IMPORTANT NOTICE. Special Enrollment Requirements from Cigna

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 866.494.2111 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. 837151 c PCL 07/14

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 866.494.2111. 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. 837151 c PCL 07/14 2014 Cigna. Some content provided under license. NO PCL

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 - 1500 OAP - 4527321. Version# 5 1 of 6 Cigna 2015

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 - 1500 OAP - 4527321. Version# 5 2 of 6 Cigna 2015

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 - 1500 OAP - 4527321. 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

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 - 1500 OAP - 4527321. Version# 5 4 of 6 Cigna 2015

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 www.mycigna.com 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 www.mycigna.com 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 - 1500 OAP - 4527321. Version# 5 5 of 6 Cigna 2015

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 - 1500 OAP - 4527321. Version# 5 6 of 6 Cigna 2015

High Bridge Associates Inc: Open Access Plus Coverage Period: 05/01/2015-04/30/2016 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 www.mycigna.com or by calling 1-866-494-2111 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 www.mycigna.com or call 1-866-494-2111. 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 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 1 of 8

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---------- 40% co-insurance ------- none ------- 40% co-insurance $250 penalty for no precertification. Questions: Call 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 2 of 8

Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is at www.mycigna.com 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 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 3 of 8

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 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 4 of 8

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 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 5 of 8

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 1-866-494-2111. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. 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 1-866-494-2111. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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 1-866-494-2111. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-494-2111. Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 1-866-494-2111. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-494-2111. ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.----------- Questions: Call 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 6 of 8

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 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 7 of 8

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: 4527321 BenefitVersion: 5 Plan Name: 1500 OAP Questions: Call 1-866-494-2111 or visit us at www.mycigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-866-494-2111 to request a copy. 8 of 8

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. 835912 c 06/13 Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company.

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 1.800.285.4812, 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 1.800.285.4812 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.

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.

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 1.800.351.3616. To request order forms, call us at 1.800.351.3606. 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 1.800.351.3606 to use our automated phone system, or fax a completed order form to 1.800.351.3616. 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. 835912 c 06/13 2013 Cigna. Some content provided under license.

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 email you when its time to refill your prescriptions Fast answers from Cigna pharmacists 24/7 1.800.285.4812 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. 822825 b 04/12 2012 Cigna. Some content provided under license.

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. 827293 k 10/14

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

Health care reform and you The Patient Protection and Affordable Care Act (PPACA), commonly referred to as health care reform, was signed into law on March 23, 2010. This important legislation will result in changes to every American s health coverage. Cigna will comply with all provisions of the law including those that impact your pharmacy coverage plan. For example, coverage for medications that have not traditionally been included in pharmacy plans, such as specific over-the-counter (OTC) medications, may be made available at no cost share to you. As with all covered medications, we would require a prescription from your doctor to process the claim under your pharmacy plan (including OTC medications). To get the most current information, visit informedonreform.com or Cigna.com and look for the Informed on Reform link. If you have any questions Remember, this list is just a sample of the most commonly used medications, and is subject to change. You can use the Prescription Drug Price Quote tool available on mycigna.com to see and compare the prices of all medications covered under your plan. Or, you can call the number on the back of your ID card to speak with a customer service representative at any time. 3

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS amphetamine clonidine HCl dexmethylphenidate HCl ER dexmethylphenidate HCl dextroamphetamine dextroamphetamine/ amphetamine ER Metadate ER-methylphenidate HCl methamphetamine methylphenidate HCl methylphenidate ER/ER 24 HR modafanil abacavir* abacavir/lamivudine/ zidovudine* didanosine* lamivudine* lamivudine/zidovudine* nevirapine* nevirapine ER* stavudine* zidovudine* ADD/ADHD AND STIMULANTS Adderall XR Focalin XR Intuniv Strattera Vyvanse AIDS/HIV Aptivus* Crixivan* Emtriva* Epzicom* Fuzeon* (PA) Invirase* Isentress* Kaletra* Lexiva* Norvir* Prezista* Rescriptor* Reyataz* Selzentry* Sustiva* Trizivir* Truvada* Viracept* Viramune XR* Viread* Adderall (PA, ST) Concerta (PA, ST) Daytrana (PA, ST) Desoxyn (PA, ST) Dexadrine (PA, ST) Focalin (PA, ST) Kapvay Metadate CD (PA, ST) Methylin (PA, ST) Nuvigil (PA) Provigil (PA) Quillivant XR (PA, ST) Ritalin (PA, ST) Ritalin LA Ritalin SR (PA, ST) Xyrem* (PA) Zenzedi (PA, ST) Atripla* Combivir* Complera* Edurant* Epivir* Fulyzaq (PA) Intelence* Retrovir* Stribild* Triumeq* Videx* Viramune* Zerit* Ziagen* 4

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS ALLERGY azelastine HCl azelastine nasal budesonide clemastine fumarate cyproheptadine cyproheptadine HCl desloratadine epinastine epinephrine (QL) flunisolide nasal fluticasone nasal hydroxyzine ipratropium nasal levocetirizine montelukast triamcinolone nasal donepezil HCl galantamine hydrobromide rivastigmine tartrate capsules Astepro Epipen 2 pk (QL) Epipen Jr. (QL) Nasonex Veramyst ALZHEIMER S DISEASE ANXIETY Adrenaclick (QL) Astelin Atrovent (nasal) AUVI-Q (QL) Beconase AQ (PA, ST) Dymista (PA, ST) Flonase (PA, ST) Karbinal ER Nasacort AQ (PA, ST) Omnaris (PA, ST) Patanase QNASL (PA, ST) Rhinocort AQ (PA, ST) Semprex-D Singulair Xyzal Zetonna (PA, ST) Aricept Aricept ODT Exelon Namenda XR Razadyne Razadyne ER alprazolam buspirone diazepam lorazepam oxazepam Lorazepam Intensol Niravam ASTHMA AND RESPIRATORY albuterol sulfate (nebulizer solution) budesonide (nebulizer solution) caffeine citrate cromolyn sodium (nebulizer solution) dyphylline guaifenesin/theophylline ipratropium bromide (nebulizer solution) levalbuterol HCl (nebulizer solution) Advair, Advair HFA Asmanex Atrovent HFA Combivent Respimat Flovent Diskus/HFA ProAir HFA Pulmicort Pulmozyme* (PA) QVAR Serevent Spiriva Symbicort Accolate Accuneb nebulizer (PA, ST) Adcirca* (PA) Adempas* (PA) Aerospan Alvesco Anoro Ellipta Arcapta Breo Ellipta Brovana nebulizer (PA, ST) Daliresp Dulera 5

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS ASTHMA AND RESPIRATORY (CONTINUED) metaproterenol sulfate (syrup, tabs) montelukast sodium racepinephine HCl sildenafil* (PA) terbutaline sulfate theophylline anhydrous zafirlukast Ventolin HFA Xolair* (PA) Foradil Letairis* Opsumit* (PA) Orenitram ER* (PA) Perforomist (PA, ST) Proventil HFA Revatio* (PA) S-2 Racepinephine Singulair Striverdi Respimat Tracleer* Tudorza Pressair (PA, ST) Ventavis* Xopenex HFA Xopenex nebulizer (PA, ST) BIRTH CONTROL Please check your enrollment materials to determine whether these medications are covered under your specific plan. Altavera Alyacen Amethia Amethia Lo Amethyst Apri Aranelle Aubra Aviane Azurette Balziva Briellyn Camila Camrese Camrese Lo Caziant Chateal Cryselle Cyclafem Dasetta Daysee desogestrel-ethinyl estradiol Elinest Emoquette Enpress Enskyce Errin Estarylla BeYaz Lomedia 24 FE LoSeasonique Minastrin 24 FE NuvaRing Ortho Evra Ortho TriCyclen Lo Angeliq Brevicon Cyclessa Depo-Provera Subq Desogen Ella Estrostep FE Femcon FE Generess FE Loestrin Loestrin FE Mircette Modicon Natazia Nordette Norinyl 1+35 Norinyl 1+50 Nor-QD Ortho Micronor Ortho-Cept Ortho-Cyclen Ortho-Novum 7-7-7 Ortho-Tri-Cyclen Ovcon-35 Quartette Safyral Seasonale Seasonique 6

