Exhibit 30a - Cal Yr 2025 City of MIami CIGNA VIS Vision Benefit imbedded in Medical Plan Document ASO71.pdf

City of Miami

CIGNA VISION INSURANCE

For Network Participants

EFFECTIVE DATE: January 1, 2025

ASO71

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.

HCVIS-CVR0 01-24

EXHIBIT 30a

Table of Contents Important Information

Important Notices

How to Find a Cigna Vision Provider and File a Claim

Eligibility - Effective Date

Cigna Vision The Schedule

Covered Expenses

Exclusions

Coordination of Benefits

Expenses For Which A Third Party May Be Responsible

Payment of Benefits

Termination of Insurance Rescissions

Miscellaneous

Definitions

Federal Requirements Notice of Provider Directory/Networks Qualified Medical Child Support Order (QMCSO) Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) Group Plan Coverage Instead of Medicaid Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) Claim Determination Procedures Appointment of Authorized Representative Vision - When You Have a Complaint or an Appeal COBRA Continuation Rights Under Federal Law

HCVIS-TOC0 01-24

Important Information

THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR

ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY CITY OF MIAMI WHICH IS

RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY

(CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT

INSURE THE BENEFITS DESCRIBED.

THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE

THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO

INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA,"

"INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR

"EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND

"INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."

HCVIS-NOT1 01-24

Explanation of Terms You will find terms starting with capital letters throughout Your Certificate. To help You understand Your benefits, most of these terms are defined in the Definitions section of Your Certificate.

The Schedule The Schedule is a brief outline of Your maximum benefits which may be payable under Your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents.

HCVIS-NOTICE 01-24

myCigna.com6

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

Cigna:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters Information written in other languages

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by writing to the following address:

Cigna Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. Call 1.877.478.7557

(TTY: 800.428.4833).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1.877.478.7557

(TTY: 800.428.4833).

Chinese –

1.877.478.7557 800.428.4833

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi 1.877.478.7557

(TTY: 800.428.4833).

Korean

1.877.478.7557

(TTY: 800.428.4833)

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Tumawag sa 1.877.478.7557

(TTY: 800.428.4833).

Russian – ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 1.877.478.7557 (линия TTY телетайп:

800.428.4833).

French Creole – ATANSYON: Gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1.877.478.7557 (TTY:

800.428.4833).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le

1.877.478.7557 (ATS: 800.428.4833).

Portuguese – ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.

Ligue 1.877.478.7557 (TTY: 800.428.4833).

Polish – UWAGA: Możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1 877 478 7557

(TTY: 800.428.4833).

Japanese –

1.877.478.7557

TTY: 800.428.4833

Arabic – ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 1.877.478.7557

(رقم هاتف الصم والبكم: 800.428.4833).

myCigna.com7

Italian – ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1.877.478.7557 (TTY:

800.428.4833).

German – ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1.877.478.7557 (TTY:

800.428.4833).

HC-NOT99 07-17

Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call

1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese –

Cigna ID

1.800.244.6224 711

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean

Cigna

ID

1.800.244.6224

TTY 711

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224

(TTY: 711).

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro

1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para

1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese –

Cigna

ID

1.800.244.6224 TTY:

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione.

In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung.

Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte

an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

Persian (Farsi) – توجه: خدمات کمک زبانی٬ به صورت رایگان به شما ارائه میشود. با شماره 1.877.478.7557 تماس بگیرید

(شماره تلفن ویژه ناشنوایان: 800.428.4833).

myCigna.com8

HC-NOT97 07-17

How to Find a Cigna Vision Provider and File a Claim Cigna Vision Providers To find a Cigna Vision Provider, or to get a claim form, You should visit myCigna.com and use the link on the vision coverage page, or You may call Customer Service using the toll-free number on Your identification card.

