IMPORTANT NOTICE. Special Enrollment Requirements from Cigna

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1 Special Enrollment Requirements from Cigna IMPORTANT NOTICE This flyer contains important information you should read before you enroll. If you have any questions about this information, please contact your benefits manager. If You Are Declining Enrollment If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if: You or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents other coverage). However, you must request enrollment within 30 days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). If the other coverage is COBRA continuation coverage, you and your dependents must complete your entire COBRA coverage period before you can enroll in this plan, even if your former employer ceases contributions toward the COBRA coverage. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 or later, if you or your dependents lose eligibility for state Medicaid or Children s Health Insurance Program (CHIP) coverage or become eligible for assistance with group health plan premium payment under a state Medicaid or CHIP plan, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days after the state Medicaid or CHIP coverage ends or you are determined eligible for premium assistance. To request special enrollment or obtain more information, contact our Customer Service Team at Other Late Entrants If you decide not to enroll in this plan now, then want to enroll later, you must qualify for special enrollment. If you do not qualify for special enrollment, you may have to wait until an open enrollment period, or you may not be able to enroll, depending on the terms and conditions of your health plan. Please contact your plan administrator for more information c PCL 07/14

2 Women s Health and Cancer Rights Act (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance or copays applicable to other medical and surgical benefits provided under this plan as shown in the Summary of Benefits. If you would like more information on WHCRA benefits, call our Customer Service Team at Cigna, and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. In Arizona, HMO plans are offered by Cigna HealthCare of Arizona, Inc. In California, HMO and Network plans are offered by Cigna HealthCare of California, Inc. In Connecticut, HMO plans are offered by Cigna HealthCare of Connecticut, Inc. In North Carolina, HMO plans are offered by Cigna HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by CGLIC or CHLIC. All models are used for illustrative purposes only c PCL 07/ Cigna. Some content provided under license. NO PCL

3 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. High Bridge Associates Inc Open Access Plus General Services In-Network Out-of-Network Primary care physician You pay $30 copay per visit Physician office visit Specialist You pay $60 copay per visit Urgent care visit All services including Lab & X-ray Urgent care copay You pay $75 Preventive Care Plan pays 100%, no copay, no deductible Preventive Services Plan pays 100%, no copay, no deductible Immunizations Performance pharmacy plan Includes contraceptives - with specific products covered at 100% If a Brand name drug is requested when there is a Generic equivalent, member must purchase the Generic drug, or pay 100% of the difference between the Brand name price and the Generic price, plus the appropriate brandname copay (unless the physician indicates "Dispense As Written" DAW) Cigna National Pharmacy Network Coinsurance Plan pays 100%, no copay, no deductible Tier 1: $10 Tier 2: $35 Tier 3: $60 Home Delivery 2.5x 90-Day supply at 3x retail copay You pay 20% Plan pays 80% Not Covered 5/1/2015 ASO / EHB State: GA Open Access Plus OAP Version# 5 1 of 6 Cigna 2015

4 General Services In-Network Out-of-Network Calendar year deductible Carryover Deductible provision included but does not credit the out-of-pocket amount Deductible waived for in-network Lab & X-ray in office or outpatient facility and for office surgery when performed in-network. Deductible is not Individual $1,500 Family $3,000 Individual $3,000 Family $6,000 waived for advanced radiology and infertility testing for Lab/X-ray. In-network and out-of-network expenses do not cross accumulate Out-of-pocket annual maximum Medical copays apply towards the out-of-pocket maximums Medical deductibles apply towards the out-ofpocket maximums Expenses do not cross accumulate between innetwork and out-of-network out-of-pocket maximums Pharmacy copays and coinsurance apply towards the out-of-pocket maximums Lifetime maximum Emergency room care All services rendered apply to ER benefit including Lab & X-ray Ambulance Unlimited per day maximum Office surgery Office visit copay applies even if no office visit charges are incurred Other office services 100% after office visit copay Independent lab paid based on status of the facility Outpatient lab and x-ray Independent Lab and X-ray paid based on status of the facility Office advanced radiology imaging services Includes MRI, MRA, PET, CT-Scan and Nuclear medicine Outpatient advanced radiology imaging services Includes MRI, MRA, PET, CT-Scan and Nuclear medicine Durable medical equipment Unlimited lifetime maximum Unlimited annual maximum Includes external prosthetic appliances Does accumulate towards the out-of-pocket maximum Individual $6,000 Family $12,000 Unlimited Per individual Emergency room copay You pay $200 Individual $12,000 Family $24,000 You pay 20% Plan pays 80% after the in-network deductible is met Plan pays 100% after office visit copay Plan pays 100% after office visit copay Plan pays 100% no deductible You pay 20% Plan pays 80% You pay 20% Plan pays 80% You pay 20% Plan pays 80% 5/1/2015 ASO / EHB State: GA Open Access Plus OAP Version# 5 2 of 6 Cigna 2015