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS BIRTH CONTROL (CONTINUED) Please check your enrollment materials to determine whether these medications are covered under your specific plan. ethinyl estradiol/ drospirenone Falmina Gianvi Gildagia Gildess Heather Introvale Jencycla Jolessa Junel Junel FE Kariva Kelnor Kurvelo Larin Larin FE Leena Lessina Levonest levonorgestrel levonorgestrel-ethestra levonorgestrel-ethin estradiol Levora l-norgest-eth estr/ ethin estra Loryna Low-Ogestrel Lutera Lyza Marlissa Microgestin Microgestin FE Mono-Linyah Mononessa Myzilra Necon Next Choice Nora-Be noreth a-et estra/ fe fumarate noreth-ethinyl estradiol/iron norethindrone norgestimate-ethinyl estradiol Tri-Norinyl Yasmin 28 Yaz 7

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS BIRTH CONTROL (CONTINUED) Please check your enrollment materials to determine whether these medications are covered under your specific plan. norgestrel-ethinyl estradiol Nortrel Ocella Ogestrel Orsythia Philith Pimtrea Pirmella Portia Previfem Quasense Reclipsen Sprintec Sronyx Syeda Tilia FE Tri-Estarylla Tri-Legest FE Tri-Linyah Trinessa Tri-Previfem Tri-Sprintec Trivora Velivet Vestura Viorele Vyfemla Wera Wymzya FE Xulane Zarah Zenchent Zenchent FE Zeosa Zovia BLADDER PROBLEMS flavoxate oxybutynin/xl potassium citrate ER tolterodine tartrate trospium chloride Elmiron Toviaz VESIcare Detrol (PA, ST) Detrol LA (PA, ST) Ditropan XL (PA, ST) Enablex (PA, ST) Gelnique (PA, ST) Myrbetriq (PA, ST) Oxytrol (PA, ST) (For Men Only) Sanctura (PA, ST) Sanctura XR (PA, ST) Urocit-K 8

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS CANCER anastrozole azacitidine* bicalutamide* capecitabine cyclophosphamide* exemestane flutamide* letrozole lomustine tamoxifen citrate temozolomide* (PA) anagrelide* cilostazol clopidogrel dipyridamole enoxaparin* (QL) fondaparinux* (QL) heparin Jantoven ticlopidine warfarin Gleevec* (PA) Granix* Hexalen* Leukeran Lupron Depot* (PA) Lysodren Matulane* Myleran Neulasta* (PA) Neupogen* (PA) Nexavar* (PA) Revlimid* (PA) Sprycel* (PA) Sutent* (PA) Tarceva* (PA) Thalomid* (PA) Xeloda* Zolinza* (PA) Afinitor* (PA) Afinitor Disperz* (PA) Arimidex Aromasin Bosulif* (PA) Caprelsa* (PA) Casodex* Cometriq* (PA) Droxia Erivedge* (PA) Fareston Femara Gilotrif* (PA) Imbruvica* (PA) Inlyta* (PA) Jakafi* (PA) Mekinist* (PA) Purixan* Pomalyst* (PA) Stivarga* (PA) Sylatron* (PA) Sylvant* (PA) Tafinlar* (PA) Targretin* Tasigna* (PA) Tykerb* (PA) Valchlor* Votrient* (PA) Xalkori* (PA) Xtandi* (PA) Zelboraf* (PA) Zydelig* (PA) Zykadia* (PA) Zytiga* (PA) CARDIOVASCULAR BLOOD THINNER/ANTI-CLOTTING Aggrenox Agrylin* Arixtra* (QL) Brillinta Effient Coumadin Fragmin* (QL) Eliquis (ST) Xarelto Lovenox* (QL) Plavix Pletal Pradaxa (ST) Zontivity 9

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS CARDIOVASCULAR (CONTINUED) acebutolol HCl acetazolamide amiloride HCl amlodipine besylate amlodipine besylate/ benazepril amlodipine/ atorvastatin calcium apresoline atenolol benazepril HCl benazepril HCl/amlodipine benazepril HCl/HCTZ bendroflumethiazide/nadolol betaxolol HCl bisoprolol fumarate bisoprolol/hctz bumetanide candesartan candesartan cilexetil candesartan HCTZ captopril captopril/hctz carvedilol chlorothiazide chlorthalidone chlorthalidone/atenolol clonidine clonidine HCl Clorpres diltiazem diltiazem 24HR ER doxazosin mesylate enalapril maleate enalapril maleate/hctz eplerenone eprosartan mesylate felodipine fosinopril sodium fosinopril sodium/hctz furosemide guanfacine hydralazine HCl hydrochlorothiazide hydrochlorothiazide/amilor HCl indapamide irbesartan HIGH BLOOD PRESSURE/HEART MEDICATIONS Benicar Benicar HCT Bystolic Coreg CR Exforge Exforge HCT Tarka Tekturna Tekturna HCT Accupril (PA, ST) Accuretic (PA, ST) Aceon (PA, ST) Altace (PA, ST) Amturnide Atacand (PA, ST) Avalide (PA, ST) Avapro (PA, ST) Azor Betapace AF Cardura Cardura XL Catapres, Catapres TTS Coreg Corgard Cozaar (PA, ST) Diovan (PA, ST) Diovan HCT Dutoprol Edarbi (PA, ST) Edarbychlor (PA, ST) Hemangeol Hyzaar (PA, ST) Inderal LA Innopran XL Levatol Lotensin (PA, ST) Lotensin HCT (PA, ST) Lotrel Mavik (PA, ST) Micardis (PA, ST) Micardis HCT (PA, ST) Norpace Norpace CR Norvasc Nymalize Prinivil (PA, ST) Prinzide (PA, ST) Sular Tekamlo Teveten (PA, ST) Teveten HCT (PA, ST) Toprol XL Tribenzor Twynsta Uniretic (PA, ST) 10

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS irbesartan/hctz isradipine labetalol HCl lisinopril lisinopril/hctz losartan potassium losartan potassium/hctz methazolamide methyldopa methyldopa/hctz metolazone metoprolol succinate metoprolol tartrate metoprolol/hctz minoxidil moexipril HCl moexipril HCl/HCTZ nadolol nicardipine HCl nifedipine nimodipine perindopril erbumine pindolol prazosin HCl propranolol HCl propranolol/hctz quinapril quinapril HCl/HCTZ ramipril (caps only) reserpine sotalol HCl spironolactone spironolactone/hctz telmisartan telmisartan/amlodipine telmisartan/hctz terazosin HCl timolol maleate torsemide trandolapril triamterene/hctz valsartan valsartan/hctz Vecamyl-mecamylamine HCl verapamil verapamil SR CARDIOVASCULAR (CONTINUED) HIGH BLOOD PRESSURE/HEART MEDICATIONS Univasc (PA, ST) Vaseretic (PA, ST) Vasotec (PA, ST) Verelan Zestoretic (PA, ST) Zestril (PA, ST) 11