How to File a Claim Reimbursement/Filing a Claim When You have an exam or purchase Vision Materials from a Cigna Vision Provider You pay any applicable Copayment, Coinsurance or Deductible shown in The Schedule at the time of purchase. You do not need to file a claim form. There is no paperwork to submit for Covered Vision Services received from a Participating Provider.

If You have an exam or purchase Vision Materials from a provider who is not a Cigna Vision Provider, You pay the full cost at the time of purchase. You must submit a claim form to be reimbursed or the claim can be submitted by the provider if the provider is able and willing to file on Your behalf.

If Your plan provides coverage when care is received only from a Participating Provider, You may still have claims for services received from a Non-Participating Provider. For example, when Emergency Services are received from a Non- Participating Provider, You should follow the claim submission instructions for those claims. Claims can be submitted by the provider if the provider is able and willing to file on Your behalf. If the provider is not submitting on Your behalf, You must send Your completed claim form and itemized bills to the claims address listed below.

Send a completed Cigna Vision claim form and itemized receipt to:

Cigna Vision, Claims Dept. c/o FAA PO Box 8504 Mason, OH 45040-7111

Cigna Vision will pay for covered expenses within ten business days of receiving the completed claim form and itemized receipt.

You may get the required claim forms from the website listed on Your identification card, if You received one, or by calling Customer Services using the toll-free number listed below.

Cigna’s Toll Free Number(s):

1-(800) CIGNA 24 (1-800-244-6224) or 1-(888)-353-2653 Claim Reminders

BE SURE TO USE YOUR MEMBER ID AND

ACCOUNT/GROUP NUMBER WHEN YOU FILE CLAIM

FORMS, OR WHEN YOU CALL OUR CLAIM OFFICE.

YOUR MEMBER ID IS THE ID SHOWN ON YOUR

BENEFIT IDENTIFICATION CARD.

YOUR ACCOUNT/GROUP NUMBER IS SHOWN ON

YOUR BENEFIT IDENTIFICATION CARD.

BE SURE TO FOLLOW THE INSTRUCTIONS LISTED ON

THE BACK OF THE CLAIM FORM CAREFULLY WHEN

SUBMITTING A CLAIM TO US.

Timely Filing of Claims We will consider claims for coverage under Your plan when proof of loss (a claim) is submitted to Us within:

12 months for In-Network claims 12 months for Out-of-Network claims after services are rendered. If services are rendered on consecutive days, the limit will be counted from the last date of service. If claims are not submitted to Us within the timeframe shown above, the claim will not be considered valid and will be denied. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

NOTE: We consider one month to equal 30 days regardless of the number of days within a calendar month.

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person: files an application for insurance or statement of claim containing any materially false information; or conceals for the purpose of misleading, information concerning any material fact thereto, myCigna.com9 may be guilty of committing a fraudulent insurance act determined by a court of law.

HCVIS-CLM0 01-24

Eligibility - Effective Date Eligible Class Each Employee as reported to Us by Your Employer.

Eligibility for Vision Insurance You will become eligible for insurance on the day You complete the Eligibility Waiting Period, if any, and:

You are an eligible Full-Time Employee;

You normally work at least 30 hours a week; and You pay any required contribution.

Eligibility Waiting Period – New Hire Your Eligibility Waiting Period is:

90 days after the date of hire.

Effective Date of Your Insurance You will become insured on:

the date that:

You are in Active Service and You elect the insurance by:

authorizing premium payment, approving a payroll deduction, or signing an enrollment form, as applicable, but no earlier than the date You become eligible.

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

Late Entrant You are a Late Entrant if:

You elect the insurance more than 30 days after You initially become eligible; or You again elect it after You cancel Your payroll deduction (if required).

If You are a Late Entrant:

You will not be able to enroll in the plan, until the next enrollment period, except due to a life status change event.

Dependent Insurance For Your Dependents to be insured under the Policy, You must elect the Dependent Insurance for Yourself no later than

30 days after You become eligible. For Your Dependents to be insured, You will have to pay the required contribution, if any, toward the cost of Dependent Insurance.