5 General Services In-Network Out-of-Network Breast-feeding equipment and supplies Plan pays 100%, Limited to the rental of one breast pump per no copay, birth as ordered or prescribed by a physician. no deductible Includes related supplies Benefits In-Network Out-of-Network Hospital Services Inpatient hospital services In-network facility Out-of-network facility Including anesthesia You pay 20% Inpatient Lab & X-ray services are subject to the professional service reimbursement Plan pays 80% Outpatient hospital services Outpatient surgery Outpatient facility Outpatient facility Including anesthesia You pay 20% Ambulatory Surgery Plan pays 80% Lab & X-Ray paid based on facility network status Skilled nursing facility care 60 days per calendar year maximum Hospice care Home health care 60 visits per calendar year maximum Mental Health and Chemical Dependency Inpatient mental health Inpatient chemical dependency Outpatient mental health Outpatient chemical dependency Therapy Services Outpatient physical therapy 20 visits per calendar year 5/1/2015 ASO / EHB State: GA Open Access Plus OAP Version# 5 You pay 20% Plan pays 80% You pay 20% Plan pays 80% You pay 20% Plan pays 80% In-network facility You pay 20% Plan pays 80% In-network facility You pay 20% Plan pays 80% You pay $60 copay You pay $60 copay You pay $60 copay Out-of-network facility Out-of-network facility Outpatient speech therapy, hearing therapy and occupational therapy You pay $60 copay 20 visits per calendar year Chiropractic services 20 visits per calendar year You pay $60 copay Unlimited lifetime dollar maximum Acupuncture Not Covered Not Covered 3 of 6 Cigna 2015

6 Benefits In-Network Out-of-Network Additional Services Family planning Vasectomy Includes elective abortions Includes infertility testing for diagnosis only Contraceptives Includes contraceptive devices as ordered or prescribed by a physician Surgical services such as tubal ligation are covered (excluding reversals) Physician services TMJ Unlimited calendar year maximum for surgical and non-surgical treatment Organ transplant Services paid at network level if performed at Cigna LifeSOURCE Transplant Network Facilities Travel maximum $10,000 per transplant (only available if using Cigna LifeSOURCE Transplant Network facility) Out-of-area services Coverage for services rendered outside a network area ER and Ambulance paid the same as network services Preventive care services covered at 100% for out of area Out-of-network deductible and out-of-pocket maximums apply Varies based on place of service Plan pays 100%, no copay, no deductible Varies based on place of service In-network facility You pay 20% Plan pays 80% Out-of-network facility with transplant maximums Heart - $150,000 Liver - $230,000 Bone Marrow - $130,000 Kidney - $80,000 Pancreas - $50,000 Kidney/Pancreas - $80,000 Heart/Lung - $185,000 Lung - $185,000 For all other services You pay 20% Plan pays 80% after the out-of-network deductible is met 5/1/2015 ASO / EHB State: GA Open Access Plus OAP Version# 5 4 of 6 Cigna 2015

