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Cigna HealthCare

Point of Service

Important Information

THIS IS A SAMPLE DOCUMENT.

NO BENEFITS ARE GUARANTEED. NO COVERAGE REPRESENTATION IS CONSIDERED TO BE

ACTUAL MEDICAL BENEFITS PROVIDED TO YOU BY CIGNA.

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Important Information

THIS IS A SAMPLE DOCUMENT.

NO BENEFITS ARE GUARANTEED. NO COVERAGE REPRESENTATION IS CONSIDERED TO BE

ACTUAL MEDICAL BENEFITS PROVIDED TO YOU BY CIGNA.

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Group Service Agreement

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NOTICE

Continuity of Care

In certain circumstances, if you are receiving continued care from a network provider and that provider’s network status

changes to out-of-network, you may be eligible to continue to receive care from the provider at the Participating Provider

cost-sharing amount for up to 90 days from the date you are notified of your provider’s termination. A continuing care

patient is an individual who is: undergoing treatment for a serious and complex condition; pregnant and undergoing

treatment for the pregnancy; receiving inpatient care; scheduled to undergo urgent or emergent surgery, including

postoperative; or terminally ill (having a life expectancy of 6 months or less) and receiving treatment from the provider for

the illness. If applicable, you will be notified of your continuity of care options.

Provider Directories and Provider Networks

A list of network providers is available to you, without charge, by visiting the website or calling the phone number on your

ID card. The network consists of providers, including hospitals, of varied specialties as well as generic practice, affiliated or

contracted with Cigna Healthcare or an organization contracting on its behalf.

Provider directory content is verified and updated, and processes are established for responding to provider network status

inquiries, in accordance with applicable requirements of the federal No Surprises Act.

A list of network pharmacies is available to you, without charge, by visiting the website or calling the phone number on your

ID card. The network consists of pharmacies affiliated or contracted with Cigna Healthplan or an organization contracting on

its behalf.

If you rely on a provider’s network status in the provider directory or by contacting Cigna Healthcare at the website or phone

number on your ID card to receive covered services from that provider, and that network status is incorrect, then an in-

network cost-share must be applied to the covered service as if the service were provided by a Participating 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 pre-approved treatment plan, or procedures for

making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, access

the website or call the phone number on your ID.

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

children, you may designate a pediatrician as the primary care provider. For information on how to select a primary

care provider, and for a list of the participating primary care providers, access the website or call the phone number on

your ID card.

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Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at a network hospital or ambulatory surgical

center, you are protected from balance billing. In these situations, you should not be charged more than your plan’s

copayments, coinsurance, and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment,

coinsurance, and/or deductible. You may have added costs or have to pay the entire bill if you see a provider or visit a health

care facility that is not in your health plan’s network.

“Out-of-network” means providers and facilities that have not signed a contract with your health plan to provide services.

Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount

charged for a service. This is called “balance billing”. This amount is likely more than in-network costs for the same service

and might not count toward your plan’s deductible or annual out-of-pocket limit.

1. “Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved

in your care – such as when you have an emergency or when you schedule a visit at an in-network facility

but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of

dollars depending on the procedure or service.

2. You are protected from balance billing for:

• Emergency services – If you have an emergency medical condition and get emergency services from an

out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount

(such as a copayments, coinsurance, and deductibles). You cannot be balanced billed for these emergency

services. This includes services you may get after you are in stable condition, unless you give written

consent and give up your protections not to be balanced billed for these post-stabilization services.

• Certain non-emergency services at an in-network hospital or ambulatory surgical center – When you

get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-

of-network. In these cases, the most those providers can bill you is your plan’s in-network cost sharing

amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology,

assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not

ask you to give up your protections not to be balanced billed.

If you get other types of services at these in-network facilities, out-of-network providers cannot balance bill

you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. You also are not required to get out-of-

network care. You can choose a provider or facility in your plan’s network.

When balance billing is not allowed, you have these protections:

• You are only responsible for paying your share of the cost (such as copayments, coinsurance, and deductibles that

you would pay if the provider were in-network). Your health plan will pay any additional costs to out-of-network

providers and facilities directly.

• Generally, your health plan must:

- Cover emergency services without requiring you to get approval in advance for services (also known as prior

authorization).

- Cover emergency services provided by out-of-network providers.

- Base what you owe the provider or facility (cost sharing) on what it would pay an in-network provider or facility

and show that amount in your Explanation of Benefits (EOB).

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- Count any amount you pay for emergency services or out-of-network services toward your in-network

deductible and out-of-pocket limit.

If you think you have been wrongly billed, contact Cigna Healthcare at the phone number on your ID card. You can also

contact No Surprises Help Desk at 1-800-985-3059 or www.cms.gov/nosurprises for more information about your rights

under federal law.

PPACA Notice 10/10

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NOTICE

MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT

The group agreement is amended as stated below.

In the event of a conflict between the provisions of your plan documents and the provisions of this notice, the provisions

that provide the better benefit shall apply.

Covered Services and Supplies:

Mental Health Residential Treatment Services

Benefits are payable for Mental Health Residential Treatment Services.

Inpatient Mental Health Services

Services that are provided by a Participating Hospital while you or your Dependent is confined in a Participating

Hospital for the treatment and evaluation of Mental Health. Inpatient Mental Health Services include Mental Health

Residential Treatment Services.

Mental Health Residential Treatment Services provided by a Participating Hospital for the evaluation and treatment

of the psychological and social functional disturbances that are a result of subacute Mental Health conditions.

Mental Health Residential Treatment Center means an institution which specializes in the treatment of

psychological and social disturbances that are the result of Mental Health conditions; provides a subacute, structured,

psychotherapeutic treatment program, under the supervision of Participating Providers; provides twenty-four (24) hour

care, in which a person lives in an open setting; and is licensed in accordance with the laws of the appropriate legally

authorized agency as a residential treatment center.

A Member is considered confined in a Mental Health Residential Treatment Center when she/he is a registered bed

patient in a Mental Health Residential Treatment Center upon the recommendation of a Participating Provider.

Outpatient Mental Health Services

Partial Hospitalization sessions are services that are provided for not less than four (4) hours and not more than twelve

(12) hours in a twenty-four (24) hour period by a certified/licensed Mental Health program in accordance with the

laws of the appropriate legally-authorized agency.

Inpatient Substance Use Disorder Rehabilitation Services

Services provided for rehabilitation, while you or your Dependent is confined in a Participating Hospital, when

required for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs. Inpatient Substance Use

Disorder Services include Residential Treatment services.

Substance Use Disorder Residential Treatment Services are services provided by a Participating Hospital for the

evaluation and treatment of the psychological and social functional disturbances that are a result of subacute Substance

Use Disorder conditions.

Substance Use Disorder Residential Treatment Center means an institution which specializes in the treatment of

psychological and social disturbances that are the result of Substance Use Disorder; provides a subacute, structured,

psychotherapeutic treatment program, under the supervision of Participating Providers; provides twenty-four (24) hour

care, in which a person lives in an open setting; and is licensed in accordance with the laws of the appropriate legally

authorized agency as a residential treatment center.

A Member is considered confined in a Substance Use Disorder Residential Treatment Center when she/he is a

registered bed patient in a Substance Use Disorder Residential Treatment Center upon the recommendation of a

Physician.

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Outpatient Substance Use Disorder Services

Partial Hospitalization sessions are services that are provided for not less than four (4) hours and not more than twelve

(12) hours in a twenty-four (24) hour period by a certified/licensed Substance Use Disorder program in accordance

with the laws of the appropriate legally-authorized agency.

Mental Health and Substance Use Disorder Exclusions:

The following exclusions are hereby deleted and no longer apply:

Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or

custody or visitation evaluations unless Medically Necessary and otherwise covered under this Agreement;

Mental Health residential treatment.

Terms within the agreement:

The term "mental retardation" within your Group Service Agreement is hereby changed to "intellectual disabilities".

Visit Limits:

Any health care service billed with a Mental Health or Substance Use Disorder diagnosis, will not incur a visit limit,

including but not limited to genetic counseling and nutritional evaluation.

Parity Notice - MH Residential Treatment-A 1/16

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NOTICE

PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA)

The group agreement is amended as stated below.

In the event of a conflict between the provisions of your plan documents and the provisions of this endorsement, the

provisions that provide the better benefit shall apply.

Clinical Trials

Benefits are payable for Routine Patient Services associated with an approved clinical trial (Phases I-IV) for treatment of

cancer or other life-threatening diseases or conditions for a covered person who meets the following requirements:

1. Is eligible to participate in an approved clinical trial according to the trial protocol with respect to the prevention,

detection or treatment of cancer or other life-threatening disease or condition; and

2. Either

the referring health care professional is a participating health care provider and has concluded that the individual's

participation in such a trial would be appropriate based upon the individual meeting the conditions described in

Paragraph (1); or

the covered person provides medical and scientific information establishing that participation in such a trial would

be appropriate based on the individual meeting the conditions described in Paragraph (1).

For purposes of clinical trials, the term "life-threatening disease or condition" means any disease or condition from which

the likelihood of death is probable unless the course of the disease or condition is interrupted.

An approved clinical trial must meet one of the following requirements:

be approved or funded by any of the agencies or entities authorized by federal law to conduct clinical trials;

be conducted under an investigational new drug application reviewed by the Food and Drug administration; or

involve a drug trial that is exempt from having such an investigational new drug application.

Routine Patient Services are costs associated with the provision of health care items and services including drugs, items,

devices and services typically covered by Cigna for a covered patient who is not enrolled in a clinical trial, including the

following:

services typically provided absent a clinical trial;

services required for the clinically appropriate monitoring of the investigational drug, device, item or service;

services provided for the prevention of complications arising from the provision of the investigational drug,

device, item or service; and

reasonable and necessary care arising from the provision of the investigational drug, device, item or service,

including the diagnosis or treatment of complications.

Routine Patient Services do not include:

the investigational item, device, or service itself; or

items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the

direct clinical management of the patient.

Clinical trials conducted by non-participating providers will be covered at the in-network benefit level if:

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there are not in-network providers participating in the clinical trial that are willing to accept the individual as a

patient; or

the clinical trial is conducted outside the individual's state of residence.

Exclusions and Limitations

Any services and supplies for or in connection with experimental, investigational or unproven services.

Experimental, investigational or unproven services do not include routine patient care costs related to qualified clinical

trials as described in your plan document.

Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder

or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the

Healthplan Medical Director to be:

not demonstrated, through existing peer-reviewed, evidence-based scientific literature to be safe and effective for

treating or diagnosing the condition or illness for which its use is proposed; or

not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be

lawfully marketed for the proposed use; or

the subject of review or approval by an Institutional Review Board for the proposed use.

PPACA Notice - Clinical Trials 1/20

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NOTICE

Discrimination is Against the Law

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national

origin, age, disability or sex. Cigna does not exclude people or treat them differently because of race, color, national

origin, age, disability or sex.

Cigna:

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

- Qualified sign language interpreters.

- Written information in other formats (large print, audio, accessible electronic formats, other formats).

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

- Qualified interpreters

- Information written in other languages

If you need these services, contact Customer Service at the toll-free phone number shown on your ID card, and ask a

Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color,

national origin, age, disability or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by

writing to the following address:

Cigna

Nondiscrimination Complaint Disorder

P.O. Box 188016

Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to

ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human

Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://

ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

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

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

Federal Discrimination Notice 1/17

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Proficiency of Language Assistance Services

Federal Language Assistance Notice 7/17

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Thank you for choosing Cigna.

We are pleased to provide important information about your Point of Service plan.

Your plan:

Does more than provide coverage when you're sick or injured. We focus on helping you take care of yourself so

you can stay your healthiest.

Includes preventive care services. We cover physicals, child immunizations, and women's health services such as

no-referral OB/GYN checkups, mammograms and Pap tests. You'll also receive discounts on health and wellness

programs and services.

Covers emergency and urgent care, 24 hours a day, worldwide.

Gives you options for accessing quality health care. Each time you access care, you have two options. You can

choose to see your Primary Care Physician (PCP) first and use participating health care professionals, a choice

that will keep your costs lower and eliminate paperwork. Your PCP will provide care and refer you to participating

specialists or facilities when you need them. Your second option gives you the freedom to visit any doctor or use any

facility -even those not contracted with Cigna -or to go to any doctor without a referral from your PCP. However, your

costs will be higher and you will have to file claims.

It's easy to get the information you need.

myCigna.com offers a number of self-service features. You can review your benefits plan information; find

participating doctors, specialists, pharmacies and hospitals closest to home or work; view the status of your claims;

order a new Cigna ID card; or change your PCP.

Customer Service Representatives are ready to answer your questions and help solve problems. Just call the toll-free

number on your Cigna ID card.

Your Cigna ID card lists the toll-free Customer Service phone number, your PCP's name and phone number, and

payment information.

Our Commitment to Quality guide gives you access to the latest information about our program activities and

results, including how we met our goals, as well as details about key guidelines and procedures. Log on to

www.myCigna.com to view this information. If you have questions about the quality program, would like to provide

your feedback and/or cannot access the information online and would like a paper copy, please call the number on the

back of your Cigna ID card.

We want you to be satisfied with your Cigna HealthCare plan. If you ever have a question about your plan or how to

obtain services and supplies, just call. We're here to help.

INTRODUCTION(GSA POS)-A 1/11

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Table of Contents

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GSA-TOC 9/99

POS-TOC 11/0

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I. Definitions of Terms Used

in This Group Service Agreement

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Section I. Definitions of Terms Used in This

Group Service Agreement

The following definitions will help you in understanding

the terms that are used in this Group Service Agreement.

As you are reading this Group Service Agreement you can

refer back to this section. We have identified defined terms

throughout the Agreement by capitalizing the first letter of

the term.

Agreement

This Agreement, the Face Sheet, the Schedule of

Copayments, any optional Riders, any other

attachments, your Enrollment Application, and any

subsequent written amendment or written modification

to any part of the Agreement.

Anniversary Date of Agreement

The date written on the Face Sheet as the Agreement

anniversary date.

Contract Year

The 12-month period beginning at 12:01 a.m. on the

first day of the initial term or any renewal term and

ending at 12:01 a.m. on the next anniversary of that

date.

Copayment

The amount shown in the Schedule of Copayments that

you pay for certain Covered Services and Supplies.

The Copayment may be a fixed dollar amount or a

percentage of the Participating Providers' negotiated

charge. The Copayment you are required to pay under

the plan is in addition to any Plan Deductible. When

the Participating Provider has contracted with the

Healthplan to receive payment on a basis other than a

fee-for-service amount, the charge may be calculated

based on a Healthplan-determined percentage of actual

billed charges.

Custodial Services

Any services that are of a sheltering, protective or

safeguarding nature. Such services may include a stay

in an institutional setting, at-home care or nursing

services to care for someone because of age or mental

or physical condition. This service primarily helps

the person in daily living. Custodial care also can

provide medical services given mainly to maintain the

person's current state of health. These services cannot

be intended to greatly improve a medical condition;

they are intended to provide care while the patient

cannot care for himself or herself.

Custodial Services include but are not limited to:

services related to watching or protecting a person;

services related to performing or assisting a person

in performing any activities of daily living, such as:

a) walking, b) grooming, c) bathing, d) dressing,

e) getting in or out of bed, f) toileting, g) eating, h)

preparing foods, or i) taking medications that can

be self-administered, and

services not required to be performed by trained or

skilled medical or paramedical personnel.

Days

Calendar days; not 24 hour periods unless otherwise

expressly stated.

Deductible

See Plan Deductible.

Dependent

An individual in the Subscriber's family who is enrolled

as a Member under this Agreement. You must meet the

Dependent eligibility requirements in "Section II.

Enrollment and Effective Date of Coverage" to be

eligible to enroll as a Dependent.

Emergency Services

Emergency Services are defined in "Section IV.

Covered Services and Supplies."

Enrollment Application

The enrollment process that must be completed by an

eligible individual in order for coverage to become

effective.

Essential Health Benefits

Means, to the extent covered under the plan, expenses

incurred with respect to covered services, in at least

the following categories: ambulatory patient services,

emergency services, hospitalization, maternity and

newborn care, mental health and substance use disorder

services, including behavioral health treatment,

prescription drugs, rehabilitative and habilitative

services and devices, laboratory services, preventive

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I. Definitions of Terms Used

in This Group Service Agreement

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and wellness services and chronic disease management

and pediatric services, including oral and vision care.

Face Sheet

The part of this Agreement that contains certain

provisions affecting the relationship between the

Healthplan and the Group. You can get a copy of the

Face Sheet from the Group.

Group

The employer, labor union, trust, association,

partnership, government entity, or other organization

listed on the Face Sheet to this Agreement which enters

into this Agreement and acts on behalf of Subscribers

and Dependents who are enrolled as Members in the

Healthplan.

Healthplan

The Cigna HealthCare health maintenance organization

(HMO) which is organized under applicable law and

is listed on the Face Sheet to this Agreement. Also

referred to as "we", "us" or "our".

Healthplan Medical Director

A Physician charged by the Healthplan to assist in

managing the quality of the medical care provided by

Participating Providers in the Healthplan; or designee.

Medical Services

Professional services of Physicians or Other

Participating Health Professionals (except as limited

or excluded by this Agreement), including medical,

psychiatric, surgical, diagnostic, therapeutic, and

preventive services.

Medically Necessary/Medical Necessity

Medically Necessary Covered Services and Supplies

are those determined by the Healthplan Medical

Director to be:

required to diagnose or treat an illness, injury,

disease or its symptoms; and

in accordance with generally accepted standards of

medical practice; and

clinically appropriate in terms of type, frequency,

extent, site and duration; and

not primarily for the convenience of the patient,

Physician, or other health care provider; and

not more costly than an alternative service(s),

medication(s) or supply(ies) that is at least as likely

to produce equivalent therapeutic or diagnostic

results with the same safety profile as to the

prevention, evaluation, diagnosis or treatment

of your sickness, injury, condition, disease or its

symptoms; and

rendered in the least intensive setting that is

appropriate for the delivery of the services and

supplies. Where applicable, the Healthplan Medical

Director may compare the cost-effectiveness of

alternative services, settings or supplies when

determining the least intensive setting.

In determining whether health care services,

supplies, or medications are Medically Necessary, the

HealthPlan Medical Director or Review Organization

may rely on the clinical coverage policies maintained

by the Healthplan or the Review Organization. Clinical

coverage policies may incorporate, without limitation

and as applicable, criteria relating to U.S. Food and

Drug Administration-approved labeling, the standard

medical reference compendia and peer-reviewed,

evidence-based scientific literature or guidelines.

Member

An individual meeting the eligibility criteria as

a Subscriber or a Dependent who is enrolled for

Healthplan coverage and for whom all required

Prepayment Fees have been received by the

Healthplan. Also referred to as "you" or "your".

Membership Unit

The unit of Members made up of the Subscriber and his

or her Dependent(s).

Open Enrollment Period

The period of time established by the Healthplan

and the Group as the time when Subscribers and

their Dependents may enroll for coverage. The Open

Enrollment Period occurs at least once every Contract

Year.

Other Participating Health Care Facility

Other Participating Health Care Facilities are any

facilities other than a Participating Hospital or hospice

facility that is operated by or has an agreement to

render services to Members. Examples of Other

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I. Definitions of Terms Used

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Participating Health Care Facilities include, but are

not limited to, licensed skilled nursing facilities,

rehabilitation hospitals and sub-acute facilities.

Other Participating Health Professional

An individual other than a Physician who is licensed

or otherwise authorized under the applicable state law

to deliver Medical Services and who has an agreement

with the Healthplan to provide Covered Services and

Supplies to Members. Other Participating Health

Professionals include, but are not limited to physical

therapists, registered nurses and licensed practical

nurses.

Participating Hospital

An institution licensed as an acute care hospital under

the applicable state law, which has an agreement to

provide hospital services to Members.

Participating Physician

A Primary Care Physician (PCP) or other Physician

who has an agreement to provide Medical Services to

Members.

Participating Provider

Participating Providers are Participating Hospitals,

Participating Physicians, Other Participating Health

Professionals, and Other Participating Health Care

Facilities.

Patient Protection and Affordable Care Act of 2010

Means the Patient Protection and Affordable Care

Act of 2010 (Public Law 111-148) as amended by the

Health Care and Education Reconciliation Act of 2010

(Public Law 111-152).

Physician

An individual who is qualified to practice medicine

under the applicable state law (or a partnership or

professional association of such people) and who is

a licensed Doctor of Medicine (M.D.) or Doctor of

Osteopathy (D.O.).

Plan Deductible

The Plan Deductible includes Covered Services and

Supplies to be paid by you or your Dependent before

benefits are payable under this plan. Deductibles are

in addition to any Coinsurance. Once the Deductible

maximum in The Schedule has been reached, you

and your family need not satisfy any further medical

deductible for the rest of that year.

The Individual Deductible is the amount you are

responsible for paying out-of-pocket, each Contract

Year, for covered Prescription Drugs Products (as

identified in the Supplemental Prescription Drug Rider)

and Covered Services and Supplies (as identified in the

Group Service Agreement).

You must meet your Individual Deductible before the

Healthplan begins to pay the cost associated with your

coverage.

However, when the amount paid by individuals in your

Membership Unit to meet their Individual Deductibles

equals the Family Deductible amount, all Members in

the Membership Unit will be considered to have met

their Individual Deductible for that Contract Year.

Prepayment Fee

The sum of money paid to the Healthplan by the Group

in order for you to receive the Services and Supplies

covered by this Agreement.

Primary Care Physician (PCP)

A Physician who practices general medicine, family

medicine, internal medicine or pediatrics who, through

an agreement with the Healthplan, provides basic

health care services to you if you have chosen him as

your Primary Care Physician (PCP). Your Primary Care

Physician (PCP) also arranges specialized services for

you.

Primary Plan

The Plan that determines and provides or pays its

benefits without taking into consideration the existence

of any other Plan.

Prior Authorization

The approval a Participating Provider must receive

from the Healthplan Medical Director, prior to services

being rendered, in order for certain Services and

Supplies to be covered under this Agreement.

Qualified Medical Child Support Order

A Qualified Medical Child Support Order is a

judgment, decree or order (including approval of

a settlement agreement) or administrative notice,

which is issued pursuant to a state domestic relations

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I. Definitions of Terms Used

in This Group Service Agreement

law (including a community property law), or to

an administrative process, which provides for child

support or provides for health benefit coverage to such

child and relates to benefits under the group health

plan, and satisfies all of the following:

the order recognizes or creates a child's right

to receive group health benefits for which a

participant or beneficiary is eligible;

the order specifies your name and last known

address, and the child's name and last known

address, except that the name and address of an

official of a state or political subdivision may be

substituted for the child's mailing address;

the order provides a description of the coverage

to be provided, or the manner in which the type of

coverage is to be determined;

the order states the period to which it applies; and

if the order is a National Medical Support Notice

completed in accordance with the Child Support

Performance and Incentive Act of 1998, such

notice meets the requirement above.

Referral

The approval you must receive from your PCP in

order for the services of a Participating Provider, other

than the PCP, or participating OB/GYN, chiropractic

Physician to be covered.

Review Organization

The term Review Organization refers to an affiliate of

the Healthplan or another entity to which the

Healthplan has delegated responsibility for performing

utilization review services. The Review Organization

is an organization with a staff of clinicians which

may include Physicians, Registered Graduate Nurses,

licensed mental health and substance use disorder

professionals, and other trained staff members who

perform utilization review services.

Rider

An addendum to this Agreement between the Group

and the Healthplan.

Schedule of Copayments

The section of this Agreement that identifies applicable

Copayments and maximums.

Service Area

The geographic area, as described in the Provider

Directory applicable to your plan, where the Healthplan

is authorized to provide services.

Stabilize

Means, with respect to an emergency medical

condition, to provide medical treatment as

necessary to assure that no material deterioration of

the condition is likely if the individual is transferred

from a facility, or with respect to a pregnant woman who is

having contractions, to deliver.

Subscriber

An employee, retiree or a participant in the Group

who is enrolled as a Member under this Agreement.

You must meet the requirements contained in "Section

II. Enrollment and Effective Date of Coverage" to be

eligible to enroll as a Subscriber.

Total Copayment Maximums

The total amount of Copayments that an individual

Member or Membership Unit must pay within a

Contract Year. When the individual Member or

Membership Unit has paid applicable Copayments

up to the Total Copayment Maximums, that Member

or Membership Unit will not be required to pay

Copayments for those Services and Supplies for the

remainder of the Contract Year. It is the Subscriber's

responsibility to maintain a record of Copayments

which have been paid and to inform the Healthplan

when the amount reaches the Total Copayment

Maximums. The Total Copayment Maximums and the

Copayments that apply toward these maximums are

identified in the Schedule of Copayments.

Urgent Care

Urgent Care is defined in "Section IV. Covered

Services and Supplies."

We/Us/Our

Cigna HealthCare Inc.

You/Your

The Subscriber and/or any of his or her Dependents.

GSA-DEF(01)-F 1/20

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II. Enrollment and Effective Date of Coverage

Section II. Enrollment and Effective Date of

Coverage

Who Can Enroll as a Member

To be eligible for covered Services and Supplies you

must be enrolled as a Member. To be eligible to enroll

as a Member you must meet either the Subscriber or

Dependent eligibility criteria listed below. You must

also meet and continue to meet the Group-specific

enrollment and eligibility rules on the Face Sheet.

A. To be eligible to enroll as a Subscriber, you must:

1 be an employee of the Group or a participant in

the Group; and

2. reside or work in the Service Area; and

3. meet and continue to meet these criteria.

B. To be eligible to enroll as a Dependent, you must:

1. be the Subscriber's lawful spouse of same or

opposite sex and you must reside in the Service

Area; or

2. be the natural child, step-child, or adopted child

of the Subscriber; or the child for whom the

Subscriber is the legal guardian, or the child

legally placed with the Subscriber for adoption,

or supported pursuant to a court order imposed

on the Subscriber (including a qualified medical

child support order), provided that the child.

a. resides in the Service Area (unless the child

is a full-time registered student outside the

Service Area) and

i. has not yet reached age twenty-six (26);

ii. the child is twenty-six (26) or older

and continuously incapable of

self-sustaining support because of

intellectual disabilities or a physical

handicap which existed prior to

attaining twenty-six (26) years of age

and became mentally or physically

handicapped prior to the age at which

Dependent coverage would otherwise

terminate under this Agreement. If the

child became mentally or physically

handicapped while covered under this

Agreement you may be required to

submit proof of the child's condition

and dependence within thirty-one

(31) days after the date the child

ceases to qualify as a Dependent under

subsection (i) and (ii) above or upon

enrollment if the handicap existed prior

to enrollment. You may be required,

from time to time during the next

two (2) years, to provide proof of the

continuation of the child's condition

and dependence. Thereafter, you may

be required to provide such proof only

once a year.

A Subscriber's grandchild is not eligible for

coverage unless the grandchild meets the

eligibility criteria for a Dependent.

A child born of a Member, when that Member

is acting as a surrogate parent, is not eligible for

coverage.

Anyone who is eligible as an employee will

not be considered as a Dependent spouse. A

child under age 26 may be covered as either an

employee or as a Dependent child. You cannot

be covered as an employee while also covered

as a Dependent of a Subscriber.

GSA-ENRL(01)-E 1/17

C. To be eligible to enroll as a domestic partner, you

must be a person of the same or opposite sex

who:

1. shares a permanent residence with the

Subscriber;

2. has resided with the Subscriber for not less than

one year;

3. is at least eighteen years of age;

4. is financially interdependent with

the Subscriber and have proven such

interdependence by providing documentation of

at least two (2) of the following arrangements:

a. common ownership of real property or

a common leasehold interest in such

property;

b. common ownership of a motor vehicle;

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II. Enrollment and Effective Date of Coverage

c. a joint bank account or a joint credit

account;

d. designation as a beneficiary for life

insurance or retirement benefits or under

the Subscriber's last will and testament;

e. assignments of a durable power of attorney

or health care power of attorney; or

f. such other proof as is considered by the

Healthplan to be sufficient to establish

financial interdependency under the

circumstances of a particular case.

5. is not a blood relative any closer than would

prohibit legal marriage;

6. has signed jointly with the Subscriber a

notarized affidavit in form and content which

is satisfactory to the Healthplan and make this

affidavit available to the Healthplan; and

7. has registered with the Subscriber as domestic

partners if you reside in a state that provides for

such registration.

You are not eligible to enroll as a domestic

partner if either you or the Subscriber has signed

a domestic partner affidavit or declaration with

any other person within twelve months prior to

designating each other as domestic partners under

this Agreement; are currently legally married to

another person; or have any other domestic partner,

spouse or spouse equivalent of the same or opposite

sex.

An eligible domestic partner's children who meet

the Dependent eligibility requirements in "Section

II. Enrollment and Effective Date of Coverage" are

also eligible to enroll.

The "Continuation of Group Coverage under

COBRA" section of this Agreement does not apply

to the Subscriber's domestic partner and his or her

Dependents.

GSA-ENRL(02)-B 6/04

Enrollment and Effective Date of Coverage

A. Enrollment during an Open Enrollment Period

If you meet the Subscriber or Dependent eligibility

criteria, you may enroll as a Member during

the Open Enrollment Period by submitting a

completed Enrollment Application, together with

any applicable fees, to the Group.

If enrolled during the Open Enrollment Period,

your effective date of coverage is the first day of

the Contract Year.

B. Enrollment after an Open Enrollment Period

1. If, after the Open Enrollment Period, you

become eligible for coverage as a Subscriber

or a Dependent, you may enroll as a Member

within thirty-one (31) days of the day on which

you met the eligibility criteria. To enroll,

you must submit an Enrollment Application,

together with any additional fees due, to the

Group. If so enrolled, your effective date of

coverage will be the day on which you meet the

eligibility criteria.

If you do not enroll within the thirty-one (31)

days, your next opportunity to enroll will be

during the next Open Enrollment Period.

2. If you are a Subscriber who is enrolled as a

Member, you may enroll a newborn child prior

to the birth of the child or within thirty-one

(31) days after the child's birth. To enroll a

newborn child, you must submit an Enrollment

Application, together with any additional fees

due, to the Group. If so enrolled, the effective

date of coverage for your newborn child will be

the date of his or her birth.

If you do not enroll a newborn child within the

thirty-one (31) days, your next opportunity to

enroll the child will be during the next Open

Enrollment Period.

3. If you are a Subscriber who is enrolled as a

Member, you may enroll an adopted child or

child for whom you have been granted legal

guardianship within thirty-one (31) days of

the date the child is legally placed with you

for adoption or within thirty-one (31) days of

the date you are granted legal guardianship.

To enroll an adopted child or a child for whom

you are the legal guardian, you must submit

an Enrollment Application, together with any

additional fees due, to the Group. If so enrolled,

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II. Enrollment and Effective Date of Coverage

the effective date of coverage for your child

will be the date of legal placement of the child

for adoption or the date of court ordered legal

guardianship.

If you do not enroll an adopted child or a child

for whom you are legal guardian within the

thirty-one (31) days, your next opportunity to

enroll the child will be during the next Open

Enrollment Period.

C. Full and Accurate Completion of Enrollment

Application

Each Subscriber must fully and accurately complete

the Enrollment Application. False, incomplete

or misrepresented information provided in any

Enrollment Application may, in the Healthplan's

sole discretion, cause the coverage of the

Subscriber and/or his or her Dependents to be null

and void from its inception.

D. Hospitalization on the Effective Date of

Coverage

If you are confined in a hospital on the effective

date of your coverage, you must notify us of such

a hospitalization within two (2) days, or as soon as

reasonably possible thereafter. When you become

a Member of the Healthplan, you agree to permit

the Healthplan to assume direct coordination of

your health care. We reserve the right to transfer

you to the care of a Participating Provider and/or

Participating Hospital if the Healthplan Medical

Director, in consultation with your attending

Physician, determines that it is medically safe to do

so.

If you are hospitalized on the effective date of

coverage and you fail to notify us of this

hospitalization, refuse to permit us to coordinate

your care, or refuse to be transferred to the care of

a Participating Provider or Participating Hospital,

we will not be obligated to pay for any medical

or hospital expenses that are related to your

hospitalization following the first two (2) days after

your coverage begins.

E. To be eligible to enroll as a Member, you must:

1. never have been terminated as a Member of

any Cigna HealthCare Healthplan for any of

the reasons explained in the "Section VII.

Termination of Your Coverage" and

2. not have any unpaid financial obligations to

the Healthplan or any other Cigna HealthCare

Healthplan.

GSA-ENRL(03) 4/09

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III. Agreement Provisions

Section III. Agreement Provisions

A. Healthplan's Representations and Disclosures

1. The Healthplan is a for-profit health maintenance

organization (HMO) which arranges for the

provision of covered Services and Supplies

through a network of Participating Providers. The

list of Participating Providers is provided to all

Members at enrollment without charge. If you

would like another list of Participating Providers,

please contact Member Services at the toll-free

number found on your Cigna HealthCare ID card

or visit the Cigna HealthCare web site at

myCigna.com.

2. With the exception of any employed Physicians

who work in a facility operated by the

Healthplan (so-called "staff model" providers),

the Participating Providers are independent

contractors. They are not the agents or

employees of the Healthplan and they are not

under the control of the Healthplan or any Cigna

company. All Participating Providers are

required to exercise their independent medical

judgment when providing care.

3. The Healthplan maintains all medical information

concerning a Member as confidential in

accordance with applicable laws and professional

codes of ethics. A copy of the Healthplan's

confidentiality policy is available upon request.

4. We do not restrict communication between

Participating Providers and Members

regarding treatment options.

5. Under federal law (the Patient Self Determination

Act), you may execute advance directives, such as

living wills or a durable power of attorney for health

care, which permit you to state your wishes regarding

your health care should you become incapacitated.