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS CARDIOVASCULAR (CONTINUED) amiodarone digoxin disopyramide flecainide isosorbide dinitrate isosorbide mononitrate nitroglycerin procainamide propafenone SR atorvastatin cholestyramine cholestyramine powder cholestyramine/aspartame cholestyramine/sucrose colestipol fenofibrate fenofibric acid fluvastatin gemfibrozil lovastatin niacin omega-3-acid ethyl esters pravastatin sodium simvastatin CHOLESTEROL LOWERING Crestor Lescol XL Lovaza Simcor Welchol Zetia OTHER Multaq Nitrolingual spray Tikosyn Lanoxin Nitromist Ranexa (PA, ST) Rythmol SR Samsca (PA) Advicor Altoprev (PA, ST) Antara Caduet Colestid Fenoglide Juxtapid* (PA) Kynamro* (PA) Lescol Lipitor (PA, ST) Liptruzet (PA, ST) Livalo (PA, ST) Lofibra Mevacor (PA, ST) Niaspan Pravachol (PA, ST) TriCor Trilipix Vascepa (ST) Vytorin (PA, ST) Zocor (PA, ST) 12

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS DEPRESSION amitriptyline bupropion bupropion SR citalopram desipramine desvenlafaxine duloxetine HCl escitalopram fluoxetine fluvoxamine imipramine mirtazapine nortriptyline paroxetine paroxetine CR protriptyline sertraline trazodone venlafaxine venlafaxine XR Pristiq Wellbutrin XL DIABETES Aplenzin (PA,ST) Brintellix (PA,ST) Celexa (PA,ST) Cymbalta (PA,ST) Desvenlafaxine ER (ST) Desvenlafaxine Fumarate (PA,ST) Effexor XR (PA,ST) Emsam Fetzima (PA,ST) Forfivo XL (PA,ST) Khedezla (PA,ST) Lexapro (PA,ST) Luvox CR Marplan Paxil (PA,ST) Paxil CR (PA,ST) Pexeva (PA,ST) Prozac (PA,ST) Remeron Sarafem (PA,ST) Tofranil Venlafaxine HCl ER (PA,ST) Viibryd (PA,ST) Vivactil Wellbutrin (PA,ST) Wellbutrin SR (PA,ST) Zoloft (PA,ST) acarbose chlorpropamide glimepiride glipizide glipizide/metformin glyburide glyburide, micronized glyburide/metformin metformin HCl metformin ER nateglinide pioglitazone pioglitazone/glimepiride pioglitazone/metformin repaglinide tolazamide tolbutamide ACCU-CHEK test strips Apidra Apidra SoloStar BD Insulin Syringes/ Pen Needles Bydureon (QL) Byetta GlucaGen HypoKit Glucagon Emergency Kit (QL) Humalog Humulin Janumet Janumet XR Januvia Kombiglyze XR Lantus Lantus SoloStar Actoplus Met Actoplus Met XR Actos Amaryl Avandamet Avandaryl Avandia Cycloset Duetact Farxiga (PA,ST) Fortamet Glucophage XR Glyset Invokamet (PA, ST) Invokana (PA, ST) Jardiance (PA, ST) Jentadueto (PA, ST) 13

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS DIABETES (CONTINUED) allopurinol cabergoline (QL) desmopressin* fluoxymesterone octreotide* (PA) apraclonidine HCl atropine azelastine brimonidine bromfenac bromfenac sodium ciprofloxacin diclofenac dorzolamide dorzolamide/timolol epinastine flurbiprofen gatifloxacin ketorolac latanoprost levofloxacin pilocarpine timolol tobramycin/dexamethasone travoprost trifluridine Levemir NovoFine/NovoTwist needles Novolin NovoLog One Touch test strips Onglyza Prandimet SymlinPen Victoza ENDOCRINE AND METABOLIC OTHER Colcrys Increlex* (PA) LupronDepot-PED* (PA) Megace ES Nilandron Sandostatin LAR* (PA) Somavert* (PA) Uloric EYE CONDITIONS Alomide Alphagan P 0.10% AzaSite Azopt Betoptic S Ciloxan (ointment) Iopidine Lotemax (drops & gel) Maxidex Moxeza Pataday Patanol Restasis Tobradex (ointment) Travatan Z Vexol Vigamox Kazano (PA, ST) Nesina (PA, ST) Oseni (PA, ST) Prandin Precose Starlix Tanzeum (PA, QL, ST) Tradjenta (PA, ST) V-Go Egrifta* (PA) Sandostatin* (PA) Signifor* (PA) Somatuline Depot* (PA) Acular LS Alocril Alrex Bepreve Besivance Ciloxan (drops) Cosopt Cystaran Durezol Elestat Emadine Ilevro Lastacaft Lotemax (ointment) Optivar Prolensa Rescula Simbrinza (PA, ST) Timoptic Tobradex (drops) Tobradex ST Trusopt Voltaren Zioptan (PA, ST) Zymaxid 14

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS GASTROINTESTINAL (NOT HEARTBURN/ULCER) balsalazide belladonna alkaloids/ phenobarbital budesonide cromolyn sodium (solution) PEG 3350/potassium/ sodium bicarb/salt PEG 3350/potassium/sodium bicarb/salt/sodium sulf triamcinolone acetonide cimetidine famotidine lansoprazole lansoprazole/amoxicillin/ clarithromycin metoclopramide metoclopramide HCl misoprostol nizatidine omeprazole omeprazole/sodium bicarbonate pantoprazole rabeprazole HCl ranitidine sucralfate Apriso Asacol HD Canasa Creon Delzicol GoLytely Humira* (PA) Lialda Pentasa Urso/Urso Forte Zenpep GROWTH HORMONES Humatrope* (PA) Saizen* (PA) HEARTBURN/ULCER Nexium Amitiza Cimzia* (PA) Colazal Colyte Donnatal Entocort EC Entyvio* (PA) Giazo Linzess NuLytely Pancreaze Pertzye Pancreaze Prepopik Rayos (ST) Relistor (PA) Remicade* (PA) Simponi* (PA) Simponi Aria* (PA) Suclear Sucraid* Uceris Ultresa Viokace Genotropin* (PA) Norditropin* (PA) Norditropin Nordiflex* (PA) Nutropin AQ* (PA) Nutropin AQ Nuspin*(PA) Omnitrope* (PA) Serostim* (PA) Tev-Tropin* (PA) Aciphex (PA, ST) Dexilant (PA, ST) Esomeprazole Strontium (PA, ST) Omeclamox-Pak Prevacid (PA, ST) Prevpac Prilosec (PA, ST) Protonix (PA, ST) Zantac Effertab Zantac Syrup Zegerid (PA, ST) 15

