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

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1 Home Office: Bloomfield, Connecticut Mailing Address: Hartford, Connecticut CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter called Cigna) CERTIFICATE RIDER No. CR7SIASO2-1 Policyholder: Rider Eligibility: Boulder Valley School District RE-2 Each Employee as reported to the insurance company by your Employer. Policy No. or Nos OAPS EFFECTIVE DATE: July 1, 2014 You will become insured on the date you become eligible 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. If you are not insured for the benefits described in your certificate on that date, the effective date of this certificate rider will be the date you become insured. This certificate rider forms a part of the certificate issued to you by Cigna describing the benefits provided under the policy(ies) specified above. HC-RDR V1 1

2 The sections entitled Out-of-Pocket Maximum and Physician s Services in THE SCHEDULE Open Access Plus Medical Benefits in your certificate are changed to read as attached. The following is being added to THE SCHEDULE Open Access Plus Medical Benefits in your certificate under the section entitled Combined Medical/Pharmacy Out-of-Pocket Maximum. THE SCHEDULE Prescription Drug Benefits section in your certificate is changed to read as attached 2

3 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Combined Out-of-Pocket Maximum for Pharmacy Individual $4,500 per person $13,500 per person Family Maximum $9,000 per family $27,000 per family Family Maximum Calculation Individual Calculation: Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of- Pocket being met, their claims will be paid at 100%. 3

4 BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Combined Medical/Pharmacy Outof-Pocket Maximum Combined Medical/Pharmacy Outof-Pocket: includes retail and home delivery prescription drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Out-of-Pocket Maximum Physician s Services Primary Care Physician s Office Visit Boulder Valley Care CSN: Applies to Family Practice, Internal Medicine, Pediatrics, GYN, OBGYN providers only Yes Yes No charge after $25 per office visit copay $10 copay, then Plan pays 100% Note: Lab & Xray payable at 80% after plan deductible. In-Network coverage only In-Network coverage only Specialty Care Physician s Office Visits Consultant and Referral Physician s Services Note: OB/GYN providers will be considered as a PCP. Surgery Performed in the Physician s Office Boulder Valley Care CSN: Applies to Family Practice, Internal Medicine, Pediatrics, GYN, OBGYN providers only No charge after $50 Specialist per office visit copay No charge after the $25 PCP or $50 Specialist per office visit copay $10 copay, then Plan pays 100% Second Opinion Consultations (provided on a voluntary basis) Boulder Valley Care CSN: Applies to Family Practice, Internal Medicine, Pediatrics, GYN, OBGYN providers only No charge after the $25 PCP or $50 Specialist per office visit copay $10 copay, then Plan pays 100% Allergy Treatment/Injections No charge Allergy Serum (dispensed by the Physician in the office) No charge 4

5 k Prescription Drug Benefits The For You and Your Dependents This plan provides Prescription Drug benefits for Prescription Drugs and Related Supplies provided by Pharmacies as shown in this. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for Prescription Drugs and Related Supplies. That portion includes any applicable Copayment, Deductible and/or Coinsurance. Copayments Copayments are expenses to be paid by you or your Dependent for Covered Prescription Drugs and Related Supplies. BENEFIT HIGHLIGHTS Lifetime Maximum Out-of-Pocket Maximum Individual Family PARTICIPATING Non-PARTICIPATING Retail Prescription Drugs The amount you pay for each 30- The amount you pay for each 30- Medications required as part of preventive care services (detailed information is available at are covered at 100% with no copayment or deductible. Tier 1 Generic* drugs on the Prescription No charge after $7 copay Tier 2 Brand-Name* drugs designated as preferred on the Prescription Drug List with no Generic equivalent Tier 3 Brand-Name* drugs with a Generic equivalent and drugs designated as non-preferred on the Prescription No charge after $30 copay No charge after $75 copay Generic Preventive Drugs No charge Mandatory Generic with a flat penalty of $25 for 30 day retail, $50 for 60 day retail and $75 for 90 day retail and mail order prescriptions. 5

6 BENEFIT HIGHLIGHTS PARTICIPATING Non-PARTICIPATING * Designated as per generally-accepted industry sources and adopted by the Insurance Company Home Delivery Prescription Drugs The amount you pay for each 90- The amount you pay for each 90- Medications required as part of preventive care services (detailed information is available at are covered at 100% with no copayment or deductible. Tier 1 Generic* drugs on the Prescription No charge after $21 copay Tier 2 Brand-Name* drugs designated as preferred on the Prescription Drug List with no Generic equivalent No charge after $90 copay Tier 3 Brand-Name* drugs with a Generic equivalent and drugs designated as non-preferred on the Prescription No charge after $225 copay Generic Preventive Drugs No charge Mandatory Generic with a flat penalty of $25 for 30 day retail, $50 for 60 day retail and $75 for 90 day retail and mail order prescriptions. * Designated as per generally-accepted industry sources and adopted by the Insurance Company 6

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

CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter called Cigna) Home Office: Bloomfield, Connecticut Mailing Address: Hartford, Connecticut 06152 CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter called Cigna) CERTIFICATE RIDER No CR7SI006-1 Policyholder:

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