6. Upon your admission to a participating inpatient

facility, a Participating Physician other than your

PCP may be asked to direct and oversee your care

for as long as you are in the inpatient facility.

This Participating Physician is often referred to as

an "inpatient manager" or "hospitalist."

7. The terms of this Agreement may be changed in

the future either as a result of an amendment

agreed upon by the Healthplan and the Group or to

comply with changes in law. The Group or the

Healthplan may terminate this Agreement as

specified in this Agreement. In addition, the Group

reserves the right to discontinue offering any plan

of coverage.

8. Choosing a Primary Care Physician

When you enroll as a Member, you must choose a

Primary Care Physician (PCP). Each covered

Member of your family must also choose a PCP.

Your PCP is your personal doctor and serves as your

health care manager. If you do not select a

PCP, we will assign one for you. If your PCP leaves the

Cigna HealthCare network, you will be able to choose a

new PCP. You may voluntarily change your PCP for

other reasons but not more than once in any calendar

month. We reserve the right to determine the number of

times during a Contract Year that you will be allowed to

change your PCP.

If you select a new PCP before the fifteenth day of the

month, the designation will be effective on the first

day of the month following your selection. If you

select a new PCP on or after the fifteenth

day of the month, the designation will be effective on

the first day of the month following the next full

month. For example, if you notify us on June

10, the change will be effective on July 1. If you notify

us on June 15, the change will be effective on August

Your choice of a PCP may affect the specialists

and facilities from which you may receive services.

Your choice of a specialist may be limited to specialists

in your PCP's medical group or network. Therefore,

you may not have access to every specialist or

Participating Provider in your Service Area. Before you

select a PCP, you should check

to see if that PCP is associated with the specialist or

facility you prefer to use. If the Referral is not possible,

you should ask the specialist or facility about which

PCPs can make Referrals to them, and then verify the

information with the PCP before making your

selection.

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III. Agreement Provisions

9. Referrals to Specialists

You must obtain a Referral from your PCP before

visiting any provider other than your PCP in order for

the visit to be covered. The Referral authorizes the

specific number of visits that you may make to a

provider within a specified period of time. If you

receive treatment from a provider other than your PCP

without a Referral from your PCP, the treatment is not

covered.

Exceptions to the Referral Process:

If you are a female Member, you may visit a

qualified Participating Provider for covered

obstetrical and gynecological services, as defined

in "Section IV. Covered Services and Supplies,"

without a Referral from your PCP.

You do not need a Referral from your PCP for

Emergency Services as defined in the "Section IV.

Covered Services and Supplies." In the event of an

emergency, get help immediately. Go to the nearest

emergency room, the nearest hospital or call or ask

someone to call 911 or your local emergency

service, police or fire department for help. You do

not need a Referral from your PCP for Emergency

Services, but you do need to call your PCP as soon

as possible for further assistance and advice on

follow-up care. If you require specialty care or a

hospital admission, your PCP will coordinate it and

handle the necessary authorizations for care or

hospitalization.

In an emergency, you should seek immediate

medical attention and then as soon as possible

thereafter you need to call your PCP for further

assistance and advice on follow-up care. If you

require specialty care or a hospital admission, your

PCP will coordinate it and handle the necessary

authorization for care or hospitalization.

In an Urgent Care situation a Referral is not

required but you should, whenever possible, contact

your PCP for direction prior to receiving services.

You may also visit a qualified Participating

Provider for covered Chiropractic Care Services,

as defined in "Section IV. Covered Services and

Supplies", without a Referral from your PCP.

Direct Access for Mental Health and Substance

Use Disorder Services

Members covered by this Agreement are allowed

direct access to a licensed/certified Participating

Provider for covered Mental Health and Substance

Use Disorder Services. There is no requirement to

obtain a referral from your Primary Care Physician

for individual or group therapy visits to the

Participating Provider of your choice for Mental

Health and Substance Use Disorder Services.

10. Provider Compensation

We compensate our Participating Providers in ways

that are intended to emphasize preventive care,

promote quality of care, and assure the most

appropriate use of Medical Services. You can discuss

with your provider how he is compensated by us. The

methods we use to compensate Participating Providers

are:

Discounted fee for service - payment for service is

based on an agreed upon discounted amount for the

services provided.

Capitation - Physicians, provider groups and

Physician/hospital organizations are paid a fixed

amount at regular intervals for each Member

assigned to the Physician, provider group or

Physician/hospital organization, whether or

not services are provided. This payment covers

Physician and/or, where applicable, hospital or

other services covered under the benefit plan.

Medical groups and Physician/hospital

organizations may in turn compensate providers

using a variety of methods.

Capitation offers health care providers a predictable

income, encourages Physicians to keep people well

through preventive care, eliminates the financial

incentive to provide services that will not benefit

the patient, and reduces paperwork.

Providers paid on a "capitated" basis may participate

with us in a risk sharing arrangement. They agree

upon a target amount for the cost of certain health

care services, and they share all

or some of the amount by which actual costs are

over target. Provider services are monitored for

appropriate utilization, accessibility, quality and

Member satisfaction.

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We may also work with third parties who administer

payments to Participating Providers. Under these

arrangements, we pay the third party a fixed monthly

amount for these services. Providers are compensated

by the third party for servicesprovided to Healthplan

participants from the fixed amount. The compensation

varies based on overall utilization.

Salary - Physicians and other providers who are

employed to work in our medical facilities are

paid a salary. The compensation is based on a

dollar amount, decided in advance each year, that

is guaranteed regardless of the services provided.

Physicians are eligible for any annual bonus

based on quality of care, quality of service and

appropriate use of Medical Services.

Incentives to Participating Providers

Cigna continuously develops programs to help you

access quality, cost-effective health care. Some

programs include Participating Providers receiving

financial incentives from Cigna Healthplan for

providing care to you in a way that meets or

exceeds certain quality and/or cost-efficiency

standards, when, in the Participating Provider’s

professional judgment, it is appropriate to do so

within the applicable standard of care. For

example, some Participating Providers could

receive financial incentives for prescribing lower-

cost prescription drugs to manage certain

conditions, utilizing or referring you to alternative

sites of care as determined by the plan rather than

in a more expensive setting, or achieving particular

outcomes for certain health

conditions. Participating Providers may also

receive purchasing discounts when purchasing

certain prescription drugs from Cigna Healhplan

affiliates. Such programs can help make you

healthier, decrease your health care costs, or

both. These programs are not intended to affect

your access to the health care that you need. We

encourage you to talk to your Participating Provider

if you have questions about whether they receive

financial incentives from Cigna Healthplan and

whether those incentives apply to your care.

Per Diem - A specific amount is paid to a hospital

per day for all health care received. The payment

may vary by type of service and length of stay.

Case Rate - A specific amount is paid for all the

care received in the hospital for each standard

service category as specified in our contract with

the provider (e.g., for a normal maternity delivery).

GSA-PROV(01)-C 1/16

11. Care Management and Care Coordination

Services

Your plan may enter into specific collaborative

arrangements with health care professionals

committed to improving quality care, patient

satisfaction and affordability. Through these

collaborative arrangements, health care

professionals commit to proactively providing

participants with certain care management and care

coordination services to facilitate achievement of

these goals. Reimbursement is provided at 100%

for these services when rendered by designated

health care professionals in these collaborative

arrangements.

Services may include, but are not limited to:

professional-to-professional consultations, outreach

to patients, care coordination, and other services

intended to achieve improved health outcomes.

GSA-PROV(01).2 1/16

B. Member's Rights, Responsibilities and

Representations

You have the right to:

1. Medical treatment that is available when you need

it and is handled in a way that respects your

privacy and dignity.

2. Get the information you need about your health

care plan, including information about services

that are covered, services that are not covered, and

any costs that you will be responsible for paying.

3. Have access to a current list of providers in

our network and have access to information

about a particular provider's education,

training and practice.

4. Select a Primary Care Physician (PCP) for

yourself and each covered Member of your family,

and to change your PCP for any reason.

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5. Have your medical information kept

confidential by our employees and your health

care provider. Confidentiality laws and

professional rules of behavior allow us to

release medical information only when it's

required for your care, required

by law, necessary for the administration of

your plan or to support our programs or

operations that evaluate quality and service.

We may also summarize information in reports

that do not identify you or any other

participants specifically.

6. Have your health care provider give you

information about your medical condition and

your treatment options, regardless of benefit

coverage or cost. You have the right to receive this

information in terms you understand.

7. Learn about any care you receive. You should be

asked for your consent to all care unless there is

an emergency and your life and health are in

serious danger.

8. Refuse medical care. If you refuse medical

care, your health care provider should tell you

what might happen. We urge you to discuss

your concerns about care with your PCP or

another Participating Physician. Your doctor

will give you advice, but you will always have

the final decision.

9. Be heard. Our complaint-handling process is

designed to hear and act on your complaint or

concern about us and/or the quality of care you

receive, provide a courteous, prompt response, and

to guide you through our appeals process if you do

not agree with our decision.

10. Make recommendations regarding our policies on

Member rights and responsibilities. If you have

recommendations, please contact Member Services

at the toll-free number on your Cigna HealthCare

ID card.

You have the responsibility to:

1. Review and understand the information you receive

about your health care plan. Please call Cigna

HealthCare Member Services when you have

questions or concerns.

2. Understand how to obtain covered Services and

Supplies that are provided under your plan.

3. Show your Cigna HealthCare ID card before you

receive care.

4. Schedule a new patient appointment with any new

Cigna HealthCare PCP; build a comfortable relationship

with your doctor; ask questions about things you don't

understand; and follow your doctor's advice. You should

also understand that your condition may not improve

and may even get worse if you don't follow your

doctor's advice.

5. Understand your health condition and work with your

doctor to develop treatment goals that you both agree

upon, to the extent that this is possible.

6. Provide honest, complete information to the

providers caring for you.

7. Know what medicine you take, why, and how to take

it.

8. Pay all Copayments for which you are responsible at

the time the service is received.

9. Keep scheduled appointments and notify the doctor's

office ahead of time if you are going to be late or miss

an appointment.

10. Pay all charges for missed appointments and for

services that are not covered by your plan.

11. Voice your opinions, concerns or complaints to

Cigna HealthCare Member Services and/or your

provider.

12. Notify your employer as soon as possible about any

changes in family size, address, phone number or

membership status.

You represent that:

1. The information provided to us and the Group in

the Enrollment Application is complete and

accurate.

2. By enrolling in the Healthplan, you accept and

agree to all terms and conditions of this Agreement.

3. By presenting your Cigna HealthCare ID card and

receiving treatment and services from our Participating

Providers, you authorize the following to the extent

allowed by law:

a. any provider to provide us with information and

copies of any records related to your condition and

treatment;

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III. Agreement Provisions

b. any person or entity having confidential

information to provide any such confidential

information upon request to us, any

Participating Provider, and any other provider

or entity performing a service, for the purpose

of administration of the plan, the performance

of any Healthplan program or operations,

or assessing or facilitating quality and

accessibility of health care Services and

Supplies;

c. us to disclose confidential information to any

persons, company or entity to the extent we

determine that such disclosure is necessary or

appropriate for the administration of the plan,

the performance of the Healthplan programs

or operations, assessing or facilitating quality

and accessibility of health care Services and

Supplies, or reporting to third parties involved

in plan administration; and

d. that payment be made under Part B of Medicare

to us for medical and other services furnished to

you for which we pay or have paid, if

applicable.

This authorization will remain in effect until

you send us a written notice revoking it or for

such shorter period as required by law. Until

revoked, we and other parties may rely upon

this authorization.

With respect to Members, confidential

information includes any medical, dental,

mental health, substance use disorder,

communicable disease, AIDS and HIV related

information and disability or employment

related information.

4. You will not seek treatment as a Cigna

HealthCare Member once your eligibility for

coverage under this Agreement has ceased.

GSA-PROV(02)-A

1/16

C. When You Have a Complaint or an Appeal

(For the purposes of this section, any reference to

"you", "your" or "Member" also refers to a

representative or provider designated by you to act

on your behalf, unless otherwise noted.)

We want you to be completely satisfied with the care you

receive. That's why we've established a process for

addressing your concerns and solving your problems.

Start with Customer Service

We're here to listen and help. If you have a concern

regarding a person, a service, the quality of care, or

contractual benefits, or a rescission of coverage, you can

call us at our toll-free number and explain your concern

to one of our Customer Services representatives. You

can also express that concern in writing. Please call or

write to us at the following:

Healthplan Name

Healthplan Address

Customer Services Toll-Free Number

that appears on your Cigna

HealthCare ID card or Benefit

Identification card.

We'll do our best to resolve the matter on your initial

contact. If we need more time to review or investigate your

concern, we'll get back to you as soon as possible, but in any

case within thirty (30) days.

If you are not satisfied with the results of a coverage

decision, you can start the appeals procedure.

Appeals Procedure

Any external review process available under the plan will

apply to any adverse determination regarding claims

subject to the federal No Surprises Act.

The Healthplan has a two step appeals procedure for

coverage decisions. To initiate an appeal for most claims,

you must submit a request for an appeal at the address

shown above within 365 days of receipt of a denial notice.

If you appeal a reduction or termination in coverage for an

ongoing course of treatment that the Healthplan has

previously approved, you will receive, as required by

applicable law, continued coverage pending the outcome of

an appeal. You should state the reason why you feel your

appeal should be approved and include any information

supporting your appeal. You should state the reason why

you feel your appeal should be approved and include any

information supporting your appeal. If you are unable or

choose not to write, you may ask to register your appeal by

calling the toll-free number on your Cigna HealthCare ID

card or Benefit Identification card.

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III. Agreement Provisions

Level One Appeal

Your appeal will be reviewed and the decision made by

someone not involved in the initial decision. Appeals

involving Medical Necessity or clinical appropriateness

will be considered by a health care professional.

For level one appeals, we will respond in writing with a

decision within fifteen (15) calendar days after we receive

the appeal for a pre-service or concurrent coverage

determination, and within thirty (30) calendar days after

we receive an appeal for a post-service coverage

determination. If more time or information

is needed to make the determination, we will notify you in

writing to request an extension of up to fifteen calendar

days and to specify any additional information needed to

complete the review.

You may request that the appeal process be expedited if

the time frames under this process would seriously

jeopardize your life, health or ability to regain maximum

functionality or in the opinion of your physician would

cause you severe pain which cannot be managed without

the requested services.

If you request that your appeal be expedited, you may also

ask for an expedited external Independent Review at the

same time, if the time to complete an expeditedlevel-one

appeal would be detrimental to your medical condition.

The Healthplan Medical Director, in consultation with the

treating Physician, will decide if an expedited appeal is

necessary. When an appeal is expedited, we will respond

orally with a decision within seventy-two (72) hours,

followed up in writing.

Level Two Appeal

If you are dissatisfied with our level one appeal decision, you

may request a second review. To initiate a level two appeal,

follow the same process required for a level one appeal.

If the appeal involves a coverage decision based on issues

of Medical Necessity, clinical appropriateness or

experimental treatment, a medical review will be

conducted by a Physician reviewer in the same or similar

specialty as the care under consideration, as determined

by the Healthplan Medical Director. For all other

coverage plan-related appeals, a second-level review will

be conducted by someone who was a)

not involved in any previous decision related to your

appeal, and b) not a subordinate of previous decision

makers. Provide all relevant documentation with your

second-level appeal request.

For required pre-service and concurrent care coverage

determinations the Healthplan's review will be completed

within fifteen (15) calendar days and for post-service

claims, the Healthplan's review will be completed within

thirty (30) calendar days.

If more time or information is needed to make the

determination, we will notify you in writing to request an

extension of up to fifteen (15) calendar days and to specify

any additional information needed, to complete the review.

In the event any new or additional information

(evidence) is considered, relied upon or generated by the

Healthplan in connection with the level-two appeal, the

Healthplan will provide this information to you as soon

as possible and sufficiently in advance of the decision, so

that you will have an opportunity to respond. Also, if any

new or additional rationale is considered by the

Healthplan, the Healthplan will provide the rational to

you as soon as possible and sufficiently in advance of the

decision so that you will have an opportunity to respond.

You will be notified in writing of the decision within five

(5) business days after the decision is made, and within

the review time frames above if the Healthplan does not

approve the requested coverage.

You may request that the appeal process be expedited if,

(a) the time frames under this process would seriously

jeopardize your life, health or ability to regain maximum

functionality or in the opinion of your physician would

cause you severe pain which cannot be managed without

the requested services; or (b) your appeal involves non-

authorization of an admission of continuing inpatient

hospital stay. The Healthplan Medical Director, in

consultation with the treating Physician, will decide if an

expedited appeal is necessary. When an appeal is

expedited, we will

respond orally with a decision within seventy-two (72)

hours, followed up in writing.

GSA-PROV(03)-B 01/20

Independent Review Procedure

If you are not fully satisfied with the decision of the

Healthplan's level two appeal review regarding your

Medical Necessity or clinical appropriateness issue, you

may request that your appeal be referred to an

Independent Review Organization. The Independent

Review Organization is composed of persons who are

not employed by Cigna HealthCare or any of

its affiliates. A decision to request an appeal to an

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III. Agreement Provisions

Independent Review Organization will not affect the

claimant's rights to any other benefits under the plan.

There is no charge for you to initiate this independent

review process. The Healthplan will abide by the

decision of the Independent Review Organization.

In order to request a referral to an Independent Review

Organization, certain conditions apply. The reason for

the denial must be based on a Medical Necessity or

clinical appropriateness determination by the

Healthplan. Administrative, eligibility or benefit

coverage limits or exclusions are not eligible for

appeal under this process.

To request a review, you must notify the Appeals

Coordinator within 180 (one hundred eighty) days of

your receipt of the Healthplan level two appeal review

denial. The Healthplan will then forward the file to the

Independent Review Organization.

The Independent Review Organization will render an

opinion within 45 days. When requested and if (a) a delay

would be detrimental to your medical condition, as

determined by The Healthplan Medical Director, or

if (b) your appeal concerns an admission, availability of

care, continued stay, or health care item or service for

which you received emergency services, but you have not

yet been discharged from a facility, the review shall be

completed within 72 hours.

Assistance from the State of State Name

You have the right to contact the Department of

Insurance/Health Name for assistance at any time. The

Regulator Name may be contacted at the following

address and telephone number:

Department of Insurance/Health Name Department of

Insurance/Health Address Department of

Insurance/Health Toll Free Number

Notice of Benefit Determination on Appeal

Every notice of a determination on appeal will be

provided in writing or electronically and will include:

(1) information sufficient to identify the claim; (2) the

specific reason or reasons for the adverse

determination; (3) reference to the specific plan

provisions on which the determination is based; (4) a

statement that the claimant is entitled to receive, upon

request and free of charge, reasonable access to and

copies of all documents, records, and other Relevant

Information as defined; (5) a statement describing any

voluntary appeal procedures offered by the plan and the

claimant's right to bring an action under ERISA section

502(a); (6) upon request and free of charge, a copy of any

internal rule, guideline, protocol or other similar criterion

that was relied upon in making the adverse determination

regarding your appeal, and an explanation of the scientific

or clinical judgment for a determination that is based on a

medical necessity, experimental treatment or other similar

exclusion or limit; and (7) information about any office of

health insurance consumer assistance or ombudsman

available to assist you in the appeal process. A final notice

of an adverse determination will include a discussion of

the decision.

You also have the right to bring a civil action under

Section 502(a) of ERISA if you are not satisfied with the

decision on review. You or your plan may have other

voluntary alternative dispute resolution options such as

Mediation. One way to find out what may be available is

to contact your local U.S. Department of Labor office

and your State insurance regulatory agency. You may

also contact the Plan Administrator.

Relevant Information

Relevant Information is any document, record, or other

information which (a) was relied upon in making the

benefit determination; (b) was submitted, considered, or

generated in the course of making the benefit

determination, without regard to whether such

document, record, or other information was relied upon

in making the benefit determination; (c) demonstrates

compliance with the administrative processes and

safeguards required by federal law in making the

benefit determination; or (d) constitutes a statement of

policy or guidance with respect to the plan concerning the

denied treatment option or benefit for the claimant's

diagnosis, without regard to whether such advice

or statement was relied upon in making the benefit

determination.

Legal Action

If your plan is governed by ERISA, you have the right to

bring a civil action under Section 502(a) of ERISA if you

are not satisfied with the outcome of the Appeals

Procedure. In most instances, you may not initiate a legal

action against the Healthplan until you have completed the

Level One and Level Two Appeal processes. If your

Appeal is expedited, there is no need to complete the Level

Two process prior to bringing legal action.

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III. Agreement Provisions

Appointment of Authorized Representative

You may appoint an authorized representative to assist

you in submitting a claim or appealing a claim denial.

However, the Healthplan may require you to designate

your authorized representative in writing using a form

approved by the Healthplan. At all times, the appointment

of an authorized representative is revocable by you. To

ensure that a prior appointment remains valid, the

Healthplan may require you to re- appoint your authorized

representative, from time to time.

The Healthplan reserves the right to refuse to honor the

appointment of a representative if the Healthplan

reasonably determines that:

the signature on an authorized representative form

may not be yours, or

the authorized representative may not have disclosed

to you all of the relevant facts and circumstances

relating to the overpayment or underpayment of any

claim, including, for example, that the billing

practices of the provider of medical services may

have jeopardized your coverage through the waiver

of the cost-sharing amounts that you are required to

pay under your plan.

If your designation of an authorized representative is

revoked, or the Healthplan does not honor your

designation, you may appoint a new authorized

representative at any time, in writing, using a form

approved by the Healthplan.

GSA-PROV(04)-C 01/20

Arbitration

To the extent permitted by law, any controversy between

the Healthplan and the Group, or an insured (including

any legal representative acting on your behalf), arising out

of or in connection with this Agreement may be submitted

to arbitration upon written notice by one party to another.

Such arbitration shall be governed by the provisions of the

Commercial Arbitration Rules of the American

Arbitration Association, to the extent that such provisions

are not inconsistent with the provisions of this section.

If the parties cannot agree upon a single arbitrator

within thirty (30) days of the effective date of the

written notice of arbitration, each party shall choose

one arbitrator within fifteen (15) working days after the

expiration of such thirty (30) day period and the two

(2) arbitrators so chosen shall choose a third arbitrator,

who shall be an attorney duly licensed to practice law in

the applicable state. If either party refuses or otherwise

fails to choose an arbitrator within such fifteen (15)

working day period, the arbitrator chosen shall choose a

third (3rd) arbitrator in accordance with these

requirements.

The arbitration hearing shall be held within thirty (30)

days following appointment of the third arbitrator,

unless otherwise agreed to by the parties. If either

party refuses to or otherwise fails to participate in such

arbitration hearing, such hearing shall proceed and

shall be fully effective in accordance with this section,

notwithstanding the absence of such party.

The arbitrator(s) shall render a decision within thirty

(30) days after the termination of the arbitration

hearing. To the extent permitted by law, the decision of

the arbitrator, or the decision of any two (2) arbitrators

if there are three (3) arbitrators, shall be binding upon

both parties, conclusive of the controversy in question

and enforceable in any court of competent jurisdiction.

No party to this Agreement shall have a right to cease

performance of services or otherwise refuse to carry

out its obligations under this Agreement pending the

outcome of arbitration in accordance with this section,

except as otherwise specifically provided under this

Agreement.

GSA-PROV(05) 1/03

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IV. Covered Services and Supplies

Section IV. Covered Services and Supplies

The covered Services and Supplies available to

Members under this plan are described below. Any

applicable Copayments or limits are identified in the

Schedule of Copayments. Unless otherwise authorized

in writing by the Healthplan Medical Director, covered

Services and Supplies are available to Members only if:

They are Medically Necessary and not specifically

excluded in this Section or in Section V.

Provided by Your Primary Care Physician (PCP) or

if Your PCP has given You a Referral, by another

Participating Provider. However, "Emergency

Services" do not require a Referral from Your PCP

and do not have to be provided by Participating

Providers. Also, You do not need a Referral from

Your PCP for "Obstetrical and Gynecological

Services," "Chiropractic Care Services," and

"Urgent Care."

Prior Authorization is obtained from the Healthplan

Medical Director by the Participating Provider, for

those services that require Prior Authorization.

Services that require Prior Authorization include,

but are not limited to, inpatient hospital services,

inpatient services at any Other Participating Health

Care Facility, residential treatment, Outpatient

Facility Services, partial hospitalization, intensive

outpatient programs, advanced radiological imaging,

Home Health Care Services, Radiation Therapy,

non-emergency ambulance, and Transplant Services.

As determined by the Healthplan, Covered Services and

Supplies may also include all charges made by an entity

that has directly or indirectly contracted with the

Healthplan to arrange, through contracts with providers of

services and/or supplies, for the provision of any services

and/or supplies listed below.

Physician Services

All diagnostic and treatment services provided by

Participating Physicians and Other Participating

Health Professionals, including office visits, periodic

health assessments, well-child care and routine

immunizations provided in accordance with

accepted medical practices, hospital care,

consultation, and surgical procedures.

Inpatient Hospital Services

Inpatient hospital services for evaluation or treatment

of conditions that cannot be adequately treated on an

ambulatory basis or in an Other Participating Health

Care Facility. Inpatient hospital services include

semi-private room and board; care and services in an

intensive care unit; drugs, medications, biologicals,

fluids, blood and blood products, and chemotherapy;

special diets; dressings and casts; general nursing

care; use of operating room and related facilities;

laboratory and radiology services and other diagnostic

and therapeutic services; anesthesia and associated

supplies and administration services; inhalation

therapy; radiation therapy; and other services which

are customarily provided in acute care hospitals.

Inpatient hospital services rendered by a non-

Participating Provider: Charges for services furnished

by a non-Participating Provider in a Participating facility

while you are receiving Participating Provider services at

that Participating facility are payable at the cost-sharing

level applicable to Participating Providers. The

allowable amount used to determine the plan’s benefit

payment for the non-Participating Provider services is

the amount agreed to by the non-Participating Provider

and the Healthplan, or as required by applicable state or

Federal law. You are responsible for applicable cost-

sharing amounts (any Deductible, Copayment or

Coinsurance). You are not responsible for any charges

that may be made in excess of the allowable amount. If

the non-Participating Provider bills you for an amount

higher than the amount you owe as indicated on the

Explanation of Benefits (EOB), contact Member

Services at the phone number on your ID card.

Outpatient Facility Services

Services provided on an outpatient basis, including:

diagnostic and/or treatment services; administered

drugs, medications, fluids, biologicals, blood and blood

products; inhalation therapy; and procedures which can

be appropriately provided on an outpatient basis,

including certain surgical procedures, anesthesia, and

associated supplies and administration, and recovery

room services.

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IV. Covered Services and Supplies

Outpatient facility services rendered by a non-

Participating Provider: Charges for services

furnished by a non-Participating Provider in a

Participating facility while you are receiving

Participating Provider services at that Participating

facility are payable at the cost-sharing level applicable

to Participating Providers. The allowable amount used

to determine the plan’s benefit payment for the non-

Participating Provider services is the amount agreed to

by the non-Participating Provider and the Healthplan,

or as required by applicable state or Federal law. You

are responsible for applicable cost-sharing amounts

(any Deductible, Copayment [or Coinsurance]). You

are not responsible for any charges that may be made

in excess of the allowable amount. If the non-

Participating Provider bills you for an amount higher

than the amount you owe as indicated on the

Explanation of Benefits (EOB), contact Member

Services at the phone number on your ID card.

GSA-BEN(01)-C 1/20

Emergency Services and Urgent Care

Emergency Services Both In and Out of the Service

Area. In the event of an emergency, get help

immediately. Go to the nearest emergency room, the

nearest hospital or call or ask someone to call 911 or

your local emergency service, police or fire department

for help. You do not need a Referral for Emergency

Services, but you do need to call your PCP or the

Cigna HealthCare 24-Hour Health Information Line

as soon as possible for further assistance and advice on

follow-up care. If you require specialty care or a

hospital admission, your PCP or the Cigna HealthCare

24-Hour Health Information Line

will coordinate it

and handle the necessary authorizations for care or

hospitalization. Participating Providers are on call

twenty-four (24) hours a day, seven (7) days a week, to

assist you when you need Emergency Services.

If you receive Emergency Services outside the Service

Area, you must notify us as soon as reasonably possible.

We may arrange to have you transferred to a

Participating Provider for continuing or follow-up care if

it is determined to be medically safe to do so.

Emergency medical condition means a medical

condition , including a mental health condition or

substance use disorder, manifesting itself by acute

symptoms of sufficient severity (including severe

pain) such that a prudent layperson, who possesses

an average knowledge of health and medicine, could

reasonably expect the absence of immediate medical

attention to result in placing the health of the

individual (or, with respect to a pregnant woman, the

health of the woman or her unborn child) in serious

jeopardy; serious impairment to bodily functions; or

serious dysfunction of any bodily organ or part.

Emergency services means, with respect to an

emergency medical condition: a medical screening

examination that is within the capability of the

emergency department of a hospital or of an

independent freestanding emergency facility,

including ancillary services routinely available to the

emergency department to evaluate such emergency

medical condition; and such further medical

examination and treatment, to the extent they are

within the capabilities of the staff and facilities

available at the hospital, or emergency department, as

are required to stabilize the patient.

Urgent Care Inside the Service Area. For Urgent

Care inside the Service Area, you must take all

reasonable steps to contact the Cigna HealthCare

24-Hour Health Information Line

or your PCP

for direction and you must receive care from a

Participating Provider, unless otherwise authorized

by your PCP or the Healthplan.

Urgent Care Outside the Service Area. In the event

you need Urgent Care while outside the Service Area,

you should, whenever possible, contact the Cigna

HealthCare 24 Hour Health Information Line

or your

PCP for direction and authorization prior to receiving

services.

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IV. Covered Services and Supplies

Urgent Care is defined as medical, surgical, hospital and

related health care services and testing which are not

Emergency Services, but which are determined by the

Healthplan Medical Director in accordance with generally

accepted medical standards to have been necessary to treat

a condition requiring prompt medical attention. This does

not include care that could have been foreseen before

leaving the immediate area where you ordinarily receive

and/or are scheduled to receive services. Such care

includes but is not limited to: dialysis, scheduled medical

treatments or therapy, or care received after a Physician's

recommendation that you should not travel due to any

medical condition.

Continuing or Follow-up Treatment. Continuing or

follow-up treatment, whether in or out of the Service Area,

is not covered unless it is provided or arranged for by your

PCP, a Participating Physician or upon

Prior Authorization of the Healthplan Medical Director.

Notification, Proof of a Claim, and Payment. Inpatient

hospitalization for any Emergency Services or Urgent Care

requires notification to and authorization

by the Healthplan Medical Director. Notification of

inpatient hospitalization is required as soon as

reasonably possible, but no later than within forty- eight

(48) hours of admission. This requirement shall not

cause denial of an otherwise valid claim if you

could not reasonably comply, provided that notification is

given to us as soon as reasonably possible. If you receive

Emergency Services or Urgent Care from non-

Participating Providers, you must submit a claim to

us no later than sixty (60) days after the first service is

provided. The claim shall contain an itemized statement of

treatment, expenses, and diagnosis. This requirement shall

not cause denial of an otherwise valid claim if you could

not reasonably comply, provided you submit the claim and

the itemized statement to us as soon as reasonably possible.

Coverage for Emergency Services and Urgent Care

received through non-Participating Providers shall be

limited to covered services to which you would have been

entitled under this Agreement. Emergency Services

received through non-Participating Providers shall be

reimbursed as indicated below. Urgent Care received

through non- Participating Providers shall be reimbursed at

the prevailing rate for self-pay patients in the area where

the services were provided.

Emergency Services rendered by a non-

Participating Provider. Emergency Services are

covered at the cost-sharing level applicable to

Participating Providers.

The allowable amount used to determine the plan's

benefit payment for covered Emergency Services

rendered in a non-Participating Hospital, or by a non-

Participating Provider in a Participating Hospital, is

the amount agreed to by the non-Participating provider and

the Healthplan, or as required by applicable state or Federal

law.

The allowable amount used to determine the plan’s

benefit payment when Emergency Services result in a

non-Participating Hospital admission is the median

amount negotiated with Participating facilities.

You are responsible for applicable cost-sharing

amounts (any Deductible, Copayment or Coinsurance).

You are not responsible for any charges that may be

made in excess of the allowable amount. If the non-

Participating Provider bills you for an amount higher

than the amount you owe as indicated on the

Explanation of Benefits (EOB), contact Member

Services at the phone number on your ID card.

GSA-BEN(02)-C 1/20

Ambulance Service

Licensed ambulance services to the nearest appropriate

provider or facility where the needed medical care and

treatment can be provided.

Air ambulance services rendered by a non-

Participating Provider: Covered air ambulance

services are payable at the cost-sharing level applicable

to Participating Providers. The allowable amount used

to determine the plan’s benefit payment for covered air

ambulance services rendered by a non-Participating

Provider is the amount agreed to by the non-

Participating Provider and the Healthplan, or as

required by applicable state or Federal law. You are

responsible for applicable cost-sharing amounts (any

Deductible, Copayment or Coinsurance). You are not

responsible for any charges that may be made in excess

of the allowable amount. If the non-Participating

Provider bills you for an amount higher than the

amount you owe as indicated on the Explanation of

Benefits (EOB), contact Member Services at the phone

number on your ID card.

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IV. Covered Services and Supplies

Breast Reconstruction and Breast Prostheses

Following a mastectomy, the following Services and

Supplies are covered:

surgical services for reconstruction of the breast on

which surgery was performed;

surgical services for reconstruction of the non-

diseased breast to produce symmetrical appearance;

post-operative breast prostheses; and

mastectomy bras and prosthetics, limited to

the lowest cost alternative available that

meets prosthetic placement needs.

During all stages of mastectomy, treatment of physical

complications, including lymphedema therapy, are

covered.