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS estradiol estradiol/norethindrone acetate estropipate ethinyl estradiol levothroid levothyroxine Levoxyl liothyronine medroxyprogesterone progesterone, micronized testosterone cypionate testosterone enanthate thyroid Unithroid acyclovir adefovir dipivoxil* amantadine amoxicillin/er amoxicillin/clavulanate atovaquone azithromycin cefaclor ER cefadroxil cefdinir cefprozil ceftibuten dihydrate ceftriaxone cefuroxime axetil cephalexin ciprofloxacin clarithromycin clindamycin clindamycin phosphate cycloserine doxycycline entacavir erythromycin famciclovir fluconazole flucytosine HORMONE REPLACEMENT Alora Anadrol-50 (PA) Androderm (QL) AndroGel (QL) Armour Thyroid Divigel Enjuvia Estraderm Premarin Premphase Prempro Synthroid Testim (QL) Vivelle-Dot INFECTIONS Baraclude* Cipro HC Otic Ciprodex Epivir HBV* Gris-Peg Intron-A* (PA) Mycostatin (tabs) Pegasys* (PA) PegIntron* (PA) Primsol Tamiflu (QL) Valcyte Activella Axiron (PA, QL, ST) Cenestin Combipatch Cytomel Delatestryl Depot Testosterone Estrace Femhrt Femring Fortesta (PA, QL, ST) Menest Minivelle Prefest Prometrium Striant (QL) testosterone gel (QL) Vagifem Vogelxo Acticlate (PA, ST) Ancobon Augmentin Augmentin ES 600 Augmentin XR Avelox Bethkis* Biaxin Biaxin XL Cedax Cetraxal Ciclodan Cipro Cipro XR CNL 8 Coartem (QL) Copegus* Dificid (PA) Ery-Tab Famvir Flagyl ER Garamycin* Grifulvin V Hepsera* Incivek* (PA) Keflex 16

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS ganciclovir* gentamicin sulfate griseofulvin griseofulvin, microsize griseofulvin, ultramicrosize itraconazole (QL) ketoconazole lamivudine* metronidazole minocycline minocycline HCl Moderiba* moxifloxacin HCl mupirocin nitrofurantoin nystatin ofloxacin penicillin v potassium ribavirin* rifabutin rifampin rimantadine sulfamethoxazole/ trimethoprim terbinafine (QL) terconazole tetracycline tobramycin valacyclovir vancomycin voriconazole (PA) INFECTIONS (CONTINUED) Ketodan Lamisil (QL) Levaquin Malarone (PA) Monurol Moxatag Noxafil Olysio* (PA) Onmel (PA, QL, ST) Penlac Priftin Rebetol* Relenza (QL) Rocephin Sirturo Sitavig Sivextro (PA) Solodyn (PA, ST) Sovaldi* (PA) Spectracef Sporanox (QL) Suprax Tobi* Tobi Podhaler* Tyzeka* Valtrex Vfend (PA) Victrelis* (PA) Zithromax Zyvox (PA) acetaminophen/caffeine/ butalbital dihydroergotamine mesylate (QL) isomethepten/caf/ acetaminophen naratriptan (QL) rizatriptan (QL) sumatriptan (QL) sumatriptan succinate (QL) zolmitriptan (QL) MIGRAINE Treximet (QL) Cafergot Alsuma (QL) Amerge (QL) Axert (QL) DHE 45 (QL) Frova (QL) Imitrex (QL) Maxalt (QL) Maxalt MLT (QL) Migranal (QL) Relpax (QL) Sumavel DosePro (QL) Zomig/Zomig ZMT (QL) Zomig nasal (QL) 17

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS MULTIPLE SCLEROSIS dronabinol granisetron ondansetron prochlorperazine promethazine trimethobenzamide alendronate sodium calcitonin-salmon etidronate disodium Fortical ibandronate sodium syringe* ibandronate sodium tablet raloxifene HCl risedronate buprenorphine butalbital/acetaminophen butalbit/acetamin/ caff/codeine butorphanol nasal (QL) codeine phos/carisoprodol/asa codeine phosphate codeine phosphate/aspirin codeine sulfate cyclophosphamide* dexamethasone diclofenac diclofenac/misoprostol dihy-cod tt/apap/caffeine etodolac fenoprofen fentanyl citrate (lozenge on stick) (PA) fentanyl transdermal (QL) Ampyra* (PA) Avonex/Avonex Pen* (PA) Copaxone* (PA) Rebif* (PA) Rebif Rebidose* (PA) Tecfidera* (PA) NAUSEA AND VOMITING Emend capsule* (QL) OSTEOPOROSIS Evista Forteo* Miacalcin PAIN RELIEF AND INFLAMMATORY DISEASE Actimmune* (PA) Avinza (QL) Celebrex (QL) Dilaudid-5 Dipentum Enbrel* (PA) Fentora (PA) Humira* (PA) Indocin (suppository) Kadian (QL) Lidoderm Lyrica Nucynta (QL, ST) Nucynta ER (QL) OxyContin (QL) Ponstel Rheumatrex* Roxicet Savella Aubagio* (PA) Betaseron* (PA) Extavia* (PA) Gilenya* (PA) Anzemet inj* (PA) Anzemet tabs* (QL) Diclegis Marinol Sancuso (QL) Zofran Zuplenz (PA, QL, ST) Actonel (PA,ST) Atelvia (PA,ST) Binosto (PA,ST) Boniva syringe* (PA,ST) Boniva tab (PA,ST) Fosamax (PA,ST) Fosamax Plus D (PA,ST) Skelid (PA,ST) Abstral (PA) Actemra* (PA) Actiq (PA) Ansaid (PA,ST) Arthrotec (PA, ST) Butrans (QL) Cambia (PA, ST) Cimzia* (PA) Conzip (PA, QL, ST) Demerol (PA,ST) Dilaudid (PA,ST) Duexis (PA, ST) Duragesic (QL) Exalgo (QL) Fioricet w/codeine Flector (PA, QL, ST) Horizant (PA, ST) Hycet (PA,ST) Kineret* (PA) 18

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED) flurbiprofen hydrocodone bitartrate/apap hydrocodone bitartrate/ aspirin hydromorphone HCl ibuprofen ibuprofen/hydrocod bit indomethacin ketoprofen ketorolac (QL) leflunomide levorphanol tartrate lidocaine lidocaine-prilocaine meclofenamate mefenamic acid meloxicam meperidine HCl metaxalone methotrexate* methylprednisolone migergot morphine sulfate (QL) nabumetone naproxen opium opium/belladonna alkaloids orphenadrine/aspirin/caffeine oxaprozin oxycodone HCl oxycodone HCl/ acetaminophen oxycodone/aspirin oxymorphone Oxymorphone HCl pentazocine HCl/ acetaminophen pentazocine HCl/naloxone HCl piroxicam prednisone sulindac tolmetin tramadol ER (QL) tramadol HCl (QL) tramadol HCl/ acetaminophen (QL) Suboxone film tab (PA) Trexall* Lazanda (PA) Lortab (PA,ST) Mobic (PA, ST) MS Contin (QL) Nalfon (PA,ST) Naprelan (PA, ST) Norco (PA,ST) Onsolis (PA) Opana (QL) Opana ER (QL) Otrexup* (PA) Oxecta (PA,ST) Pennsaid (PA, ST) Percocet (PA,ST) Percodan (PA,ST) Primalev (PA,ST) Prodrin Quflora Rasuvo* (PA) Rayos (PA, ST) Remicade* (PA) Roxicodone (PA,ST) Ryzolt Simponi* (PA) Simponi Aria* (PA) Skelaxin Sprix (QL) Suboxone SL tab (PA) Subsys (PA) Synalgos-DC (PA,ST) Ultracet (PA, QL, ST) Ultram (PA, QL, ST) Ultram ER (PA, QL, ST) Vicodin (PA,ST) Vicoprofen (PA,ST) Vimovo (PA, QL, ST) Voltaren Gel (PA, ST) Voltaren XR (PA, ST) Xartemis XR (QL) Xeljanz* (PA) Xodol (PA,ST) Zamicet (PA,ST) Zohydro (QL) Zolvit (PA,ST) Zorvolex (PA,ST) 19