Eligibility for Dependent Insurance Your Dependent will become eligible for Dependent Insurance on the later of:

the day You meet the eligibility requirements noted above;

or the day You acquire Your first Dependent.

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 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.

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

You elect that insurance more than 30 days after You initially become eligible for it; or You again elect it after You cancel Your payroll deduction (if required).

If You are a Late Entrant:

You will not be able to enroll in the plan, until the next enrollment period, except due to a life status change event.

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 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 vision 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.

Exception for Newborns Any Dependent 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.

myCigna.com10

Dual Eligibility If both You and Your Spouse or Your Domestic 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 or Your Domestic Partner. If the Spouse or Your Domestic 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 or Domestic Partner.

HCVIS-ELG0 01-24

myCigna.com11

Cigna Vision

The Schedule

For You and Your Dependents

Allowance The maximum amount Cigna will pay each Covered Person per Calendar Year, the member is responsible for any amount over the allowance.

Copayments Copayments are amounts to be paid by you or your Dependent for covered services.

Calendar Year The term Calendar Year means the period that begins on January 1st and ends on December 31st of that year.

BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK

Out-of-Pocket Maximum

Individual Refer to the Medical Benefits Schedule

Family Refer to the Medical Benefits Schedule

The Plan will pay 100% after any Copayment, subject to any maximum Allowance shown below

Examinations One Eye Exam every Calendar Year

$10 Copayment

Maximum Allowance and Copayment applies to In-and Out-of-Network Providers myCigna.com12

BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK

Eyeglass Lenses One pair per Calendar Year

Single Vision Lenses For covered persons under age 19:

100%

For covered persons age 19 and over:

100% up to $20

Lined Bifocal Lenses For covered persons under age 19:

100%

For covered persons age 19 and over:

100% up to $30

Lined Trifocal Lenses For covered persons under age 19:

100%

For covered persons age 19 and over:

100% up to $40

Lenticular Lenses For covered persons under age 19:

100%

For covered persons age 19 and over:

100% up to $75

Contact Lenses and Professional Services One pair per Calendar Year

Elective For covered persons under age 19:

100%

For covered persons age 19 and over:

100% up to $75

Therapeutic For covered persons under age 19:

100%

For covered persons age 19 and over:

100% up to $75

Frames One pair per Calendar Year

For covered persons under age 19:

100%

For covered persons age 19 and over:

100% up to $30 myCigna.com13

Vision Benefits Please be aware that the Vision network is different from the network of your medical and/or dental benefits.

Covered Expenses For You and Your Dependents Benefits Include:

Examination(s) Comprehensive Examination - One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction and prescription for glasses.

Retinal Screening – One retinal imaging, which takes digital pictures of the inside of the eye. Does not replace a dilate eye examination. Must be in conjunction with an eye Examination.

Contact Lens Professional Services (Fit & Follow-up) – All fitting and evaluation services provided by a Vision Provider.

Available when an eye Examination has been completed.

Materials Vision Materials Coverage Eyeglass Lenses (Glasses) – One pair of prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms).

Coverage for One of the following eyeglass lens types:

Single Vision Eyeglass Lenses (pair) Lined Bifocal Eyeglass Lenses (pair) Lined Trifocal Eyeglass Lenses (pair) Lenticular Eyeglass Lenses (pair)

Frames – One frame - choice of frame covered up to retail plan allowance.

Contact Lenses and Professional Services – One pair or a single purchase of a supply of contact lenses in lieu of eyeglass lenses and frame benefit (may not receive eyeglass lenses, contact lenses and frames in same benefit year).

Contact lens allowance can be applied towards contact lens materials as well as the cost of supplemental contact lens professional services including fitting and evaluation, up to the stated allowance.