7 Additional Information Selection of a Primary Care Provider- Your plan may require or allow the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. If your plan requires designation of a primary care provider, Cigna may designate one for you until you make this designation. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider. Direct Access to Obstetricians and Gynecologists- You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a preapproved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit or contact customer service at the phone number listed on the back of your ID card. Out of Pocket Maximum Once you reach the individual or family out-of-pocket maximum (non-covered benefits are excluded from this total) in any one calendar year, covered services will be payable at 100% for the remainder of the year. Medical copays apply towards the out-of-pocket maximums Medical deductibles apply towards the out-of-pocket maximums Plan Coverage for Out-of-network Providers The allowable covered expense for non-network services is based on the lesser of the health care professional's normal charge for a similar service or at 110% of a fee schedule developed by Cigna that is based on a methodology similar to one used by Medicare to determine the allowable fee for the same or similar service in a geographic area. In some cases, the Medicare based fee schedule will not be used and the maximum reimbursable charge for covered services is based on the lesser of the health care professional's normal charge for a similar service or supply or the amount charged for that service by 80% of the health care professionals in the geographic area where it is received. Out-of-network services are subject to a calendar year deductible and maximum reimbursable charge limitations. Precertification Penalty Pre-authorization is required on all inpatient admissions and outpatient surgery not performed in the doctor's office. Network providers are contractually obligated to perform pre-authorization on behalf of their customers. For an out-of-network provider, the customer is responsible for following the pre-authorization procedures. If a customer does not follow the recommended care plan for obtaining pre-treatment authorization for an out-of-network provider, an ineligible expense penalty of $250 will be applied. General Notice of Preexisting Condition Exclusion Not applicable 5/1/2015 ASO / EHB State: GA Open Access Plus OAP Version# 5 5 of 6 Cigna 2015

8 Exclusions What's Not Covered (This Is Not All Inclusive; check your plan documents for a complete list) Services that aren't medically necessary Experimental or investigational treatments, except for routine patient care costs related to qualified clinical trials as described in your plan document Accidental injury that occurs while working for pay or profit Sickness for which benefits are paid or payable under any Worker's Compensation or similar law Services provided by government health plans Cosmetic surgery, unless it corrects deformities resulting from illness, breast reconstruction surgery after a mastectomy, or congenital defects of a newborn or adopted child or child placed for adoption Dental treatments and implants Custodial care Sex transformation Surgical procedures for the improvement of vision that can be corrected through the use of glasses or contact lenses Vision therapy or orthoptic treatment Hearing aids Reversal of sterilization procedures Nonprescription drugs or anti-obesity drugs Gene manipulation therapy Smoking cessation programs Non-emergency services incurred outside the United States Bariatric surgery Infertility services These are only the highlights This summary outlines the highlights of your plan. For a complete list of both covered and not-covered services, including benefits required by your state, see your employer's insurance certificate or summary plan description -- the official plan documents. If there are any differences between this summary and the plan documents, the information in the plan documents takes precedence. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc. and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 5/1/2015 ASO / EHB State: GA Open Access Plus OAP Version# 5 6 of 6 Cigna 2015

9 High Bridge Associates Inc: Open Access Plus Coverage Period: 05/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual + Family Plan Type: OAP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: For in-network providers $1,500 person / $3,000 family; For out-of-network providers $3,000 person / $6,000 family. What is the overall Does not apply to in-network preventive care, office deductible? visits, emergency room visits, in-network urgent care facility visits. Co-payments don't count toward the deductible. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? No. Yes. For in-network providers $6,000 person / $12,000 family; For out-of-network providers $12,000 person / $24,000 family. Premium, balance-billed charges, penalties for no preauthorization, and health care this plan doesn't cover. No. Yes. For a list of participating providers, see or call No. You don't need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of the covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-ofpocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 8