Clinical Trials

This benefit plan covers routine patient care costs

and services related to an approved clinical trial for a

qualified individual. The individual must be eligible to

participate according to the trial protocol and EITHER

of the following conditions are met:

• health care provider and has concluded

that the individual's participation in such

trial would be appropriate, or

• the individual provides medical and

scientific information establishing that the

individual's participation in the qualified trial

would be appropriate.

In addition to qualifying as an individual, the clinical trial

must also meet certain criteria in order for patient care

costs and services to be covered: it is a phase I, phase II,

phase III or phase IV clinical trial conducted in relation to

the prevention, detection or treatment of cancer or other

life-threatening disease or condition that meets ANY of

the following criteria:

it is a Federally funded trial: The study or

investigation is approved or funded (which may

include funding through in-kind contributions) by one

or more of the following:

National Institutes of Health (NIH)

Centers for Disease Control and Prevention

(CDC)

Agency for Health Care Research and Quality

(AHRQ)

Centers for Medicare and Medicaid Services

(CMS)

A cooperative group or center of any of the

entities described above or the Department of

Defense (DOD) or the Department of Veterans

Affairs (VA)

A qualified non-governmental research entity

identified in NIH guidelines for center support

grants.

Or ANY of the following:

Department of Energy

Department of Defense

Department of Veteran’s Affairs

if BOTH of the following conditions are met:

study or investigation has been reviewed and

approved through a system of peer review

comparable to the system of peer review of

studies and

investigations used by the National Institutes of

Health assures unbiased review of the highest

scientific standards by qualified individuals who

have no interest in the outcome of the review.

The study or investigation is conducted under an

investigational new drug application reviewed by the

Food and Drug Administration.

The study or investigation is a drug trial that is

exempt from having such an investigational new drug

application.

The benefit plan does not cover ANY of the following

services associated with a clinical trial:

services that are not considered routine patient care

costs/services, including the following:

the investigational drug, device, item, or service

that is provided solely to satisfy data collection

and analysis needs.

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IV. Covered Services and Supplies

an item or service that is not used in the direct

clinical management of the individual

a service that is clearly inconsistent with widely

accepted and established standards of care for a

particular diagnosis

an item or service provided by the research

sponsors free of charge for any person enrolled in

the trial

travel and transportation expenses unless otherwise

covered under the plan, including, but not limited

to the following:

fees for personal vehicle, rental car, taxi,

medical van, ambulance, commercial airline,

train

mileage reimbursement for driving a personal

vehicle

lodging

meals

Examples of Routine Patient Care Costs and Services

include:

• Radiological services

• Laboratory services

• Intraveneous therapy

• Anesthesia services

• Hospital services

• Physician services

• Office visits

• Hospital room and board, and medical

supplies that typically would be covered

under the plan for an individual who is not

enrolled in a clinical trial.

Clinical trials conducted only by out-of-network

providers will be covered at Out-of-Network benefit

levels as described in the schedule only when the

following conditions are met:

In-Network providers are not participating in the

clinical trial

the clinical trial is conducted outside the

individual's state of residence.

The Qualified Individual's plan provides coverage for

out of network services.

GSA-BEN(03)-D 1/20

Durable Medical Equipment

Purchase or rental of Durable Medical Equipment that

is ordered or prescribed by a Participating Physician

and provided by a vendor approved by the Healthplan

for use outside a Participating Hospital or Other

Participating Health Care Facility. Coverage for

repair, replacement or duplicate equipment is provided

only when required due to anatomical change and/

or reasonable wear and tear. All maintenance and

repairs that result from a member's misuse are the

member's responsibility. Coverage for Durable Medical

Equipment is limited to the lowest-cost alternative as

determined by the Healthplan Medical Director.

Durable Medical Equipment is defined as items which

hroutine patient costs obtained out-of-network when are

designed for and able to withstand repeated usnon-

network benefits do not exist under the plan by more

than one person; customarily serve a medical purpose;

generally are not useful in the absence of illness or

injury; are appropriate for use in the home; and are not

disposable. Such equipment includes, but is not limited

to, crutches, hospital beds, respirators, wheel chairs and

dialysis machines.

Durable Medical Equipment items that are not covered,

include but are not limited to those that are listed

below.

Bed related items: bed trays, over the bed tables,

bed wedges, pillows, custom bedroom equipment,

mattresses, including non-power mattresses,

custom mattresses and posturepedic mattresses.

Bath related items: bath lifts, non-portable

whirlpools, bathtub rails, toilet rails, raised toilet

seats, bath benches, bath stools, hand held showers,

paraffin baths, bath mats and spas.

Chairs, Lifts and Standing Devices: computerized

or gyroscopic mobility systems, roll about chairs,

geriatric chairs, hip chairs, seat lifts (mechanical or

motorized), patient lifts (mechanical or motorized -

manual hydraulic lifts are covered if patient is two

of metabolism (e.g. disorders of amino acid or

organic acid metabolism).

• Fixtures to real property: ceiling lifts and

wheelchair ramps.

• Car/van modifications

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IV. Covered Services and Supplies

• Air quality items: room humidifiers, vaporizers,

air purifiers, and electrostatic machines.

•

• Blood/injection related items: blood pressure

cuffs, centrifuges, nova pens and needle-less

injectors.

•

• Other equipment: heat lamps, heating pads,

cryounits, cryotherapy machines, electronic-

controlled therapy units, ultraviolet cabinets,

sheepskin pads and boots, postural drainage board,

AC/DC adapters, Enuresis alarms, magnetic

equipment, scales (baby and adult), stair gliders,

elevators, saunas, any exercise equipment and

diathermy machines.

Enteral Nutrition

Medically Necessary medical foods that are specially

formulated for enteral feedings or oral consumption.

Coverage includes medically approved formulas prescribed

by a Physician for treatment of inborn errors of metabolism

(e.g. disorders of amino acid or organic acid metabolism).

External Prosthetic Appliances and Devices

The initial purchase and fitting of external prosthetic

appliances and devices that are ordered by a

Participating Physician, available only by prescription

and are necessary for the alleviation or correction of

illness, injury or congenital defect.

External prosthetic appliances and devices include

prostheses/prosthetic appliances and devices, orthoses

and orthotic devices, braces and splints.

Prostheses/Prosthetic Appliances and Devices

Prostheses/Prosthetic appliances and devices are

defined as fabricated replacements for missing

body parts. Prostheses/prosthetic appliances and

devices include, but are not limited to:

• limb prostheses;

• Terminal devices such as hands or hooks;

• Speech prostheses; and

• Facial Prostheses

Orthoses and orthotic devices

Orthoses and orthotic devices are defined as

orthopedic appliances or apparatuses used to support,

align, prevent or correct deformities. Coverage is

provided for custom foot orthoses and other orthoses

as follows:

Non-foot orthoses - only the following non-foot

orthoses are covered:

a. Rigid and semi-rigid custom fabricated

orthoses;

b. Semi-rigid pre-fabricated and flexible

orthoses; and

c. Rigid pre-fabricated orthoses including

preparation, fitting and basic additions, such

as bars and joints.

Custom foot orthotics - custom foot orthoses are

only covered as follows:

a. For Members with impaired peripheral

sensation and/or altered

peripheralcirculation (e.g. diabetic

neuropathy

b. and peripheral vascular disease);

b. When the foot orthosis is an integral part of a

leg brace, and it is necessary for the proper

functioning of the brace;

c. When the foot orthosis is for use as a

replacement or substitute for missing parts of

the foot (e.g. amputation) and is

necessary for the alleviation or correction of

illness, injury, or congenital defect; and

d. For Members with neurologic or neuromuscular

condition (e.g. cerebral palsy, hemiplegia, spina

bifida) producing spasticity, malalignment, or

pathological positioning of the foot, and there is

reasonable expectation of improvement.

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IV. Covered Services and Supplies

The following are specifically excluded orthosis

and orthotic devices:

Prefabricated foot orthoses;

Cranial banding/cranial orthoses/other similar

devices are excluded, except when used

postoperatively for synostotic plagiocephaly.

When used for this indication, the cranial

orthosis will be subject to the limitations

and maximums of the External Prosthetic

Appliances and Devices benefit;

Orthosis shoes, shoe additions, procedures for

foot orthopedic shoes, shoe modifications and

transfers;

Non-foot Orthoses primarily used for cosmetic

rather than functional reasons; and

Non-foot Orthoses primarily for improved

athletic performance or sports participation.

Braces

A brace is defined as an orthosis or orthopedic

appliance that supports or holds in correct position

any movable part of the body and that allows for

motion of that part.

The following braces are specifically excluded:

Copes scoliosis braces.

Splints

A splint is defined as an appliance for preventing

movement of joints or for the fixation of displaced

or movable parts.

Coverage for replacement of external prosthetic

appliances and devices is limited to the following:

Replacement due to regular wear. Replacement

for damage due to abuse or misuse by the

member will not be covered; and

Replacement required because anatomic change

has rendered the external prosthetic appliance

or device ineffective. Anatomic change includes

significant weight gain or loss, atrophy and/or

growth.

Replacement due to a surgical alteration or

revision of the impacted site.

Coverage for replacement is limited as follows:

No more than once every 24 months for

Members 19 years of age and older;

No more than once every 12 months for

Members 18 years of age and under;

The following are specifically excluded external

prosthetic appliances and devices:

External and internal power enhancements;

Power controls for prosthetic limbs and terminal

devices; and

Myoelectric prosthesis peripheral nerve

stimulators.

GSA-BEN(04)-D 1/20

Family Planning Services (Contraception and

Voluntary Sterilization)

Family planning services including: medical history;

physical examination; related laboratory tests; medical

supervision in accordance with generally accepted

medical practice; other Medical Services; information

and counseling on contraception; implanted/injected

contraceptives; and, after appropriate counseling,

Medical Services connected with surgical therapies

(vasectomy or tubal ligation).

Family Planning Services- Men's Family Planning

Charges for Men's family planning, counseling,

testing and sterilization (e.g. vasectomies), excluding

reversals.

Foot Disorders – Medically Necessary

Medically Necessary foot care for diabetes, peripheral

neuropathies and peripheral vascular disease.

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IV. Covered Services and Supplies

Gene Therapy

Charges for gene therapy products and services directly

related to their administration are covered when

Medically Necessary. Gene therapy is a category of

pharmaceutical products approved by the U.S. Food

and Drug Administration (FDA) to treat or cure a

disease by:

replacing a disease-causing gene with a healthy

copy of the gene.

inactivating a disease-causing gene that may not be

functioning properly.

introducing a new or modified gene into the body

to help treat a disease.

Each gene therapy product is specific to a particular

disease and is administered in a specialized manner.

The Healthplan determines which products are in

the category of gene therapy, based in part on the

nature of the treatment and how it is distributed and

administered.

Coverage includes the cost of the gene therapy product;

medical, surgical, and facility services directly related

to administration of the gene therapy product; and

professional services.

Gene therapy products and their administration are

covered when approved by the Healthplan Medical

Director and received at a facility that is designated

by the Healthplan to provide the specific gene therapy

service. Gene therapy products and their administration

at other participating facilities are not covered.

Gene Therapy – Travel Services

Charges made for non-taxable travel expenses incurred

by you in connection with a prior authorized gene

therapy procedure are covered subject to the following

conditions and limitations.

Benefits for transportation and lodging are available

to you only when you are the recipient of a prior

authorized gene therapy, and when the gene therapy

products and services directly related to their

administration are received at a facility designated by

the Healthplan for the specific gene therapy service.

The term recipient is defined to include a person

receiving prior authorized gene therapy related services

during any of the following: evaluation, candidacy,

event, or post care.

Travel expenses for the person receiving the gene

therapy include charges for: transportation to and from

the gene therapy site (including charges for a rental car

used during a period of care at the facility); and lodging

while at, or traveling to and from, the site.

In addition to your coverage for the charges associated

with the items above, such charges will also be

considered covered travel expenses for one companion

to accompany you. The term companion includes your

spouse, a member of your family, your legal guardian,

or any person not related to you, but actively involved

as your caregiver who is at least 18 years of age.

The following are specifically excluded travel

expenses: any expenses that if reimbursed would be

taxable income: travel costs incurred due to travel

within 60 miles of your home; food and meals; laundry

bills; telephone bills; alcohol or tobacco products; and

charges for transportation that exceed coach class rates.

Home Health Care Services

Home health care services are provided only if the

Healthplan Medical Director has determined in

advance that the home is a medically appropriate

setting. If you are a minor or an adult who is

dependent upon others for non-skilled care and/or

Custodial Services (e.g. bathing, eating, toileting),

home health care services will only be provided

for you during

times when there is a family member or care giver

present in the home to meet your non-skilled care and/

or Custodial Services needs.

Home health care services are services that can be

provided during visits by Other Participating Health

Professionals. The services of a home health aide are

covered when rendered in direct support of skilled

health care services provided by Other Participating

Health Professionals. A visit is defined as a peri2

hours or less. Home health care services are subject

to a maximum of 16 hours in total per day. Necessary

consumable medical supplies and home infusion

therapy administered or used by Other Participating

Health Professionals in providing home health care

services are covered.

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IV. Covered Services and Supplies

Home health care services do not include services

by a person who is a member of your family or your

Dependent's family or who normally resides in your

house or your Dependent's house even if that person

is an Other Participating Health Professional. Skilled

nursing services or private duty nursing services are

not covered outside the home and are subject to the

rules that apply to home health care services. Physical,

occupational, and other Outpatient Therapy services

provided in the home are not subject to the Home

Health Services benefit limitations in the Schedule of

Copayments, but are subject to the benefit limitations

described under Outpatient Therapy in the Schedule of

Copayments.

Hospice Services

Hospice care services which are provided under an

approved hospice care program when provided to a

Member who has been diagnosed by a Participating

Physician as having a terminal illness with a prognosis

of six months or less to live. Hospice care services

include inpatient care; outpatient services; professional

services of a Physician; services of a psychologist,

social worker or family counselor for individual and

family counseling; and home health care services.

Hospice care services do not include the following:

services of a person who is a member of your

family or your Dependent's family or who normally

resides in your house or your Dependent's house;

services and supplies for curative or life-prolonging

procedures;

services and supplies for which any other benefits

are payable under the Agreement;

services and supplies that are primarily to aid you

or your Dependent in daily living;

services and supplies for respite (custodial) care;

and

nutritional supplements, non-prescription drugs or

substances, medical supplies, vitamins or minerals.

Hospice care services are services provided by a

Participating Hospital; a participating skilled nursing

facility or a similar institution; a participating home

health care services agency; a participating hospice

facility, or any other licensed facility or agency under a

Medicare approved hospice care program.

A hospice care program is a coordinated,

interdisciplinary program to meet the physical,

psychological, spiritual and social needs of dying

persons and their families; a program that provides

palliative and supportive medical, nursing, and other

health services through home or inpatient care during

the illness; and a program for persons who have a

terminal illness and for the families of those persons.

A hospice facility is a participating institution or

portion of a facility which primarily provides care

for terminally ill patients; is a Medicare approved

hospice care facility; meets standards established by the

Healthplan; and fulfills all licensing requirements of

the state or locality in which it operates.

GSA-BEN(05)-E 1/20

Inpatient Services at Other Participating Health Care

Facilities

Inpatient services at Other Participating Health Care

Facilities including semi-private room and board;

skilled and general nursing services; Physician visits;

physiotherapy; speech therapy; occupational therapy;

x-rays; and administration of drugs, medications,

biologicals and fluids.

Internal Prosthetic/Medical Appliances

Internal prosthetic/medical appliances that provide

permanent or temporary internal functional supports

for non-functional body parts are covered. Medically

Necessary repair, maintenance or replacement of a

covered appliance is also covered.

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IV. Covered Services and Supplies

Laboratory and Radiology Services

Laboratory services and radiation therapy and other

diagnostic and therapeutic radiological procedures

including:

diagnostic x-ray

advanced radiological imaging, including for

example CT Scans, MRI, MRA and PET scans and

laboratory examinations, x-ray, radiation therapy

and radium and radioactive isotope treatment and

other therapeutic radiological procedures

chemotherapy.

Maternity Care Services

Medical, surgical and hospital care during the term of

pregnancy, upon delivery and during the postpartum

period for normal delivery, spontaneous abortion

(miscarriage) and complications of pregnancy.

Coverage for a mother and her newly born child shall

be available for a minimum of 48 hours of inpatient

care following a vaginal delivery and a minimum of

96 hours of inpatient care following a cesarean section.

Any decision to shorten the period of inpatient care

for the mother or the newborn must be made by the

attending Physician in consultation with the mother.

GSA-BEN(07)-C 1/20

Mental Health and Substance Use Disorder Services

Mental Health Services are services that are required

to treat a disorder that impairs the behavior, emotional

reaction or thought processes. In determining benefits

payable, charges made for the treatment of any

physiological conditions related to mental health will

not be considered to be charges made for treatment of

mental health.

Substance Use Disorder is defined as the

psychological or physical dependence on alcohol or

other mind-altering drugs that requires diagnosis, care,

and treatment. In determining benefits payable, charges

made for the treatment of any physiological conditions

related to rehabilitation services for alcohol or drug

abuse or addiction will not be considered to be charges

made for treatment of Substance Use Disorder.

Inpatient Mental Health Services

Inpatient services that are provided by a

Participating Hospital for the treatment and

evaluation of mental health. Inpatient Mental

Health Services include Mental Health Residential

Treatment Services.

Mental Health Residential Treatment Services

Services provided by a Participating Hospital for the

evaluation and treatment of the psychological and

social functional disturbances that are a result of sub-

acute Mental Health conditions.

Mental Health Residential Treatment Center means

an institution which (a) specializes in the treatment of

psychological and social disturbances that are the result

of Mental Health conditions; (b) provides a sub-acute,

structured, psychotherapeutic treatment program, under

the supervision of Participating Providers; (c) provides

twenty-four (24)-hour care, in which a person lives in

an open setting; and (d) is licensed in accordance with

the laws of the appropriate legally-authorized agency

as a residential treatment center.

A Member is considered confined in a Mental

Health Residential Treatment Center when she/he

is a registered bed patient in a Mental Health

Residential Treatment Center upon the

recommendation of a Participating Provider.

Outpatient Mental Health Services

Services of Participating Providers who are qualified

to treat Mental Health when treatment is provided on

an outpatient basis in an individual, group or Mental

Health Partial Hospitalization

or Mental Health Intensive Outpatient Therapy

Program. Covered services include, but are not

limited to, outpatient treatment of conditions such

as: anxiety or depression which interferes with

daily functioning; emotional adjustment

or concerns related to chronic conditions, such as

psychosis or depression; emotional reactions

associated with marital problems or divorce;

child/adolescent problems of conduct or poor impulse

control; affective disorders; suicidal or homicidal

threats or acts; eating disorders; or acute exacerbation

of chronic mental health conditions (crisis intervention

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IV. Covered Services and Supplies

and relapse prevention) and outpatient testing and

assessment.

Mental Health Partial Hospitalization Services are

rendered not less than four (4) hours and not more

than twelve (12) hours in any twenty-four (24)-hour

period by a certified/licensed MentalHealth program

in accordance with the laws of the appropriate

legally-authorized agency.

Mental Health Intensive Outpatient Therapy

Program

A Mental Health Intensive Outpatient Therapy

Program consists of distinct levels or phases of

treatment that are provided by a certified/licensed

mental health program in accordance with the

laws of the appropriate legally-authorized agency.

Intensive Outpatient Therapy Programs provide

a combination of individual, family and/or group

therapy in a day, totaling nine (9) or more hours in

a week.

Inpatient Substance Use Disorder Rehabilitation

Services

Services provided by a facility designated by the

Healthplan for rehabilitation when required for

the diagnosis and treatment of abuse or addiction

to alcohol and/or drugs. Inpatient Substance Use

Disorder Services include Residential Treatment

Services.

Inpatient substance abuse benefits are exchangeable

with partial hospitalization sessions when benefits

are provided for not less than four (4) hours and

not more than twelve (12) hours in any twenty four

(24) hour period. The benefit exchange will be two

(2) partial hospitalization sessions are equal to one

(1) day of inpatient care.

Substance Use Disorder Residential Treatment

Services

Services provided by a Participating Hospital for

the evaluation and treatment of the psychological

and social functional disturbances that are a result

of sub-acute Substance Use Disorder conditions.

Substance Use Disorder Residential Treatment Center

means an institution which (a) specializes in the treatment of

psychological and social disturbances that are the result of

Substance Use Disorder; (b) provides a sub-acute,

structured, psychotherapeutic treatment program, under the

supervision of Participating Providers; (c) provides twenty-

four (24) hour care, in which a person lives in an open

setting; and (d) is licensed in accordance with the laws of

the appropriate legally-authorized agency as a residential

treatment center.

A Member is considered confined in a Substance Use

Disorder Residential Treatment Center when she/he is a

registered bed patient in a Substance Use Disorder

Residential Treatment Center upon the recommendation

of a Participating Provider.

Outpatient Substance Use Disorder Rehabilitation

Services

Services for the diagnosis and treatment of abuse or

addiction to alcohol and/or drugs including outpatient

rehabilitation in an individual or a Substance Use

Disorder Partial Hospitalization or Intensive

Outpatient Therapy Program.

Substance Use Disorder Partial Hospitalization services

are rendered not less than four (4) hours and not more

than twelve (12) hours in any twenty- four (24)-hour

period by a certified/licensed Substance Use Disorder

program in accordance with the laws of the appropriate

legally-authorized agency.

Substance Use Disorder Intensive Outpatient

Therapy Program

A Substance Use Disorder Intensive Outpatient

Therapy Program consists of distinct levels or phases of

treatment that are provided by a certified/ licensed

Substance Use Disorder Program in accordance with

the laws of the appropriate legally- authorized agency.

Intensive Outpatient Therapy Programs provide a

combination of individual, family and/or group therapy

in a day, totaling nine (9) or more hours in a week.

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IV. Covered Services and Supplies

Substance Use Disorder Detoxification Services

Detoxification and related medical ancillary services

are provided when required for the diagnosis and

treatment of addiction to alcohol and/ or drugs. The

Healthplan Medical Director will decide, based on the

Medical Necessity of each situation, whether such

services will be provided in an inpatient or outpatient

setting.

Excluded Mental Health and Substance Use

Disorder Services

The following are specifically excluded from Mental

Health and Substance Use Disorder Services:

Counseling for activities of an educational nature;

Counseling for borderline intellectual

functioning; Counseling for occupational

problems;

Counseling related to consciousness raising;

Vocational or religious counseling;

I.Q. testing;

Custodial care, including but not limited to geriatric

day care;

Psychological testing on children requested by or

for a school system; and

Occupational/recreational therapy programs even if

combined with supportive therapy for age-related

cognitive decline.

GSA-BEN(08) IOP-B 1/16

Nutritional Counseling

Nutritional counseling from a Participating Provider

when diet is a part of the medical management of a

medical or behavioral condition.

Obstetrical and Gynecological Services

Obstetrical and gynecological services that are

provided by qualified Participating Providers for

pregnancy, well-women gynecological exams,

primary and preventive gynecological care and

acute gynecological conditions. For these services

and supplies you have direct access to qualified

Participating Providers; you do not need a Referral

from your PCP.

Transplant Services and Related Specialty Care

Human organ and tissue transplant services at

designated facilities throughout the United States.

Transplant services include solid organ and bone

marrow/stem cell procedures. This coverage is subject

to the following conditions and limitations.

Transplant services include the recipient's medical,

surgical and hospital services; inpatient

immunosuppressive medications; and costs for organ

or bone marrow/stem cell procurement. Transplant

services are covered only if they are required to

perform any of the following human to human organ or

tissue transplants: allogeneic bone marrow/stem cell,

autologous bone marrow/stem cell, cornea, heart, heart/

lung, kidney, kidney/pancreas, liver, lung, pancreas or

intestinal, which includes small bowel, small bowel/

liver or multivisceral.

All transplant services other than cornea, must

be received at a qualified or provisional Cigna

LifeSOURCE Transplant Network® facility.

Coverage for organ procurement costs are limited to

costs directly related to the procurement of an organ,

from a cadaver or a live donor. Organ procurement

costs shall consist of surgery necessary for organ

removal, organ transportation and the transportation

(refer to Transplant Travel Services), hospitalization

and surgery of a live donor. Compatibility testing

undertaken prior to procurement is covered if

Medically Necessary. Costs related to the search and

identification of a bone marrow or stem cell donor for

an allogeneic transplant are also covered.

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IV. Covered Services and Supplies

Transplant Travel Services

Non-taxable travel expenses incurred by you in

connection with a pre-approved organ/tissue transplant

are covered subject to the following conditions

and limitations. Transplant Travel benefits are not

available for cornea transplants. Benefits for

transportation and lodging are available to you only

if you are the recipient of a pre-approved organ/tissue

transplant from a designated Cigna LifeSOURCE

Transplant Network® facility. The term recipient is

defined to include a Member receiving authorized

transplant related services during any of the following:

evaluation, candidacy, transplant event, or post-

transplant care. Travel expenses for the Member

receiving the transplant will include charges for:

transportation to and from the transplant site

(including charges for a rental car used during a

period of care at the transplant facility); and

lodging while at, or traveling to and from the

transplant site.

In addition to you being covered for the charges

associated with the items above, such charges will

also be considered covered travel expenses for one

companion to accompany you. The term companion

includes your spouse, a member of your family, your

legal guardian, or any person not related to you, but

actively involved as your caregiver who is at least

eighteen (18) years of age.

The following are specifically excluded travel

expenses:

any expenses that if reimbursed would be taxable

income;

travel costs incurred due to travel within sixty (60)

miles of your home;

food and meals;

laundry bills;

telephone bills;

alcohol or tobacco products; and

charges for transportation that exceed coach class

rates.

These benefits are only available when the Member is

the recipient of an organ/tissue transplant. Travel

expenses for the designated live donor for a covered

recipient are covered subject to the same conditions and

limitations noted above. Charges for the expenses of a

donor companion are not covered. No benefits are

available where the Member is a donor.

Oxygen

Oxygen and the oxygen delivery system. However,

coverage of oxygen that is routinely used on an

outpatient basis is limited to coverage within the

Service Area. Oxygen Services and Supplies are not

covered outside of the Service Area, except on an

emergency basis.

Reconstructive Surgery

Reconstructive surgery or therapy to repair or correct

a severe physical deformity or disfigurement, which

is accompanied by functional deficit (other than

abnormalities of the jaw or related to TMJ disorder)

provided that:

the surgery or therapy restores or improves

function; or

reconstruction is required as a result of Medically

Necessary, non-cosmetic surgery; or

the surgery or therapy is performed prior to age

(19) and is required as a result of the congenital

absence or agenesis (lack of formation or

development) of a body part.

Repeat or subsequent surgeries for the same condition

are covered only when there is the probability of

significant additional improvement as determined by

the Healthplan Medical Director.

GSA-BEN(09)-D 1/20

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IV. Covered Services and Supplies

Obesity Surgery and Treatment (Bariatric) Services

Charges made for medical and surgical services for the

treatment or control of clinically severe obesity as

defined below, when performed at approved centers,

and if the services are demonstrated, through existing

peer reviewed, evidence based, scientific literature and

scientifically based guidelines, to be safe and effective

for the treatment or control of the condition. Clinically

severe obesity is defined by the National Heart, Lung

and Blood Institute (NHLBI) as a Body Mass Index

(BMI) of 40 or greater without comorbidities, or a BMI

of 35-39 with comorbidities. The following items are

specifically excluded:

Medical and surgical services to alter appearances

or physical changes that are the result of any

medical or surgical services performed for the

treatment or control of obesity or clinically severe

obesity; and

Weight loss programs or treatments, whether or not

they are prescribed or recommended by a Physician

or under medical supervision.

GSA-BEN(09).2

1/06Preventive Care

Charges made for preventive care services as defined

by recommendations from the following:

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.

Detailed information is available at

www.healthcare.gov. For additional information on

immunizations, visit the immunization schedule section

of www.cdc.gov.

GSA-BEN(09).4-A

Short-term Rehabilitative Therapy

Short-term rehabilitative therapy that is part of a

rehabilitation program, including physical, speech,

occupational, cognitive, osteopathic manipulative,

cardiac rehabilitation and pulmonary rehabilitation

therapy, when provided in the most medically

appropriate setting.

The following limitation applies to short-term

rehabilitative therapy:

occupational therapy is provided only for purposes

of enabling Members to perform the activities of

daily living after an illness or an injury.

Short-term Rehabilitative Therapy services that are not

covered include, but are not limited to:

sensory integration therapy; group therapy;

treatment of dyslexia; behavior modification or

myofunctional therapy for dysfluency, such as

stuttering or other involuntarily-acted conditions

without evidence of an underlying medical

condition or neurological disorder;

treatment for functional articulation disorder, such

as correction of tongue thrust, lisp, verbal apraxia

or swallowing dysfunction that is not based on an

underlying diagnosed medical condition or injury;

and

maintenance or preventive treatment consisting of

routine, long-term or non-Medically Necessary care

provided to prevent reoccurrences or to maintain

the patient's current status.

If multiple outpatient services are provided on the

same day they constitute one visit, but a separate

Copayment will apply to the services provided by each

Participating Provider.

Services that are provided by a chiropractic

Physician are not covered. These services include

the management of neuromusculoskeletal conditions

through manipulation and ancillary physiological

treatment rendered to restore motion, reduce pain and

improve function.

GSA-BEN(10).2-C 1/07

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IV. Covered Services and Supplies

Virtual Care - Medical

Includes charges for the delivery of medical and health-

related consultations via secure telecommunications

technologies, including telephones and internet, when

delivered through a contracted medical provider.

Virtual Care - Behavioral

Behavioral consultations and services via secure

telecommunications technologies that include video

capability, including telephones and internet, when

delivered through a behavioral provider.

GSA-BEN(12)-D 01/20

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V. Exclusions and Limitations

Section V. Exclusions and Limitations

Exclusions

Any Services and Supplies which are not described as

covered in "Section IV. Covered Services and Supplies"

or in an attached Rider or are specifically excluded in

"Section IV. Covered Services and Supplies" or an attached

Rider are not covered under this Agreement.

In addition, the following are specifically excluded

Services and Supplies:

1. Care for health conditions that are required by state or

local law to be treated in a public facility.

2. Care required by state or federal law to be supplied by

a public school system or school district.

3. Care for military service disabilities treatable through

governmental services if the Member is legally

entitled to such treatment and facilities are reasonably

available.

4. Treatment of an illness or injury which is due to war,

declared or undeclared.

5. Charges for which you are not obligated to pay or for

which you are not billed or would not have been billed

except that you were covered under this Agreement.

For example, if the Healthplan determines that a

Participating Provider is or has waived, reduced,

or forgiven any portion of its charges and/or any

portion of Copayment, Deductible, and/or Coinsurance

amount(s) you are required to pay for Covered

Services and Supplies (as shown on the Schedule

of Copayments) without the Healthplan's express

consent, then the Healthplan in its sole discretion

shall have the right to deny the payment of benefits in

connection with the Covered Services and Supplies,

or reduce the benefits in proportion to the amount

of the Copayment, Deductible, and/or Coinsurance

amounts waived, forgiven or reduced, regardless of

whether the Participating Provider represents that

you remain responsible for any amounts that this

Agreement does not cover. In the exercise of that

discretion, the Healthplan shall have the right to require

you to provide proof sufficient to the Healthplan that

you have made your required cost share payment(s)

prior to the payment of any benefits by the Healthplan.

This exclusion includes, but is not limited to, charges

of a Non-Participating Provider who has agreed to

charge you or charged you at an in-network benefits

level or some other benefits level not otherwise

applicable to the services received. Provided further,

if you use a coupon provided by a pharmaceutical

manufacturer or other third party that discounts the

cost of a prescription medication or other product,

the Healthplan may, in its sole discretion, reduce

the benefits provided under the plan in proportion

to the amount of the Copayment, Deductible, and/or

Coinsurance amounts to which the value of the coupon

has been applied by the pharmacy or other third party,

and/or exclude from accumulation toward any Plan

Deductible or Out-of-Pocket Maximum the value of

any coupon applied to any Copayment, Deductible and/

or Coinsurance you are required to pay.

6. Assistance in the activities of daily living, including,

but not limited to, eating, bathing, dressing or other

Custodial Services or self-care activities, homemaker

services and services primarily for rest, domiciliary or

convalescent care.

7. Any services and supplies for or in connection with

experimental, investigational or unproven services.

Experimental, investigational and unproven services

do not include routine patient care costs related to

qualified clinical trials as described in your plan

document.

Experimental, investigational and unproven services

are medical, surgical, diagnostic, psychiatric, substance

use disorder or other health care technologies, supplies,

treatments, procedures, drug therapies or devices that

are determined by the Healthplan Medical Director to

be.

not demonstrated, through existing peer-reviewed,

evidence-based scientific literature to be safe and

effective for treating or diagnosing the condition or

illness for which its use is proposed; or

not approved by the U.S. Food and Drug

Administration (FDA) or other appropriate

regulatory agency to be lawfully marketed for the

proposed use; or

the subject of review or approval by an Institutional

Review Board for the proposed use, or

the subject of an ongoing phase I, II or III clinical

trial, except for routine patient care costs related to

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V. Exclusions and Limitations

qualified clinical trials as provided in the "Clinical

Trials" section(s) of this plan.

In determining whether any such technologies,

supplies, treatments, drug or Biologic therapies, or

devices are experimental, investigational, and/or

unproven, the utilization review Physician may rely

on the clinical coverage policies maintained by the

Healthplan or the Review Organization. Clinical

coverage policies may incorporate, without limitation

and as applicable, criteria relating to U.S. Food and

Drug Administration-approved labeling, the standard

medical reference compendia and peer-reviewed,

evidence-based scientific literature or guidelines.

