Exhibit 19 - Cal Yr 2025 City of Miami CIGNA Medical - SBC Comp Ded 300 Max Out of Pocket 1K.pdf

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 - 12/31/2025 City of Miami: Open Access Plus Coverage for: Individual/Individual + Family | Plan Type: OAP

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

For in-network providers: $300/individual or $900/family For out-of-network providers: $600/individual or $1,800/family

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. In-network preventive care & immunizations, in-network prescription drugs, emergency room visits, urgent care facility visits.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For in-network providers: $1,000/individual or $1,000/family For out-of-network providers: $2,000/individual or $2,000/family Combined medical/behavioral and pharmacy out-of-pocket limit

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Penalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

EXHIBIT 19

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Important Questions Answers Why This Matters:

Will you pay less if you use a network provider?

Yes. See www.cigna.com or call 1-800-Cigna24 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will PayCommon Medical Event Services You May Need In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

Limitations, Exceptions, & Other Important Information

Primary care visit to treat an injury or illness 30% coinsurance/visit 50% coinsurance None

Specialist visit 30% coinsurance/visit 50% coinsurance None If you visit a health care provider's office or clinic Preventive care/ screening/ immunization No charge Deductible does not apply Not covered

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

Diagnostic test (x-ray, blood work) 30% coinsurance 50% coinsurance None

If you have a test Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification.

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at

Generic drugs (Tier 1)

$15 copay/prescription (retail 30 days), No charge/prescription (retail & home delivery 90 days) Deductible does not apply

Not covered

Coverage is limited up to a 90-day supply (retail and home delivery).

Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits.

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

Preferred brand drugs (Tier 2)

$25 copay/prescription (retail 30 days), $50 copay/prescription (retail & home delivery 90 days) Deductible does not apply

Not covered www.cigna.com

Non-preferred brand drugs (Tier 3)

$25 copay/prescription (retail 30 days), $50 copay/prescription (retail & home delivery 90 days) Deductible does not apply

Not covered

For drugs in the Cigna Patient Assurance Program you may pay less than the noted retail or home delivery cost share amounts.

In-network Federally required preventive drugs will be provided at no charge.

Facility fee (e.g., ambulatory surgery center) 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification.If you have outpatient surgery Physician/surgeon fees 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification.

Emergency room care $75 copay/visit Deductible does not apply

$75 copay/visit Deductible does not apply

Per visit copay is waived if admitted.

Out-of-network services are paid at the in-network cost share.

Emergency medical transportation 30% coinsurance 30% coinsurance

Out-of-network air ambulance services are paid at the in-network cost share and deductible.

If you need immediate medical attention

Urgent care $75 copay/visit Deductible does not apply

$75 copay/visit Deductible does not apply None

Facility fee (e.g., hospital room) 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification.If you have a hospital stay Physician/surgeon fees 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification.

If you need mental health, behavioral health, or substance abuse services

Outpatient services 30% coinsurance/office visit 30% coinsurance/all other services

50% coinsurance/office visit 50% coinsurance/all other services

$750 penalty if no precert of out-of-network non-routine services (i.e., partial hospitalization, etc.). Includes medical services for MH/SA diagnoses.

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Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

Inpatient services 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses.

Office visits 30% coinsurance 50% coinsurance Childbirth/delivery professional services 30% coinsurance 50% coinsurance

If you are pregnant Childbirth/delivery facility services 30% coinsurance 50% coinsurance

Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy.

Cost sharing does not apply for preventive services.

Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

Home health care 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification.

16 hour maximum per day

If you need help recovering or have other special health needs Rehabilitation services

30% coinsurance/PCP visit

30% coinsurance/ Specialist visit

50% coinsurance/PCP visit

50% coinsurance/ Specialist visit

$750 penalty for failure to precertify out-of-network speech therapy services. Coverage is limited to annual max of: 180 days for Rehabilitation and Chiropractic care services; 36 days for Cardiac rehab services.

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

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Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

Habilitation services 30% coinsurance/PCP visit

30% coinsurance/ Specialist visit

50% coinsurance/PCP visit

50% coinsurance/ Specialist visit

$750 penalty for failure to precertify out-of-network speech therapy services. Services are covered when Medically Necessary to treat a mental health condition (e.g. autism) or a congenital abnormality.

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Skilled nursing care 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification.

Coverage is limited to 180 days annual max.

Durable medical equipment 30% coinsurance Not covered None

Hospice services 30% coinsurance/inpatient services 30% coinsurance/outpatient services

50% coinsurance/inpatient services 50% coinsurance/outpatient services

$750 penalty for no out-of-network precertification.

Children's eye exam Not covered Not covered None Children's glasses Not covered Not covered NoneIf your child needs dental or eye care Children's dental check-up Not covered Not covered None https://www.healthcare.gov/sbc-glossary/#habilitation-services https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#medically-necessary https://www.healthcare.gov/sbc-glossary/#skilled-nursing-care https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#hospice-services https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Cosmetic surgery Dental care (Adult) Dental care (Children) Eye care (Children)

Hearing aids Long-term care Non-emergency care when traveling outside the

U.S.

Private-duty nursing

Routine eye care (Adult) Routine foot care Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Acupuncture (20 days) Bariatric Surgery (in-network only Surgeon

Charges Lifetime max $10,000)

Chiropractic care (combined with Rehabilitation Services)

Infertility treatment (Lifetime max $20,000)

Your Rights to Continue Coverage:

There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Cigna at 1-800-Cigna24, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:

There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-800- Cigna24.

Does this plan provide Minimum Essential Coverage? Yes.

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes.

If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Managing Joe's Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)

Mia's Simple Fracture (in-network emergency room visit and follow up care)

■ The plan's overall deductible $300

■ Specialist coinsurance 30%

■ Hospital (facility) coinsurance 30%

■ Other coinsurance 30%

■ Hospital (facility) coinsurance 30%

■ Other coinsurance 30%

■ Hospital (facility) coinsurance 30%

■ Other coinsurance 30%

This EXAMPLE event includes services like:

Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

This EXAMPLE event includes services like:

Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

This EXAMPLE event includes services like:

Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $300 Copayments $0 Coinsurance $700

What isn't covered Limits or exclusions $20 The total Peg would pay is $1,020

Total Example Cost $5,600

In this example, Joe would pay:

Deductibles $300 Copayments $400 Coinsurance $300

What isn't covered Limits or exclusions $40 The total Joe would pay is $1,040

Total Example Cost $2,800

In this example, Mia would pay:

Deductibles $300 Copayments $80 Coinsurance $500

What isn't covered Limits or exclusions $0 The total Mia would pay is $880

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: OAP Plan Comp EEs Ben Ver: 31 Plan ID: 32183692 https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#primary-care-physician https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#prescription-drugs https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#rehabilitation-services https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment

Discrimination is against the law.

Medical coverage

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

Cigna Healthcare:

• 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 number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna Healthcare 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 Healthcare 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, DC 20201

1.800.368.1019, 800.537.7697 (TDD)

Complaint forms are available at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html