10 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charge is $1,500 for an overnight stay and allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Your Cost if you use an In-Network Provider Out-of-Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $30 co-pay/visit 40% co-insurance none Specialist visit $60 co-pay/visit 40% co-insurance none Other practitioner office visit $60 co-pay/visit for chiropractor 40% co-insurance for chiropractor Coverage is limited to 20 visits annual max for chiropractor Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) No charge No charge after initial co-pay for office visit, No charge at an outpatient facility 20% co-insurance during an office visit or at an outpatient facility 40% co-insurance (office visit & all other services) none % co-insurance none % co-insurance $250 penalty for no precertification. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

11 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is at If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Your Cost if you use an In-Network Provider Out-of-Network Provider Limitations & Exceptions $10 co-pay/prescription (retail), Coverage is available up to a 90- day supply (retail) at 3X copay Generic drugs $25 co-pay/prescription (home delivery) Not Covered (retail), otherwise a 30-day supply (retail) and a 90-day supply (home delivery) Preferred brand drugs $35 co-pay/prescription (retail), $88 co-pay/prescription (home delivery) Not Covered Coverage is available up to a 90- day supply (retail) at 3X copay (retail), otherwise a 30-day supply (retail) and a 90-day supply (home delivery) Coverage is available up to a 90- $60 co-pay/prescription (retail), day supply (retail) at 3X copay Non-preferred brand drugs $150 co-pay/prescription (home Not Covered (retail), otherwise a 30-day delivery) supply (retail) and a 90-day supply (home delivery) Facility fee (e.g., $250 penalty for no 20% co-insurance 40% co-insurance ambulatory surgery center) precertification. Physician/surgeon fees 20% co-insurance 40% co-insurance $250 penalty for no precertification. Emergency room services $200 co-pay/visit $200 co-pay/visit none Emergency medical transportation 20% co-insurance 20% co-insurance none Urgent care $75 co-pay/visit 40% co-insurance none Facility fee (e.g., hospital $250 penalty for no 20% co-insurance 40% co-insurance room) precertification. Physician/surgeon fee 20% co-insurance 40% co-insurance $250 penalty for no precertification. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

12 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you have a recovery or other special health need Services You May Need Your Cost if you use an In-Network Provider Out-of-Network Provider Limitations & Exceptions Mental/Behavioral health $250 penalty for no $60 co-pay/visit 40% co-insurance outpatient services precertification. Mental/Behavioral health $250 penalty for no 20% co-insurance 40% co-insurance inpatient services precertification. Substance use disorder $250 penalty for no $60 co-pay/visit 40% co-insurance outpatient services precertification. Substance use disorder $250 penalty for no 20% co-insurance 40% co-insurance inpatient services precertification. Prenatal and postnatal care 20% co-insurance 40% co-insurance none Delivery and all inpatient $250 penalty for no 20% co-insurance 40% co-insurance services precertification. $250 penalty for no Home health care 20% co-insurance 40% co-insurance precertification. Coverage is limited to 60 visits annual max $250 penalty for failure to precertify speech therapy $60 co-pay/visit for Physical and 40% co-insurance for Physical and services. Coverage is limited to Rehabilitation services Speech, Hearing & Occupational Speech, Hearing & Occupational an annual max of 20 visits for Therapy Therapy Physical Therapy and 20 visits for Speech, Hearing, & Occupational Therapy Habilitation services Not Covered Not Covered none Skilled nursing care 20% co-insurance 40% co-insurance Durable medical equipment 20% co-insurance 40% co-insurance Hospice service 20% co-insurance 40% co-insurance $250 penalty for no precertification. Coverage is limited to 60 days annual max $250 penalty for no precertification. $250 penalty for no precertification. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

13 Common Medical Event If your child needs dental or eye care Services You May Need Your Cost if you use an In-Network Provider Out-of-Network Provider Limitations & Exceptions Eye exam Not Covered none Glasses Not Covered none Dental check-up Not Covered Not Covered none Excluded Services & Other Covered Services Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Infertility treatment Acupuncture Long-term care Bariatric surgery Non-emergency care when traveling outside Cosmetic surgery of the U.S. Dental care (Adult) Weight loss programs Private-duty nursing Dental care (Children) Routine eye care (Adult) Habilitation services Routine eye care (Children) Hearing aids Routine foot care Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