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS PARKINSON S DISEASE amantadine benztropine bromocriptine carbidopa carbidopa/levodopa carbidopa/levodopa CR carbidopa/levodopa/ entacapone entacapone pramipexole ropinirole ropinirole XL selegiline alfuzosin doxazosin finasteride leuprolide acetate* (PA) prazosin tamsulosin terazosin clozapine haloperidol loxapine olanzapine olanzapine/fluoxetine HCl quetiapine risperidone thiothixene ziprasidone Apokyn* (PA) Azilect PROSTATE Avodart Cialis (PA, QL) Jalyn Zoladex* (PA) SCHIZOPHRENIA Seroquel XR Comtan Eldepryl Lodosyn Mirapex Mirapex ER Neupro Northera* (PA) Parcopa Requip Requip XL Sinemet CR Stalevo Tasmar Zelapar Firmagon* (PA) Flomax Proscar Rapaflo Uroxatral Abilify Abilify Discmelt Clozaril (PA, ST) Fanapt (PA, ST) Fazaclo (PA, ST) Geodon (PA, ST) Invega (PA, ST) Latuda (PA, ST) Orap Risperdal/ Risperdal M (PA, ST) Saphris (PA, ST) Seroquel (PA, ST) Symbyax Versacloz (PA,ST) Zyprexa (PA, ST) Zyprexa Zydis (PA, ST) 20

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS carbamazepine clonazepam diazepam divalproex ethosuximide felbamate gabapentin lamotrigine levetiracetam oxcarbazepine phenytoin tiagabine HCl topiramate valproate zonisamide valproate sodium SEIZURE Celontin Diastat Diastat Acudial Dilantin (30 MG only) Felbatol Gabitril Keppra Lamictal ODT Lyrica Peganone Vimpat Aptiom Banzel Carbatrol Depakote (all forms) Dilantin Fycompa Keppra XR Lamictal Lamictal XR Neurontin Oxtellar XR Potiga Qudexy XR Saphris Stavzor Tegretol XR Topamax topiramate XR caps Trileptal Zarontin Zonegran SEXUAL DYSFUNCTION Please check your enrollment materials to determine whether these medications are covered under your specific plan. Cialis (PA, QL) Muse (PA, QL) Viagra (QL) Caverject (PA, QL) Edex (PA, QL) Levitra ( PA, QL) Osphena Staxyn (PA, QL) Stendra (QL) 21

Performance Prescription Drug List 22 NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS acitretin adapalene (AGE) alclometasone dipropionate amcinonide amnesteem (QL) Apexicon E (diflorasone diacetate) cream betamethasone betamethasone dipropionate betamethasone dipropionate/ propylene glycol betamethasone valerate calcipotriene calcipotriene-betamethasone calcitriol ointment Claravis (QL) clinicamycinphosphate/ benzoyl peroxide gel clobetasol propionate clobetasol propionate/emoll clocortolone pivalate desonide desoximetasone diclofenac sodium diflorasone diacetate fluocinolone acetonide fluocinonide fluocinonide/emollient fluorouracil topical fluticasone propionate fluticasone propionate halobetasol prop/ ammonium lac halobetasol propionate hydrocortisone hydrocortisone acetate/ aloe vera hydrocortisone acetate/urea hydrocortisone butyrate hydrocortisone valerate imiquimod Isotretinoin (QL) mafenide acetate methoxsalen, rapid metronidazole mometasone furoate podofilox prednicarbate SKIN CONDITIONS Ala-Scalp HP (PA, ST) Benzaclin (Gel w/pump) Benzamycin Pak Capex Shampoo (PA, ST) Carac Carmol HC (PA,ST) Cloderm (PA, ST) Cordran (PA, ST) Cordran SP (PA, ST) Differin (AGE) Enbrel* (PA) Exelderm Fluoroplex Furacin Humira* (PA) Kenalog spray (PA, ST) Klaron Locoid (lotion) Loprox shampoo Metrogel 1% Naftin Noritate Nucort (PA, ST) Oracea Tazorac Texacort (PA, ST) Absorica (QL) Acanya Aclovate (PA, ST) Alcortin A Aldara Apexicon ointment (PA, ST) Apop Aqua Glycolic HC (PA, ST) Atralin (AGE) Avar Avar LS Avita Bactroban Benoxyldoxy 30 Benzaclin Benzefoam Clindacin Pac Clobex (PA, ST) Clodan (PA, ST) Condylox Cutivate (PA, ST) Derma-Smoothe/FS (PA, ST) Dermasorb AF Dermasorb HC (PA,ST) Dermasorb TA (PA,ST) Dermasorb XM Dermatop (PA, ST) Desonate (PA, ST) Desowen (PA, ST) Diprolene (PA, ST) Diprolene AF (PA, ST) Dovonex Duac Ecoza Elidel (PA, ST) Elocon (PA, ST) Epiduo First Hydrocortisone (PA, ST) Halog (PA, ST) Hydro 35 Jublia (PA, ST) Kenalog (PA, ST) Kerydin (PA, ST) Locoid (cream, ointment, solution) Locoid Lipocream (PA, ST) Luxiq (PA, ST) Luzu

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS salicylic acid Sotret (QL) sulfacetamide sulfacetamide sodium/sulfur sulfacetamide sulfur sulfacetamide/sulfur/cleanser tretinoin (AGE) triamcinolone acetonide urea SKIN CONDITIONS (CONTINUED) Metrogel Metrolotion Momexin (PA, ST) Neuac Olux (PA, ST) Olux-E (PA, ST) Otezla* (PA) Ovace Plus cream, lotion and wash Pandel (PA, ST) Panretin* Pediaderm HC (PA, ST) Plexion Protopic (PA, ST) Regranex (PA) Remicade* (PA) Retin-A cream (PA, AGE) Retin-A Micro (PA, AGE) Retin-A Micro Pump (PA, AGE) Riax Rosula Scalacort DK (PA, ST) Solaraze Soriatane Sorilux Stelara* (PA) Sumadan XLT Synalar (PA, ST) Synalar TS (PA, ST) Taclonex Targretin gel* Temovate (PA, ST) Topicort (PA, ST) Topicort LP (PA, ST) Tretin-X (PA) Ultrasal-ER Ultravate (PA, ST) Ultravate X (PA, ST) Umecta Vanos (PA, ST) Vectical Verdeso (PA, ST) Vytone Westcort (PA, ST) Xolegel Ziana Zyclara (PA, ST) 23

Performance Prescription Drug List 24 eszopiclone zaleplon zolpidem zolpidem ER NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS SLEEP azathioprine* cyclosporine* mycophenolate moefetil* mycophenolate sodium* sirolimus* tacrolimus* Silenor TRANSPLANT Azasan* Cellcept* Neoral* Prograf* Rapamune* Sandimmune* VITAMINS (Available as generic where ^ is noted). calcitriol Active OB^ cyanocobalamin Bal-Care DHA Essential folic acid Citranatal Citranatal 90 DHA Citranatal Assure^ Citranatal B-Calm Citranatal DHA Citranatal Harmony^ Citranatal Rx Duet DHA Duet DHA EC Focalgin-B^ Folet One Gesticare DHA Infanate Balance Natachew Natafort Natelle One^ Neevo Neevo DHA Nestabs^ Nestabs ABC Nestabs DHA^ Nexa Plus OB Complete OB Complete DHA Ambien (PA, ST) Ambien CR (PA, ST) Edluar (PA, ST) Intermezzo (PA, ST) Lunesta (PA, ST) Rozerem (PA, ST) Sonata (PA, ST) Zolpimist (PA, ST) Imuran* Myfortic* Zortress* All plans cover all generic prescription prenatal vitamins, even though not listed here MaxFe Nascobal