8. Cosmetic Surgery or Therapies. Cosmetic surgery or

therapy is defined as surgery or therapy performed to

improve or alter appearance or self-esteem.

9. The following services are excluded from coverage

regardless of clinical indications:

Macromastia or Gynecomastia Surgeries;

Surgical treatment of varicose veins;

Abdominoplasty;

Panniculectomy;

Rhinoplasty;

Blepharoplasty;

Redundant skin surgery;

Removal of skin tags;

Acupressure;

Craniosacral/cranial therapy;

Dance therapy, movement therapy;

Applied kinesiology;

Rolfing;

Prolotherapy; and

Extracorporeal shock wave lithotripsy (ESWL) for

musculoskeletal and orthopedic conditions.

10. Treatment of surgical and non-surgical TMJ disorder.

11. Dental treatment of the teeth, gums or structures

directly supporting the teeth, including dental x-rays,

examinations, repairs, orthodontics, periodontics,

casts, splints and services for dental malocclusion, for

any condition. However, charges made for services

or supplies provided for or in connection with an

accidental injury to teeth are covered.

12. Unless otherwise covered as a basic benefit, reports,

evaluations, physical examinations, or hospitalization

not required for health reasons including, but not

limited to, employment, insurance or government

licenses, and court ordered, forensic or custodial

evaluations.

13. Court ordered treatment or hospitalization, unless such

treatment is being sought by a Participating Physician

or otherwise covered under "Section IV. Covered

Services and Supplies."

14. Infertility services, infertility drugs, surgical or medical

treatment programs for infertility, including in vitro

fertilization, gamete intrafallopian transfer (GIFT),

zygote intrafallopian transfer (ZIFT), variations of

these procedures, and any costs associated with the

collection, washing, preparation or storage of sperm

for artificial insemination (including donor fees).

Cryopreservation of donor sperm and eggs are also

excluded from coverage.

15. Reversal of male and female voluntary sterilization

procedures.

16. Any services, supplies, medications or drugs for the

treatment of male or female sexual dysfunction such

as, but not limited to, treatment of erectile dysfunction

(including penile implants), anorgasmia, and premature

ejaculation.

17. Medical and hospital care and costs for the infant child

of a Dependent, unless this infant child is otherwise

eligible under the Agreement.

18. Non-medical counseling and/or ancillary services

including, but not limited to Custodial Services,

educational services, vocational counseling, training

and rehabilitation services, behavioral training,

biofeedback, neurofeedback, hypnosis, sleep therapy,

return-to-work services, work hardening programs, and

driving safety courses.

19. Therapy or treatment intended primarily to improve or

maintain general physical condition or for the purpose

of enhancing job, school, athletic or recreational

performance, including, but not limited to, routine,

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V. Exclusions and Limitations

long-term or maintenance care which is provided after

the resolution of the acute medical problem and when

significant therapeutic improvement is not expected.

20. Consumable medical supplies other than ostomy

supplies and urinary catheters. Excluded supplies

include, but are not limited to bandages and other

disposable medical supplies, skin preparations and test

strips, except as specified in the "Inpatient Hospital

Services," "Outpatient Facility Services," "Home

Health Care Services" or "Breast Reconstruction and

Breast Prostheses" sections of "Section IV. Covered

Services and Supplies."

21. Private hospital rooms and/or private duty nursing

except as provided in the "Home Health Care Services"

section of "Section IV. Covered Services and Supplies."

22. Personal or comfort items such as personal care

kits provided on admission to a hospital, television,

telephone, newborn infant photographs, complimentary

meals, birth announcements, and other articles which

are not for the specific treatment of illness or injury.

23. Artificial aids, including but not limited to corrective

orthopedic shoes, arch supports, elastic stockings,

garter belts, corsets, dentures and wigs.

24. Hearing aids, including, but not limited to semi-

implantable hearing devices, audiant bone conductors

and Bone Anchored Hearing Aids (BAHAs). A hearing

aid is any device that amplifies sound.

25. Aids or devices that assist with non-verbal

communications, including, but not limited to

communication boards, pre-recorded speech devices,

laptop computers, desktop computers, Personal Digital

Assistants (PDAs), Braille typewriters, visual alert

systems for the deaf and memory books.

26. Corrective lenses and associated services (prescription

exams and fittings), including eyeglass lenses and

frames and contact lenses, except for the first pair

of contact lenses, or first set of eyeglass lenses and

frames, and associated services following treatment of

keratoconus or post-cataract surgery.

27. Routine refraction, eye exercises and surgical treatment

for the correction of a refractive error, including radial

keratotomy.

28. Treatment by acupuncture.

29. All non-injectable prescription drugs, injectable

prescription drugs that do not require physician

supervision and are typically considered self-

administered drugs, non-prescription drugs, and

investigational and experimental drugs, except as

provided in "Section IV. Covered Services and

Supplies."

30. Routine foot care, including the paring and removing

of corns and calluses or trimming of nails. However,

services associated with foot care for diabetes

and peripheral vascular disease are covered when

Medically Necessary.

31. Membership costs or fees associated with health clubs,

weight loss programs and smoking cessation programs.

32. Genetic screening or pre-implantation genetic

screening. General population-based genetic screening

is a testing method performed in the absence of any

symptoms or any significant, proven risk factors for

genetically-linked inheritable disease.

33. Dental implants for any condition.

34. Fees associated with the collection or donation of blood

or blood products, except for autologous donation

in anticipation of scheduled services where in the

Healthplan Medical Director's opinion the likelihood of

excess blood loss is such that transfusion is an expected

adjunct to surgery.

35. Blood administration for the purpose of general

improvement in physical condition.

36. Cost of biologicals that are immunizations or

medications for the purpose of travel, or to protect

against occupational hazards and risks.

37. Cosmetics, dietary supplements and health and beauty

aids.

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V. Exclusions and Limitations

38. All nutritional supplements and formulae are excluded,

except for infant formula needed for the treatment of

inborn errors of metabolism.

39. Services for or in connection with an injury or illness

arising out of, or in the course of, any employment for

wage or profit.

40. Massage Therapy.

41. Charges for the delivery of medical and health

related services via telecommunications technologies,

including telephone and internet, unless provided as

specifically described in "Section IV. Covered Services

and Supplies".

In addition to the provisions of this "Exclusions and

Limitations" section, you will be responsible for payments

on a fee-for-service basis for Services and Supplies under

the conditions described in the "Reimbursement" provision

of "Section VI. Other Sources of Payment for Services and

Supplies."

Limitations

Circumstance Beyond the Healthplan's Control. To the

extent that a natural disaster, war, riot, civil insurrection,

epidemic or any other emergency or similar event not

within our control results in our facilities, personnel, or

financial resources being unavailable to provide or arrange

for the provisions of a basic or supplemental health service

or supplies in accordance with this Agreement, we will

make a good faith effort to provide or arrange for the

provision of the services or supplies, taking into account

the impact of the event.

GSA-EXCL(01)-F 01/20

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VI. Other Sources of Payment

for Services and Supplies

Section VI. Other Sources of Payment for

Services and Supplies

Subrogation

If you are injured or rendered ill under circumstances

which create a liability for a third party to pay claims or

damages to you, we are subrogated to all rights, claims,

or interests which you may have against such third

party and shall have automatically, without the need to

file with such third party or with a tribunal or court of

competent jurisdiction, a lien upon the proceeds of any

recovery from such third party as follows:

We have the right to recover from the third party

the cost of the care which we have provided for

you; and

We have the right to recover from the third party

to the extent of payments that we have paid for

Services and Supplies and not rendered services.

If permitted by applicable state or federal law,

we may require you, your guardian, personal

representative, estate, Dependents, or survivors,

as appropriate, to assign your claim or cause of

action against the third party to us and to execute

and deliver such instruments to secure our right to

that claim.

You must assist the Healthplan in pursuing any

subrogation rights by providing requested information.

Reimbursement

If you receive any payment from any third

party, including, but not limited to, any worker's

compensation fund or carrier, Medicare, a tort feasor,

or any other insurance carrier, for Services and

Supplies either rendered or paid by us, we have the

right to receive reimbursement from you to the extent

that you have received payment as follows:

We have the right to receive reimbursement from

you to the extent of the prevailing rates for your

care and treatment which we have directly rendered

or arranged to be rendered for you; and

We have the right to receive reimbursement from

you to the extent that we have paid for Services and

Supplies and not rendered services.

If you are not reimbursed from any third party because

you knowingly chose not to apply for, or to reject,

or to waive coverage, then you will be responsible for

payment of all expenses for services rendered on

account of such injury or illness. In addition, you will

be obligated to fully cooperate with us in any attempts

to recover such expenses from your employer if your

employer failed to take the steps required by law or

regulation to obtain such coverage.

GSA-PMT(01)-A 1/16

Coordination of Benefits

This section applies if you are covered under another

plan besides this health plan and determines how the

benefits under the plans will be coordinated. If you

are covered by more than one health benefit plan, you

should file all claims with each plan.

A. Definitions

For the purposes of this section, the following

terms have the meanings set forth below them:

Plan

Any of the following that provides benefits or

services for medical care or treatment:

Group insurance and/or group-type coverage,

whether insured or self-insured, which neither

can be purchased by the general public nor is

individually underwritten, including closed

panel coverage;

Coverage under Medicare and other

governmental benefits as permitted by law,

excepting Medicaid and Medicare supplement

policies;

Medical benefits coverage of group, group-type,

and individual automobile contracts.

Each type of coverage you have in these three (3)

categories shall be treated as a separate Plan. Also,

if a Plan has two parts and only one part has

coordination of benefit rules, each of the parts shall

be treated as a separate Plan.

Closed Panel Plan

A Plan that provides health benefits primarily in

the form of services through a panel of employed

or contracted providers and that limits or excludes

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VI. Other Sources of Payment

for Services and Supplies

benefits provided by providers outside of the panel,

except in the case of emergency or if referred by a

provider within the panel.

Primary Plan

The Plan that determines and provides or pays

its benefits without taking into consideration the

existence of any other Plan.

Secondary Plan

A Plan that determines and may reduce its benefits

after taking into consideration the benefits provided

or paid by the Primary Plan. A Secondary Plan

may also recover the Reasonable Cash Value of any

services it provided to you from the Primary Plan.

Allowable Expense

The amount of charges considered for payment

under the plan for a Covered Service prior to

any reductions due to coinsurance, copayment or

deductible amounts. If the Healthplan contracts

with an entity to arrange for the provision of

Covered Services through that entity's contracted

network of health care providers, the amount

that the Healthplan has agreed to pay that entity

is the allowable amount used to determine your

coinsurance or deductible payments. If the Plan

provides benefits in the form of services, the

Reasonable Cash Value of each service is the

Allowable Expense and is a paid benefit.

Examples of expenses or services that are not an

Allowable Expense include, but are not limited to

the following:

1. An expense or service or a portion of an

expense or service that is not covered by any of

the Plans is not an Allowable Expense.

2. If you are confined to a private hospital room

and no Plan provides coverage for more than

the semi-private room, the difference in cost

between the private and semi-private rooms in

not an Allowable Expense.

3. If you are covered by two or more Plans that

provide services or supplies on the basis of

usual and customary fees, any amount in excess

of the highest usual and customary fee is not an

Allowable Expense.

4. If you are covered by one Plan that provides

services or supplies on the basis of usual and

customary fees and one Plan that provides

services and supplies on the basis of negotiated

fees, the Primary Plan's fee arrangement shall

be the Allowable Expense.

5. If your benefits are reduced under the Primary

Plan (through the imposition of a higher

copayment amount, higher coinsurance

percentage, a deductible and/or a penalty)

because you did not comply with Plan

provisions or because you did not use a

preferred provider, the amount of the reduction

is not an Allowable Expense. Examples of Plan

provisions are second surgical opinions and

pre-certification of admissions or services.

Claim Determination Period

A calendar year, but it does not include any part of

a year during which you are not covered under this

Agreement or any date before this section or any

similar provision takes effect.

Reasonable Cash Value

An amount which a duly licensed provider of health

care services usually charges patients and which

is within the range of fees usually charged for the

same service by other health care providers located

within the immediate geographic area where the

health care service is rendered under similar or

comparable circumstances.

B. Order of Benefit Determination Rules

A Plan that does not have a coordination of benefits

rule consistent with this section shall always be the

Primary Plan. If the Plan does have a coordination

of benefits rule consistent with this section, the first

of the following rules that applies to the situation is

the one to use:

1. The Plan that covers you as a Subscriber or an

employee shall be the Primary Plan and the

Plan that covers you as a Dependent shall be

the Secondary Plan;

2. If you are a Dependent child whose parents are

not divorced or legally separated, the Primary

Plan shall be the Plan which covers the parent

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VI. Other Sources of Payment

for Services and Supplies

whose birthday falls first in the calendar year as

a Subscriber or employee;

3. If you are the Dependent of divorced or

separated parents, benefits for the Dependent

shall be determined in the following order:

a. first, if a court decree states that one parent

is responsible for the child's health care

expenses or health coverage and the Plan

for that parent has actual knowledge of the

terms of the order, but only from the time

of actual knowledge;

b. then, the Plan of the parent with custody of

the child;

c. then, the Plan of the spouse of the parent

with custody of the child;

d. then, the Plan of the parent not having

custody of the child, and

e. finally, the Plan of the spouse of the parent

not having custody of the child.

4. The Plan that covers you as an active employee

(or as that employee's Dependent) shall be

the Primary Plan and the Plan that covers you

as a laid-off or retired employee (or as that

employee's Dependent) shall be the Secondary

Plan. If the other Plan does not have a similar

provision and, as a result, the Plans cannot

agree on the order of benefit determination, this

paragraph shall not apply.

5. The Plan that covers you under a right of

continuation which is provided by federal or

state law shall be the Secondary Plan and the

Plan that covers you as an active employee

or retiree (or as that employee's Dependent)

shall be the Primary Plan. If the other Plan does

not have a similar provision and, as a result,

the Plans cannot agree on the order of benefit

determination, this paragraph shall not apply.

6. If one of the Plans that covers you is issued out

of the state whose laws govern this Agreement

and determines the order of benefits based

upon the gender of a parent, and as a result,

the Plans do not agree on the order of benefit

determination, the Plan with the gender rules

shall determine the order of benefits.

If none of the above rules determines the order

of benefits, the Plan that has covered you for the

longer period of time shall be primary.

When coordinating benefits with Medicare, this

Plan will be the Secondary Plan and determine

benefits after Medicare, where permitted by the

Social Security Act of 1965, as amended. However,

when more than one Plan is secondary to Medicare,

the benefit determination rules identified above,

will be used to determine how benefits will be

coordinated.

C. Effect on the Benefits of this Agreement

If we are the Secondary Plan, we may reduce

benefits so that the total benefits paid by all Plans

during a Claim Determination Period are not more

than one hundred (100%) percent of the total of all

Allowable Expenses.

The difference between the benefit payments that

we would have paid had we been the Primary Plan

and the benefit payments that we actually paid as

the Secondary Plan shall be recorded as a benefit

reserve for you. We will use this benefit reserve

to pay any Allowable Expense not otherwise paid

during the Claim Determination Period.

As to each claim that is submitted, we shall

determine the following:

1. Our obligation to provide Services and Supplies

under this Agreement;

2. Whether a benefit reserve has been recorded for

you; and

3. Whether there are any unpaid Allowable

Expenses during the Claim Determination

Period.

If there is a benefit reserve, we shall use the benefit

reserve recorded for you to pay up to one hundred

(100%) percent of the total of all Allowable

Expenses. At the end of the Claim Determination

Period, your benefit reserve shall return to zero (0)

and a new benefit reserve shall be calculated for

each new Claim Determination Period.

D. Recovery of Excess Benefits

If we provide Services and Supplies that should

have been paid by the Primary Plan or if we

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VI. Other Sources of Payment

for Services and Supplies

provide services in excess of those for which we

are obligated to provide under this Agreement,

we shall have the right to recover the actual

payment made or the Reasonable Cash Value of any

services.

We shall have the sole discretion to seek such

recovery from any person to, or for whom, or with

respect to whom, such services were provided or

such payments were made; any insurance company;

health care Plan or other organization. If we

request, you shall execute and deliver to us such

instruments and documents as we determine are

necessary to secure its rights.

E. Right to Receive and Release Information

We, without consent of or notice to you, may obtain

information from and release information to any

Plan with respect to you in order to coordinate your

benefits pursuant to this section. You shall provide

us with any information we request in order to

coordinate your benefits pursuant to this section.

F. Coordination of Benefits with Medicare

If you, your spouse, or your Dependent are covered

under this Plan and qualify for Medicare, federal

law determines which plan is the primary payer and

which is the secondary payer. The primary payer

always determines covered benefits first, without

considering what any other coverage will pay. The

secondary payer determines its coverage only after

the primary plan has completed its determination.

When Medicare is the Primary Payer

Medicare will be the primary payer and this Plan

will be the secondary payer, even if you don't elect

to enroll in Medicare or you receive services from a

provider who does not accept Medicare payments,

in the following situations:

COBRA or State Continuation: You, your

spouse, or your covered Dependent qualify for

Medicare for any reason and are covered under

this Plan due to COBRA or state continuation of

coverage.

Retirement or Termination of Employment:

You, your spouse, or your covered Dependent

qualify for Medicare for any reason and are

covered under this Plan due to your retirement

or termination of employment.

Disability: You, your spouse, or your covered

Dependent qualify for Medicare due to a

disability, you are an active Employee, and your

Employer has fewer than 100 employees.

Age: You, your spouse, or your covered

Dependent qualify for Medicare due to age, you

are an active Employee, and your Employer has

fewer than 20 employees.

End Stage Renal Disease (ESRD): You, your

spouse, or your covered Dependent qualify

for Medicare due to End Stage Renal Disease

(ESRD) and you are an active or retired

Employee. This plan will be the primary payer

for the first 30 months. Beginning with the 31st

month, Medicare will be the primary payer.

When This Plan is the Primary Payer

This Plan will be the primary payer and Medicare

will be the secondary payer in the following

situations:

Disability: You, your spouse, or your covered

Dependent qualify for Medicare due to a

disability, you are an active Employee, and your

Employer has 100 or more employees.

Age: You, your spouse, or your covered

Dependent qualify for Medicare due to age, you

are an active Employee, and your Employer has

20 or more employees.

End Stage Renal Disease (ESRD): You, your

spouse, or your covered Dependent qualify

for Medicare due to End Stage Renal Disease

(ESRD) and you are an active or retired

Employee. This plan is the primary payer for

the first 30 months. Beginning with the 31st

month, Medicare will be the primary payer.

Domestic Partners

Under federal law, when Medicare coverage is

due to age, Medicare is always the primary payer

and this Plan is the secondary payer for a person

covered under this Plan as a Domestic Partner.

However, when Medicare coverage is due to

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VI. Other Sources of Payment

for Services and Supplies

disability, the Disability payer explanations above

will apply.

IMPORTANT: If you, your spouse, or your

Dependent do not elect to enroll in Medicare

Parts A and/or B when first eligible, or you

receive services from a provider who does

not accept Medicare payments, this Plan will

calculate payment based on what should have

been paid by Medicare as the primary payer if

the person had been enrolled or had received

services from a provider who accepts Medicare

payments. A person is considered eligible for

Medicare on the earliest date any coverage

under Medicare could become effective.

Failure to Enroll in Medicare

If you, your spouse, or your Dependent do not

enroll in Medicare Parts A and/or B during the

person's initial Medicare enrollment period, or

the person opts out of coverage, the person may

be subject to Medicare late enrollment penalties,

which can cause a delay in coverage and result in

higher Medicare premiums when the person does

enroll. It can also result in a reduction in coverage

under Medicare Parts A and B. If you are planning

to retire or terminate employment and you will

be eligible for COBRA, state Continuation, or

retiree coverage under this Plan, you should enroll

in Medicare before you terminate employment

to avoid penalties and to receive the maximum

coverage under Medicare. Please consult Medicare

or the Social Security Administration for more

information.

Assistance with Medicare Questions

For more information on Medicare's rules

and regulations, contact Medicare toll-free

at 1-800-MEDICARE (1-800-633-4227) or

at www.medicare.gov. You may also contact

the Social Security Administration toll-free at

1-800-772-1213, at www.ssa.gov, or call your local

Social Security Administration office.

GSA-PMT(02)-B 1/20

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VII. Termination of Your Coverage

Section VII. Termination of Your Coverage

We may terminate your coverage for any of the reasons

stated below.

Termination For Cause

Upon written notice to the Group and you, we may

terminate your coverage or your Membership Unit's

coverage for cause if any of the following events occur:

1. You omit, misrepresent, or provide materially

false information in the Enrollment Application;

in which case, we may render coverage of a

Membership Unit to be null and void from the

effective date of coverage;

2. You permit a non-Member to use your Cigna

HealthCare ID card or to falsely obtain services and

supplies;

3. You obtain or attempt to obtain services and

supplies by means of false, misleading or

fraudulent information, acts or omissions;

4. You fail to pay any Copayment, or any other

amount due as a result of receiving services and

supplies;

5. You fail to establish a satisfactory Physician/patient

relationship with any Participating Physician after

we assist you in establishing such a relationship;

6. Your behavior, in our sole opinion, is disruptive,

unruly, abusive or uncooperative to such an extent

that we are seriously impaired in our ability to

provide services to you or to any other Member; or

7. You threaten the life or wellbeing of any

Healthplan employee, Participating Provider, or

another Member.

In no event, however, will we terminate your coverage

due to health status or utilization of services and

supplies.

Termination By Reason of Ineligibility

When you fail to meet the eligibility criteria in "Section

II. Enrollment and Effective Date of Coverage" as

either a Subscriber or Dependent, your coverage

under this Agreement shall cease. Coverage of all

Members within a Membership Unit shall cease when

the Subscriber fails to meet the eligibility criteria. The

Group shall notify us of all Members who fail to meet

the eligibility criteria.

Unless otherwise provided by law, if you fail to meet

the eligibility criteria your coverage shall cease at

midnight of the day that the loss of eligibility occurs,

and we shall have no further obligation to provide

Services and Supplies.

Termination By Termination of This Agreement

This Agreement may be terminated for any of the

following reasons:

1. Termination for Non-Payment of Fees. We may

terminate this Agreement for the Group's non-

payment of any Prepayment Fees owed to us.

2. Termination on Notice. The Group, without cause,

may terminate this Agreement upon sixty (60) days

prior written notice to us. We, without cause, may

terminate this Agreement upon either: (i) ninety

(90) days prior written notice to the Group of our

decision to discontinue offering this particular type

of coverage; or (ii) one hundred eighty (180) days

prior written notice to the Group of our decision to

discontinue offering all coverage in the applicable

market. If coverage is terminated in accordance

with (i) above, the Group may purchase a type of

coverage currently being offered in that market.

3. Termination for Fraud or Misrepresentation. We

may terminate this Agreement upon thirty (30) days

prior written notice to the Group if, at any time, we

determine that the Group has performed an act or

practice that constitutes fraud or has intentionally

misrepresented a material fact.

4. Termination for Violation of Contribution or

Participation Rules. We may terminate this

Agreement upon thirty (30) days prior written

notice to the Group if, after the initial twelve

(12) month or other specified time period, it is

determined that the Group is not in compliance

with the participation and/or contribution

requirements as established by us.

5. Termination Due to Association Membership

Ceasing. If this Agreement covers an association,

we may terminate this Agreement in accordance

with applicable state or federal law as to a member

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VII. Termination of Your Coverage

of a bona fide association if the member is no

longer a member of the bona fide association.

6. Termination in Accordance with State and/or

Federal law. We may terminate this Agreement

upon prior notice to the Group in accordance with

any applicable state and/or federal law.

Termination Effective Date. Coverage under this

Agreement shall terminate at midnight of the date of

termination provided in the written notice, except in the

case of termination for non-payment of fees, in which

case this Agreement shall terminate immediately upon

our notice to the Group.

Notice of Termination to Members. If this Agreement

is terminated for any reason in this section, the Group

shall notify you of the termination effective date and

any applicable rights you may have.

Responsibility for Payment. The Group shall be

responsible for the payment of all Prepayment Fees due

through the date on which coverage ceases. You shall

be financially responsible for all services rendered after

that date. The Group shall be responsible for providing

appropriate notice of cancellation to all Members in

accordance with applicable state law. If the Group fails

to give written notice to you prior to such date, the

Group shall also be financially responsible for, and

shall submit to us, all Prepayment Fees due until such

date as the Group gives proper notice.

Rescissions

Your coverage may not be rescinded (retroactively

terminated) by the Healthplan or the plan sponsor

unless: (1) the plan sponsor or an individual (or a

person seeking coverage on behalf of the individual)

performs an act, practice or omission that constitutes

fraud; or (2) the plan sponsor or individual (or a person

seeking coverage on behalf of the individual) makes an

intentional misrepresentation of material fact.

Certification of Creditable Coverage Upon Termination

We will issue you a Certification of Creditable Group

Health Plan Creditable Coverage as required by law

and based on information provided to us by the Group

at the following times:

1. When your coverage is terminated for cause or by

reason of ineligibility or you otherwise become

covered under "Section VIII. Continuation of

Coverage";

2. When your continuation coverage, if you elected to

receive it, is exhausted;

3. When you make a request within twenty-four (24)

months after the date coverage expires under either

of the above two situations; and

4. When you make a request while you are covered

under this Agreement.

GSA-TERM(01)-B 10/10

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VIII. Continuation of Coverage

Section VIII. Continuation of Coverage

Continuation of Group Coverage under COBRA

Introduction

This notice contains important information about your

right to COBRA continuation coverage, which is a

temporary extension of coverage under the Plan. The

right to COBRA continuation coverage was created

by a federal law, the Consolidated Omnibus Budget

Reconciliation Act of 1985 (COBRA). COBRA

continuation coverage can become available to you

and to other members of your family who are covered

under the Plan when you would otherwise lose your

group health coverage. This notice generally explains

COBRA continuation coverage, when it may become

available to you and your family, and what you need

to do to protect the right to receive it. This notice

gives only a summary of your COBRA continuation

coverage rights. For more information about your

rights and obligations under the Plan and under federal

law, you should either review the Plan's Summary Plan

Description or get a copy of the Plan Document from

the Plan Administrator.

The Plan Administrator information is provided on

the page titled "ERISA Summary Plan Description,"

if applicable. Please contact the Plan Administrator

for the name, address and phone number of the Plan's

COBRA Administrator.

COBRA Continuation Coverage

COBRA continuation coverage is a continuation of

Plan coverage when coverage would otherwise end

because of a life event known as a "qualifying event."

Specific qualifying events are listed later in this notice.

COBRA continuation coverage must be offered to each

person who is a "qualified beneficiary." A qualified

beneficiary is someone who will lose coverage under

the Plan because of a qualifying event. Depending on

the type of qualifying event, employees, spouses of

employees and dependent children of employees may

be qualified beneficiaries. Under the Plan, qualified

beneficiaries who elect COBRA continuation coverage

must pay for COBRA continuation coverage.

If you are an employee, you will become a qualified

beneficiary if you will lose your coverage under the

Plan because either one of the following qualifying

events happens:

1) Your hours of employment are reduced, or

2) Your employment ends for any reason other than

your gross misconduct.

If you are the spouse of an employee, you will become

a qualified beneficiary if you will lose your coverage

under the Plan because any of the following qualifying

events happens:

1) Your spouse dies;

2) Your spouse's hours of employment are reduced;

3) Your spouse's employment ends for any reason

other than his or her gross misconduct;

4) Your spouse becomes enrolled in Medicare (Part A,

Part B, or both); or

5) You become divorced or legally separated from

your spouse.

Your dependent children will become qualified

beneficiaries if they will lose coverage under the

Plan because any of the following qualifying events

happens:

1) The parent-employee dies;

2) The parent-employee's hours of employment are

reduced;

3) The parent-employee's employment ends for any

reason other than his or her gross misconduct;

4) The parent-employee becomes enrolled in

Medicare (Part A, Part B, or both);

5) The parents become divorced or legally separated;

6) The child stops being eligible for coverage under

the Plan as a "dependent child."

If the Plan provides retiree health coverage

Sometimes, filing a proceeding in bankruptcy under

title 11 of the United States Code can be a qualifying

event. If a proceeding in bankruptcy is filed with

respect to your employer, and that bankruptcy results

in the loss of coverage of any retired employee

covered under the Plan, the retired employee is a

qualified beneficiary with respect to the bankruptcy.

The retired employee's spouse, surviving spouse and

SAMPLE DOCUMENT

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VIII. Continuation of Coverage

dependent children will also be qualified beneficiaries

if bankruptcy results in the loss of their coverage under

the Plan. Coverage will continue until: (a) for you, your

death; and (b) for your Dependent surviving spouse or

Dependent child, up to 36 months from your death.

The Plan will offer COBRA continuation coverage

to qualified beneficiaries only after the Plan

Administrator has been notified that a qualifying

event has occurred. When the qualifying event is

the end of employment or reduction of hours of

employment, death of the employee, enrollment of the

employee in Medicare (Part A, Part B, or both), or, if

the Plan provides retiree coverage, commencement of a

proceeding in bankruptcy with respect to the Employer,

the employer must notify the Plan Administrator of the

qualifying event within 30 days of any of these events.

For the other qualifying events (divorce or legal

separation of the employee and spouse or a

dependent child's losing eligibility for coverage

as a dependent child), you must notify the Plan

Administrator. The Plan requires you to notify

the Plan Administrator within 60 days after the

qualifying event occurs. You must send this notice to

your Employer.

Once the Plan Administrator receives notice that a

qualifying event has occurred, COBRA continuation

coverage will be offered to each of the qualified

beneficiaries. For each qualified beneficiary who elects

COBRA continuation coverage, COBRA continuation

coverage will begin on the date of the qualifying event.

COBRA continuation coverage is a temporary

continuation of coverage. When the qualifying event is

the death of the employee, enrollment of the employee

in Medicare (Part A, Part B, or both), your divorce

or legal separation, or a dependent child losing

eligibility as a dependent child, COBRA continuation

coverage lasts for up to 36 months from the date of the

qualifying event.

When the qualifying event is the end of employment or

reduction of the employee's hours of employment,

COBRA continuation coverage lasts for up to 18

months from the date of the qualifying event. There are

two ways in which this 18-month period of COBRA

continuation coverage can be extended.

Disability extension of 18-month period of continuation

coverage

If you or anyone in your family covered under the

Plan is determined by the Social Security

Administration to be disabled at any time during

the first 60 days of COBRA continuation coverage

and you notify the Plan Administrator in a timely

fashion, you and your entire family can receive up

to an additional 11 months of COBRA continuation

coverage, for a total maximum of 29 months from

the date of the initial qualifying event. You must

make sure that the Plan Administrator is notified of

the Social Security Administration's determination

within 60 days of the date of the determination

and before the end of the 18-month period of

COBRA continuation coverage. This notice should

be sent to the Plan Administrator. You must provide

a copy of the Social Security Administration's

determination. Termination of coverage for all

covered persons during the additional 11 months

will occur if the disabled person is found by the

Social Security Administration to be no longer

disabled. Termination for this reason will occur on

the first day of the month beginning no more than

30 days after the date of the final determination.

Please refer to "Early Termination of COBRA

Continuation" below for additional circumstances

under which COBRA continuation may terminate

before the end of the maximum period of coverage.

Second qualifying event extension of 18-month period

of continuation coverage

If your family experiences another qualifying event

while receiving COBRA continuation coverage, the

spouse and dependent children in your family can get

additional months of COBRA continuation coverage,

up to a maximum of 36 months from the initial

qualifying event. This extension is available to the

spouse and dependent children if the former employee

dies, enrolls in Medicare (Part A, Part B, or both), or

gets divorced or legally separated. The extension is also

available to a dependent child when that child stops

being eligible under the Plan as a dependent child. In

all of these cases, you must make sure that the Plan

Administrator is notified of the second qualifying

event within 60 days of the second qualifying event.

This notice must be sent to the Plan Administrator.

SAMPLE DOCUMENT

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VIII. Continuation of Coverage

Early Termination of COBRA Continuation

Continuation coverage will be terminated before the

end of the maximum period if any required premium

is not paid on time, if a qualified beneficiary becomes

covered under another group health plan that does

not impose any pre-existing condition exclusion for

a pre-existing condition of the qualified beneficiary,

if a covered employee enrolls in Medicare, or if the

employer ceases to provide any group health plan for

its employees. Continuation coverage may also be

terminated for any reason the Plan would terminate

coverage of a participant or beneficiary not receiving

continuation coverage (such as fraud).

Cost of COBRA Continuation Coverage

Generally, each qualified beneficiary may be required

to pay the entire cost of continuation coverage. The

amount a qualified beneficiary may be required to

pay may not exceed 102% of the cost to the group

health plan (including both employer and employee

contributions) for coverage of a similarly situated

plan participant or beneficiary who is not receiving

continuation coverage (or, in the case of an extension

of continuation coverage due to a disability, 150%).

If you or your dependents experience a qualifying

event, the Plan Administrator will send you a notice

of continuation rights, which will include the required

premium.

The Trade Act of 2002 created a new tax credit for

certain individuals who become eligible for trade

adjustment assistance (eligible individuals). Under

the new tax provisions, eligible individuals can either

take a tax credit or get advance payment of 65% of

premiums paid for qualified health insurance, including

continuation coverage. If you have questions about

these new tax provisions, you may call the Health

Care Tax Credit Customer Contact Center toll-free

at 1-866-628-4282. TTD/TTY callers may call toll-

free at 1-866-626-4282. More information about

the Trade Act is also available at www.doleta.gove/

tradeact/2002act_index.asp.