Coverage for Therapeutic contact lenses will be provided when visual acuity cannot be corrected to 20/70 in the better eye with eyeglasses and the fitting of the contact lenses would obtain this level of visual acuity; and in certain cases of anisometropia, keratoconus, or aphakis; as determined and documented by your Vision Provider. Contact lenses fitted for other therapeutic purposes or the narrowing of visual fields due to high minus or plus correction will be covered in accordance with the Elective contact lens benefit shown on the Schedule of Benefits.

HCVIS-COV0 01-24

Vision Benefits For You and Your Dependents

Exclusions Covered Vision Expenses will not include, and no payment will be made for:

Orthoptic or vision training and any associated supplemental testing.

Medical or surgical treatment, services or supplies for the treatment of the eyes or supporting structures.

Refraction, when not provided as part of a Comprehensive Eye Examination.

Any eye examination, or any corrective eyewear, required by an employer as a condition of employment.

Charges incurred after the Policy ends or the insured's coverage under the Policy ends, except as stated in the Policy.

Services rendered after the date a Covered Person ceases to be covered under the Policy, except when Vision Materials are ordered before coverage ended and are delivered within 31 days from date of such order.

Experimental or non-conventional treatment or device.

Charges in excess of the usual and customary charge for the service or materials.

For or in connection with experimental procedures or treatment methods not approved by the American Optometric Association or the appropriate vision specialty society.

Any injury or illness when paid or payable by Workers’ Compensation or similar law, or which is work-related.

Claims submitted and received in excess of 12 months from the original date of service.

Electronic vision devices.

Magnification or low vision aids.

Spectacle lens treatments, “add-ons”, or lens coatings not shown as covered in The Schedule.

Two pair of glasses, in lieu of bifocals or trifocals.

Prescription sunglass 'add-ons' or lens coatings not shown as covered in The Schedule.

myCigna.com14

Any non-prescription (minimum RX required) eyeglasses, lenses, or contact lenses.

Safety glasses or lenses required for employment.

Solutions, cleaning products or frame cases.

Lost, stolen or broken lenses, frames, glasses, or contact lenses that are replaced before the next benefit frequency when Vision Materials would next become available.

For cosmetic contact lenses that do not improve vision.

Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply.

HCVIS-EXC0 01-24

Coordination of Benefits This section applies if You or any one of Your Dependents are covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Any other health coverage plans for You or any of Your covered Dependents are taken into account when benefits are paid.

Coverage under this Plan plus another Plan will not guarantee 100% reimbursement.

Definitions For the purposes of this section, the following terms have the meanings set forth below:

A. Plan. A Plan is any of the following that provides benefits or services for medical or vision care or treatment. Plan includes group and non-group insurance contracts, health maintenance organization (HMO) contracts, Closed Panel Plans or other forms of group or non-group type coverage (whether insured or uninsured); and medical or vision benefits under group or individual automobile contracts;

Medicare, Medicaid or any other federal governmental plan, as permitted by law.

Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan.

B. Closed Panel Plan. A Plan that provides medical or vision benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel.

C. Primary Plan. The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan. A Plan that does not contain a coordination of benefits provision that is consistent with this section is always primary.

D. Secondary Plan. A Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to You.

E. Allowable Expenses. The amount of charges considered for payment under the Plan for a Covered Vision Service prior to any reductions due to Coinsurance or Deductible amounts. If We contract with an entity to arrange for the provision of Covered Vision Services through that entity’s contracted network of health care providers, the amount that We have agreed to pay that entity is the allowable amount used to determine Your Coinsurance or Deductible payments. If the Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.

Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following:

An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense.

If You are covered by two or more Plans that provide services or supplies on the basis of Reasonable and Customary fees, any amount in excess of the highest Reasonable and Customary fee is not an Allowable Expense.

If You are covered by one Plan that provides services or supplies on the basis of Reasonable and Customary fees and one Plan that provides services and supplies on the basis of negotiated fees, the Primary Plan's fee arrangement shall be the Allowable Expense.

If Your benefits are reduced under the Primary Plan (through the imposition of a higher Coinsurance percentage, a Deductible, and/or a penalty) because You did not comply with Plan provisions or because You did not use a Participating Provider, the amount of the reduction is not an Allowable Expense. Such Plan provisions include second surgical opinions and precertification of services.