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS VITAMINS (CONTINUED) All plans cover all generic prescription prenatal vitamins, even though not listed here (Available as generic where ^ is noted). OB Complete One OB Complete Petite OB Complete Premier PNV Folic Acid-Iron PNV-DHA Plus Precare Premier Prefera-OB One PreferaOB Prenatal Vitamin Prenaissance Next-B Prenata Prenatal 19 Prenate AM Prenate Chewable Prenate DHA Prenate Elite Prenate Enhance Prenate Mini Prenate Restore Prenate Star Provida OB Select-OB Stuart Prenatal Stuartnatal Plus Stuartnatal Plus 3 TL-Select DHA Tricare Tricare Prenatal Compleat Tricare Prenatal DHA One^ Vinate Care Vinate DHA Virt-Bal DHA^ Vita Fol-OB DHA Vitafol Nano Vitafol Ultra Vitafol-One VitamedMD Redichew Rx Vitapearl Viva DHA VP CH Ultra VP-PNV-DHA 25

Performance Prescription Drug List NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS aminocaproic acid* buprenorphine buprenorphine HCl/ naloxone HCl (PA) cyclobenzaprine doxercalciferol hydrocodone/ chlorpheniramine suspension hydrocortisone leucovorin* levocarnitine lindane megestrol methocarbamol naltrexone naltrexone HCl paricalcitol* pentoxifylline pramoxine/hydrocortisone pseudoephed/ hydrocodone/cpm quinine sulfate riluzole* sevelamer carbonate sodium phenylbutyrate sodium polystyrene sulfonate spinosad tizanidine tranexamic acid* MISCELLANEOUS Analpram Advanced Aranesp* (PA) Buphenyl Chantix* Epogen* (PA) Fosrenol Klor-Con M15 Leukine* Pramosone Procrit* (PA) Proctofoam-HC Pulmuzyme* (PA) Renvela SPS Suboxone film tab (PA) TussiCaps Zavesca* (PA) Analpram-E Analpram HC Arcalyst* (PA) Brisdelle (QL) Bunavail (PA) Cerdelga* (PA) Cortifoam Cuvposa Epifoam Evzio Gattex* (PA) Glycate Hectorol Hetlioz (PA) Ilaris* (PA) Kuvan* Lupaneta Pack* (PA) Lysteda* Natroba Neo-Synalar Nimotop Nuedexta Nymalize Oxandrin (PA) Phoslo Phoslyra Procysbi* (PA) Promacta* (PA) Ravicti* (PA) Rectiv Renagel Revia Rilutek* Sklice Suboxone SL tab (PA) Tussionex Ulesfia Velphoro Vituz Zanaflex Zemplar* Zubsolv (PA, ST) Zutripro 26

Exclusions and Limitations Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan: 1. Any medications available over-the-counter (OTC) that do not require a prescription by federal or state law, and any medication that is a pharmaceutical alternative to an OTC medication other than insulin. [examples include OTC Benadryl, Maalox, Sudafed PE, etc.]. 2. Medications that are therapeutically equivalent as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee in which at least one of the medications within the class is available over the counter [examples include Rx equivalents to OTC Allegra, Claritin and Zyrtec (Allegra D, Clarinex, Xyzal) and Rx equivalents to OTC Prevacid, Prilosec, Zantac (Aciphex, Kapidex, Nexium, Axid, Pepcid, Zantac)]. 3. Any injectable infertility medications, and any injectable medications that require health care professional supervision and are not typically considered selfadministered medications. The following are examples of health care professionalsupervised medications: injectables used to treat hemophilia and RSV (respiratory syncytial virus), chemotherapy injectables and endocrine and metabolic agents. 4. Any medications that are experimental or investigational within the meaning set forth in the summary plan description. 5. Food and Drug Administration (FDA) approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal. 6. Any prescription and non-prescription supplies (such as ostomy supplies), devices and appliances. 7. Implantable contraceptive products. 8. Any fertility medication. 9. Any prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride products. 10. Medications used for cosmetic purposes, such as medications used to reduce wrinkles, medications to promote hair growth, medications used to control perspiration and fade cream products. 11. Any diet pills or appetite suppressants (anorectics). 12. Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis (the prevention of travel-related diseases). 13. Replacement of prescription medications and related supplies due to loss or theft. 14. Medications used to enhance athletic performance. 15. Medications that are to be taken by, or administered to, a customer while the customer is a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals. 16. Prescriptions more than one year from the original date of issue. 27

Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. Cigna and the Tree of Life logo are registered service marks, and Cigna Home Delivery Pharmacy and Together, all the way. 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 Specialty Pharmacy Services refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. All models are used for illustrative purposes only. 827293 k 10/14 2014 Cigna. Some content provided under license.

Click with a site that clicks with you mycigna.com is completely personalized, so it s easy to quickly find exactly what you re looking for. Find doctors and medical services Manage and track claims See cost estimates for medical procedures Compare quality of care ratings for doctors and hospitals Access a variety of health and wellness tools and resources Manage your health and health care expenses with ease. It s all waiting for you on mycigna.com. Connect with better health. Here s how: Health and wellness My health assessment. In just twenty minutes, this confidential, online questionnaire will give you a better understanding of your health today and teach you simple steps for improving your health in the future. Condition and wellness resources. Using our interactive medical library, find information on health conditions, first aid, medical exams, wellness and more. Cost estimates and quality of care ratings Find a doctor. Personalized search results make it easy to find the right doctor for you. Search by name, specialty, procedure, location and other criteria. Estimate medical costs. Review estimated costs for specific, in-network procedures, treatments and facilities so there aren t any surprises. Compare hospitals and doctors. See how they compare by cost, patient outcomes and more. Quality of care. Quality distinctions and cost-efficiency ratings for doctors appear with every search result, with quality-designated doctors appearing at the top of your list. Prescription drug price quote tool. Compare prices between Cigna Home Delivery Pharmacy SM and our network of retail pharmacies to help ensure you re getting the best price possible. Manage and track claims. Quickly search and sort claims, as well as track account balances, like deductibles and out-ofpocket maximums. 841211 d 04/14

Prescription services Live pharmacists 24/7 to help answer all your prescription drug-related questions and put you at ease. Refill prescriptions with Cigna Home Delivery Pharmacy. Save time and money by reordering prescriptions online and getting up to a 90-day supply delivered right to your mailbox. Manage your Cigna Home Delivery Pharmacy prescription orders. You can easily place a new order, track shipments and view how many refills you have left on your prescription. Sign up for QuickFill. This refill reminder service lets you know when your prescription is about to run out and fill it at the same time. Instant access to Cigna Home Delivery Pharmacy and retail prescription information. View your pharmacy claim history, plan details and account balances. It s all designed to click with you. For a quick tour on how to get the most out of mycigna.com, go to: mycigna.com > Site Benefits To register: mycigna.com > Learn How to Register You can access mycigna.com from any smartphone or web-enabled mobile device.* With the mycigna Mobile App, it s never been easier to be on the go and in the know. Your health has met its App. SM Get the mycigna Mobile App today!* The Apple logo is a trademark of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. Android and Google Play are trademarks of Google Inc. Web-enabled device with the internet or other online connectivity is required. mycigna features and functionality may vary between mycigna.com, mycigna Mobile and the mycigna Mobile App. Actual features may also vary depending on your specific plan and mobile device. The downloading and use of the mycigna Mobile App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and data usage charges apply. The listing of a doctor or facility in the health care professional directory does not guarantee that the services rendered by that doctor or facility are covered under your specific medical plan. Check your official plan documents, or call the number listed on your ID card, for more information about the services covered under your plan benefits. Cigna, Tree of Life logo, GO YOU 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 by or through 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), Tel-Drug, Inc., Tel-Drug of Pennsylvania, LLC, 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. Cigna Home Delivery Pharmacy refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, LLC. 841211 d 04/14 2014 Cigna. Some content provided under license.