Conversion Available Following Continuation

If the Plan provides for a conversion privilege, the plan

must offer this option within 180 days following the

maximum period of continuation. However, no

conversion will be provided if the qualified beneficiary

does not maintain COBRA continuation coverage for

the maximum allowable period or does not otherwise

meet the eligibility requirements for a conversion plan.

Service Area Restrictions

This plan includes a service area restriction which

requires that all enrolled participants and beneficiaries

receive services in the Employer's service area. This

restriction also applies to COBRA continuation

coverage. If you or your Dependents move outside

the Employer's service area, COBRA continuation

coverage under your current plan in your new location

will be limited to emergency services only. To obtain

coverage for non-emergency services, you must

obtain such services from a network provider in the

Employer's service area. If your Employer offers

other benefit options that are available in your new

location, you may be allowed to obtain COBRA

continuation coverage under that option. If you or your

Dependent is moving outside the Employer's service

area, please contact your Employer for information on

the availability of other plan options.

If You Have Questions

If you have questions about your COBRA continuation

coverage, you should contact the Plan Administrator, or

you may contact the nearest Regional or District Office

of the U.S. Department of Labor's Employee Benefits

Security Administration (EBSA). Addresses and phone

numbers of Regional and District EBSA Offices are

available through EBSA's website at www.dol.gov/

ebsa.

Keep Your Plan Informed of Address Changes

In order to protect your family's rights, you should

keep the Plan Administrator informed of any

changes in the addresses of family members. You

should also keep a copy, for your records, of any

notices you send to the Plan Administrator.

IMPORTANT NOTICE

COBRA BENEFITS WILL ONLY BE

ADMINISTERED ACCORDING TO THE TERMS

OF THE CONTRACT. THE HEALTHPLAN WILL

NOT BE OBLIGATED TO ADMINISTER OR

SAMPLE DOCUMENT

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VIII. Continuation of Coverage

FURNISH ANY COBRA BENEFITS AFTER THE

CONTRACT HAS TERMINATED.

GSA-CONT(01)-A 1/05

Conversion to Non-Group (Individual) Coverage

If you have properly elected and completed any

COBRA continuation or other continuation coverage

(i.e. completed the maximum coverage period under

the continuation coverage), and are not eligible for

other individual insurance coverage on a guarantee

issue basis, you may apply to the Healthplan for

conversion to non-group (individual) coverage.

If you do not elect, fail to properly elect or fail to

complete any COBRA continuation coverage or other

continuation coverage for which you are eligible,

and are eligible for other individual coverage on

a guarantee issue basis, conversion to non-group

coverage is not available to you.

You must continue to reside in the Service Area in

order to be eligible for non-group (individual)

coverage. You may apply for non-group (individual)

coverage as follows:

A. Conversion After Loss of Subscriber Eligibility

If you, as the Subscriber, are no longer eligible

for coverage under this Agreement for any

reason other than the reasons stated in the

"Termination for Cause" or "Termination By

Termination of Agreement" provisions of "Section

VII. Termination of Your Coverage," and are

not eligible for other individual coverage on

a guarantee issue basis, you may apply for

conversion to non-group (individual) coverage.

You must apply and pay the applicable prepayment

fee within thirty-one (31) days of the loss of group

coverage. At the time of conversion to non-group

(individual) coverage, you may also apply for

non-group (individual) coverage for Dependents

who were Members at the time of your loss of

eligibility. If your application and all non-group

fees, including all fees for the period since the

termination of group coverage, are submitted

within thirty-one (31) days of the loss of group

coverage, your non-group (individual) coverage

will be effective as of the date of such termination.

B. Conversion Upon Death or Divorce of

Subscriber

If you are a Dependent who has lost eligibility for

coverage under this Agreement due to the death

or divorce of the Subscriber, and are not eligible

for other individual coverage on a guarantee issue

basis, you may apply for conversion to non-group

(individual) coverage under the provisions of

paragraph A of this section.

C. Conversion Upon Meeting Age Limitation

If you are a Dependent who has lost eligibility for

coverage under this Agreement due to your

attainment of an age limitation identified in the

Agreement, and are not eligible for individual

coverage on a guarantee issue basis, you may apply

for conversion to non-group (individual) coverage

under the provisions of paragraph A of this section.

D. Conversion After Expiration of COBRA or

Other Continuation Coverage

A Member whose COBRA or other continuation

coverage has expired after the maximum coverage

period, and are not eligible for other individual

coverage on a guarantee issue basis, may apply

for conversion to non-group (individual) coverage

under the provisions of paragraph A of this section.

The services and supplies, terms and conditions

of the non-group (individual) coverage, including

premiums, Copayments and deductibles, if any, shall

be in accordance with the rules of Healthplan in effect

at the time of conversion and will not necessarily be

identical to the services and supplies provided under

this Agreement.

Continuation of Coverage Under FMLA

If the Group is subject to the requirements of the

federal law known as the Family and Medical Leave

Act of 1993, as amended (FMLA), the Subscriber shall

have coverage under this Agreement during a leave of

absence if the Subscriber is an eligible employee under

the terms of FMLA and the leave of absence qualifies

as a leave of absence under FMLA.

In such a case, the Subscriber shall pay to the Group

the portion of the Prepayment Fee, if any, that the

Subscriber would have paid had the Subscriber not

taken leave and the Group shall pay the Healthplan the

SAMPLE DOCUMENT

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VIII. Continuation of Coverage

Prepayment Fee for the Subscriber as if the Subscriber

had not taken leave.

NOTICE OF FEDERAL REQUIREMENTS -

UNIFORMED SERVICES EMPLOYMENT AND

REEMPLOYMENT RIGHTS ACT OF 1994

(USERRA)

The Uniformed Services Employment and

Reemployment Rights Act of 1994 (USERRA) sets

requirements for continuation of health coverage and

re-employment in regard to military leaves of absence.

These requirements apply to medical coverage for you

and your Dependents.

Continuation of Coverage

You may continue coverage for yourself and your

Dependents as follows:

You may continue benefits, by paying the required

premium to your employer, until the earliest of the

following:

24 months from the last day of employment with

the employer;

the day after you fail to apply or return to work;

and

the date the policy cancels.

Your employer may charge you and your Dependents

up to 102% of the total premium.

Following continuation of health coverage per

USERRA requirements, you may convert to a plan

of individual coverage according to any "Conversion

Privilege" shown in your Agreement.

Reinstatement of Benefits

If your coverage ends during the leave because you do

not elect USERRA, or an available conversion plan at

the expiration of USERRA, and you are reemployed

by your current employer, coverage for you and your

Dependents may be reinstated if, (a) you gave your

employer advance written or verbal notice of your

military service leave, and (b) the duration of all

military leaves while you are employed with your

current employer does not exceed 5 years.

You and your Dependents will be subject to only the

balance of a Pre-existing Conditions Limitation (PCL)

or waiting period, if any, that was not yet satisfied

before the leave began. However, if an injury or

sickness occurs or is aggravated during the military

leave, full plan limitations will apply.

Any 63-day break in coverage rule regarding credit

for time accrued toward a PCL waiting period will be

waived.

GSA-CONT(02)-C 1/16

SAMPLE DOCUMENT

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IX. Miscellaneous

Section IX. Miscellaneous

Additional Programs

We may, from time to time, offer or arrange for

various entities to offer discounts, benefits or other

consideration to our Members for the purpose of

promoting the general health and well being of our

Members. We may also arrange for the reimbursement

of all or a portion of the cost of services provided

by other parties to the Group. Contact us for details

regarding any such arrangements.

Administrative Policies Relating to this Agreement

We may adopt reasonable policies, procedures, rules

and interpretations that promote orderly administration

of this Agreement.

Assignability

The benefits under this Agreement are not assignable

unless agreed to by the Healthplan. The Healthplan

may, at its option, make payment to the Subscriber

for any cost of any Covered Services and Supplies

received by the Subscriber or Subscriber's covered

Dependents from a non-Participating Provider. The

Subscriber is responsible for reimbursing the non-

Participating Provider.

Clerical Error

No clerical error on the part of the Healthplan shall

operate to defeat any of the rights, privileges or

benefits of any Member.

Entire Agreement

This Agreement constitutes the entire Agreement

between the Healthplan, the Group, and Members and

supersedes any previous agreement. Only an officer of

the Healthplan has authority to waive any conditions

or restrictions of this Agreement, extend the time for

making payment, or bind the Healthplan by making

any promise or representation, or by giving or receiving

any information. No change in this Agreement shall

be valid unless stated in a Rider or an amendment

attached hereto signed by an officer of the Healthplan.

In the event of any direct conflict between information

contained in the Group Service Agreement and other

collaterals, the terms of the Group Service Agreement

shall govern.

No Implied Waiver

Failure by the Healthplan, the Group, or a Member

to avail themselves of any right conferred by this

Agreement shall not be construed as a waiver of that

right in the future.

Notice

The Healthplan, the Group, and the Member shall

provide all notices under this Agreement in writing,

which shall be hand-delivered or mailed, postage pre-

paid, through the United States Postal Service to the

addresses set forth on the Cover Sheet.

Records

The Healthplan maintains records regarding Members,

but the Healthplan shall not be liable for any obligation

dependent upon information from the Group prior to

receipt by the Healthplan in a form satisfactory to the

Healthplan. Incorrect information furnished by the

Group may be corrected, if the Healthplan shall not

have acted to its prejudice by relying on it. All records

of the Group and the Healthplan that have a bearing on

coverage of a Member shall be open for review by the

Healthplan, the Group or the Member at any reasonable

time.

Service Marks

The Cigna HealthCare 24 Hour Health Information

Line

and Cigna LifeSOURCE Transplant Network®

are registered service marks of Cigna Corporation.

Severability

If any term, provision, covenant or condition of this

Agreement is held by a court of competent jurisdiction

to be invalid, void, or unenforceable, the remainder of

this Agreement shall remain in full force and effect and

shall in no way be affected, impaired, or invalidated.

Successors and Assigns

This Agreement shall be binding upon and shall inure

to the benefit of the successors and assigns of the

Group and the Healthplan, but shall not be assignable

by any Member.

GSA-MISC(01)-C 1/20

SAMPLE DOCUMENT

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Schedule of Copayments

THIS SCHEDULE OF COPAYMENTS IS A SUPPLEMENT TO THE GROUP SERVICE AGREEMENT

PROVIDED TO YOU AND IS NOT INTENDED AS A COMPLETE SUMMARY OF THE SERVICES AND

SUPPLIES COVERED OR EXCLUDED.

It is recommended that you review your Group Service Agreement for an exact description of the Services and Supplies

that are covered, those which are excluded or limited, and other terms and conditions of coverage.

Plan Deductible - The plan deductible amount and how it applies to Covered Services and Supplies is described on the

separate Deductible provision page.

Covered Services and Supplies

Copayments

Physician Services

Primary Care Physician Office visit

$XX Copayment per office visit

The office visit Copayment will be waived when

immunization is the only service provided

The office visit Copayment will be waived for

allergy injections

Specialty Care Physician Office Visit

Office Visits

Surgery Performed in the Physician's Office

$YY Copayment per office visit

The office visit Copayment will be waived for

allergy injections

Preventive Care Services

Well-Baby Care

Well-Child Care

Adult Care

Well-Woman Care

No Charge

SAMPLE DOCUMENT

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Schedule of Copayments

Covered Services and Supplies Copayments

Inpatient Hospital Services

Semi Private Room and Board

Laboratory, Radiology and other Diagnostic and

Therapeutic Services

Administered Drugs, Medications, Biologicals

and Fluids

Special Care Units

Operating Room, Recovery Room

Anesthesia

Inhalation Therapy

Radiation Therapy and Chemotherapy

$ZZZ Copayment per admission after Plan Deductible

The Inpatient Hospital Copayment will be waived

if you are readmitted to a Participating Hospital

or Skilled Nursing Facility for the same condition

within 10 - 30 days of a Hospital admission

Physician and Surgeon Charges No Charge

Outpatient Facility Services

Operating Room, Recovery Room,

Procedures Room, and Treatment Room

including:

Laboratory and Radiology Services

Administered Drugs, Medications, Biologicals

and Fluids

Anesthesia

Inhalation Therapy

$AAA Copayment per facility use after Plan

Deductible

Physician and Surgeon Charges No Charge

Emergency and Urgent Care Services

Physician's Office Same as Physician Office Visit Copayment

Hospital Emergency Room $BBB Copayment per visit

The emergency room Copayment will be waived if

you are admitted to a participating hospital directly

from the emergency room

Urgent Care Facility or Outpatient Facility $CC Copayment per visit

The urgent care facility Copayment will be waived if

you are admitted to a participating hospital directly

from the urgent care facility

Ambulance Services

No Charge

Diabetic Services and Supplies

SAMPLE DOCUMENT

Schedule of Copayments

Covered Services and Supplies

Copayments

Self Management Courses and Training

Same as Physician Office Visit Copayment

Supplies

(Provided under the Supplemental Prescription Drug

Pharmacy Rider if employer Group has purchased the

Rider)

Equipment

Same as Durable Medical Equipment Copayment per

item

Insulin

Provided under the Supplemental Prescription Drug

Pharmacy Rider if employer Group has purchased the

Rider

Durable Medical Equipment

No Charge

External Prosthetic Appliances and Devices

No Charge

Family Planning Services for Men

Office Visits (Tests, Counseling)

Same as Physician Office Visit Copayment

Surgical Sterilization Procedures

Same as Inpatient Hospital, Outpatient Facility or

Physician Office Visit Copayment, depending on

facility used

Family Planning Services for Women

Office Visits (Tests, Counseling)

No Charge

Surgical Sterilization Procedures

No Charge

Home Health Care Services

No Charge

60 day maximum per Member per Contract Year,

the limit is not applicable to Mental Health and

Substance Use Disorder conditions.

Maximum of 16 hours in total per day

Hospice Services

Inpatient Services

No Charge after Plan Deductible

Outpatient Services

No Charge

Inpatient Services at Other Participating Health

Care Facilities

60 days maximum per Member per Contract Year

myCigna.com

SAMPLE DOCUMENT

Schedule of Copayments

Covered Services and Supplies

Copayments

Rehabilitation Hospital

No Charge after Plan Deductible

Skilled Nursing Facility and Sub-Acute

Facilities

Outpatient Laboratory and Radiology Services

$DDD Copayment per Scan Type (charges include

all views per Scan Type per day) after Plan

Deductible

No Charge after Plan Deductible

No Charge

Advanced Radiological Imaging

(MRIs, MRAs, CAT scans, PET scans, etc.)

Other Laboratory and Radiology Services

Outpatient Hospital Facility

Independent Facility

Maternity Care Services

Same as Physician's Office Visit Copayment

No Charge

Same as Inpatient Hospital

Initial Office Visit to Confirm Pregnancy

All Other Office Visits

Delivery

Mental Health**

Same as Inpatient Hospital

$XX Copayment per office visit

No Charge after Plan Deductible

Inpatient Services

(i.e. acute inpatient and residential treatment)

Outpatient Services

Office Visit

(i.e. individual, family and group

psychotherapy, medication management, and

Virtual Care Behavioral consultation, etc.)

All Other Outpatient Services

(i.e. partial hospitalization, intensive

outpatient services, and Virtual Care

Behavioral consultation, etc.)

Substance Use Disorder**

myCigna.com

SAMPLE DOCUMENT

Schedule of Copayments

Covered Services and Supplies

Copayments

Inpatient Services

Same as Inpatient Hospital

(i.e. acute inpatient detoxification, acute inpatient

rehabilitation and residential treatment)

Outpatient Services

Office Visit

$XX Copayment per office visit

(i.e. individual, family and group

psychotherapy, medication management, and

Virtual Care Behavioral consultation, etc.)

All Other Outpatient Services

(i.e. partial hospitalization, intensive

outpatient services, and Virtual Care

Behavioral consultation, etc.)

No Charge after Plan Deductible

Nutritional Evaluation

No Charge

3 visit maximum per Member per Contract Year

Visit limit will not apply to the treatment of

diabetes and/or to Mental Health and Substance

Use Disorder conditions

Genetic Counseling

Same as Physician’s Office Visit Copayment

3 visits per person for Genetic Counseling for

both pre- and post-genetic testing; however, the

3 visit limit will not apply to Mental Health and

Substance Use Disorder conditions

Gene Therapy

Includes prior authorized gene therapy products and

services directly related to their administration, when

Medically Necessary

Gene therapy must be received at an In-Network

facility specifically contracted with Cigna to provide

the specific gene therapy. Gene therapy at other In-

Network facilities is not covered.

Inpatient Services

Same as Inpatient Hospital Copayment

Outpatient Facility Services

Same as Outpatient Facility Services Copayment

myCigna.com

SAMPLE DOCUMENT

Schedule of Copayments

Covered Services and Supplies

Copayments

Operating Room, Recovery Room,

Procedures Room, and Treatment Room

including:

Laboratory and Radiology Services

Administered Drugs, Medications,

Biologicals and Fluids

Anesthesia

Inhalation Therapy

Office Visit

Same as Physician's Office Visit Copayment

Physician and Surgeon Charges

No Charge

Gene Therapy Travel Maximum

No Charge

$10,000 per episode of gene therapy

(available only for travel when approved by the

Healthplan Medical Director and received at a

facility that is designated by the Healthplan to

provide the specific gene therapy service)

Obesity Surgery & Treatment (Bariatric) Services

Lifetime Maximum $8,000 (applies to surgery

only)

Surgical Procedure

Place of Service copayment depending on facility

used

Other Treatment

Place of Service copayment depending on facility

used

Transplant Travel Services Maximum

$10,000 per transplant

Outpatient Therapy Services, Cardiac

$EE Copayment per office visit

Rehabilitation Services

Chiropractic Care Services

$FF Copayment per office visit

Services provided on an outpatient basis are

limited to a 30 day maximum per Member per

Contract Year

Virtual Care - Medical

$GG Copayment per office visit

myCigna.com

SAMPLE DOCUMENT

Schedule of Copayments

myCigna.com

Plan Deductible

Individual Deductible

$HHH

Family Deductible

$IIII

Plan Deductible - The following are not subject to the Plan Deductible provision. Copayments do not apply to the Plan

Deductible:

Office visits

Inpatient professional charges

Outpatient professional charges

Emergency and urgent care services

Ambulance services

Durable medical equipment

External prosthetic appliances

Home health care services; and

Hospice outpatient services

Total Copayment Maximum *

Individual Member Total Copayment Maximum

$JJJJ per Contract Year

Membership Unit Total Copayment Maximum

$KKKK per Contract Year

*All Copayments identified in this Schedule of Copayments and the Plan Deductible which have been paid by a Member

for Covered Services and Supplies apply to the Total Copayment Maximum. When the Total Copayment Maximum

shown above is reached, all Covered Services and Supplies, are payable by the benefit plan at 100%.

**Medical treatment required as a result of an emergency, such as a suicide attempt, will be considered a medical expense

until the medical condition is stabilized and will not count toward any plan limits that are shown in the Schedule for

mental health and substance use disorder services including in-hospital services. Once the medical condition is stabilized,

whether the treatment will be characterized as either a medical expense or a mental health/substance use disorder expense

will be determined by the Healthplan Medical Director in accordance with the applicable mixed services claim guidelines.

GSA-SOC-N 1/20

SAMPLE DOCUMENT

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Prescription Drug Rider

Supplemental Rider

Prescription Drugs

This Supplemental Rider is a part of the Cigna HealthCare

Inc. Group Service Agreement ("the Agreement") and

subject to all of the terms, conditions

and limitations contained therein. In consideration for an

additional monthly fee incorporated into the Prepayment

Fee, the following supplemental Prescription Drug benefit

is added to the Agreement.

I. Definitions

Biologic means a virus, therapeutic serum, toxin, antitoxin,

vaccine, blood, blood component or derivative, allergenic

product, protein (except any chemically synthesized

polypeptide), or analogous product, or arsphenamine or

derivative of arsphenamine (or any other trivalent organic

arsenic compound), used for the prevention, treatment,

or cure of a disease or condition of human beings, as

defined under Section 351(i) of the Public Health Service

Act (42 USC 262(i)) (as amended by the Biologics Price

Competition and Innovation Act of 2009, title VII of

the Patient Protection and Affordable Care Act, Pub. L.

No. 111-148, § 7002 (2010), and as may be amended

thereafter).

Biosimilar means a Biologic that is highly similar to

the reference Biologic product notwithstanding minor

differences in clinically inactive components, and has

no clinically meaningful differences from the reference

Biologic in terms of its safety, purity, and potency, as

defined under Section 351(i) of the Public Health Service

Act (42 USC 262(i)) (as amended by the Biologics Price

Competition and Innovation Act of 2009, title VII of

the Patient Protection and Affordable Care Act, Pub. L.

No. 111-148, § 7002 (2010), and as may be amended

thereafter).

Brand Drug means a Prescription Drug Product that the

Healthplan identifies as a Brand Drug product across its

book-of-business, principally based on available data

resources, including, but not limited to, First DataBank

or another nationally recognized drug indicator source,

that classify drugs or Biologics as either brand or generic

based on a number of factors. Not all products identified

as a "brand name" by the manufacturer, Pharmacy, or Your

Physician may be classified as a Brand Drug under the

Healthplan.

Business Decision Team means a committee comprised

of voting and non-voting representatives across various

business units such as clinical, medical and business

leadership that is duly authorized by the Healthplan

to make decisions regarding coverage treatment of

Prescription Drug Products or Medical Pharmaceuticals

based on clinical findings provided by the P&T

Committee, including, but not limited to, decisions

regarding tier placement and application of utilization

management to Prescription Drug Products or Medical

Pharmaceuticals.

Copayment means the amount shown in the Prescription

Drug Schedule of Copayments that you must pay for

Prescription Drug Products. The Copayment may be a

fixed dollar amount or a percentage the Healthplan charges

the group with respect to the Prescription Drug Charge for

a Prescription Drug Product.

Designated Pharmacy means a Network Pharmacy that

has entered into an agreement with the Healthplan, or

with an entity contracting on the Healthplan’s behalf, to

provide Prescription Drug Products or services, including,

without limitation, specific Prescription Drug Products, to

Healthplan enrollees on a preferred or exclusive basis. For

example, a Designated Pharmacy may provide enrollees

certain Specialty Prescription Drug Products that have

limited distribution availability, provide enrollees with an

extended days’ supply of Prescription Drug Products or

provide enrollees with Prescription Drug Products on a

preferred cost share basis. The fact that a Pharmacy is a

Network Pharmacy does not mean that it is a Designated

Pharmacy.

Generic Drug means a Prescription Drug Product that the

Healthplan identifies as a Generic Drug product at a

book-of-business level principally based on available data

resources, including, but not limited to, First DataBank

or another nationally recognized drug indicator source,

that classify drugs or Biologics (including Biosimilars) as

either brand or generic based on a number of factors. Not

all products identified as a "generic" by the manufacturer,

Pharmacy or Your Physician may be classified as a Generic

Drug under the Healthplan. A Biosimilar may be classified

as a Generic Drug for the purposes of benefits under the

Healthplan even if it is identified as a “brand name” drug

by the manufacturer, Pharmacy or Your Physician.

SAMPLE DOCUMENT

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Prescription Drug Rider

Home Delivery Pharmacy means a home delivery

Network Pharmacy owned and operated by licensed

Pharmacy affiliates of Cigna HealthCare Inc..

Maintenance Drug Product means a Prescription Drug

Product that is prescribed for use over an extended period

of time for the treatment of chronic or long-term conditions

such as asthma, hypertension, diabetes and heart disease,

and is identified principally based on consideration of

available data resources, including, but not limited to, First

DataBank or another nationally recognized drug indicator

source and clinical factors. For the purposes of benefits,

the list of Your Healthplan’s Maintenance Drug Products

does not include compounded medications, Specialty

Prescription Drug Products or Prescription Drug Products,

such as certain narcotics that a Pharmacy cannot dispense

above certain supply limits per Prescription Drug Order

or Refill under applicable federal or state law. You may

determine whether a drug is a Maintenance Drug Product

by calling member services at the telephone number on

Your ID card.

Medical Pharmaceutical means an FDA-approved

prescription pharmaceutical product, including a Specialty

Prescription Drug Product, typically required to be

administered in connection with a covered service by a

Physician or other health care provider within the scope

of the provider's license. This definition includes certain

pharmaceutical products whose administration may

initially or typically require Physician oversight but may be

self-administered under certain conditions specified in the

product’s FDA labeling. This definition does not include

any charges for mobile, web-based or other electronic

applications or software, even if approved for marketing as

a prescription product by the FDA.

Network Pharmacy means a retail or home delivery

Network Pharmacy that has:

Entered into an agreement with the Healthplan or

an entity contracting on the Healthplan’s behalf to

provide Prescription DrugProducts to Healthplan

enrollees.

Agreed to accept specified reimbursement rates for

dispensing Prescription Drug Products.

Been designated as a Network Pharmacy for the

purposes of coverage under your Healthplan.

New Prescription Drug Product means a Prescription

Drug Product, or new use or dosage form of a previously

FDA-approved Prescription Drug Product, for the period of

time starting on the date the Prescription Drug Product or

newly-approved use or dosage form becomes available on

the market following approval by the U.S. Food and Drug

Administration (FDA) and ending on the date the Business

Decision Team makes a Prescription Drug List coverage

status decision.

[Non-PPACA] Preventive Medications are certain

Prescription Drug Products used to prevent a disease that

has not yet manifested itself or not yet become clinically

apparent or to prevent the reoccurrence of a disease from

which a person has recovered, such as Prescription Drug

Products with demonstrated effectiveness in primary or

secondary disease prevention. The term Non-PPACA

Preventive Medication does not include medications

covered at 100% as required as preventive care services

by PPACA, the terms of coverage for which are addressed

separately in this plan.

Pharmacy means a duly licensed pharmacy that dispenses

Prescription Drug Products in a retail setting or via home

delivery. A home delivery Pharmacy is a Pharmacy that

primarily provides Prescription Drugs through Home

Delivery.

Pharmacy & Therapeutics (P&T) Committee means a

committee comprised of both voting and non-voting

clinicians, Medical Directors and Pharmacy Directors that

are employed by the Healthplan, and non-employees such

as Participating Providers that represent a range of clinical

specialties. The committee regularly reviews Prescription

Drug Products, including New Prescription Drug Products,

for safety and efficacy, the findings of which clinical

reviews inform coverage status decisions made by the

Business Decision Team. The P&T Committee’s review

may be based on consideration of, without limitation,

U.S. Food and Drug Administration-approved labeling,

standard medical reference compendia, or scientific studies

published in peer-reviewed English-language bio-medical

journals.

Prescription Drug List means a list that categorizes

Prescription Drug Products covered under the

Healthplan’s Prescription Drug Benefits into coverage

tiers. This list is

SAMPLE DOCUMENT

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Prescription Drug Rider

developed by Cigna based on

clinical factors communicated by the P&T Committee, and

adopted by the Group as part of the Healthplan. The list

is subject to periodic review and change, and is subject

to the limitations and exclusions of the Healthplan. You

may determine to which tier a particular Prescription

Drug Product has been assigned through the Internet at

www.mycigna.com or by calling customer service at the

telephone number on your ID card.

Prescription Drug Product means a drug, Biologic

(including a Biosimilar), or other product that has been

approved by the U.S. Food and Drug Administration

(FDA), certain products approved under the Drug Efficacy

Study Implementation review, or products marketed

prior to 1938 and not subject to review and that can,

under federal or state law, be dispensed only pursuant

to a Prescription Order or Refill. A Prescription Drug

Product includes a drug, Biologic or product that, due

to its characteristics, is approved by the FDA for self-

administration or administration by a non-skilled caregiver.

For the purpose of benefits under the Plan, this definition

also includes:

The following diabetic supplies: alcohol pads,

swabs, wipes, Glucagon/Glucagen, injection aids,

insulin pump accessories (but excluding insulin

pumps), needles including pen needles, syringes,

test strips, lancets, urine glucose and ketone strips;

Needles and syringes for self-administered

medications or Biologics covered under the Plan’s

Pharmacy Benefit; and

Inhaler assistance devices and accessories, peak

flow meters.

This definition does not include any charges for mobile,

web-based or other electronic applications or software,

even if approved for marketing as a prescription product by

the FDA.

Prescription Order or Refill means the lawful directive to

dispense a Prescription Drug Product issued by a Physician

whose scope of practice permits issuing such a directive.

Specialty Prescription Drug Product means a

Prescription Drug Product considered by the Healthplan

to be a Specialty Prescription Drug Product based on

consideration of the following factors, subject to applicable

law: whether the Prescription Drug Product is prescribed

and used for the treatment of a complex, chronic or rare

condition; whether the Prescription Drug Product has a

high acquisition cost; and, whether the Prescription Drug

Product is subject to limited or restricted distribution,

requires special handling and/or requires enhanced patient

education, provider coordination or clinical oversight. A

Specialty Prescription Drug Product may not possess all

or most of the foregoing characteristics, and the presence

of any one such characteristic does not guarantee that a

Prescription Drug Product will be considered a Specialty

Prescription Drug Product. Specialty Prescription Drug

Products may vary by Healthplan benefit assignment

based on factors such as method or site of clinical

administration, or by tier assignment or utilization

management requirements based on factors such as

acquisition cost. You may determine whether a medication

is a Specialty Prescription Drug Product through the

internet at www.mycigna.com or by calling member

services at the telephone number on your ID card.

Therapeutic Alternative means a Prescription Drug

Product that is of the same therapeutic or pharmacological

class, and usually can be expected to have similar

outcomes and adverse reaction profiles as, another

Prescription Drug Product or over-the-counter medication

Therapeutic Equivalent means a Prescription Drug

Product that is a pharmaceutical equivalent to another

Prescription Drug Product or over-the-counter medication.

Usual and Customary (U&C) Charge means the usual

fee that a Pharmacy charges individuals for a Prescription

Drug Product (and any services related to the dispensing

thereof) without reference to reimbursement to the

Pharmacy by third parties. The Usual and Customary

(U&C) Charge includes a dispensing fee and any

applicable sales tax.

II. Services and Benefits

Prescription Drug Benefits

Your Healthplan provides benefits on the Prescription

Drug List for Prescription Drug Products dispensed by a

Pharmacy. Details regarding your Healthplan’s Covered

Expenses, which for the purposes of the Prescription Drug

Benefit include Medically Necessary Prescription Drug

Products ordered by a Physician, limitations and

exclusions are provided below and/or in your Schedule of

Copayments.

Introduction

SAMPLE DOCUMENT

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Prescription Drug Rider

Prescription Drug List Management

The Prescription Drug List (or formulary) offered under

your Group’s Healthplan is managed by the Business

Decision Team. Your Healthplan’s coverage tiers may

contain Prescription Drug Products that are Generic

Drugs, Brand Drugs or Specialty Prescription Drug

Products. The Business Decision Team makes the final

assignment of a Prescription Drug Product to a certain

coverage tier and decides whether utilization management

requirements or other coverage conditions should apply to

a Prescription Drug Product by considering a number of

factors including, but not limited to, clinical and economic

factors. Clinical factors may include, but are not limited to,

the P&T Committee’s evaluations of the place in therapy,

relative safety or relative efficacy of the Prescription

Drug Product, as well as whether certain supply limits or

other utilization management requirements should apply.

Economic factors may include, but are not limited to, the

Prescription Drug Product's acquisition cost including,

but not limited to, assessments on the cost effectiveness

of the Prescription Drug Product and available rebates.

When considering a Prescription Drug Product for tier

placement or other coverage conditions, the Business

Decision Team reviews clinical and economic factors

regarding enrollees as a general population across its

book-of-business. Whether a particular Prescription Drug

Product is appropriate for you or any of your Dependents

regardless of its eligibility coverage under your Healthplan

is a determination that is made by you (or your Dependent)

and the prescribing Physician.

The coverage status of a Prescription Drug Product may

change periodically for various reasons. For example,

a Prescription Drug Product may be removed from the

market, a New Prescription Drug Product in the same

therapeutic class as a Prescription Drug Product may

become available, or other market events may occur.

Market events that may affect the coverage status of a

Prescription Drug Product include, but are not limited to,

an increase in the acquisition cost of a Prescription Drug

Product. As a result of coverage changes, for the purposes

of benefits the Healthplan may require you to pay more

or less for that Prescription Drug Product, to obtain the

Prescription Drug Product from a certain Pharmacy(ies)

for coverage, or try another covered Prescription Drug

Product(s). Please access www.mycigna.com through

the Internet or call member services at the telephone

number on your ID card for the most up-to-date tier status,

utilization management, or other coverage limitations for a

Prescription Drug Product.

Benefits for Prescription Drug Products

If you or any one of your Dependents, while insured for

Prescription Drug Benefits, incurs expenses for charges

made by a Pharmacy for Medically Necessary

Prescription Drug Products ordered by a Physician, your

plan will provide coverage for those expenses as shown

in the Schedule of Copayments. Your benefits may vary

depending on which of the Prescription Drug List tiers the

Prescription Drug Product is listed, or the Pharmacy that

provides the Prescription Drug Product.

Coverage under your Healthplan’s Prescription Drug

Benefits also includes Medically Necessary Prescription

Drug Products dispensed pursuant to a Prescription

Order or Refill issued to you or your Dependents by a

licensed dentist for the prevention of infection or pain in

conjunction with a dental procedure.

When you or a Dependent is issued a Prescription Order or

Refill for Medically Necessary Prescription Drugs Products

as part of the rendering of emergency services and the

Healthplan determines that it cannot reasonably be filled

by a Network Pharmacy, the prescription will be covered

pursuant to the, as applicable, Copayment or Coinsurance

for the Prescription Drug Product when dispensed by a

Network Pharmacy.

Any Prescription Drug Product not listed on the

Prescription Drug List that is not otherwise excluded and

the Healthplan or its Review Organization approves as

Medically Necessary shall be covered at the coverage tier

with the highest cost-share requirement as set forth in the

Schedule.