F. Custodial Parent. The parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one-half of the Calendar Year, excluding any temporary visitation.

G. Claim Determination Period. A Calendar Year, but does not include any part of a year during which You are not myCigna.com15 covered under this Policy or any date before this section or any similar provision takes effect.

H. Reasonable Cash Value. An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area where the health care service is rendered under similar or comparable circumstances.

Order of Benefit Determination Rules A Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan.

If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use:

Employee: The Plan that covers a person as an Employee shall be the Primary Plan and the Plan that covers a person as a Dependent shall be the Secondary Plan.

Dependent: For a Dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which covers the parent whose birthday falls first in the Calendar Year.

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 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 of the parent not having custody of the child.

Employee in Active Service or laid-off Employee: The Plan that covers You as an Employee in Active Service and Your Dependent shall be the Primary Plan and the Plan that covers You as a laid-off Employee and Your Dependent shall be the Secondary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.

COBRA or State Continuation of Coverage: The Plan that covers You under a right of continuation which is provided by federal or state law shall be the Secondary Plan and the Plan that covers You as an Employee in Active

Service or Your Dependent, shall be the Primary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.

If one of the Plans that covers You is issued out of the state whose laws govern this Policy, and determines the order of benefits based upon the gender of a parent, and as a result, the Plans do not agree on the order of benefit determination, the Plan with the gender rules shall determine the order of benefits.

Longer or Shorter Length of Coverage: The Plan that covers a person for a longer period of time is the Primary Plan and the Plan that covered the person for the shorter period of time is the Secondary Plan.

If the preceding rules do not determine the order of benefits, the Allowable Expenses shall be shared equally between each of the Plans meeting the definition of a Plan. In addition, this Plan will not pay more than it would have paid had it been the Primary Plan.

Effect on the Benefits of This Plan If this Plan is the Secondary Plan, this Plan may reduce benefits so that the total benefits paid by all Plans during a Claim Determination Period are not more than 100% of the total of all Allowable Expenses.

The difference between the amount that this Plan would have paid if this Plan had been the Primary Plan, and the benefit payments that this Plan had actually paid as the Secondary Plan, will be recorded as a benefit reserve for You. We will use this benefit reserve to pay any Allowable Expense not otherwise paid during the Claim Determination Period.

As each claim is submitted, We will determine the following:

Our obligation to provide services and supplies under this Policy;

whether a benefit reserve has been recorded for You; and whether there are any unpaid Allowable Expenses during the Claims Determination Period.

If there is a benefit reserve, We will use the benefit reserve recorded for You to pay up to 100% of the total of all Allowable Expenses. At the end of the Claim Determination Period, Your benefit reserve will return to zero and a new benefit reserve will be calculated for each new Claim Determination Period.

Recovery of Excess Benefits If We pay charges for benefits that should have been paid by the Primary Plan, or if We pay charges in excess of those for which We are obligated to provide under the Policy, We will myCigna.com16 have the right to recover the actual payment made or the Reasonable Cash Value of any services.

We will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, healthcare plan or other organization. If We request, You must execute and deliver to Us such instruments and documents as We determine are necessary to secure the right of recovery.

Right to Receive and Release Information We, without consent or notice to You, may obtain information from and release information to any other Plan with respect to You in order to coordinate Your benefits pursuant to this section. You must provide Us with any information We request in order to coordinate Your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, You will be advised that the "other coverage" information, (including an Explanation of Benefits paid under the Primary Plan) is required before the claim will be processed for payment. If no response is received within 55 days of the request, the claim will be closed. If the requested information is subsequently received, the claim will be processed.

HCVIS-COB0V1 01-24

Expenses For Which A Third Party May Be Responsible This plan does not cover:

Expenses incurred by You or Your Dependent(s)for which another party may be responsible as a result of having caused or contributed to an injury or sickness.