14 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Cigna Customer service at You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

15 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Note: These numbers assume enrollment in individual-only coverage. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays: $5,330 Patient pays: $2,210 Sample care costs: Hospital charges (mother) $2,700 Routine Obstetric Care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductible $1,500 Co-pays $90 Co-insurance $590 Limits or exclusions $30 Total $2,210 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $4,210 Patient pays: $1,190 Sample care costs: Prescriptions $2,900 Medical equipment and supplies $1,300 Office visits & procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductible $0 Co-pays $910 Co-insurance $0 Limits or exclusions $280 Total $1,190 Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

16 Questions and answers about Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Plan ID: BenefitVersion: 5 Plan Name: 1500 OAP Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

17 PRESCRIPTION drug program Your Cigna pharmacy benefit program helps you and your doctor pick the best drug for your medical needs and budget, and provides options to help you lower the cost of your medications. Visit mycigna.com for all your pharmacy needs It s easy to enroll and to use your pharmacy benefits. Log in to mycigna.com today. You can: View your benefit details See the amount you will pay for each category of drugs. Read other important benefit information. Access your prescription history Review your prescription information for the last 12 months. Get home delivery service Take advantage of easy access to prescriptions through Cigna Home Delivery Pharmacy SM. To mail in new prescriptions, simply print an order form. You can also order refills, compare prices, track order and ship dates, and see the number of refills you have left. Get ready for your doctor visit Use time with your doctor better with a kit made just for you. Share your prescription history. See the approved list of prescriptions. Print questions about your health. Print and bring in order forms for Cigna Home Delivery Pharmacy. Review real-time drug pricing information Use the prescription drug price quote tool to find a pharmacy, review pricing options based on your pharmacy benefit plan and discover potential cost savings through Cigna Home Delivery Pharmacy as well as generic and low-cost therapeutic drug alternatives. Network Pharmacies For a list of the over 62,000 pharmacies in our network, log in to mycigna.com. Cigna Home Delivery Pharmacy save time and money If you take medicine on a long-term basis, consider Cigna Home Delivery Pharmacy. You will save time and money because for certain drugs you can get up to a three-month supply at a lower cost. You will also find it handy to have your prescriptions delivered right to your door at no extra cost. And, Cigna customers who use Cigna Home Delivery Pharmacy are 20% more adherent to their medications than those customers who fill their prescriptions through a retail pharmacy c 06/13 Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company.

18 Convenience Cigna Home Delivery Pharmacy delivers the prescription medications you need (including specialty medications requiring refrigeration and/or overnight delivery) right to your home or other preferred location. You can order up to a 90-day supply, so you fill less often. Manage your medications online, 24/7 Cigna Home Delivery Pharmacy gives you the ability to manage your medications online, 24/7, at mycigna.com. You can compare prices, track order and ship dates, see the number of refills you have left and much more. Save money on your medications* Cigna Home Delivery Pharmacy can help you save money. See how much you can save on quality generic and name-brand prescription medications. Log in to mycigna.com and visit the prescription drug price quote tool on the pharmacy home page or call , and ask for a price quote. Cigna Home Delivery Pharmacy is dedicated to your sensitive specialty medication needs If you have a condition that requires treatment with specialty medication, Cigna Home Delivery Pharmacy can help you manage your pharmacy needs. Q How do I start using Cigna Home Delivery Pharmacy? A Request a prescription from your doctor for a 90-day supply with refills. Sign on to mycigna.com. and print and complete a home delivery order form. You or your doctor can then mail or fax your order in with your prescription. Or call our toll-free number to utilize our QuickSwitch service. An associate will help you get started using Cigna Home Delivery Pharmacy. Q Is there an extra cost to use the Cigna Home Delivery Pharmacy service? A No. It s part of your normal pharmacy benefits. There s also no charge for regular shipping. Q Can I have my prescriptions delivered to me overnight? A Yes, if you want them that fast. Please remember, there s an extra cost for overnight or rush delivery, but standard shipping is always free. Overnight service will expedite the shipping of your prescription, but not the processing of your order. Q What if I m going to be on vacation or away from home for a while? A If you re at a temporary address for 14 or more days, your prescriptions can be sent to that address. Cigna Home Delivery Pharmacy can help you manage your pharmacy needs. 90-day retail drug program If you have a prescription for a maintenance drug (medication for treatment of cholesterol, ulcer, depression, oral contraceptives, etc., taken on a regular basis), you may request a 90-day prescription from your physician. You must pay three copays, but you can have it filled at any pharmacy that honors the 90-day retail program and enjoy the convenience of receiving a three-month supply of medication with one pharmacy visit. Unlike Cigna Home Delivery Pharmacy, there is no copay cost savings with this option. Not all network pharmacies honor the 90-day retail program. To see which pharmacies do, check the Contracted Chain Pharmacies list, which can be found by logging in to mycigna.com. An asterisk (*) next to a pharmacy name means that it participates in the 90-day retail program. If you have questions about a pharmacy s participation in the program, whether a prescription is a maintenance drug, or which prescriptions qualify for the program, please call the phone number on your ID card.