The amount you or your Dependent pays for any excluded

Prescription Drug Product or other product or service will

not be included in calculating any applicable Healthplan

Out-of-Pocket Maximum. You are responsible for paying

100% of the cost (the amount the Pharmacy charges you)

for any excluded Prescription Drug Product or other

product, and any negotiated Prescription Drug Charge will

not be available to you.

Reimbursement/Filing a Claim

Retail Pharmacy

SAMPLE DOCUMENT

myCigna.com

Prescription Drug Rider

When you or your Dependents purchase your Prescription

Drug Products through a retail Network Pharmacy, you

pay any applicable Copayment or Deductible shown in

the Schedule of Benefits at the time of purchase. You

do not need to file a claim form unless you purchase a

Prescription Drug Product at a non-Network Pharmacy.

Home Delivery Pharmacy

To purchase Prescription Drug Products from a home

delivery Network Pharmacy, see your home delivery drug

introductory kit for details, or contact member services for

assistance.

Prior Authorization Requirements

Coverage for certain Prescription Drug Products prescribed

to you requires your Physician to obtain prior authorization

from the Healthplan or its Review Organization. The

reason for obtaining prior authorization from the

Healthplan is to determine whether the Prescription Drug

Product is Medically Necessary in accordance with the

Healthplan's coverage criteria. Coverage criteria for a

Prescription Drug Product may vary based on the clinical

use for which the Prescription Order or Refill is submitted,

and may change periodically based on changes in, without

limitation, clinical guidelines or practice standards, or

market factors.

If the Healthplan or its Review Organization reviews

the documentation provided and determines that the

Prescription Drug Product is not Medically Necessary

or otherwise excluded, your Healthplan will not cover

the Prescription Drug Product. The Healthplan, or its

Review Organization, will not review claims for excluded

Prescription Drug Products or other services to determine if

they are Medically Necessary, unless required by law.

When Prescription Drug Products that require prior

authorization are dispensed at a Pharmacy, you or your

prescribing Physician are responsible for obtaining prior

authorization from the Healthplan. If you do not obtain

prior authorization from us before the Prescription Drug

Product is dispensed by the Pharmacy, you can ask us

to consider reimbursement after you pay for and receive

the Prescription Drug Product. You will need to pay for

the Prescription Drug Product at the Pharmacy prior to

submitting a reimbursement request.

When you submit a claim on this basis, you will need

to submit a paper claim using the form that appears on

www.mycigna.com.

Step Therapy

Certain Prescription Drug Products are subject to step

therapy requirements. This means that in order to receive

Benefits for such Prescription Drug Products you are

required to try a different Prescription Drug Product(s)

first, unless you satisfy the coverage exception criteria.

You may identify whether a particular Prescription Drug

Product is subject to step therapy requirements through

the Internet at www.mycigna.com or by calling member

services at the telephone number on your ID card.

Supply Limits

Benefits for Prescription Drug Products are subject to the

supply limits that are stated in the Schedule of Benefits.

For a single Prescription Order or Refill, you may receive a

Prescription Drug Product up to the stated supply limit.

Some products are subject to additional supply limits,

quantity limits or dosage limits based on coverage criteria

that the Healthplan has approved based on consideration of

the P&T Committee's clinical findings. Coverage criteria

is subject to periodic review and modification. The limit

may restrict the amount dispensed per Prescription Order

or Refill and/or the amount dispensed per month's supply,

or may require that a minimum amount be dispensed.

You may determine whether a Prescription Drug Product

has been assigned a dispensing supply limit or similar

limit or requirement at www.mycigna.com or by calling

customer services at the telephone number on your ID card.

Specialty Prescription Drug Products

Benefits are provided for Specialty Prescription Drug

Products. If you require Specialty Prescription Drug

Products, the Healthplan may direct you to a Designated

Pharmacy with whom the Healthplan has an arrangement

to provide those Specialty Prescription Drug Products. If

you are directed to a Designated Pharmacy and you choose

not to obtain your Specialty Prescription Drug Product

from a Designated Pharmacy, you will not receive coverage

for that Specialty Prescription Drug Product.

Designated Pharmacies

If you require certain Prescription Drug Products,

including, but not limited to, Specialty Prescription Drug

SAMPLE DOCUMENT

myCigna.com

Prescription Drug Rider

Products, the Healthplan may direct you to a Designated

Pharmacy with whom we have an arrangement to provide

those Prescription Drug Products. If you are directed to a

Designated Pharmacy and you choose not to obtain your

Prescription Drug Product from a Designated Pharmacy,

you will not receive coverage for that Prescription Drug

Product.

Coupons, Incentives and Other Communications

At various times, the Healthplan or its designee may

send mailings to you or your Dependents or to your

Physician that communicate a variety of messages,

including information about Prescription Drug Products.

These mailings may contain coupons or offers from

pharmaceutical manufacturers that enable you or your

Dependents, at your discretion, to purchase the described

Prescription Drug Product at a discount or to obtain it at

no charge. Pharmaceutical manufacturers may pay for

and/or provide the content for these mailings. Only your

Physician can determine whether a particular medication is

appropriate for your medical condition. The Healthplan and

its affiliates are not responsible in any way for any decision

you make in connection with any coupon, incentive,

or other offer you may receive from a pharmaceutical

manufacturer or Physician.

New Prescription Drug Products

The Business Decision Team may or may not place a New

Prescription Drug Product on a Prescription Drug List tier

upon its market entry. The Business Decision Team will

use reasonable efforts to make a tier placement decision

for a New Prescription Drug Product within six months of

its market availability. The Business Decision Team’s tier

placement decision shall be based on consideration of,

without limitation, the P&T Committee’s clinical review

of the New Prescription Drug Product and economic

factors. If a New Prescription Drug Product not listed on

the Prescription Drug List is approved by the Healthplan

or its Review Organization as Medically Necessary in

the interim, the New Prescription Drug Product shall be

covered at the applicable coverage tier as set forth in The

Schedule.

III. Limitations

Each Prescription Order or refill shall be limited as

follows:

to up to a consecutive thirty (30) day supply at a

retail Network Pharmacy, unless limited by the

drug manufacturer's packaging; or

to up to a consecutive ninety (90) day supply at a

home delivery Participating Pharmacy, unless

limited by the drug manufacturer's packaging; or

to a dosage and/or dispensing limit as determined

by the P&T Committee.

IV. Member Payments

Covered Prescription Drug Products purchased at a

Pharmacy are subject to any applicable Copayments or

Coinsurance shown in The Schedule of Copayments,

as well as any limitations or exclusions set forth in this

plan. Please refer to The Schedule of Copayments for any

required Copaymentsor Coinsurance.

Copayment

Your plan requires that you pay a Copayment for covered

Prescription Drug Products as set forth in the Prescription

Drug Schedule of Copayments.

After satisfying the applicable annual Deductible set forth

in the Prescription Drug Schedule of Copayments, your

costs for a covered Prescription Drug Product dispensed

by a Participating Pharmacy and that is subject to a fixed

dollar Copayment requirement, will be the lowest of the

following amounts:

the fixed dollar Copayment for the Prescription

Drug Product set forth in the Prescription Drug

Schedule of Copaments; or

the Prescription Drug Charge; or

the Network Pharmacy's submitted Usual and

Customary (U&C) Charge, if any.

Payments

Any reimbursement due to you under this plan for

a covered Prescription Drug Product dispensed by a

Pharmacy may be determined by applying the Deductible,

if any, and/or Pharmacy Coinsurance amount set forth in

The Schedule to the average wholesale price (or "AWP"),

or other benchmark price the Healthplan applies, for a

Prescription Drug Product dispensed by a Pharmacy. Your

reimbursement, if any, for a covered Prescription Drug

Product dispensed by a Pharmacy will never exceed the

SAMPLE DOCUMENT

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Prescription Drug Rider

average wholesale price (or other benchmark price applied

by the Healthplan) for the Prescription Drug Product.

When a treatment regimen contains more than one type of

Prescription Drug Products that are packaged together for

your, or your Dependent's, convenience, any applicable

Copayment may apply to each Prescription Drug Product.

You will need to obtain prior approval from the Healthplan

or its Review Organization for any Prescription Drug

Product not listed on the Prescription Drug List that is

not otherwise excluded. If the Healthplan or its Review

Organization approves coverage for the Prescription Drug

Product because it meets the applicable coverage exception

criteria, the Prescription Drug Product shall be covered at

the applicable coverage tier as set forth in The Schedule.

The amount you or your Dependent pays for any excluded

Prescription Drug Product or other product or service will

not be included in calculating any applicable plan Out-of-

Pocket Maximum. You are responsible for paying 100%

of the cost (the amount the Pharmacy charges you) for any

excluded Prescription Drug Product or other product.

Reimbursement/Filing a Claim

When you or your Dependents purchase your Prescription

Drug Product through a Participating Pharmacy, you

pay any applicable Copayment or Deductible shown in

Prescription Drug Schedule of Copayments at the time

of purchase. You do not need to file a claim form for a

Prescription Drug Product obtained at a Participating

Pharmacy unless you pay the full cost of a Prescription

Drug Product at a Participating Pharmacy and later seek

reimbursement for the Prescription Drug Product under the

Healthplan or you dispute the accuracy of your payment.

For example, if you must pay the full cost of a Prescription

Drug Product to the retail Participating Pharmacy because

you did not have your ID card, then you must submit a

claim to the Healthplan for any reimbursement or benefit

you believe is due to you. If, under this example, your

payment to the retail Participating Pharmacy for the

covered Prescription Drug Product exceeds any applicable

fixed dollar Copayment, then you will be reimbursed the

difference, if any, between the applicable fixed dollar

Copayment and the Prescription Drug Charge for the

Prescription Drug Product.

You can obtain a claim form through the website shown

on your ID card or by calling member services at the

telephone number on your ID card.

Important Information

Rebates and Other Payments

This Healthplan or its affiliates may receive rebates or

other remuneration from pharmaceutical manufacturers

in connection with certain medications covered under

the Agreement’s medical benefit by the Healthplan and

Prescription Drug Products included on the Prescription

Drug List. These rebates or remuneration are not obtained

on you or your Group’s behalf or for your benefit.

This Healthplan and its affiliates are not obligated to pass

these rebates on to you, or apply them to your Deductible

if any or take them into account in determining your

Copayments. Healthplan and its affiliates or designees

may also conduct business with various pharmaceutical

manufacturers separate and apart from the benefits set forth

in this this Rider or other medication benefits offered under

the Agreement. Such business may include, but is not

limited to, data collection, consulting, educational grants

and research. Amounts received from pharmaceutical

manufacturers pursuant to such arrangements are not

related to this Rider or the Agreement. Healthplan and its

affiliates are not required to pass on to you, and do not pass

on to you, such amounts.

V. Exclusions

Except as otherwise set forth in this Rider, coverage for

Prescription Drug Products is subject to the exclusions and

limitations set forth in the "Exclusions and Limitations"

Section of the Agreement. In addition, any services or

benefits related to Prescription Drug Products, which are

not described in this Supplemental Rider, are excluded

from coverage under the Agreement. By way of example,

but not of limitation, the following are specifically

excluded services and benefits:

Coverage for Prescription Drug Products for the

amount dispensed (days' supply) which exceeds

the applicable supply limit, or is less than any

applicable supply minimum, set forth in the

Schedule of Copayments, or quantity limit or

dosage limit set by the P&T Committee.

More than one Prescription Order or Refill for

a given prescription supply period for the same

Prescription Drug Product prescribed by one or

more Physicians and dispensed by one or more

Pharmacies.

SAMPLE DOCUMENT

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Prescription Drug Rider

Prescription Drug Products dispensed outside the

jurisdiction of the United States, except as required

for emergency or urgent care treatment.

Prescription Drug Products which are prescribed,

dispensed or intended to be taken by or

administered to you while you are a patient in a

licensed Hospital, Skilled Nursing Facility, rest

home, rehabilitation facility, or similar institution

which operates on its premises or allows to be

operated on its premises a facility for dispensing

pharmaceutical products

Prescription Drug Products furnished by the local,

state or federal government (except for a Network

Pharmacy owned or operated by a local, state or

federal government).

Medications available over-the-counter that do not

require a Prescription Order or Refill by federal or

state law before being dispensed, unless state or

federal law requires coverage of such medications

or the Healthplan has designated the over-the-

counter medication as eligible for coverage as if it

were a Prescription Drug Product.

Certain Prescription Drug Products that are a

Therapeutic Equivalent or Therapeutic Alternative

to an over-the-counter drug(s), or are available in

over-the-counter form. Such determinations may be

made periodically, and benefits for a Prescription

Drug Product that was previously excluded under

this provision.

Injectable infertility drugs and any injectable

drugs that require Physician supervision and

are not typically considered self-administered

drugs. The following are examples of Physician

supervised injectable drugs: injectables used to

treat hemophilia and RSV (respiratory syncytial

virus), chemotherapy injectables and endocrine and

metabolic agents.

Any drugs that are experimental or investigational,

drug or Biologic therapies or devices that are

determined by the utilization review Physician to

be:

not approved by the U.S. Food and Drug

Administration (FDA) or other appropriate

regulatory agency to be lawfully marketed;

not demonstrated, through existing peer-

reviewed, evidence-based, scientific

literature to be safe and effective for treating

or diagnosing the condition or Sickness for

which its use is proposed;

the subject of review or approval by an

Institutional Review Board for the proposed

use except as provided in the "Clinical

Trials" sections of this plan; or

the subject of an ongoing phase I, II or III

clinical trial, except for routine patient care

costs related to qualified clinical trials as

provided in the "Clinical Trials" sections of

this plan.

In determining whether any such technologies,

supplies, treatments, drug or Biologic therapies,

or devices are experimental, investigational, and/

or unproven, the utilization review Physician may

rely on the clinical coverage policies maintained

by the Healthplan or the Review Organization.

Clinical coverage policies may incorporate, without

limitation and as applicable, criteria relating to U.S.

Food and Drug Administration-approved labeling,

the standard medical reference compendia and

peer-reviewed, evidence-based scientific literature

or guidelines.

Prescription and non-prescription supplies other

than supplies covered as Prescription Drug

Products.

Implantable contraceptive products covered under

your Plan’s Medical Benefits.

Any fertility product prescribed to treat infertility.

within the meaning set forth in the Agreement.

Experimental, investigational and unproven

services are medical, surgical, diagnostic,

psychiatric, Substance Use Disorder or other health

care technologies, supplies, treatments, procedures,

Prescription Drug Products used for the treatment

of male or female sexual dysfunction, including,

but not limited to erectile dysfunction, delayed

ejaculation, anorgasmy, hypoactive sexual desire

disorder and decreased libido.

SAMPLE DOCUMENT

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Prescription Drug Rider

Vitamins, except prenatal vitamins that require a

Prescription Order or Refill, unless coverage for

such product(s) is required by federal or state law.

Any product for which the primary use is a source

of nutrition, nutritional supplements, or dietary

management of disease, even when used for the

treatment of sickness or injury, unless coverage for

such product(s) is required by federal or state law.

Medications used for cosmetic or anti-aging

purposes, including, without limitation, medications

used to reduce wrinkles, medications used to

promote hair growth, or medications used to control

perspiration and fade cream products.

Any Prescription Drug Product prescribed for the

purpose of appetite suppression (anorectics) or

weight loss.

Immunization agents, biological products for

allergy immunization, biological sera, blood, blood

plasma and other blood products or fractions and

medications used for travel prophylaxis [unless

specifically identified on the Prescription Drug

List.

Replacement of Prescription Drug Products due to

loss or theft.

Prescription Drug Products used to enhance athletic

performance.

Prescriptions more than one year from the original

date of issue

Any ingredient(s) in a compounded Prescription

Drug Product that has not been approved by the

U.S. Food and Drug Administration (FDA)

charges which you are not obligated to pay or for

which you are not billed or for which you would

not have been billed except that they were covered

under this plan. For example, if the Healthplan

determines that a provider or Pharmacy is or

has waived, reduced, or forgiven any portion of its

charges and/or any portion of Copayment,

Deductible, and/or Coinsurance amount(s) you are

required to pay for a Covered Expense (as shown

on The Schedule of Copayments) without the

Healthplan's express consent, then the Healthplan

in its sole discretion shall have the right to deny the

payment of benefits in connection with the Covered

Expense, or reduce the benefits in proportion to

the amount of the Copayment, Deductible,

and/or Coinsurance amounts waived, forgiven or

reduced, regardless of whether the provider or

Pharmacy represents that you remain responsible

for any amounts that your plan does not cover.

In the exercise of that discretion, the Healthplan

shall have the right to require you to provide proof

sufficient to the Healthplan that you have made

your required cost share payment(s) prior to the

payment of any benefits by the Healthplan. This

exclusion includes, but is not limited to, charges

of a non-Participating Provider who has agreed to

charge you or charged you at an in-network

benefits level or some other benefits level not

otherwise applicable to the services received.

[Provided further, if you use a coupon provided by

a pharmaceutical manufacturer or other third party

that discounts the cost of a prescription medication

or other product, the Healthplan may, in its sole

discretion, reduce the benefits provided under the

plan in proportion to the amount of the Copayment,

Deductible, and/or Coinsurance amounts to which

the value of the coupon has been applied by the

Pharmacy or other third party, and/or exclude

from accumulation toward any plan Deductible or

Out-of-Pocket Maximum the value of any coupon

applied to any Copayment, Deductible and/or Co-

insurance you are required to pay.]

RX-3 & 4 TIER-D (1/20)

SAMPLE DOCUMENT

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Prescription Drug

Schedule of Copayments

Prescription Drug Schedule of Copayments

Certain Specialty Prescription Drug Products are only covered when dispensed by a home delivery Network Pharmacy,.

Specialty Prescription Drug Products are limited to up to a consecutive 30-day supply per Prescription Order or Refill.

Maintenance Drug Products

Maintenance Drug Products may be filled in an amount up to a consecutive 90 day supply per Prescription Order or Refill

at a retail Designated Pharmacy.

In this context, a retail Designated Pharmacy is a retail Network Pharmacy that has contracted with the Healthplan for

dispensing of covered Prescription Drug Products, including Maintenance Drug Products, in 90-day supplies per

Prescription Order or Refill. Please see our website at www.CIGNA.com or call the Member Services number on your ID

card for a list of retail Designated Pharmacies that offer a 90-day supply of Prescription Drug Products.

SAMPLE DOCUMENT

myCigna.com

Prescription Drug

Schedule of Copayments

Pharmacy Schedule

(Schedule of Copayments)

Copayment

Type of

Drug

Retail Network

Pharmacy Copayment

(applies to each 30

day supply.)

Retail Designated

Pharmacy Copayment

(applies to each

90 day supply)

Home Delivery Network

Pharmacy Copayment

(applies to each

90 day supply.)

Tier 1

Generic

Drugs on the

Prescription

Drug List.

$ LL $OO $RR

Tier 2

Brand Drugs

designated

as preferred

on the

Prescription

Drug List

$MM $PP $SS

Tier 3

Brand Drugs

designated as

non-preferred

on the

Prescription

Drug List.

$NN $QQ $TT

RX-3 & 4 TIER-E (1/20)

SAMPLE DOCUMENT

myCigna.com

Out-of-Network Medical Benefits

Out-of-Network Certificate

The benefits described in the pages to follow are underwritten by Connecticut General Life Insurance Company.

POS-COVER 11/01

SAMPLE DOCUMENT

myCigna.com

Out-of-Network Medical Benefits

Home Office: Bloomfield, Connecticut

Mailing Address: Hartford, Connecticut 06152

CONNECTICUT GENERAL LIFE INSURANCE COMPANY

a Cigna company (called CG) certifies that it insures certain Employees for the

benefits provided by the following policy:

POLICYHOLDER: SAMPLE PLAN

GROUP POLICY(S) - COVERAGE

MEDICAL EXPENSE INSURANCE

SAMPLE DOCUMENT

Corporate Secretary

V-2

GM6000 C2

CER7 M

POS-TITLE 11/01

SAMPLE DOCUMENT

myCigna.com

Out-of-Network Medical Benefits

Notice of Federal Requirements

COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMY

When a person insured for benefits under this certificate who has had a mastectomy at any time, decides to have breast

reconstruction, based on consultation between the attending Physician and the patient, the following benefits will be

subject to the same coinsurance and deductibles which apply to other plan benefits:

surgical services for reconstruction of the breast on which the mastectomy was performed;

surgical services for reconstruction of the non-diseased breast to produce a symmetrical appearance;

post-operative breast prostheses; and

mastectomy bras and external prosthetics, limited to the lowest cost alternative available that meets external prosthetic

replacement needs.

During all stages of mastectomy, treatment of physical complications, including lymphedema therapy are covered.

If you have any questions about your benefits under this Plan, please call the number on your ID card or contact your

Employer.

MATERNITY HOSPITAL STAY

Group health plans and health insurance issuers offering group health insurance coverage generally may not, under federal

law restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less

than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider

obtain authorization from the plan or insurance issuer for prescribing a length of stay not in excess of the above periods.

The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from

discharging the mother or newborn earlier than 48 or 96 hours, as applicable. Please review this Plan for further details on

the specific coverage available to your and your Dependents.

POS-NOTICE 11/01

SAMPLE DOCUMENT

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Out-of-Network Medical Benefits

Explanation of Terms

You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of

these terms are defined in the Definitions section of your certificate.

The Schedule

The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full

description of each benefit, refer to the appropriate section.

POS 11/01

SAMPLE DOCUMENT

myCigna.com

Out-of-Network Medical Benefits

Schedule of Out-of-Network Medical Benefits

For You and Your Dependents

Covered Expenses Payments

Contract Year Maximum Unlimited

Individual Out-of-Pocket Maximum $AAAA

Family Out-of-Pocket Maximum

(See section entitled "Full Payment Area")

Major Medical Deductible

Individual

Family

After Major Medical Deductibles totaling the

amount shown at right have been applied

in a Contract Year for either (a) you and your

Dependents or (b) your Dependents, any

Medical Deductible will be waived for your

family for the rest of that Contract Year.

Listed below are the Deductibles paid by you and

the Benefit Percentage paid by CG for Covered

Expenses incurred for:

$BBBB

$CCCC

$DDDD

Inpatient Hospital $EEE per admission Deductible then 60% after Major

Medical Deductible

Outpatient Facility $FF per visit Deductible then 60% after Major

Medical Deductible

Durable Medical Equipment Not Covered

External Prosthetic Appliances Not Covered

Home Health Care Maximum

40 days per Contract Year

Laboratory and Radiology Outpatient Services

Outpatient Advanced Radiological Imaging

(Scan Types: MRIs, MRAs, CAT scans, PET

scans etc.)

GM6000 06BNR4

Other Laboratory and Radiology Services

60% after Major Medical Deductible

$GGG per Scan Type (charges include all views

per Scan Type per day) then 60% after Major

Medical Deductible

60% after Major Medical Deductible

Mental Health and Substance Abuse

SAMPLE DOCUMENT

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Out-of-Network Medical Benefits

Services**

Inpatient Mental Health Maximum

Same as Inpatient Hospital

Outpatient Individual Mental Health

Maximum

60% after Major Medical Deductible

Outpatient Group Mental Health Maximum

60% after Major Medical Deductible

Mental Health Intensive Outpatient Therapy

Program

GM6000 SCH35

60% after Major Medical Deductible

Inpatient Substance Abuse Rehabilitation

Maximum

Same as Inpatient Hospital

Outpatient Individual Substance Abuse

Rehabilitation Maximum

60% after Major Medical Deductible

Substance Abuse Intensive Outpatient

Therapy Program

GM6000 SCH35

60% after Major Medical Deductible

Substance Abuse Detoxification Services

Inpatient

Same as Inpatient Hospital

Outpatient

60% after Major Medical Deductible

Prescription Drugs

Not Covered

Skilled Nursing Facility Maximum

60 days per Contract Year

60% after Major Medical Deductible

All Other Covered Expenses 60% after Major Medical Deductible

The day limits, visit limits and dollar maximums (other than Out-of-Pocket Maximums) shown in this Schedule will be

reduced by the number of days, visits or equivalent dollar amounts for which you receive Basic Benefits in the same

Contract Year.

Maximum Reimbursable Charge - In-Network covered services are paid based on the fee agreed upon with the

provider. Out-of-network covered services are paid based on the Maximum Reimbursable Charge. For this plan, the

Maximum Reimbursable Charge is determined based on the lesser of the provider's normal charge for a similar service or

SAMPLE DOCUMENT

myCigna.com

Out-of-Network Medical Benefits

supply or the 70th percentile of charges made by providers of such service or supply in the geographic area as compiled

in a database that CG has selected. The Maximum Reimbursable Charge is subject to all other benefit limitations and

applicable coding and payment methodologies determined by CG. Additional information about how we determine the

Maximum Reimbursable Charge is available upon request.

Note: Providers may bill you for the difference between the provider's normal charge and the Maximum Reimbursable

Charge, in addition to any applicable deductibles, copayments and coinsurance.

**Treatment Resulting From Life Threatening Emergencies

Medical treatment required as a result of an emergency, such as a suicide attempt, will be considered a medical expense

until the medical condition is stabilized and will not count toward any plan limits that are shown in the Schedule for

mental health and substance abuse services including in-hospital services. Once the medical condition is stabilized,

whether the treatment will be characterized as either a medical expense or a mental health/substance abuse expense will be

determined by the utilization review Physician in accordance with the applicable mixed services claim guidelines.

GM6000 06BNR4

POS-SOC

POS-SOC-A

11/02

7/10

SAMPLE DOCUMENT

myCigna.com

Out-of-Network Medical Benefits

Medical Care Benefits

For You and Your Dependents

Pre-Admission Certification/Continued Stay Review

Requirements

Pre-Admission Certification (PAC) and Continued

Stay Review (CSR) refer to the process used to

certify the Medical Necessity and length of a Hospital

Confinement when you or your Dependent requires

treatment in a Hospital or Other Health Care Facility as

a registered bed patient. PAC and CSR are performed

through a utilization review program by a Review

Organization with which CG has contracted.

You or your Dependent should request PAC prior

to any non-emergency treatment in a Hospital or

Other Health Care Facility as described above. For

an admission due to pregnancy, you should call the

Review Organization by the end of the third month of

pregnancy. CSR should be requested, prior to the end

of the certified length of stay, for continued Hospital or

Other Health Care Facility confinement.

Covered Expenses incurred for which benefits would

otherwise be payable under this plan for Hospital or

Other Health Care Facility charges listed below will be

reduced by 50% for:

Hospital or Other Health Care Facility charges

for Bed and Board, for treatment listed above for

which PAC was not performed.

Expenses incurred for which benefits would otherwise

be payable under this plan will not include:

Hospital or Other Health Care Facility charges for

Bed and Board, during a Hospital or Other Health

Care Facility Confinement for which PAC is

performed, which are made for any day in excess of

the number of days certified through PAC or CSR;

and

any Hospital or Other Health Care Facility charges

made during any Hospital or Other Health Care

Facility Confinement as a registered bed patient: (a)

for which PAC was performed; but (b) which was

not certified as medically necessary.

In any case, those expenses incurred for which payment

is excluded by the terms set forth above will not be

considered as expenses incurred for the purpose of any

other part of this plan, except for the "Coordination of

Benefits" section.

Pre-authorization Requirement:

Prior-authorization should be requested by you or your

Dependent at least 14 days prior to the performance of

diagnostic or surgical services performed at an Outpatient

Surgical Facility and for magnetic resonance imaging.

Amounts for expenses incurred, which would otherwise

be payable under this plan, will be reduced to 50% for

services described above for which pre-authorization was

not obtained.

POS-PAC(01) 1/05

How to File a Claim

If you receive out-of-network services you are responsible

for filing a claim. The prompt filing of any required claim

form will result in faster payment of your claim.

How to Obtain a Claim Form

You may request a claim form from Cigna HealthCare's

website at myCigna.com or by calling the customer service

number on the back of your Cigna HealthCare ID card.

In some cases, your employer may be able to provide you

with a claim form.

Doctor's Bills and Other Medical Expenses

Most providers that are not contracted to provide services

under your Cigna HealthCare plan will require that you

pay for services at the time services are rendered. In these

cases, you will need to complete a claim form and mail in

the completed form along with your receipts and itemized

bills to the address on your Cigna HealthCare ID card. You

will receive an Explanation of Benefits (EOB) from Cigna

HealthCare describing the costs covered by your plan and

the charges you pay.

Some non-contracted providers may prefer to seek payment

directly from Cigna HealthCare rather than from you, in

which case the provider's staff may ask you to complete

a form authorizing Cigna HealthCare to pay the provider

directly. The office staff will send this form, a completed

hard-copy claim form and the provider's bill directly to

Cigna HealthCare, and Cigna HealthCare will then send

payment for covered services directly to the provider.

Remember, regardless of how the provider is reimbursed,

you will be responsible for paying the provider a co-

payment or coinsurance, and the appropriate deductible.

SAMPLE DOCUMENT

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Out-of-Network Medical Benefits

Your claim should be filed as soon as you have incurred

covered expenses. If you have any additional bills after the

first treatment, you may file them periodically.

Hospital Confinement

If possible, obtain your claim form before you are admitted

to the Hospital. This form will make your admission easier

and often the cash deposit usually required will be waived.

Urgent and Emergency Care

These services are covered at in-network benefit levels,

though you are responsible for submitting a claim if

services were received from a facility that is not contracted

under your benefit plan.

POS-CLM(01) 7/06

Eligibility and Effective Date of Coverage

Who is Eligible

For Employee Insurance

You will become eligible for insurance on the later of:

your Employer's Participation Date; or

the date you become a member of a Class of Eligible

Employees.

For Dependent Insurance

You will become eligible for Dependent insurance on the

later of:

the day you become eligible for yourself; or

the day you acquire your first Dependent.

CLASSES OF ELIGIBLE EMPLOYEES

Each Employee who is enrolled for Basic Benefits.

Effective Date of Coverage

Employee Insurance

This plan is offered to you as an Employee. To be insured,

you may have to pay part of the cost.

Effective Date of Your Insurance

You will become insured on the date you become

eligible; provided you have agreed to make the

required contribution toward the cost of Employee

Insurance, if any, by signing an approved payroll

deduction form.

Dependent Insurance

For your Dependents to be insured, you may have to pay

part of the cost of Dependent Insurance.

Effective Date of Dependent Insurance

Insurance for your Dependents will become effective

on the date you become eligible for Dependent

Insurance for that Dependent; provided you have

agreed to make the required contribution toward the

cost of that insurance, if any, by signing an approved

payroll deduction form. All of your Dependents, as

defined, who are enrolled for Basic Benefits, will be

included.

Your Dependents will be insured only if you are

insured.

Exception for Newborns

Any Dependent child born while you are insured for

Dependent Insurance will be insured from his date of

birth.

Any Dependent child born while you are insured

for Medical Insurance for yourself, but not for

your Dependents, will become insured for Medical

Insurance on the date of his birth if you elect

Dependent Medical Insurance no later than 31 days

after his birth.

POS-ELIG(01) 11/01

Requirements of the Omnibus Budget

Reconciliation Act of 1993 (OBRA'93)

These health coverage requirements do not apply to

any benefits for loss of life, dismemberment or loss of

income.

Any other provisions in this certificate that provide for:

(a) the definition of an adopted child and the effective

date of eligibility for coverage of that child; and (b)

eligibility requirements for a child for whom a court

order for medical support is issued; are superseded by

these provisions required by the federal Omnibus Budget

Reconciliation Act of 1993, where applicable.

A. Eligibility for Coverage under a Qualified Medical

Child Support Order

If a Qualified Medical Child Support Order is issued

for your child, that child will be eligible for coverage as

SAMPLE DOCUMENT

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Out-of-Network Medical Benefits

required by the order and you will not be considered a

Late Entrant for Dependent Insurance.

You must notify your Employer and elect coverage

for that child within 31 days of the court order being

issued.

Qualified Medical Child Support Order

A Qualified Medical Child Support Order is a

judgment, decree or order (including approval of

a settlement agreement) or administrative notice,

which is issued pursuant to a state domestic relations

law (including a community property law), or to

an administrative process, which provides for child

support or provides for health benefit coverage to such

child and relates to benefits under the group health

plan, and satisfies all of the following:

1. the order recognizes or creates a child's right

to receive group health benefits for which a

participant or beneficiary is eligible;

2. the order specifies your name and last known

address, and the child's name and last known

address, except that the name and address of an

official of a state or political subdivision may be

substituted for the child's mailing address;

3. the order provides a description of the coverage

to be provided, or the manner in which the type of

coverage is to be determined;

4. the order states the period to which it applies; and

5. if the order is a National Medical Support Notice

completed in accordance with the Child Support

Performance and Incentive Act of 1998, such

notice meets the requirement above.

The Qualified Medical Child Support Order may not

require the health insurance policy to provide coverage

for any type or form of benefit not otherwise provided

under the policy.

B. Eligibility for Coverage for Adopted Children

Any child under the age of 18 who is adopted by you,

including a child who is placed with you for adoption,

will be eligible for Dependent Insurance upon the date

of placement with you. A child will be considered

placed for adoption when you become legally obligated

to support that child, totally or partially, prior to that

child's adoption.

If a child placed for adoption is not adopted, all health

coverage ceases when the placement ends, and will not

be continued.

The provisions in the "Exceptions for Newborns"

section of this certificate that describe requirements

for enrollment and effective date of insurance will

also apply to an adopted child or a child placed

with you for adoption.

Any "Pre-existing Condition Limitation" in this

certificate will be waived for an adopted child or a

child placed for adoption.