Expenses incurred by You or Your Dependent(s)to the extent any payment is received either directly or indirectly from a third party tortfeasor or as a result of a settlement, judgment or arbitration award in connection with any automobile medical, automobile no-fault, uninsured or underinsured motorist, homeowners, workers' compensation, government insurance (other than Medicaid), or similar type of insurance or coverage. The coverage under this plan is secondary to any automobile no-fault or similar coverage.

Right of Reimbursement If a Covered Person incurs expenses for Covered Vision Services for which another party may be responsible or for which the Covered Person may receive payment as described above, We will be granted a right of reimbursement, to the extent of the benefits provided by Us, from the proceeds of any recovery whether by settlement, judgment, or otherwise.

Lien of the Plan By accepting benefits under this plan, a Covered Person:

grants a lien and assigns to Us an amount equal to the benefits paid under this plan against any recovery made by or on behalf of the Covered Person which is binding on any attorney or other party who represents the Covered Person whether or not an agent of the Covered Person or of any insurance company or other financially responsible party against whom a Covered Person may have a claim provided said attorney, insurance carrier or other party has been notified by Us or Our agents;

agrees that this lien shall constitute a charge against the proceeds of any recovery and We shall be entitled to assert a security interest thereon;

agrees to hold the proceeds of any recovery in trust for Our benefit to the extent of any payment made by Us.

Additional Terms No adult Covered Person may assign any rights that the Covered Person may have to recover vision expenses from any third party or other person or entity to any Dependent child without Our prior express written consent. Our right to recover shall apply to decedents’, minors’, and incompetent or disabled persons’ settlements or recoveries.

No Covered Person shall make any settlement, which specifically reduces or excludes, or attempts to reduce or exclude, the benefits provided by the plan.

Our right of recovery shall be a prior lien against any proceeds recovered by the Covered Person. This right of recovery shall not be defeated nor reduced by the application of any so-called “Made-Whole Doctrine”, “Rimes Doctrine”, or any other such doctrine purporting to defeat Our recovery rights by allocating the proceeds exclusively to non-vision expense damages.

No Covered Person shall incur any expenses on behalf of the plan in pursuit of the plan’s rights. Specifically; no court costs, attorneys' fees, or other representatives' fees may be deducted from the plan’s recovery without Our prior express written consent. This right shall not be defeated by any so-called “Fund Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund Doctrine”.

We shall recover the full amount of benefits provided under the plan without regard to any claim of fault on the part of any Covered Person, whether under comparative negligence or otherwise.

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We hereby disavow all equitable defenses in the pursuit of Our right of recovery. Our recovery rights are neither affected nor diminished by equitable defenses.

In the event that a Covered Person fails or refuses to honor his obligations under the plan. We shall be entitled to recover any costs incurred in enforcing the terms of the Policy including, but not limited to, attorney’s fees, litigation, court costs, and other expenses. We shall also be entitled to offset the reimbursement obligation against any entitlement to future vision benefits under the Covered Person has fully complied with his reimbursement obligations, regardless of how those future vision benefits are incurred.

By acceptance of benefits under the plan, the Covered Person agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, We shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief.

Covered Persons must assist Us in pursuing any recovery rights by providing requested information.

HCVIS-SUB0 01-24

Payment of Benefits Assignment and Payment of Benefits You may not assign to any party, including, but not limited to, a provider of healthcare services/items, Your right to benefits under this plan, nor may You assign any administrative, statutory, or legal rights or causes of action You may have under ERISA, including, but not limited to, any right to make a claim for plan benefits, to request plan or other documents, to file appeals of denied claims or grievances, or to file lawsuits under ERISA. Any attempt to assign such rights shall be void and unenforceable under all circumstances.