Customer reference guide Understanding your PREVENTIVE CARE HEALTH COVERAGE Getting the right preventive care services at the right time can help you stay healthier by: Preventing certain illnesses and health conditions from happening; or Detecting a health problem at a stage that may be easier to treat. That s why your Cigna plan covers designated preventive care services. When you receive care in-network, it generally is at a lower cost to you. Depending on your plan, in-network preventive care services may be covered at 100% but be sure to check your plan materials for details about your specific medical plan. To make sure you get the care you need without any unexpected out-of-pocket costs it s important for you to understand the following: What a preventive care service is; and Which services your health plan will cover. What is a preventive care service? Preventive care services are provided when you don t have any symptoms and haven t been diagnosed with the health issue connected with the preventive service. For example, a flu vaccination is given to prevent the flu before you get it. Other preventive care services like mammograms can help detect an illness when there aren t any symptoms. Even if you re in the best shape of your life, a serious condition with no signs or symptoms may put your health at risk. During a wellness exam, you and your doctor will determine what tests and health screenings are right for you based on your age, gender, personal health history and current health. Even when your appointment is for a preventive exam, you may receive other services during that exam that are not preventive care services. For example, your doctor may check on a chronic condition such as heart disease. When your doctor determines that you have a medical issue present, the additional screenings and tests after this diagnosis are no longer considered preventive. These services are covered under your plan s medical benefits, not your preventive care benefits. This means you may be responsible for paying a different share of the cost than you do for preventive care services. The charts on the following pages outline the various services and supplies considered as preventive care under your plan.if you have additional questions about preventive care services, talk to your doctor or call Cigna at the toll-free number on the back of your ID card. 855050 b 09/14 Offered by: Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and their affiliates. HP-POL38 03-11 GM6000 C1 et al GM5800 OR POL1 ED. 1/2001

Wellness exams SERVICE GROUP AGE, FREQUENCY Well-baby/well-child/well-person exams, including annual well-woman exam (includes height, weight, head circumference, BMI, blood pressure, history, anticipatory guidance, education regarding risk reduction, psychosocial/behavioral assessment) Birth, 1, 2, 4, 6, 9, 12, 15, 18, 24 and 30 months Additional visit at 2-4 days for infants discharged less than 48 hours after delivery Ages 3 to 21 once a year Ages 22 and older periodic visits, as doctor advises The following routine immunizations are currently designated preventive services: SERVICE Diphtheria, Tetanus Toxoids and Acellular Pertussis (DTaP, Tdap, Td) Haemophilus influenzae type b conjugate (Hib) Hepatitis A (HepA) Hepatitis B (HepB) Human papillomavirus (HPV) (age and gender criteria apply depending on vaccine brand) Influenza vaccine Measles, mumps and rubella (MMR) SERVICE Meningococcal (MCV) Pneumococcal (pneumonia) Poliovirus (IPV) Rotavirus (RV) Varicella (chickenpox) Zoster (shingles) You may view the immunization schedules on the CDC website: cdc.gov/vaccines/schedules/. Health screenings and interventions SERVICE GROUP AGE, FREQUENCY Alcohol misuse screening Anemia screening All adults Pregnant women Aspirin to prevent cardiovascular disease 1 Men ages 45-79; women ages 55-79 Autism screening Bacteriuria screening Breast cancer screening (mammogram) Breast-feeding support/counseling, supplies 2 Cervical cancer screening (pap test) HPV DNA test with pap test Chlamydia screening Cholesterol/lipid disorders screening 18, 24 months Pregnant women Women ages 40 and older, every 1 2 years During pregnancy and after birth Women ages 21 65, every 3 years Women ages 30-65, every 5 years Sexually active women ages 24 and under and older women at risk Screening of children and adolescents (after age 2, but by age 10) at risk due to known family history; when family history is unknown; or with personal risk factors (obesity, high blood pressure, diabetes) All men ages 35 and older, or ages 20-35 if risk factors All women ages 45 and older, or ages 20-45 if risk factors Colon cancer screening The following tests will be covered for colorectal cancer screening, ages 50 and older: Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually Flexible sigmoidoscopy every 5 years Double-contrast barium enema (DCBE) every 5 years Colonoscopy every 10 years Computed tomographic colonography (CTC)/virtual colonoscopy every 5 years - Requires precertification = Men, = Women, = Children/Adolescents

Health screenings and interventions SERVICE GROUP AGE, FREQUENCY Congenital hypothyroidism screening Contraception counseling/education. Contraceptive products and services 1,3, 4 Depression screening Developmental screening Newborns Women with reproductive capacity Ages 11-21, All adults 9, 18, 30 months Developmental surveillance Newborn 1, 2, 4, 6, 12, 15, 24 months. At each visit ages 3 to 21 Diabetes screening Adults with sustained blood pressure greater than 135/80 Discussion about potential benefits/risk of breast cancer preventive medication 1 Dental caries prevention (Evaluate water source for sufficient fluoride; if deficient prescribe oral fluoride 1 ) Domestic and interpersonal violence screening Fall prevention in older adults (physical therapy, vitamin D supplementation 1 ) Folic acid supplementation 1 Genetic counseling/evaluation and BRCA1/BRCA2 testing Gestational diabetes screening Gonorrhea screening Hearing screening (not complete hearing examination) Healthy diet/nutrition counseling Hemoglobin or hematocrit Hepatitis B screening Women at risk Children older than 6 months All women Community-dwelling adults ages 65 and older with risk factors Women planning or capable of pregnancy Women at risk Genetic counseling must be provided by an independent board-certified genetic specialist prior to BRCA1/BRCA2 genetic testing BRCA1/BRCA2 testing requires precertification Pregnant women Sexually active women at risk All newborns by 1 month. Ages 4, 5, 6, 8, and 10 or as doctor advises Ages 6 and older - to promote improvement in weight status. Adults with hyperlipidermia, those at risk for cardiovascular disease or diet-related chronic disease 12 months Pregnant women Hepatitis C screening Adults at risk; one-time screening for adults born between 1945 and 1965 HIV screening and counseling Iron supplementation 1 Lead screening Lung cancer screening (low-dose computed tomography) Metabolic/hemoglobinopathies (according to state law) Obesity screening Pregnant women; adolescents and adults 15 to 65 years; younger adolescents and older adults at risk; sexually active women, annually 6-12 months for children at risk 12, 24 months Adults ages 55 to 80 with 30 pack-year smoking history, and currently smoke, or have quit within the past 15 years. Computed tomography requires precertification. (coverage effective upon your plan s start or anniversary date on or after 1/1/15) Newborns Ages 6 and older. All adults Oral health evaluation/assess for dental referral 12, 18, 24, 30 months. Ages 3 and 6 Osteoporosis screening PKU screening Age 65 or older (or under age 65 for women with fracture risk as determined by Fracture Risk Assessment Score). Computed tomographic bone density study requires precertification Newborns = Men, = Women, = Children/Adolescents