POS-ELIG(02) 1/05

Major Medical Benefits

For You and Your Dependents

If, while insured for these benefits, you or any one of your

Dependents, incurs Covered Expenses, CG will pay an

amount determined as follows:

The Benefit Percentage of Covered Expenses incurred

as shown in The Schedule, if any, provided that:

(1) the Hospital Deductible shown in The Schedule

will first be deducted from the Covered Expenses

incurred for charges made by a Hospital for each

separate admission as a registered bed patient; (2)

the Skilled Nursing Facility Deductible shown in

The Schedule, if any, will first be deducted from the

Covered Expenses incurred for charges made by a

Skilled Nursing Facility for each separate confinement

in a Skilled Nursing Facility; (3) the Outpatient Facility

Deductible shown in the Schedule, if any, will first be

deducted from the Covered Expenses incurred for

charges made by an Outpatient Facility for each

separate visit to an Outpatient Facility; and (4) the

Major Medical Deductible shown in The Schedule will

first be deducted from all Covered Expenses incurred

for a person in each Contract Year.

Payment of any benefits will be subject to the

Maximum Benefit Provision.

Full Payment Area

When the amount of Covered Expenses incurred by a

person in a Contract Year for which no payment is

provided because of plan Coinsurance and Deductibles,

exclusive of the Major Medical Deductible, equals the

Individual Out-of-Pocket Maximum shown in The

SAMPLE DOCUMENT

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Out-of-Network Medical Benefits

Schedule, benefits for Covered Expenses incurred during

the rest of that Contract Year will be payable at the rate of

100%.

When the combined amount of Covered Expenses

incurred in a Contract Year by you and at least one of your

Dependents or at least two of your Dependents for which

no payment is provided because of plan Coinsurance and

Deductibles, exclusive of the Major Medical Deductible,

equals two or three times the Individual Out-of-Pocket

Maximum shown in The Schedule, benefits for you and all

of your Dependents for Covered Expenses incurred during

the rest of that Contract Year will become payable at the

rate of 100%, subject however to any applicable deductible

amount not yet satisfied by you or any of your Dependents

in that Contract Year.

Any Hospital Deductible will continue to apply even

though the rate at which benefits are payable changes.

The Major Medical Deductible, if not yet satisfied, will

continue to apply until it is satisfied.

Maximum Benefit Provision

The total amount of Major Medical Benefits payable for

all expenses incurred for a person in his lifetime will not

exceed the Maximum Benefit shown in The Schedule.

Inpatient Mental Health and Substance Abuse

Maximum

If Inpatient Mental Health and/or Substance Abuse

coverage is provided, the total amount of Major

Medical Benefits payable for all expenses incurred

for a person while he is Confined in a Hospital for or

in connection with mental illness, alcohol and drug

abuse will not exceed the Inpatient Mental Health and

Substance Abuse Maximum shown in The Schedule.

Outpatient Mental Health and Substance Abuse

Maximum

If Outpatient Mental Health and/or Substance Abuse

coverage is provided, the total amount of Major

Medical Benefits payable for all expenses incurred

for a person for or in connection with mental illness,

alcohol or drug abuse while he is not Confined in

a Hospital will not exceed the Outpatient Mental

Health and Substance Abuse Maximum shown in The

Schedule.

POS-BEN(01) 1/06

Covered Expenses

The term Covered Expenses means, expenses incurred

by or on behalf of a person for the charges listed below,

if they are incurred after he becomes insured for these

benefits. Expenses incurred for such charges are

considered Covered Expenses to the extent that the

services or supplies provided are recommended by a

Physician and are Medically Necessary, as determined

by CG, for the care and treatment of an Injury or a

Sickness:

by a Hospital or Other Health Care Facility, on its own

behalf, for Bed and Board and other Necessary Services

and Supplies and for medical care and treatment

received as an outpatient; except that, for any day of

Hospital Confinement in a private room, Covered

Expenses will not include that portion of charges for

Bed and Board which is more than the Hospital's most

common daily rate for a semi-private room; nor will

Covered Expenses include charges for any day of

confinement in excess of the Maximum, if any, shown

in the Schedule.

by a Physician for professional services.

by a Nurse, other than a member of your family or your

Dependent's family, for professional nursing service.

for anesthetics and their administration; diagnostic x-

ray and laboratory examinations; x-ray, radium, and

radioactive isotope treatments; chemotherapy; blood

and blood products; and physical therapy provided by a

licensed physical therapist.

for licensed ambulance service to or from the nearest

Hospital where the needed medical care and treatment

can be provided.

for drugs and medicines lawfully dispensed only on the

written prescription of a Physician, excluding vitamins;

provided that benefits for Prescription Drugs are

included in your Employer's Plan as determined from

The Schedule. In any event, drugs prescribed while a

person is Confined in a Hospital will be covered.

POS-BEN(02) 11/01

Breast Reconstruction and Breast Prostheses

Following a mastectomy, the following services and

supplies are covered:

surgical services for reconstruction of the breast on

which surgery was performed;

SAMPLE DOCUMENT

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Out-of-Network Medical Benefits

require skilled care;

surgical services for reconstruction of the non-

diseased breast to produce symmetrical appearance;

post operative breast prostheses; and

mastectomy bras and external prosthetics, limited

to the lowest cost alternative available that meets

external prosthetic placement needs.

During all stages of mastectomy, treatment of physical

complications, including lymphedema therapy, are

covered.

Diabetic Services and Supplies

Diabetic services and supplies for the treatment of

individuals with: (1) complete insulin deficiency or

Type I diabetes; (2) insulin resistance with partial

insulin deficiency or Type II diabetes; and (3) elevated

blood glucose levels induced by pregnancy or

gestational diabetes. Medically Necessary Diabetic

Services and Supplies are limited to the following:

equipment, including blood glucose monitors;

blood glucose monitors for the legally blind; insulin

pumps; infusion devices & related accessories,

including those adaptable for the legally blind;

medical supplies for use with insulin pumps and

insulin infusion pumps to include infusion sets,

cartridges, syringes, skin preparation, batteries

and other disposable supplies needed to maintain

insulin pump therapy;

supplies, including insulin; insulin syringes,

including pen-like insulin injection devices, pen

needles for pen-like insulin injection devices

and other disposable parts required for insulin

injection aides; pre-filled insulin cartridges for

the blind; oral blood sugar control agents; glucose

test strips; visual reading ketone strips; urine test

strips; injection aids including those adapted for

the legally blind; lancet devices and lancets for

monitoring glycemic control;

training provided by a certified, registered or

licensed health care professional with recent

education in diabetes management and which

is part of a diabetes self-management training

program that is accepted by CG, but limited to the

following:

(a) visits prescribed by the Physician upon the

diagnosis of diabetes;

(b) visits following a Physician diagnosis that

represents a significant change in symptoms

or condition that warrants change in self-

management;

prescribed by the Physician; and

(d) medical nutrition therapy related to diabetes

management.

Genetic Testing

Genetic testing that uses a proven testing method for

the identification of genetically-linked inheritable

disease. Genetic testing is only covered if:

you have symptoms or signs of a genetically-linked

inheritable disease;

it has been determined that you are at risk for

carrier status as supported by existing peer-

reviewed, evidence-based, scientific literature for

the development of a genetically-linked inheritable

disease when the results will impact clinical

outcome; or

the therapeutic purpose is to identify specific

genetic mutation that has been demonstrated in the

existing peer-reviewed, evidence-based, scientific

literature to directly impact treatment options.

Pre-implantation genetic testing, genetic diagnosis

prior to embryo transfer, is covered when either parent

has an inherited disease or is a documented carrier of a

genetically linked inheritable disease.

Genetic counseling is covered if you are undergoing

approved genetic testing or if you have an inherited

disease and are a potential candidate for genetic testing.

Genetic counseling is limited to three (3) visits per

Contract Year for both pre and post genetic testing.

Home Health Services

harges made for Home Health Services when you:

are unable to obtain the required care as an

ambulatory outpatient; and

SAMPLE DOCUMENT

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Out-of-Network Medical Benefits

do not require confinement in a Hospital or Other

Health Care Facility.

Home Health Services are provided only if CG has

determined that the home is a medically appropriate

setting.

Home Health Services are provided under the terms of

a Home Health Care plan for the person named in that

plan.

If you are a minor or an adult who is dependent upon

others for non-skilled care and/or Custodial Services

(e.g. bathing, eating, toileting), Home Health Services

will only be provided for you during times when there

is a family member or care giver present in the home to

meet your non-skilled care and/or Custodial Services

needs.

Home Health Services are those skilled health care

services that can be provided during visits by Other

Health Care Professionals. The services of a home

health aide are covered when rendered in direct support

of skilled health care services provided by Other Health

Care Professionals. A visit is defined as a period of 2

hours or less. Necessary consumable medical supplies,

and home infusion therapy administered or used by

Other Health Care Professionals in providing Home

Health Services are covered. Home Health Services

do not include services by a person who is a member of

your family or your Dependent's family or who

normally resides in your house or your Dependent's

house even if that person is an Other Health Care

Professional. Skilled nursing services or private duty

nursing services provided in the home are subject to the

Home Health Services benefit terms, conditions and

benefit limitations. Physical, occupational, and other

short-term rehabilitative therapy services provided in

the home are not subject to the Home Health Services

benefit limitation in the Schedule, but are subject to

the benefit limitations described under "Short-term

Rehabilitative Therapy" shown in The Schedule.

GM6000 05BPT104

Maternity Hospital Stay

Coverage for a mother and her newly born child shall

be available for a minimum of 48 hours of inpatient

care following a vaginal delivery and a minimum of

96 hours of inpatient care following a cesarean section.

Any decision to shorten the period of inpatient care

for the mother or the newborn must be made by the

attending Physician in consultation with the mother.

Substance Abuse Services

Substance Abuse is defined as the psychological or

physical dependence on alcohol or other mind-altering

drugs that requires diagnosis, care, and treatment. In

determining benefits payable, charges made for the

treatment of any physiological conditions related to

rehabilitation services for alcohol or drug abuse or

addiction will not be considered to be charges made for

treatment of Substance Abuse.

Substance Abuse Detoxification Services

Detoxification and related medical ancillary services

when required for the diagnosis and treatment of

addiction to alcohol and/or drugs. CG will decide,

based on the Medical Necessity of each situation,

whether such services will be provided in an inpatient

or outpatient setting.

Excluded Substance Abuse Services

The following are specifically excluded from

Substance Abuse Services:

any court ordered treatment or therapy, or any

treatment or therapy ordered as a condition

of parole, probation or custody or visitation

evaluations unless medically necessary and

otherwise covered under this Agreement;

counseling for occupational problems;

residential care; and

custodial care.

Orthognathic Surgery

Orthognathic surgery to repair or correct a severe facial

deformity or disfigurement that orthodontics alone

cannot correct; provided:

the deformity or disfigurement is accompanied

by a documented clinically significant functional

impairment, and there is a reasonable expectation

that the procedure will result in meaningful

functional improvement, or;

the orthognathic surgery is Medically Necessary as

a result of tumor, trauma, disease, or

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the orthognathic surgery is performed prior to age

19 and is required as a result of severe congenital

facial deformity or congenital condition.

Repeat or subsequent orthognathic surgeries for the

same condition are covered only when the previous

orthognathic surgery met the above requirements,

there is a high probability of significant additional

improvement as determined by the utilization review

Physician.

GM6000 06BNR10

Reconstructive Surgery

Reconstructive surgery or therapy to repair or correct

a severe physical deformity or disfigurement which

is accompanied by function deficit (other than

abnormalities of the jaw or related to TMJ disorder)

provided that:

the surgery or therapy restores or improves

function; or

reconstruction is required as a result of medically

necessary, non-cosmetic surgery; or

the surgery or therapy is performed prior to age 19

and is required as a result of the congenital absence

or agenesis (lack of formation or development) of a

body part.

Repeat or subsequent surgeries for the same condition

are covered only when there is the probability of

significant additional improvement as determined by

CG.

Short-term Rehabilitative Therapy

Short-term rehabilitative therapy that is part of a

rehabilitation program, including physical, speech,

occupational, cognitive, osteopathic manipulative, and

pulmonary rehabilitation therapy, when provided in the

most medically appropriate setting.

The following limitation applies to short-term

rehabilitative therapy:

occupational therapy provided only for purposes of

enabling insured's to perform the activities of daily

living after an illness or an injury.

Short-term Rehabilitative Therapy services that are not

covered include, but are not limited to:

sensory integration therapy, group therapy;

treatment of dyslexia; behavior modification or

myofunctional therapy for dysfluency, such as

stuttering or other involuntarily acted conditions

without evidence of an underlying medical

condition or neurological disorder;

treatment for functional articulation disorder such

as correction of tongue thrust, lisp, verbal apraxia

or swallowing dysfunction that is not based on an

underlying diagnosed medical condition or injury;

and

maintenance or preventive treatment consisting of

routine, long-term or non-Medically Necessary care

provided to prevent recurrences or to maintain the

patient's current status.

Services that are provided by chiropractic Physicians

are not covered. These services include the

management of neuromusculoskeletal conditions

through manipulation and ancillary physiological

treatment rendered to restore motion, reduce pain and

improve function.

Outpatient Cardiac Rehabilitation Services

Phase II cardiac rehabilitation is provided on an

outpatient basis following diagnosis of a qualifying

cardiac condition when Medically Necessary. Phase

II is a Hospital-based outpatient program following

an inpatient Hospital discharge. The Phase II program

must be Physician directed with active treatment and

EKG monitoring.

Phase III and Phase IV cardiac rehabilitation is not

covered. Phase III follows Phase II and is generally

conducted at a recreational facility, primarily to

maintain the patient's status achieved through Phases I

and II. Phase IV is an advancement of Phase III which

includes more active participation and weight training.

GM6000 06BNR7

POS-BEN(03) 11/01

POS-BEN(03)-A 1/07

Expenses Not Covered

Any services and supplies which are not described

as "Covered Expenses" or in an attached Rider or are

specifically excluded in "Covered Expenses" or an attached

Rider are not covered under this policy.

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In addition, the following are specifically excluded services

and supplies:

1. any services or supplies for which you or your

Dependents receive Basic Benefits;

2. care for health conditions that are required by state or

local law to be treated in a public facility;

3. care required by state or federal law to be supplied by a

public school system or school district;

4. care for military service disabilities treatable through

government services if you are legally entitled to such

treatment and facilities are reasonably available;

5. treatment of an illness or injury which is due to war,

declared or undeclared;

6. charges for which you are not obligated to pay or for

which you are not billed or would not have been billed

except that you were covered under this policy;

7. assistance in the activities of daily living, including

but not limited to eating, bathing, dressing or other

Custodial Services or self-care activities, homemaker

services and services primarily for rest, domiciliary or

convalescent care;

8. any services and supplies for or in connection with

experimental, investigational or unproven services;

Experimental, investigational and unproven services

are medical, surgical, diagnostic, psychiatric, substance

abuse or other health care technologies, supplies,

treatments, procedures, drug therapies or devices that

are determined by CG to be:

not demonstrated, through existing peer-review,

evidence-based, scientific literature to be safe and

effective for treating or diagnosing the condition or

illness for which its use is proposed; or

not approved by the U.S. Food and Drug

Administration (FDA) or other appropriate

regulatory agency to be lawfully marketed for the

proposed use; or

the subject of review or approval by an Institutional

Review Board for the proposed use; or

the subject of an ongoing clinical trial that meets

the definition of a phase I, II or III Clinical Trial

as set forth in the FDA regulations, regardless of

whether the trial is subject to FDA oversight.

9. Cosmetic surgery or therapy. Cosmetic surgery or

therapy is defined as surgery or therapy performed

to improve or alter appearance or self-esteem or to

treat psychological symptomatology or psychosocial

complaints related to one's appearance.

10. The following services are excluded from coverage

egardless of clinical indication:

Macromastia or Gynecomastia Surgeries,

Surgical treatment of varicose veins,

Abdominoplasty,

Panniculectomy,

Rhinoplasty,

Blepharoplasty,

Redundant skin surgery,

Removal of skin tags,

Acupressure,

Craniosacral/cranial therapy,

Dance therapy, movement therapy,

Applied kinesiology,

Rolfing,

Prolotherapy, and

Extracorporeal shock wave lithotripsy (ESWL) for

musculoskeletal and orthopedic conditions.

11. Dental treatment of the teeth, gums or structures

directly supporting the teeth, including dental x rays,

examinations, repairs, orthodontics, periodontics,

casts, splints and services for dental malocclusion, for

any condition. However, charges made for services

or supplies provided for or in connection with an

accidental injury to sound natural teeth are covered

provided a continuous course of dental treatment is

started within 6 months of the accident. Sound natural

teeth are defined as natural teeth that are free of active

clinical decay, have at least 50% bony support and are

functional in the arch.

12. Medical and surgical services, initial and repeat,

intended for the treatment or control of obesity

including clinically severe (morbid) obesity, including:

medical and surgical services to alter appearances or

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physical changes that are the result of any surgery

performed for the management of obesity or clinically

severe (morbid) obesity; and weight loss programs or

treatments, whether prescribed or recommended by a

physician or under medical supervision.

13. Unless otherwise covered as a basic benefit, reports,

evaluations, physical examinations, or hospitalization

not required for health reasons, including but not

limited to employment, insurance or government

licenses, and court ordered, forensic, or custodial

evaluations.

14. Court ordered treatment or hospitalization, unless such

treatment is being sought by a Physician or otherwise

covered under "Covered Expenses".

15. Infertility services, infertility drugs, surgical or medical

treatment programs for infertility, including in vitro

fertilization, gamete intrafallopian transfer (GIFT),

zygote intrafallopian transfer (ZIFT), variations of

these procedures, and any costs associated with the

collection, washing, preparation or storage of sperm

for artificial insemination (including donor fees).

Cryopreservation of donor sperm and eggs are also

excluded from coverage.

16. Reversal of male or female voluntary sterilization

procedures.

17. Transsexual surgery, including medical or

psychological counseling and hormonal therapy in

preparation for, or subsequent to, any such surgery.

18. Any services, supplies, medications or drugs for the

treatment of male or female sexual dysfunction such

as, but not limited to, treatment of erectile dysfunction

(including penile implants), anorgasmia, and premature

ejaculation.

19. Medical and Hospital care and costs for the infant child

of a Dependent, unless this infant child is otherwise

eligible under the policy.

20. Non-medical counseling or ancillary services,

including, but not limited to, Custodial Services,

education, training, vocational rehabilitation,

behavioral training, biofeedback, neurofeedback,

hypnosis, sleep therapy, employment counseling,

back school, return-to-work services, work hardening

programs, driving safety, and services, training

educational therapy or other non-medical ancillary

services for learning disabilities, developmental delays,

autism or mental retardation.

21. Therapy or treatment intended primarily to improve or

maintain general physical condition or for the purpose

of enhancing job, school, athletic or recreational

performance, including, but not limited to, routine,

long term or maintenance care which is provided after

the resolution of the acute medical problem and when

significant therapeutic improvement is not expected.

22. Consumable medical supplies other than ostomy

supplies and urinary catheters. Excluded supplies

include, but are not limited to bandages and other

disposable medical supplies, skin preparations and test

strips, except as specified in "Covered Expenses".

23. Private hospital rooms and/or private duty nursing

except as provided under the Home Health Services

provision.

GM6000 05BPT105

24. Personal or comfort items such as personal care

kits provided on admission to a hospital, television,

telephone, newborn infant photographs, complimentary

meals, birth announcements, and other articles which

are not for the specific treatment of illness or injury.

25. Artificial aids, including, but not limited to, corrective

orthopedic shoes, arch supports, orthotics, elastic

stockings, garter belts, corsets, dentures and wigs.

26. Hearing aids, including but not limited to semi-

implantable hearing devices, audiant bone conductors

and Bone Anchored Hearing Aids (BAHAs). A hearing

aid is any device that amplifies sound.

27. Aids or devices that assist with non-verbal

communications, including but not limited to

communication boards, prerecorded speech devices,

laptop computers, desktop computers, Personal Digital

Assistants (PDAs), Braille typewriters, visual alert

systems for the deaf and memory books.

28. Eyeglass lenses and frames and contact lenses (except

for the first pair of contact lenses for treatment of

keratoconus or post-cataract surgery).

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29. Routine refractions, eye exercises and surgical

treatment for the correction of a refractive error,

including radial keratotomy.

30. All injectable prescription drugs, non-injectable

prescription drugs, non-prescription drugs, and

investigational and experimental drugs, except as

provided in "Covered Expenses".

31. Routine footcare, including the paring and removing

of corns and calluses or trimming of nails. However,

services associated with foot care for diabetes

and peripheral vascular disease are covered when

Medically Necessary.

32. Membership costs or fees associated with health clubs,

weight loss programs and smoking cessation programs.

33. Genetic screening or preimplantation genetic screening.

General population-based genetic screening is a testing

method performed in the absence of any symptoms

or any significant, proven risk factors for genetically-

linked inheritable disease.

34. Dental implants for any condition.

35. Fees associated with the collection or donation of blood

or blood products, except for autologous donation

in anticipation of scheduled services where in CG's

opinion the likelihood of excess blood loss is such that

transfusion is an expected adjunct to surgery.

36. Blood administration for the purpose of general

improvement in physical condition.

37. Cost of biologicals that are immunizations or

medications for the purpose of travel, or to protect

against occupational hazards and risks.

38. Cosmetics, dietary supplements and health and beauty

aids.

39. All nutritional supplements and formulae are excluded

except infant formula needed for the treatment of

inborn errors of metabolism which is covered as a

Basic Benefit.

40. Services for or in connection with an injury or illness

arising out of, or in the course of, any employment for

wage or profit.

41. Treatment by acupuncture.

42. Telephone, e-mail and internet consultations and

telemedicine.

43. Procedures, appliances or restorations (except full

dentures) whose main purpose is to: (a) change vertical

dimension; (b) stabilize periodontally involved teeth; or

44. Medical and surgical services for or in connection

with the treatment of temporomandibular joint (TMJ)

disorders.

45. For or in connection with transplant services, including

but not limited to, immunosuppressive medication;

organ procurement costs; or donor's medical costs.

46. Services provided for the management of

neuromusculoskeletal conditions through manipulation

and ancillary physiological treatment rendered to

restore motion, reduce pain and improve function.

47. Massage Therapy.

48. Services which satisfy a Deductible shown in The

Schedule.

49. Durable Medical Equipment and External Prosthetic

Appliances.

50. Benefits not payable according to the "General

Limitations" section.

POS-EXCL(01)-A 7/06

51. For or in connection with an Injury or a Sickness which

is a Pre-existing Condition, unless those expenses are

incurred after a continuous, one-year period during

which a person is satisfying a waiting period and/or is

insured for these benefits.

52. For or in connection with Mental Health and Substance

Abuse Services.

Pre-Existing Condition

A Pre-existing Condition is an Injury or a Sickness for

which a person receives treatment, incurs expenses or

receives a diagnosis from a Physician during the 90

days before the earlier of the date that person: begins

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an eligibility waiting period, or becomes insured for

these benefits.

Exceptions to Pre-existing Condition Limitation

Pregnancy and genetic information with no related

treatment, will not be considered Pre-existing

conditions.

A newborn child, an adopted child, or a child placed

for adoption before age 18 will not be subject to any

Pre-existing Condition Limitation. If such child was

covered within 30 days of birth, adoption or placement

for adoption. Such waiver will apply only if less than

63 days elapse between coverage during a prior period

of Creditable Coverage and coverage under this plan.

Credit for Coverage under Prior Plan

If a person was previously covered under a plan which

qualifies as Creditable Coverage, the following will

apply, provided he notifies the Employer of such prior

coverage, and fewer than 63 days elapse between

coverage under the prior plan and coverage under this

plan, exclusive of any waiting period.

If you and/or your Dependent enrolled or re-enrolled

in COBRA continuation coverage or state continuation

coverage under the extended election period allowed in

the American Recovery and Reinvestment Act of 2009

("ARRA"), this lapse in coverage will be disregarded

for the purposes of determining Creditable Coverage.

CG will reduce any Pre-existing Condition limitation

period under this policy by the number of days of prior

Creditable Coverage you had under a creditable health

plan or policy, up to 12 months for a timely enrollee

and 18 months for a Late Entrant.

Certification of Prior Creditable Coverage

You must provide proof of your prior Creditable

Coverage in order to reduce a Pre-existing Condition

limitation period. You should submit proof of prior

coverage with your enrollment material. Certification,

or other proofs of coverage which need to be submitted

outside the standard enrollment form process for any

reason, may be sent directly to: Eligibility Services,

Cigna HealthCare, P.O. Box 9077, Melville, NY

11747-9077. You should contact the plan administrator

or Cigna Customer Service Representative if assistance

is needed to obtain proof of prior Creditable Coverage.

Once your prior coverage records are reviewed and

credit is calculated, you will receive a notice of any

remaining Pre-existing condition limitation period.

Creditable Coverage

Creditable Coverage will include coverage under: a

self-insured employer group health plan; individual

or group health insurance indemnity or HMO plans;

state or federal continuation coverage; individual

or group health conversion plans; Part A or Part B of

Medicare; Medicaid, except coverage solely for

pediatric vaccines; the Indian Health Service; the Peace

Corps Act; a state health benefits risk pool; a public

health plan; health coverage for current or former

members of the armed forces and their Dependents;

medical savings accounts; and health insurance for

federal employees and their Dependents.

Obtaining a Certificate of Creditable Coverage

Under This Plan

Upon loss of coverage under this plan, a Certificate of

Creditable Coverage will be mailed to each terminating

individual at the last address on file. You or your

dependent may also request a Certificate of Creditable

Coverage, without charge, at any time while enrolled

in the plan and for 24 months following termination

of coverage. You may need this document as evidence

of your prior coverage to reduce any pre-existing

condition limitation period under another plan, to help

you get special enrollment in another plan, or to obtain

certain types of individual health coverage even if

you have health problems. To obtain a Certificate of

Creditable Coverage, contact the Plan Administrator or

call the toll-free customer service number on the back

of your ID card.

POS-EXCL(02) 3/09

General Limitations - Medical Benefits

No payment will be made for expenses incurred for you or

any one of your Dependents:

to the extent that payment is unlawful where the person

resides when the expenses are incurred;

for charges which would not have been made if the

person had no insurance;

to the extent that they are more than the Maximum

Reimbursable Charge;

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for charges for unnecessary care, treatment or surgery,

except as specified in any certification requirement

shown in the PAC/CSR Requirements and Pre-

Authorization section, of the Medical Care Benefits

section;

for or in connection with Custodial Services, education

or training;

to the extent that you or any one of your Dependents

is in any way paid or entitled to payment for those

expenses by or through a public program, other than

Medicaid;

for charges made by an assistant surgeon in excess

of 20 percent of the surgeon's allowable charge; or

for charges made by a co-surgeon in excess of the

surgeon's allowable charge plus 20 percent; (For

purposes of this limitation, allowable charge means the

amount payable to the surgeon prior to any reductions

due to coinsurance or deductible amounts.);

for charges made by a Physician for or in connection

with surgery which exceed the following maximum

when two or more surgical procedures are performed

at one time: the maximum amount payable will be

the amount otherwise payable for the most expensive

procedure, and ½ of the amount otherwise payable for

all other surgical procedures;

for charges made by any covered provider who is a

member of your family or your Dependent's family.

Circumstance Beyond CG's Control. To the extent

that a natural disaster, war, riot, civil insurrection,

epidemic or any other emergency or similar event not

within our control results in our facilities, personnel,

or financial resources being unavailable to provide or

arrange for the provision of a basic or supplemental

health service or supplies in accordance with this

agreement, we will make a good faith effort to provide

or arrange for the provision of the services or supplies,

taking into account the impact of the event.

to the extent that benefits are paid or payable for

those expenses under the mandatory part of any auto

insurance policy written to comply with:

a. "no-fault" insurance law; or

b. an uninsured motorist insurance law.

CG will take into account any adjustment option chosen

under such part by you or any one of your Dependents.

for or in connection with an elective abortion unless:

a. the Physician certifies in writing that the pregnancy

would endanger the life of the mother; or

b. the expenses are incurred to treat medical

complications due to the abortion.

POS-GL(01) 11/01

Coordination of Benefits

This section applies if you or any one of your Dependents

is covered under more than one Plan (not including the

Plan of Basic Benefits) and determines how benefits

payable from all such Plans will be coordinated. You

should file all claims with each Plan.

Definitions

For the purposes of this section, the following terms have

the meanings set forth below:

Plan

Any of the following that provides benefits or services

for medical care or treatment:

(1) Group insurance and/or group-type coverage,

whether insured or self-insured which neither

can be purchased by the general public, nor is

individually underwritten, including closed panel

coverage.

(2) Coverage under Medicare and other governmental

benefits as permitted by law, excepting Medicaid

and Medicare supplement policies.

(3) Medical benefits coverage of group, group type,

and individual automobile contracts.

Each Plan or part of a Plan which has the right to

coordinate benefits will be considered a separate Plan.

Closed Panel Plan

A Plan that provides medical benefits primarily in

the form of services through a panel of employed

or contracted providers, and that limits or excludes

benefits provided by providers outside of the panel,

except in the case of emergency or if referred by a

provider within the panel.

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Primary Plan

The Plan that determines and provides or pays benefits

without taking into consideration the existence of any

other Plan.

Secondary Plan

A Plan that determines, and may reduce its benefits

after taking into consideration, the benefits provided or

paid by the Primary Plan. A Secondary Plan may also

recover the Reasonable Cash Value of any services it

provided to you.

Allowable Expense

A necessary, reasonable and customary service

or expense, including deductibles, coinsurance or

copayments that are covered in full or in part by any

Plan covering you. When a Plan provides benefits in

the form of services, the Reasonable Cash Value of

each service is the Allowable Expense and is a paid

benefit.

Examples of expenses or services that are not

Allowable Expenses include, but are not limited to the

following:

(1) An expense or service or a portion of an expense or

service that is not covered by any of the Plans is not

an Allowable Expense.

(2) If you are confined to a private Hospital room and

no Plan provides coverage for more than a

semiprivate room, the difference in cost between a

private and semiprivate room is not an Allowable

Expense.

(3) If you are covered by two or more Plans that

provide services or supplies on the basis of

reasonable and customary fees, any amount in

excess of the highest reasonable and customary fee

is not an Allowable Expense.

(4) If you are covered by one Plan that provides

services or supplies on the basis of reasonable

and customary fees and one Plan that provides

services and supplies on the basis of negotiated

fees, the Primary Plan's fee arrangement shall be

the Allowable Expense.

(5) If your benefits are reduced under the Primary Plan

(through the imposition of a higher copayment

amount, higher coinsurance percentage, a

deductible and/or a penalty) because you did not

comply with Plan provisions or because you did

not use a preferred provider, the amount of the

reduction is not an Allowable Expense. Examples

of Plan provisions are second surgical opinions and

precertification of admissions or services.

Claim Determination Period

A calendar year, but does not include any part of a year

during which you are not covered under this Policy or

any date before this section or any similar provision

takes effect.

Reasonable Cash Value

An amount which a duly licensed provider of health

care services usually charges patients and which

is within the range of fees usually charged for the same

service by other health care providers located within

the immediate geographic area where the health care

service is rendered under similar or comparable

circumstances.

Order of Benefit Determination Rules

A Plan that does not have a coordination of benefits rule

consistent with this section shall always be the Primary

Plan. If the Plan does have a coordination of benefits rule

consistent with this section, the first of the following rules

that applies to the situation is the one to use:

(1) The Plan that covers you as an enrollee or an

employee shall be the Primary Plan and the

Plan that covers you as a Dependent shall be the

Secondary Plan;

(2) If you are a Dependent child whose parents are

not divorced or legally separated, the Primary

Plan shall be the Plan which covers the parent

whose birthday falls first in the calendar year as an

enrollee or employee;

(3) If you are the Dependent of divorced or separated

parents, benefits for the Dependent shall be

determined in the following order:

(a) first, if a court decree states that one parent is

responsible for the child's healthcare expenses

or health coverage and the Plan for that parent

has actual knowledge of the terms of the order,

but only from the time of actual knowledge;

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(b) then, the Plan of the parent with custody of the

child;

custody of the child;

(d) then, the Plan of the parent not having custody

of the child, and

(e) finally, the Plan of the spouse of the parent not

having custody of the child.

(4) The Plan that covers you as an active employee

(or as that employee's Dependent) shall be the

Primary Plan and the Plan that covers you as laid

off or retired employee (or as that employee's

Dependent) shall be the secondary Plan. If the

other Plan does not have a similar provision and,

as a result, the Plans cannot agree on the order

of benefit determination, this paragraph shall not

apply.

(5) The Plan that covers you under a right of

continuation which is provided by federal or state

law shall be the Secondary Plan and the Plan that

covers you as an active employee or retiree (or as

that employee's Dependent) shall be the Primary

Plan. If the other Plan does not have a similar

provision and, as a result, the Plans cannot agree on

the order of benefit determination, this paragraph

shall not apply.

(6) If one of the Plans that cover you is issued out of

the state whose laws govern this Policy, and

determines the order of benefits based upon the

gender of a parent, and as a result, the Plans do not

agree on the order of benefit determination, the

Plan with the gender rules shall determine the order

of benefits.

If none of the above rules determines the order of

benefits, the Plan that has covered you for the longer

period of time shall be primary.

When coordinating benefits with Medicare, this Plan

will be the Secondary Plan and determine benefits

after Medicare, where permitted by the Social Security

Act of 1965, as amended. However, when more

than one Plan is secondary to Medicare, the benefit

determination rules identified above, will be used to

determine how benefits will be coordinated.

Effect on the Benefits of this Plan

If this Plan is the Secondary Plan, this Plan may reduce

benefits so that the total benefits paid by all Plans during a

Claim Determination Period are not more than one hundred

percent (100%) of the total of all Allowable Expenses.