You may, however, authorize Us to pay any healthcare benefits under this Policy to a Participating or Non- Participating Provider . When You authorize the payment of Your healthcare benefits to a Participating or Non- Participating Provider , You authorize the payment of the entire amount of the benefits due on that claim. If a provider is overpaid because of accepting duplicate payments from You and Us, it is the provider’s responsibility to reimburse the overpayment to You. We may pay all healthcare benefits for Covered Vision Services directly to a Participating Provider without Your authorization. You may not interpret or rely upon this discrete authorization or permission to pay any healthcare benefits to a Participating or Non-Participating Provider as the authority to assign any other rights under this Policy to any party, including, but not limited to, a provider of healthcare services/items.

Even if the payment of healthcare benefits to a Non- Participating Provider has been authorized by You, We may make payment of benefits to You. When benefits are paid to You, You or Your Dependents are responsible for reimbursing the a Non-Participating Provider .

Initial Determination A claim for vision benefits will be reviewed upon receipt. We will notify You of Our decision to approve or deny the claim within 30 days from the date You submitted the claim, unless an extension is required due to matters beyond Our control.

Any extension will not be more than 15 days.

If We require an extension, You will be notified in writing before the end of the initial 30 day period. The notice of extension will explain the reasons for the extension and will state when a determination will be made. If an extension is required because We require additional information from You, the time from the date of Our notice requesting further information and the time We receive the necessary information does not count toward the time period We are allowed to notify You of the claim determination. You will have 45 days from the date You receive the request for additional information to provide the requested information.

Claim Denial If Your claim is denied, in whole or in part, the notification of the claim decision will state the reason why Your claim was denied and reference the specific plan provisions upon which the denial is based. If the claim is denied because more information is needed from You, the claims decision will describe the additional information needed and why such information is needed. If We relied on an internal rule or other criterion when denying the claim, the claim decision will include the rule or other criteria or will indicate that such rule or criteria was relied upon and You may request a copy free of charge.

To Whom Payable Vision benefit payments are assignable to the provider. When You assign benefit payments to a provider, You have assigned the entire amount of the payment due on that claim. If the provider is overpaid because of accepting a patient’s payment on the charge, it is the provider’s responsibility to reimburse the patient. Because of Our contracts with providers, all claims from contracted providers should be assigned.

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We may, at Our option, make payment to You for the cost of any Covered Vision Services from a Non-Participating Provider even if benefits have been assigned. When benefits are paid to You or Your Dependent(s), You or Your Dependent(s) are responsible for reimbursing the provider.

If any person to whom benefits are payable is a minor or is not able to give a valid receipt for any payment due that person, such payment will be made to that person’s legal guardian. If no request for payment has been made by that person’s legal guardian, We will make payment to the person or institution appearing to have assumed that person’s custody and support.

In the event of the death of a Covered Person, We may receive notice that an executor of the estate has been established. The executor has the same rights as the Covered Person and benefit payments for unassigned claims should be made payable to the executor.

Payment as described above will release Us from all liability to the extent of any payment made.

Recovery of Overpayment When We have made an overpayment, We will have the right 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. In addition, Your acceptance of benefits under this Policy and/or assignment of benefits separately creates an equitable lien by agreement pursuant to which We may seek recovery of any overpayment. You agree that in seeking recovery of any overpayment as a contractual right or as an equitable lien by agreement, We may pursue the general assets of the person or entity to whom or on whose behalf the overpayment was made.

HCVIS-POB0 01-24

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.

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

Your death.

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

Temporary Layoff or Leave of Absence If your Active Service ends due to temporary layoff or leave of absence, Your insurance will be continued until the date your Employer cancels Your insurance. However, Your insurance will not be continued for more than 60 days past the date your Active Service ends.

Injury or Sickness If Your Active Service ends due to an injury or sickness, Your insurance will be continued while You remain totally and continuously disabled as a result of the injury or sickness.

However, Your insurance will not continue past the date Your Employer cancels Your insurance.

Retirement If Your Active Service ends because You retire, Your insurance will be continued until the date on which Your Employer cancels Your insurance.