Health screenings and interventions SERVICE GROUP AGE, FREQUENCY Ocular (eye) medication to prevent blindness Prostate cancer screening (PSA) Rh incompatibility test Sexually transmitted diseases counseling Sexually transmitted infections (STI) screening Sickle cell disease screening Skin cancer prevention counseling to minimize exposure to ultraviolet radiation = Men, = Women, = Children/Adolescents Syphilis screening Tobacco use/cessation interventions Tobacco use prevention (counseling to prevent initiation) Tuberculin test Ultrasound aortic abdominal aneurysm screening Vision screening (not complete eye examination) Newborns Men ages 50 and older or age 40 with risk factors Pregnant women Sexually active women, annually All sexually active adolescents. All adults at risk Newborns Ages 10-24 Individuals at risk; Pregnant women All adults; Pregnant women School-age children and adolescents Children and adolescents at risk Men ages 65-75 who have ever smoked Ages 3, 4, 5, 6, 8, 10, 12, 15 and 18 or as doctor advises = Men, = Women, = Children/Adolescents Other coverage: Your plan supplements the preventive care services listed above with additional services that are commonly ordered by primary care physicians during preventive care visits. These include services such as urinalysis, EKG, thyroid screening, electrolyte panel, Vitamin D measurement, bilirubin, iron and metabolic panels. 1 Subject to the terms of your plan s pharmacy coverage, certain drugs and products may be covered at 100%. Your doctor is required to give you a prescription, including for those that are available over-the-counter, for them to be covered under your Pharmacy benefit. Cost sharing may be applied for brand name products where generic alternatives are available. Please refer to Cigna s No Cost Preventive Medications by Drug Category Guide for information on drugs and products with no out-of-pocket cost.. 2 Subject to the terms of your plan s medical coverage, breast-feeding equipment rental and supplies may be covered at the preventive level. Your doctor is required to provide a prescription, and the equipment and supplies must be ordered through CareCentrix, Cigna s national durable medical equipment vendor. Precertification is required for some types of breast pump equipment. To obtain the breast pump and initial supplies, contact CareCentrix at 1.877.466.0164 (Option 3). To obtain replacement supplies, contact Edgepark Medical Supplies at 1.800.321.0591. 3 Examples include oral contraceptives; diaphragms; hormonal injections and contraceptive supplies (spermicide, female condoms); emergency contraception. 4 Subject to the terms of your plan s medical coverage, contraceptive products and services such as some types of IUD s, implants and sterilization procedures may be covered at the preventive level. Check your plan materials for details about your specific medical plan. These preventive health services are based on recommendations from the U.S. Preventive Services Task Force (A and B recommendations), the Advisory Committee on Immunization Practices (ACIP) for immunizations, the American Academy of Pediatrics Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care, the Uniform Panel of the Secretary s Advisory Committee on Heritable Disorders in Newborns and Children and, with respect to women, evidence-informed preventive care and screening guidelines supported by the Health Resources and Services Administration. For additional information on immunizations, visit the immunization schedule section of www.cdc.gov. This document is a general guide. Always discuss your particular preventive care needs with your doctor. Exclusions This document provides highlights of preventive care coverage generally. Some preventive services may not be covered under your plan. For example, immunizations for travel are generally not covered. Other non-covered services/supplies may include any service or device that is not medically necessary or services/supplies that are unproven (experimental or investigational). For the specific coverage terms of your plan, refer to the Evidence of Coverage, Summary Plan Description or Insurance Certificate. 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 or through 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), Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc. (IL & IN), Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc. (MO, KS & IL), Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (TN & MS), and Cigna HealthCare of Texas, Inc. 855050 b 09/14 2014 Cigna. Some content provided under license.

Understand your medical plan options open access plus How it works Cigna s Open Access Plus plan gives you important choices. Each time you need care, you can choose the doctors and other health professionals and facilities that work best for you. Enroll in the Open Access Plus and you ll get: Options for accessing quality health care Primary Care Physician (PCP) You decide if you want to choose a PCP as your personal doctor to help coordinate care and act as a personal health advocate. It s recommended but not required. In-network Choose to see doctors or other health professionals who participate in the Cigna network to keep your costs lower and eliminate paperwork. No-referral specialist care If you need to see a specialist, you do not need a referral to see a doctor who participates in the Cigna network just make the appointment and go! Pre-certification may be necessary for hospitalizations and some types of outpatient care, but there is no paperwork for you. Out-of-network You also have the freedom to visit doctors or use facilities that are not part of the Cigna network, but your costs will be higher and you may need to file a claim. 24/7 service Whenever you need us, customer service representatives are available to take your calls. You can also speak with a health care professional over the phone, any time, day or night. Health and wellness discounts Enjoy discounts on a variety of health-related products and services. Access to mycigna.com Use a personalized website to: Learn more about your plan and the coverage and programs available to you. View claim history and account transactions; print claim forms when you need them. Find information and estimate costs for medical procedures and treatments. Learn how hospitals rank by number of procedures performed, patients average length of stay and cost. Emergency and urgent care When you need care, you re covered, 24 hours a day, worldwide. 831758 d 08/12 Offered by: Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and their affiliates.

Q&A Do I have to choose a Primary Care Physician (PCP)? No. However, a PCP gives you and your covered family members a valuable resource and can be a personal health advocate. What if my doctor isn t on your list? That means your PCP does not participate in the Cigna network. To receive your maximum coverage, you should select a doctor from the Cigna list of participating doctors and other health care professionals. You can continue seeing your current doctor, even if he or she is not in Cigna s network. However, in that case, you will pay higher out-of-pocket costs, and your care will be covered at the out-of-network coverage level. Do I need a referral to see a specialist? Though you may want your personal doctor s advice and assistance in arranging care with a specialist in the network, you do not need a referral to see a participating specialist. If you choose an out-ofnetwork specialist, your care will be covered at the out-of-network coverage level. What is the difference between in-network coverage and out-of-network coverage? Each time you seek medical care, you can choose your doctor either a doctor who participates in the Cigna network or someone who does not participate. When you visit a participating doctor, you receive innetwork coverage and will have lower out-of-pocket costs. That s because our participating health care professionals have agreed to charge lower fees, and your plan covers a larger share of the charges. If you choose to visit a doctor outside of the network, your out-of-pocket costs will be higher. What if I need to be admitted to the hospital? In an emergency, your care is covered. Requests for non-emergency hospital stays other than maternity stays must be approved in advance or pre-certified. This enables Cigna to determine if the services are covered. Pre-certification is not required for maternity stays of 48 hours for vaginal deliveries or 96 hours for caesarean sections. Depending on your plan, you may be eligible for additional coverage. Any hospital stay beyond the initial 48 or 96 hours must be approved. Who is responsible for obtaining pre-certification? Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis. If your doctor participates in the Cigna network, he or she will arrange for precertification. If you use an out-of-network doctor, you are responsible for making the arrangements. Your plan materials will identify which procedures require pre-certification. How do I find out if my doctor is in the Cigna network before I enroll? It s quick and easy to search for participating doctors, specialists, pharmacies, hospitals and facilities closest to home and work. Go to Cigna.com and click on Find a Doctor. You will be able to: Review the doctor s education, languages spoken and hospital affiliations, and get a detailed map with directions. What if I go to an out-of-network doctor who sends me to a network hospital? Will I pay in-network or out-of-network charges for my hospitalization? Cigna HealthCare will cover authorized medical services provided by an Open Access Plus participating hospital at your in-network coverage level whether you were sent there by an in-or outof-network doctor. Cigna, mycigna.com and Cigna.com are registered service marks, and the Tree of Life logo and GO YOU are service marks, 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 (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 used for illustrative purposes only. Cigna insured OAP product is not available in Arkansas or Puerto Rico. 831758 d 08/12 2012 Cigna. Some content provided under license.