19 Managed drug limitation program ensures safe use of certain drugs The managed drug limitation program helps make sure you get only the right amount of a medicine for the right amount of time. For example, some pain medicines can only be taken four tablets per day for 30 or 90 days. The amount may be different depending on the medicine. Here s how it works. You have a prescription for a managed drug. The pharmacist will fill the prescription up to the highest amount allowed. If your doctor believes you need more of that drug, he or she must contact the Cigna prior authorization department (see right for more information). For a complete list of managed drugs, sign on to mycigna.com. Q Why are some drugs managed? A We pay close attention to certain drugs to make sure they are used safely. Some drugs are limited because they are also not good to use for a long time. Q What if I ve already received as much of my medicine as allowed, but I need more? A Only your doctor can decide if you need more. Check with your doctor first. If your doctor decides you need more, your doctor must send a request to our prior authorization department. Prior authorization program monitors high-cost drugs There are certain drugs that need prior authorization before your doctor can prescribe them. If you don t get prior authorization, the pharmacy will not fill your prescription. Our network doctors will get the okay for you. To stop a delay in receiving your medication, please make sure to get the needed prior authorization. The prior authorization list is reviewed and changed periodically. To see the current list, sign on to mycigna.com. Q How do I get prior authorization? A Your doctor must send a request to the Cigna prior authorization department; the form is available at Cigna.com. It includes: Your personal information name, insurance ID number, date of birth Information about the medication drug name, strength, frequency Physician information physician s first and last name, address, phone number Q Why do certain drugs require prior authorization? A It helps make sure that these drugs are used wisely, and it helps control rising drug costs. Q What is step therapy? A Step therapy is a prior authorization program designed for you and your doctor to take one step at a time when choosing your medication. It works to help you find the most affordable medication appropriate for your condition. Q What happens if I drop off a prescription without getting prior authorization? A Your pharmacist knows that some drugs must have prior authorization. They will not fill those prescriptions. They will work with your doctor to help get the required approval so they can fill your prescription as soon as possible. Q How do I know if one of the medications I take needs prior authorization? A Just sign on to mycigna.com and see the current prior authorization drug list. Q What if I visit a nonnetwork doctor? A If you visit a doctor who is not part of our network, you must get prior authorization for your medicine. For more information, call the number on your ID card.