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

the date Your insurance ceases; or the date You cease to be eligible for Dependent insurance;

or the last day for which You have made any required contribution for the insurance; or the date Dependent insurance is canceled; or the date that Dependent no longer qualifies as a Dependent;

or Your death.

HCVIS-TRM0 01-24

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Rescissions Your coverage may not be rescinded (retroactively terminated) by Cigna or the plan sponsor unless the plan sponsor or an individual (or a person seeking coverage on behalf of the individual) performs an act, practice or omission that constitutes fraud; or the plan sponsor or individual (or a person seeking coverage on behalf of the individual) makes an intentional misrepresentation of material fact.

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Miscellaneous Notice Regarding Provider Directory You may obtain a listing of Participating Providers who participate in Our vision network without charge by visiting www.cigna.com; mycigna.com; or by calling the toll-free telephone number 1-(800) CIGNA24 (1-800-244-6224).

Additional Programs We may, from time to time, offer or arrange for various entities to offer discounts, benefits or other consideration to Employees for the purpose of promoting the general health and well being of Employees. We may also arrange for the reimbursement of all or a portion of the cost of services provided by other parties to the Employees. Contact Us for details regarding any such arrangements.

Impossibility of Performance Neither Employer nor Cigna shall be liable to the other or be deemed to be in breach of this Contract for any failure or delay in performance arising out of unforeseeable events beyond the control of either party. Such events are limited to include natural disaster, war, riot, acts of terrorism (domestic and/or foreign), epidemic, pandemic, cyber events (including breakdown of communication facilities, web hosting and internet services) or any other emergency or similar event not within either party’s control which may result in facilities, personnel, or financial resources being unavailable to provide or arrange for the provision of services in accordance with this Policy. Timelines for performance shall be extended to the extent necessary and agreed upon by both parties, provided that the party whose performance is affected notifies the other promptly of the existence and nature of the delay and the impacted party makes good faith effort to provide or arrange for the provision of service, taking into account the severity of the event.

Administrative Policies Relating to this Contract We may adopt reasonable policies, procedures, rules and interpretations that promote orderly administration of this Contract.

Assignability The benefits under this Contract are not assignable unless agreed to by Us. We may, at Our option, make payment to the Employee for any cost of any Covered Vision Expense received by the Employee or Employee’s covered Dependents from a Non-Participating Provider. The Employee is responsible for reimbursing the Non-Participating Provider.

Clerical Error No clerical error on the part of Us shall operate to defeat any of the rights, privileges or benefits of any Employee.

Entire Contract The entire Contract will be made up of the Policy; the Certificate; the application of the Employer, a copy of which is attached to the Policy; any riders and amendments to the Policy or Certificate; and any enrollment forms.

Conformity with State and Federal Statutes Any provision of this Certificate that is in conflict with the applicable statutes of the state whose law governs the Policy or this Certificate or with any applicable federal statute is amended to conform to the minimum requirements of such statutes.

Statements not Warranties All statements made by the Employer or any person covered under the Certificate will, in the absence of fraud, be deemed representations and not warranties. No statement made by You or the Employer to obtain insurance will be used to avoid or reduce the insurance unless it is made in writing and signed by You or the Employer and a copy is sent to the Employer, You and/or Your beneficiary.

Time Limit on Certain Defenses After two years from the Effective Date, no misstatements, except fraudulent misstatements, made by You in the application or any application amendment will be used to void this Certificate or to deny a claim for loss incurred after the expiration of such two-year period. No claim for loss commencing after 12 months from the Effective Date will be reduced or denied on the grounds that a disease or physical condition, not excluded from coverage by name or specific description, had existed prior to such Effective Date.

Your Vision Records In order to provide benefits under this Certificate, process claims, make payments or review appeals and/or grievances, We may need to obtain information and records from the myCigna.com20

Vision Provider who provided Your services or treatment.

Your acceptance of coverage under the Policy gives Us permission to obtain, copy and use Your vision records and information for such purposes and authorizes Your Vision Provider to disclose information that pertains to Your physical condition or…