child or foster child born while You are insured will become insured on the date of the child’s birth if You elect Dependent Insurance no later than 31 days after birth. If You do not elect to insure Your newborn child within such 31 days, coverage for that child will end on the 31st day.

No benefits for expenses incurred beyond the 31st day will be payable.

HCDFB-ELG89 06-21

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Termination of Insurance Termination of Your Insurance Your insurance will cease on the earliest date below:

the date You cease to be in an Eligible Class or cease to qualify for the insurance.

the last day for which You have made any required contribution for the insurance.

the date the Policy is canceled or lapses due to a nonpayment of premium.

You commit an act of misrepresentation or fraud.

You commit an act of physical or verbal abuse unrelated to Your physical or mental condition, and such act poses a threat to a provider or to other insureds.

the last day of the calendar month in which Your Active Service ends except as described below.

Your death.

Additionally, Your insurance will cease on the later of:

the last day of the period for which a required premium contribution for the Group Policy was paid to Us by Your Employer (if the next required premium is not paid);

provided that We mail a notification of termination of the Group Policy to Your last known mailing address following Your Employer’s nonpayment of premium; or three days after we mail a notification of termination of the Group Policy to Your last known mailing address following Your Employer’s nonpayment of Premium.

Any continuation of insurance must be based on a plan which precludes individual selection.

Termination of Insurance - Dependents Your insurance for all of Your Dependents will cease on the earliest date below:

You commit an act of misrepresentation or fraud; or You commit an act of physical or verbal abuse unrelated to Your physical or mental condition, and such act poses a threat to a provider or to other insureds; or the date Dependent insurance is canceled; or the date that Dependent no longer qualifies as a Dependent;

or Your death.

HCDFB-TRM81 06-21

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Termination of Insurance - Continuation Special 31-Day Continuation Upon payment of premium by Your Employer, Your insurance will continue for 31 days after You:

cease to be an Eligible Class or cease to qualify as an Employee.

myCigna.com17 terminate employment for any reason.

In no case will the insurance continue after You become insured under any other group policy for similar benefits or after the last day for which You have made any required contribution for the insurance.

Dental Insurance for Former Spouse If Your Spouse's dental insurance would otherwise cease because of divorce or annulment of marriage, the insurance for that Spouse will be continued unless the court decree dissolving the marriage excludes such continuation. In any event, the insurance will not be continued beyond the earliest of the following dates:

the date You fail to make any required contribution;

the date You are no longer insured under the group policy;

the date Dependent insurance cancels;

the date Your former Spouse remarries;

the date You remarry, unless You make arrangements with the Employer to continue the insurance in accordance with the paragraph below entitled "Effect of Remarriage of Employee";

the date the court judgment no longer requires continued coverage.

Effect of Remarriage of Employee If You remarry, an additional contribution will be required for Your former Spouse. You must notify Your Employer of Your remarriage within 30 days of the date of Your remarriage and pay the additional contribution.

HCDFB-TRM84 06-21

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Definitions Dependent The term Dependent means:

Your former Spouse; unless the divorce decree provides otherwise; and

The term child means a child born to You or a child legally adopted by You. Coverage for an adopted child will begin on the date of the filling of a petition to adopt such child, provided the child has been residing in Your home as a foster child, and for whom You have been receiving foster care payments; or when a child has been placed in Your home by a licensed placement agency for purposes of adoption. It also includes a stepchild, a child born to one of Your Dependent children, as long as Your grandchild is living with You and

Your Dependent child is insured, or Your grandchild is primarily supported by 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).

HCDFB-DFS385 06-21

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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.

HC-ETNVRDR

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.

myCigna.com18

Local telephone numbers are: Carson City, 775-687-0700 and Las Vegas, 702-486-4009.

HCDFB-IMP20 01-18

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Definitions Domestic Partner The term Domestic Partner means a person of the same or opposite sex who:

shares Your permanent residence;

is no less than 18 years of age; and is not a blood relative any closer than would prohibit legal marriage.

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;

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 Your Domestic Partner’s Dependents.

HCDFB-DFS525 06-21

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – New Jersey Residents

Rider Eligibility: Each Employee who is located in New Jersey

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

HC-ETNJRDR

Important Notice Your health plan provides that you will not be held financially liable for payments to health care providers for any sums, other than required copayments, coinsurance or deductibles, owed for covered expenses, if Cigna fails to pay for the covered expenses for any reason.

Subsequent changes in your coverage shall be evidenced in a separate benefit rider issued to you or your dependent(s).

HC-IMP46 04/10

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Definitions Dependent Dependents include:

your lawful spouse, including civil union partners.

The term child includes any child acquired through a civil union.

myCigna.com19

The rights of married persons under federal law may not be available to parties to a civil union.

HC-DFS311 04-10

V1-ET

Medically Necessary and/or Dentally Necessary Services provided by a Dentist or Physician as determined by Cigna are Medically/Dentally Necessary if they are:

required for the diagnosis and/or treatment of the particular dental condition or disease; and consistent with the symptom or diagnosis and treatment of the dental condition or disease; and commonly and usually noted throughout the medical/dental field as proper to treat the diagnosed dental condition or disease; and the most fitting level or service which can safely be given to you or your Dependent.

A diagnosis, treatment and service with respect to a dental condition or disease, is not Medically/Dentally Necessary if made, prescribed or delivered solely for convenience of the patient or provider.

HC-DFS132 04-10

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – New York Residents

Rider Eligibility: Each Employee who is located in New York

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

HC-ETNYRDR

SECTION I. Definitions Defined terms will appear capitalized throughout this Certificate.

Spouse: The person to whom the Subscriber is legally married, including a same sex Spouse. Spouse also includes a domestic partner.

CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – North Carolina Residents

Rider Eligibility: Each Employee who is located in North 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 North Carolina group insurance plans covering insureds located in North Carolina. These provisions supersede any provisions in your certificate to the contrary unless the provisions in your certificate result in greater benefits.

HC-ETNCRDR

Eligibility - Effective Date Dependent Insurance - Foster Children, Adoptive Children, Court Ordered Coverage Newborns, foster children and adoptive children are automatically covered for the first 30 days after birth or myCigna.com20 placement in the home. Waiting periods do not apply to these categories of Dependents.

If additional premium is required You must submit an enrollment form within 30 days of acquiring the new Dependent child.

A Dependent child for whom You are required by a court or administrative order to provide coverage may be enrolled at any time. The child may not be disenrolled while You remain a subscriber unless the order is no longer valid or the child is enrolled in another plan with comparable coverage.

HCDFB-ELG85 06-21

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Payment of Benefits Recovery of Overpayment When We have made an overpayment, We will have the right within 2 years after the date of the original claim payment; at any time to: recover that overpayment from the person to whom or on whose behalf it was made; or offset the amount of that overpayment from a future claim payment.

HCDFB-POB61 06-21

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Definitions Dependent The term child means a child born to You or a child legally adopted by You, or a foster child including that child from the first day of placement in Your home regardless of whether the adoption has become final.

HCDFB-DFS383 06-21

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CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER – Ohio Residents

Rider Eligibility: Each Employee who is located in Ohio

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

HC-ETOHRDR

Covered Dental Services Teledentistry services are covered only when administered in conjunction with procedures and services which are covered under this plan.