20 Specialty pharmacy network delivers medication that requires special handling If you have a condition such as multiple sclerosis, hepatitis C, or rheumatoid arthritis, you may get medicine through Cigna Specialty Pharmacy Management, which is colocated with Cigna Home Delivery Pharmacy. This program focuses on medications that need special handling. We also offer more services just for you, such as: Prompt delivery of medicine to your home or your doctor s office, in specially designed packaging to protect quality and privacy Special packaging and overnight delivery of medications requiring refrigeration Required supplies at no additional charge, including syringes, needles, alcohol swabs and disposable containers Round-the-clock service, with Cigna specialty pharmacists available 24/7 to help you understand your medication and possible side effects Q How are orders submitted? A Fax a completed order form to To request order forms, call us at Q How soon will the order be received? A Orders are shipped in time to meet the need-by date indicated when the order is placed. Even if the order is needed the next day, we can supply the medication with no additional shipping cost. Next-day orders must be received by 4 pm CST. Q How are refills ordered? A Refills can be ordered one of two ways. Your doctor can call to use our automated phone system, or fax a completed order form to Cigna Well Informed (Gaps in Care) program The Cigna Well Informed SM program offers personalized information and tips to help you reach and sustain a healthy lifestyle. We use pharmacy and health care claim information to identify steps you might take to help improve your health. We share this information in letters we send to both you and your doctor, so that you can work together on a plan of action. Get the medications you need quickly, easily, and at the low cost you want. * Savings are based on a 90-day fill/refill and are subject to your plan s provisions. Your benefit plan may differ based on state law. Please check your plan documents for more details and to confirm that you have the Cigna Home Delivery Pharmacy benefit. Cigna, the Tree of Life logo, GO YOU and Cigna Pharmacy Management are registered service marks, and Cigna Home Delivery Pharmacy is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation. Cigna Home Delivery Pharmacy refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only c 06/ Cigna. Some content provided under license.

21 Your pharmacy at your fingertips! Cigna Home Delivery Pharmacy We re your health care company s pharmacy, designed especially for individuals who take prescription medications on a regular basis, such as those used for diabetes, asthma, heart conditions, high blood pressure, birth control and more. You ll enjoy: Easy refills up to a 90-day supply means fewer refills Reminder service to refill or take your medication available at Cigna.com/CoachRx Our free QuickFill service will call or you when its time to refill your prescriptions Fast answers from Cigna pharmacists 24/ Manage your medication Log in to mycigna.com where you can obtain the following important information about your prescription medications: Compare medication prices Check order status Review number of refills remaining Order refills and more Quickswitch we make filling a prescription simple Have the following information handy when you call. We ll do the rest! 1. Name and Cigna ID number 2. Prescription medication names and strength (for you or a covered family member) 3. Doctor information (name, phone number) 4. Payment information (American Express, Discover, MasterCard or VISA) With this information, we will request a prescription from your doctor. Once we receive it, we will fill your medication and mail it to your home or other location of your choice. Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company. Cigna and Quickswitch are registered service marks, and the Tree of Life logo, GO YOU and Cigna Home Delivery Pharmacy are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. Cigna Home Delivery Pharmacy refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only b 04/ Cigna. Some content provided under license.

22 PERFORMANCE PRESCRIPTION DRUG LIST January 2015 The Performance Prescription Drug List lets you and your doctor choose medications that work best for you. The following is a list of the most commonly used medications covered under your plan. This list is designed to cover your prescription medications at three levels. The amount you pay depends on the tier from which you and your doctor select your medication. If there is more than one medication appropriate for your condition, we suggest that you talk to your doctor about lower-cost choices like generic medications and preferred brand medications to see if they could be right for you. Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company k 10/14

23 1st Tier Generic Medications: Generic medications have the same ingredients, safety, dosage, quality and strength as their brand name counterparts. You will usually pay less for generic medications under your plan. 2nd Tier Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but less than a non-preferred brand medication under your plan. 3rd Tier Non-Preferred Brand Medications: Non-preferred brand medications are those that generally have generic alternatives and/or a preferred brand medication within the same drug class. You will usually pay more for a non-preferred brand under your plan. The symbols on the list mean If a medication on the list has one of the following symbols, your doctor may need to get an authorization for coverage of that medication. PA: QL: AGE: ST: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, feel free to give us a call. Quantity Limit means you may have coverage for a limited amount of a specific medication. Age Requirement means an individual must be within a specific age group for a specific medication to be covered. Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the ST medication is covered. * Medications marked with an asterisk are considered to be specialty medications. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. Refer to the your plan documents for more information. 2