The difference between the benefit payments that this Plan

would have paid if this Plan had been the Primary Plan,

and the benefit payments that this Plan had actually paid as

the Secondary Plan, will be recorded as a benefit reserve

for you. CG will use this benefit reserve to pay any

Allowable Expense not otherwise paid during the Claim

Determination Period.

As each claim is submitted, CG will determine the

following:

(1) CG's obligation to provide services and supplies

under this policy;

(2) whether a benefit reserve has been recorded for

you; and

(3) whether there are any unpaid Allowable Expenses

during the Claims Determination Period.

If there is a benefit reserve, CG will use the benefit

reserve recorded for you to pay up to one hundred

percent (100%) of the total of all Allowable Expenses.

At the end of the Claim Determination Period, your

benefit reserve will return to zero (0) and a new

benefit reserve shall be calculated for each new Claim

Determination Period.

Recovery of Excess Benefits

If CG pays charges for benefits that should have been

paid by the Primary Plan, or if CG pays charges in excess

of those for which we are obligated to provide under

this Policy, CG will have the right to recover the actual

payment made or the Reasonable Cash Value of any

services.

CG will have the sole discretion to seek such recovery

from any person to, or for whom, or with respect to whom,

such services were provided or such payments were made

by any insurance company, health care Plan or other

organization. If we request, you shall execute and deliver

to us such instruments and documents as we determine are

necessary to secure the right of recovery.

Right to Receive and Release Information

CG, without consent or notice to you, may obtain

information from and release information to any other Plan

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Out-of-Network Medical Benefits

with respect to you in order to coordinate your benefits

pursuant to this section. You must provide us with any

information we request in order to coordinate your benefits

pursuant to this section.

POS-COB(01)-A 1/05

Expenses for Which a Third Party May Be

Liable

This policy does not cover expenses for which another

party may be responsible as a result of having caused

or contributed to the Injury or Sickness. If you incur a

Covered Expense for which, in the opinion of CG, another

party may be liable:

1. CG shall, to the extent permitted by law, be subrogated

to all rights, claims or interests which you may have

against such party and shall automatically have a

lien upon the proceeds of any recovery by you from

such party to the extent of any benefits paid under

the Policy. You or your representative shall execute

such documents as may be required to secure CG's

subrogation rights.

2. Alternatively, CG may, at its sole discretion, pay the

benefits otherwise payable under the Policy. However,

you must first agree in writing to refund to CG the

lesser of:

a. the amount actually paid for such Covered

Expenses by CG; or

b. the amount you actually receive from the third

party for such Covered Expenses;

At the time that the third party's liability is determined and

satisfied, whether by settlement, judgment, arbitration or

award or otherwise.

POS-COB(02) 11/01

Payment of Benefits

To Whom Payable

All Medical Benefits are payable to you. However, at the

option of CG and with the consent of the Policyholder, all

or any part of them may be paid directly to the person or

institution on whose charge claim is based.

If any person to whom benefits are payable is a minor or, in

the opinion of CG, is not able to give a valid receipt for any

payment due him, such payment will be made to his legal

guardian. If no request for payment has been made by his

legal guardian, CG may, at its option, make payment to the

person or institution appearing to have assumed his custody

and support.

If you die while any of these benefits remain unpaid,

CG may choose to make direct payment to any of your

following living relatives: spouse, mother, father, child

or children, brothers or sisters; or to the executors or

administrators of your estate.

Payment as described above will release CG from all

liability to the extent of any payment made.

Time of Payment

Benefits will be paid by CG when it receives due proof of

loss.

Recovery of Overpayment

When an overpayment has been made by CG, CG will

have the right at any time to: (a) recover that overpayment

from the person to whom or on whose behalf it was made;

or (b) offset the amount of that overpayment from a future

claim payment.

POS-PMT(01) 11/01

Termination of Insurance Employees Your

insurance will cease on the earliest date below:

the date you cease to be in a Class of Eligible

Employees or cease to qualify for the insurance.

the last day for which you have made any required

contribution for the insurance.

the date the policy is canceled.

Dependents

Your insurance for all of your Dependents will cease on the

arliest date below:

the date your insurance ceases.

the date you cease to be eligible for Dependent

Insurance.

the last day for which you have made any required

contribution for the insurance.

the date Dependent Insurance is canceled.

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The insurance for any one of your Dependents will

cease on the date that Dependent no longer qualifies as a

Dependent.

POS-TRM(01) 11/01

Continuation of Coverage

Continuation of Group Coverage under COBRA

Introduction

This notice contains important information about your right

to COBRA continuation coverage, which is a temporary

extension of coverage under the Plan. The right to COBRA

continuation coverage was created by a federal law, the

Consolidated Omnibus Budget Reconciliation Act of

1985 (COBRA). COBRA continuation coverage can

become available to you and to other members of your

family who are covered under the Plan when you would

otherwise lose your group health coverage. This notice

generally explains COBRA continuation coverage,

when it may become available to you and your family,

and what you need to do to protect the right to receive

it. This notice gives only a summary of your COBRA

continuation coverage rights. For more information about

your rights and obligations under the Plan and under

federal law, you should either review the Plans' Summary

Plan Description or get a copy of the Plan Document from

the Plan Administrator.

The Plan Administrator is provided on the page titled

"ERISA Summary Plan Description", if applicable. Please

contact the Plan Administrator for the name, address and

phone number of the Plan's COBRA Administrator.

COBRA Continuation Coverage

COBRA continuation coverage is a continuation of

Plan coverage when coverage would otherwise end

because of a life event known as a "qualifying event."

Specific qualifying events are listed later in this notice.

COBRA continuation coverage must be offered to each

person who is a "qualified beneficiary." A qualified

beneficiary is someone who will lose coverage under

the Plan because of a qualifying event. Depending on

the type of qualifying event, employees, spouses of

employees, and dependent children of employees may

be qualified beneficiaries. Under the Plan, qualified

beneficiaries who elect COBRA continuation coverage

must pay for COBRA continuation coverage.

If you are an employee, you will become a qualified

beneficiary if you will lose your coverage under the

Plan because either one of the following qualifying

events happens:

1. your hours of employment are reduced, or

2. your employment ends for any reason other than

your gross misconduct.

If you are the spouse of an employee, you will become

a qualified beneficiary if you will lose your coverage

under the Plan because any of the following qualifying

events happens:

1. your spouse dies;

2. your spouse's hours of employment are reduced;

3. your spouse's employment ends for any reason

other than his or her gross misconduct;

4. your spouse becomes enrolled in Medicare (Part A,

Part B, or both); or

5. you become divorced or legally separated from

your spouse.

Your dependent children will become qualified

beneficiaries if they will lose coverage under the

Plan because any of the following qualifying events

happens:

1. the parent-employee dies;

2. the parent-employee's hours of employment are

reduced;

3. the parent-employee's employment ends for any

reason other than his or his gross misconduct;

4. the parent-employee becomes enrolled in Medicare

(Part A, Part B, or both);

5. the parents become divorced or legally separated;

6. the child stops being eligible for coverage under the

Plan as a "dependent child."

The Plan will offer COBRA continuation coverage

to qualified beneficiaries only after the Plan

Administrator has been notified that a qualifying

event has occurred. When the qualifying event is

the end of employment or reduction of hours of

employment, death of the employee, enrollment of the

employee in Medicare (Part A, Part B, or both), or, if

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the Plan provides retiree coverage, commencement of a

proceeding in bankruptcy with respect to the Employer,

the employer must notify the Plan Administrator of the

qualifying event within 30 days of any of these events.

For the other qualifying events (divorce or legal

separation of the employee and spouse or a

dependent child's losing eligibility for coverage

as a dependent child), you must notify the Plan

Administrator. The Plan requires you to notify

the Plan Administrator within 60 days after the

qualifying event occurs. You must send this notice to

your Employer.

Once the Plan Administrator receives notice that a

qualifying event has occurred, COBRA continuation

coverage will be offered to each of the qualified

beneficiaries. For each qualified beneficiary who elects

COBRA continuation coverage, COBRA continuation

coverage will begin on the date of the qualifying event.

COBRA continuation coverage is a temporary

continuation of coverage. When the qualifying event is

the death of the employee, enrollment of the employee

in Medicare (Part A, Part B, or both), your divorce or

legal separation, or a dependent child losing eligibility

as a dependent child, COBRA continuation coverage

lasts for up to 36 months.

When the qualifying event is the end of employment or

reduction of the employee's hours of employment,

COBRA continuation coverage lasts for up to 18

months from the date of the qualifying event. There are

two ways in which this 18-month period of COBRA

continuation coverage can be extended.

If the Plan provides retiree health coverage:

Sometimes, filing a proceeding in bankruptcy under

title 11 of the United States Code can be a qualifying

event. If a proceeding in bankruptcy is filed with

respect to your employer, and that bankruptcy results

in the loss of coverage of any retired employee covered

under the Plan, the retired employee is a qualified

beneficiary with respect to the bankruptcy. The

retired employee's spouse, surviving spouse, and

dependent children will also be qualified beneficiaries

if bankruptcy results in the loss of their coverage under

the Plan. Coverage will continue until: (a) for you, your

death; and (b) for your Dependent surviving spouse or

Dependent child, up to 36 months from your death.

Disability extension of 18-month period of continuation

coverage

If you or anyone in your family covered under the Plan

is determined by the Social Security Administration

to be disabled at any time during the first 60 days of

COBRA continuation coverage and you notify the Plan

Administrator in a timely fashion, you and your entire

family can receive up to an additional 11 months of

COBRA continuation coverage, for a total maximum

of 29 months from the date of the initial qualifying

event. You must make sure that the Plan Administrator

is notified of the Social Security Administration's

determination within 60 days of the date of the

determination and before the end of the 18-month

period of COBRA continuation coverage. This notice

should be sent to the Plan Administrator. You must

provide a copy of the Social Security Administration's

determination. Termination of coverage for all covered

persons during the additional 11 months will occur

if the disabled person is found by the Social Security

Administration to be no longer disabled. Termination

for this reason will occur on the first day of the month

beginning no more than 30 days after the date of the

final determination. Please refer to "Early Termination

of COBRA Continuation" below for additional reasons

COBRA continuation may terminate before the end of

the maximum period of coverage.

Second qualifying event extension of 18-month period

of continuation coverage

If your family experiences another qualifying event

while receiving COBRA continuation coverage, the

spouse and dependent children in your family can get

additional months of COBRA continuation coverage,

up to a maximum of 36 months from the initial

qualifying event. This extension is available to the

spouse and dependent children if the former employee

dies, enrolls in Medicare (Part A, Part B, or both), or

gets divorced or legally separated. The extension is also

available to a dependent child when that child stops

being eligible under the Plan as a dependent child. In

all of these cases, you must make sure that the Plan

Administrator is notified of the second qualifying

event within 60 days of the second qualifying event.

This notice must be sent to the Plan Administrator.

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Early Termination of COBRA Continuation

Continuation coverage will be terminated before the

end of the maximum period if any required premium

is not paid on time, if a qualified beneficiary becomes

covered under another group health plan that does

not impose any pre-existing condition exclusion for

a pre-existing condition of the qualified beneficiary,

if a covered employee enrolls in Medicare, or if the

employer ceases to provide any group health plan for

its employees. Continuation coverage may also be

terminated for any reason the Plan would terminate

coverage of a participant or beneficiary not receiving

continuation coverage (such as fraud).

Cost of COBRA Continuation Coverage

Generally, each qualified beneficiary may be required

to pay the entire cost of continuation coverage. The

amount a qualified beneficiary may be required to

pay may not exceed 102% of the cost to the group

health plan (including both employer and employee

contributions) for coverage of a similarly situated

plan participant or beneficiary who is not receiving

continuation coverage (or, in the case of an extension

of continuation coverage due to a disability, 150%).

If you or your dependents experience a qualifying

event, the Plan Administrator will send you a notice

of continuation rights which will include the required

premium.

The Trade Act of 2002 created a new tax credit for

certain individuals who become eligible for trade

adjustment assistance (eligible individuals). Under

the new tax provisions, eligible individuals can either

take a tax credit or get advance payment of 65% of

premiums paid for qualified health insurance, including

continuation coverage. If you have questions about

these new tax provisions, you may call the Health

Care Tax Credit Customer Contact Center toll-free

at 1-866-628-4282. TTD/TTY callers may call toll-

free at 1-866-626-4282. More information about

the Trade Act is also available at www.doleta.gove/

tradeact/2002act_index.asp

Conversion Available Following Continuation

If the Plan provides for a conversion privilege, the plan

must offer this option within the 180 days following

maximum period of continuation. However, no

conversion will be provided if the qualified beneficiary

does not maintain COBRA continuation coverage

for the maximum allowable period applicable (18-,

29- or 36-months) or does not meet the eligibility

requirements for a conversion plan.

Service Area Restrictions

This plan includes a service area restriction which

requires that all enrolled participants and beneficiaries

receive services in the Employer's service area. This

restriction also applies to COBRA continuation

coverage. If you or your Dependents move outside

the Employer's service area, coverage under your

current plan in your new location will be limited to

out-of network services only. To obtain in-network

coverage, services must be obtained from a network

provider in the Employer's service area. If your

Employer offers other benefit options that are available

in your new location, you may be allowed to obtain

COBRA continuation under that option. If you or your

Dependent is moving outside the Employer's service

area, please contact your Employer for information on

the availability of other plan options.

If You Have Questions

If you have questions about your COBRA continuation

coverage, you should contact the Plan Administrator or

you may contact the nearest Regional or District Office

of the U.S. Department of Labor's Employee Benefits

Security Administration (EBSA). Addresses and phone

numbers of Regional and District EBSA Offices are

available through EBSA's website at www.dol.gov/

ebsa.

Keep Your Plan Informed of Address Changes

In order to protect your family's rights, you should keep

the Plan Administrator informed of any changes in the

addresses of family members. You should also keep a

copy, for your records, of any notices you send to the

Plan Administrator.

IMPORTANT NOTICE

COBRA benefits will only be administered according

to the terms of the contract. CG will not be obligated

to administer or furnish any COBRA benefits after the

contract has terminated.

POS-CONT(01)-A 1/05

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Out-of-Network Medical Benefits

Continuation under Utah Law

If you continue to reside in the Service Area, you may

be eligible for Continuation of Coverage if you have lost

coverage under the Policy for any of the following reasons:

1. termination of your employment or membership,

except for gross misconduct or non-payment of

premiums;

2. your spouse or Dependent ceases to be a qualified

family member; or

3. your death.

If you were continuously insured for at least six months

prior to the date your coverage is terminated, you may be

eligible to continue coverage, provided you are not eligible

for Medicare or similar coverage under another medical

plan.

Eligibility for continued coverage cannot be denied to a

child because the child does not live with you, or because

the child is solely dependent on your former spouse rather

than on you.

You must be notified of your right to continue coverage

within thirty (30) days after coverage is terminated.

To exercise the continuation option, you must request

continued coverage and pay the required premium

within thirty (30) days of the date you received notice

of termination of coverage. The amount of the required

premium shall not be more than the amount of the

Prepayment Fee payable under the Policy for coverage.

If you elect continuation coverage, coverage will continue

until the earliest of the following dates:

1. the end of six (6) months after coverage ended;

2. you fail to pay the required premium;

3. the date on which the Policy is terminated;

4. you become eligible for similar coverage under another

group policy; or

5. you violate a material condition of the Policy.

At the end of such continuation period, you may apply

for conversion coverage in accordance with the "Medical

Conversion Privilege" provision. This section does not

apply to persons eligible for COBRA continuation or any

extension of coverage required by federal law.

POS-CONT(01).1 2/02

Medical Conversion Privilege

When a person's Medical Expense Insurance ceases, he

may be eligible to be insured under an individual policy

of medical care benefits (called the Converted Policy). A

Converted Policy will be issued by CG only to a person

who is Entitled to Convert, and only if he applies in writing

and pays the first premium for the Converted Policy to CG

within 60 days after the date his insurance ceases. Evidence

of good health is not needed.

Employees Entitled To Convert

You are Entitled To Convert Medical Expense Insurance

for yourself and all of your Dependents who were insured

when your insurance ceased, except a Dependent who is

eligible for Medicare or would be Overinsured, but only if:

you have been insured for at least three consecutive

months under the policy or under it and a prior policy

issued to the Policyholder;

your insurance ceased because you were no longer

in Active Service or no longer eligible for Medical

Expense Insurance; or the policy cancelled;

you are not eligible for Medicare;

you would not be Overinsured.

If you retire you may apply for a Converted Policy within

31 days after your retirement date in place of any

continuation of your insurance that may be available under

this plan when you retire, if you are otherwise Entitled to

Convert.

Dependents Entitled To Convert

The following Dependents are also Entitled to Convert:

a child whose insurance under this plan ceases because

he no longer qualifies as a Dependent or because of

your death;

a spouse whose insurance under this plan ceases due to

divorce, annulment of marriage or your death;

your Dependents, if you are not Entitled to Convert

solely because you are eligible for Medicare.

but only if that Dependent: (a) was insured when your

insurance ceased; (b) is not eligible for Medicare; and (c)

would not be Overinsured.

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Overinsured

A person will be considered Overinsured if either of the

following occurs:

his insurance under this plan is replaced by similar

group coverage within 31 days;

the benefits under the Converted Policy, combined with

Similar Benefits, result in an excess of insurance based

on CG's underwriting standards for individual policies.

Similar Benefits are: (a) those for which the person

is covered by another hospital, surgical or medical

expense insurance policy, or a hospital, or medical

service subscriber contract, or a medical practice or

other prepayment plan or by any other plan or program;

or (b) those for which the person is eligible, whether

or not covered, under any plan of group coverage on

an insured or uninsured basis; or (c) those available for

the person by or through any state, provincial or federal

law.

Converted Policy

The Converted Policy will be one of CG's current offerings

at the time the first premium is received based on its rules

for Converted Policies. It will comply with the laws of

the jurisdiction where the group medical policy is issued.

However, if the applicant for the Converted Policy resides

elsewhere, the Converted Policy will be on a form which

meets the conversion requirements of the jurisdiction

where he resides. The Converted Policy offering may

include medical benefits on a group basis. The Converted

Policy need not provide major medical coverage unless

it is required by the laws of the jurisdiction in which the

Converted Policy is issued.

The Converted Policy will be issued to you if you are

Entitled to Convert, insuring you and those Dependents

for whom you may convert. If you are not Entitled to

Convert and your spouse and children are, it will be issued

to the spouse, covering all such Dependents. Otherwise, a

Converted Policy will be issued to each Dependent who is

Entitled to Convert. The Converted Policy will take effect

on the day after the person's insurance under this plan

ceases. The premium on its effective date will be based on:

(a) class of risk and age; and (b) benefits.

The Converted Policy may not exclude any pre-existing

condition not excluded by this plan. During the period of

the Medical Benefits Extension of this plan, the amount

payable under the Converted Policy will be reduced so that

the total amount payable under the Converted Policy and

the Medical Benefits Extension of this plan will not be

more than the amount that would have been payable under

this plan if the person's insurance had not ceased. After

that, the amount payable under the Converted Policy will

be reduced by any amount still payable under the Medical

Benefits Extension of this plan.

CG or the Policyholder will give you, on request, further

details of the Converted Policy.

POS-CONV(01) 11/01

Requirements of Family and Medical Leave Act of 1993

Any provisions of the policy that provide for: (a)

continuation of insurance during a leave of absence; and

(b) reinstatement of insurance following a return to Active

Service; are modified by the following provisions of the

federal Family and Medical Leave Act of 1993, where

applicable:

A. Continuation of Health Insurance During Leave

Your health insurance will be continued during a leave

of absence if:

that leave qualifies as a leave of absence under the

Family and Medical Leave Act of 1993; and

you are an eligible Employee under the terms of

that Act.

The cost of your health insurance during such leave

must be paid, whether entirely by your Employer or in

part by you and your Employer.

B. Reinstatement of Canceled Insurance Following

Leave

Upon your return to Active Service following a leave

of absence that qualifies under the Family and Medical

Leave Act of 1993, any canceled insurance (health, life

or disability) will be reinstated as of the date of your

return.

You will not be required to satisfy any eligibility or

benefit waiting period or the requirements of any Pre-

existing Condition Limitation to the extent that they

had been satisfied prior to the start of such leave of

absence.

Your Employer will give you detailed information

about the Family and Medical Leave Act of 1993.

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Notice Of Federal Requirements -

Uniformed Services Employment And

Reemployment Rights Act Of 1994

(USERRA)

The Uniformed Services Employment and

Reemployment Rights Act of 1994 (USERRA) sets

requirements for continuation of health coverage and

re-employment in regard to military leaves of absence.

These requirements apply to medical coverage for you

and your Dependents.

Continuation of Coverage

You may continue coverage for yourself and your

Dependent as follows:

You may continue benefits, by paying the required

premium to your employer, until the earliest of the

following:

24 months from the last day of employment with

the employer;

the day after you fail to apply or return to work;

and

the date the policy cancels.

Your employer may charge you and your Dependents

up to 102% of the total premium.

Following continuation of health coverage per

USERRA requirements, you may convert to a plan

of individual coverage according to any "Conversion

Privilege" shown in your certificate.

Reinstatement of Benefits

If your coverage ends during the leave because you do

not elect USERRA, or an available conversion plan at

the expiration of USERRA, and you are reemployed

by your current employer, coverage for you and your

Dependents may be reinstated if, (a) you gave your

employer advance written or verbal notice of your

military service leave, and (b) the duration of all

military leaves while you are employed with your

current employer does not exceed 5 years.

You and your Dependents will be subject to only the

balance of a Pre-existing Conditions Limitation (PCL)

or waiting period, if any, that was not yet satisfied

before the leave began. However, if an injury or

sickness occurs or is aggravated during the military

leave, full plan limitations will apply.

Any 63-day break in coverage rule regarding credit

for time accrued toward a PCL waiting period will be

waived.

POS-CONT(02)-A 1/06

Policy Provisions

Notice of Claim

Written notice of claim must be given to CG within 30

days after the occurrence or start of the loss on which claim

is based. If notice is not given in that time, the claim will

not be invalidated or reduced if it is shown that written

notice was given as soon as was reasonably possible.

Claim Forms

When CG receives the notice of claim, it will give to the

claimant, or to the Policyholder for the claimant, the claim

forms which it uses for filing proof of loss. If the claimant

does not get these claim forms within 15 days after CG

receives notice of claim, he will be considered to meet

the proof of loss requirements of the policy if he submits

written proof of loss within 90 days after the date of loss.

This proof must describe the occurrence, character and

extent of the loss for which claim is made.

Proof of Loss

Written proof of loss must be given to CG within 90 days

after the date of the loss for which claim is made. If written

proof of loss is not given in that time, the claim will not be

invalidated nor reduced if it is shown that written proof of

loss was given as soon as was reasonably possible.

Physical Examination

CG, at its own expense, will have the right to examine

any person for whom claim is pending as often as it may

reasonably require.

Legal Actions

No action at law or in equity will be brought to recover on

the policy until at least 60 days after proof of loss has been

filed with CG. No action will be brought at all unless

brought within 3 years after the time within which proof of

loss is required.

POS-PROV(01) 11/01

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Out-of-Network Medical Benefits

Definitions Active Service You will

be considered in Active Service:

on any of your Employer's scheduled work days if you

are performing the regular duties of your work on a

full-time basis on that day either at your Employer's

place of business or at some location to which you are

required to travel for your Employer's business.

on a day which is not one of your Employer's scheduled

work days if you were in Active Service on the

preceding scheduled work day.

Basic Benefits

The term Basic Benefits means the group coverage

provided by Cigna HealthCare under its Group Service

Agreement with the Employer.

Bed and Board

The term Bed and Board includes all charges made by a

Hospital on its own behalf for room and meals and for

all general services and activities needed for the care of

registered bed patients.

Coinsurance

The term Coinsurance means the percentage of charges for

Covered Expenses that an insured person is required to pay

under the Plan.

Contract Year

The term Contract Year is as defined for Basic Benefits

under the Group Service Agreement.

Custodial Services

Any services that are of a sheltering, protective, or

safeguarding nature. Such services may include a stay in

an institutional setting, at-home care, or nursing services

to care for someone because of age or mental or physical

condition. This service primarily helps the person in

daily living. Custodial care also can provide medical

services given mainly to maintain the person's current state

of health. These services cannot be intended to greatly

improve a medical condition; they are intended to provide

care while the patient cannot care for himself or herself.

Custodial Services include but are not limited to:

services related to watching or protecting a person;

services related to performing or assisting a person

in performing any activities of daily living, such as:

a) walking, b) grooming, c) bathing, d) dressing,

e) getting in or out of bed, f) toileting, g) eating, h)

preparing foods, or i) taking medications that can be

self administered, and

services not required to be performed by trained or

skilled medical or paramedical personnel.

Days

Calendar days; not 24 hour periods unless otherwise

expressly stated.

Deductible

The term Deductible means the expenses to be paid by you

or your Dependent for services rendered. Deductibles are

in addition to any other expenses incurred for which no

benefits are payable because of any coinsurance factor.

Dependent

Dependents are any one of the following persons who are

enrolled for Basic Benefits:

Your lawful spouse; and

any unmarried child of yours who is:

less than 19 years old and primarily supported by

you;

19 years but less than the limiting age for Basic

Benefits, enrolled in school as a full-time student

and primarily supported by you; and

19 or more years old and primarily supported by

you and incapable of self-sustaining employment

by reason of mental or physical handicap. Proof

of the child's condition and dependence must be

submitted to CG within 31 days after the date the

child ceases to qualify above. During the next two

years CG may, from time to time, require proof of

the continuation of such condition and dependence.

After that, CG may require proof no more than

once a year.

A child includes a legally adopted child, including that

child from the first day of placement in your home. It also

includes a stepchild who lives with you.

Anyone who is eligible as an Employee will not be

considered as a Dependent.

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No one may be considered as a Dependent of more than

one Employee.

Employee

The term Employee means a full-time employee of the

Employer.

Employer

The term Employer means an employer participating in the

fund which is established under the agreement of Trust for

the purpose of providing insurance.

Home Health Care Plan

The term Home Health Care Plan means a plan for care

and treatment of a person in his home. To qualify, the plan

must be established and approved in writing by a Physician

who certifies that the person would require confinement in

a Hospital or Skilled Nursing Facility if he did not have the

care and treatment stated in the plan.

Hospital

The term Hospital means:

an institution licensed as a hospital, which: (a)

maintains, on the premises, all facilities necessary

for medical and surgical treatment; (b) provides such

treatment on an inpatient basis, for compensation,

under the supervision of Physicians; and (c) provides

24-hour service by Registered Graduate Nurses;

an institution which qualifies as a hospital or a

tuberculosis hospital, and a provider of services under

Medicare, if such institution is accredited as a hospital

by the Joint Commission on the Accreditation of

Hospitals; or

an institution which: (a) specializes in treatment of

mental health, substance abuse or other related

illnesses; (b) provides residential treatment programs;

and (c) is licensed in accordance with the laws of the

appropriate legally authorized agency.

The term Hospital will not include an institution which is

primarily a place for rest, a place for the aged, or a nursing

home.

Hospital Confinement or Confined in a Hospital

A person will be considered Confined in a Hospital if he is:

a registered bed patient in a Hospital upon the

recommendation of a Physician;

an outpatient in a Hospital because of: (a)

chemotherapy treatment; (b) surgery; or (c) planned

tests ordered by a Physician before inpatient admission

to the same Hospital;

receiving emergency care in a Hospital for an Injury, on

his first visit as an outpatient within 48 hours after the

Injury is received; or

partially Confined for treatment of mental illness,

alcohol or drug abuse or other related illness. Two days

of being Partially Confined will be equal to one day of

being Confined in a Hospital.

The term Partially Confined means continually treated for

at least 3 hours but not more than 12 hours in any 24-hour

period.

Injury

The term Injury means an accidental bodily injury.

Maximum Reimbursable Charge

The Maximum Reimbursable Charge for covered services

is determined based on the lesser of:

the provider's normal charge for a similar service or

supply; or

a policyholder-selected percentile of charges made by

providers of such service or supply in the geographic

area where it is received as compiled in a database

selected by CG.

The percentile used to determine the Maximum

Reimbursable Charge is listed in The Schedule.

The Maximum Reimbursable Charge is subject to all other

benefit limitations and applicable coding and payment

methodologies determined by CG. Additional information

about how CG determines the Maximum Reimbursable

Charge is available upon request.

GM6000 DFS1997

Medicaid

The term Medicaid means a state program of medical aid

for needy persons established under Title XIX of the Social

Security Act of 1965 as amended.

Medical Services

Professional services of Physicians or Other Health

Professionals (except as limited or excluded by this policy),

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Out-of-Network Medical Benefits

including medical, psychiatric, surgical, diagnostic,

therapeutic, and preventive services.

Medically Necessary/Medical Necessity

Medically Necessary Covered Expenses are those

determined by CG to be:

required to diagnose or treat an illness, injury, disease

or its symptoms; and

in accordance with generally accepted standards of

medical practice; and

clinically appropriate in terms of type, frequency,

extent, site and duration; and

not primarily for the convenience of the patient,

Physician, or other health care provider; and

rendered in the least intensive setting that is appropriate

for the delivery of the services and supplies. Where

applicable CG may compare the cost-effectiveness

of alternative services, settings or supplies when

determining the least intensive setting.

Medicare

The term Medicare means the program of medical care

benefits provided under Title XVIII of the Social Security

Act of 1965 as amended.

Necessary Services and Supplies

The term Necessary Services and Supplies includes:

any charges, except charges for Bed and Board,

made by a Hospital on its own behalf for medical

services and supplies actually used during Hospital

Confinement;

any charges, by whomever made, for licensed

ambulance service to or from the nearest Hospital

where the needed medical care and treatment can be

provided; and

any charges, by whomever made, for the administration

of anesthetics during Hospital Confinement.

The term Necessary Services and Supplies will not include

any charges for special nursing fees, dental fees or medical

fees.

Nurse

The term Nurse means a Registered Graduate Nurse, a

Licensed Practical Nurse or a Licensed Vocational Nurse

who has the right to use the abbreviation "R.N.," "L.P.N."

or "L.V.N."

Other Health Care Facility

Other Health Care Facilities are any facilities other than a

Hospital or hospice facility. Examples of Other Health Care

Facilities include, but are not limited to, licensed skilled

nursing facilities, rehabilitation hospitals and sub-acute

facilities.

Other Health Care Professional

An individual other than a Physician who is licensed or

otherwise authorized under the applicable state law to

deliver Medical Services. Other Health Professionals

include, but are not limited to physical therapists,

registered nurses and licensed practical nurses.

Outpatient Surgical Facility

The term Outpatient Surgical Facility means a licensed

institution which: (a) has a staff that includes Registered

Graduate Nurses; (b) has a permanent place equipped for

performing Surgical Procedures; and (c) gives continuous

Physician services on an outpatient basis.

Participation Date

The term Participation Date means the later of:

the Effective Date of the policy; or

the date on which your Employer becomes a participant

in the plan of insurance authorized by the agreement of

Trust.

Physician

The term Physician means a licensed medical practitioner

who is practicing within the scope of his license and who

is licensed to prescribe and administer drugs or to perform

surgery. It will also include any other licensed medical

practitioner whose services are required to be covered by

law in the locality where the policy is issued if he is:

operating within the scope of his license; and

performing a service for which benefits are provided

under this plan when performed by a Physician.

Qualified Medical Child Support Order

A Qualified Medical Child Support Order is a judgment,

decree or order (including approval of a settlement

agreement) or administrative notice, which is issued

pursuant to a state domestic relations law (including a

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Out-of-Network Medical Benefits

community property law), or to an administrative process,

which provides for child support or provides for health

benefit coverage to such child and relates to benefits under

the group health plan, and satisfies all of the following:

1. the order recognizes or creates a child's right to

receive group health benefits for which a participant or

beneficiary is eligible;

2. the order specifies your name and last known address,

and the child's name and last known address, except

that the name and address of an official of a state or

political subdivision may be substituted for the child's

mailing address;

3. the order provides a description of the coverage to be

provided, or the manner in which the type of coverage

is to be determined;

4. the order states the period to which it applies; and

5. if the order is a National Medical Support Notice

completed in accordance with the Child Support

Performance and Incentive Act of 1998, such notice

meets the requirement above.

Review Organization

The term Review Organization refers to an affiliate of CG

or another entity to which CG has delegated responsibility

for performing utilization review services. The review

Organization is an organization with a staff of clinicians

which may include Physicians, registered Graduate Nurses,

licensed mental health and substance abuse professionals,

and other trained staff members who perform utilization

review services.

Schedule

The section of this agreement that identifies applicable

Coinsurance, Deductibles and maximums.

Sickness

The term Sickness means a physical or mental illness. It

also includes pregnancy. Expenses incurred for routine care

of a newborn child prior to discharge from the Hospital

nursery will be considered to be incurred as a result of

Sickness.

Skilled Nursing Facility

The term Skilled Nursing Facility means a licensed

institution (other than a Hospital, as defined) which

specializes in:

physical rehabilitation on an inpatient basis; or

skilled nursing and medical care on an inpatient basis;

but only if that institution: (a) maintains on the premises

all facilities necessary for medical treatment; (b) provides

such treatment, for compensation, under the supervision of

Physicians; and (c) provides Nurses' services.

POS-DEF(01) 11/01

POS-DEF(01)-A 1/09(MRC)

Miscellaneous

Additional Programs

CG may, from time to time, offer or arrange for various

entities to offer discounts, benefits or other consideration

to Employees for the purpose of promoting their general

health and well-being. Contact CG for details of these

programs.

Assignability

The benefits under this Policy are not assignable unless

agreed to by CG. CG may, at its option, make payment to

the insured for any cost of any Covered Expense received

by the insured or insured's covered dependents from a

provider. The insured is responsible for reimbursing the

non-participating provider.

POS-MISC(01) 11/01

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ERISA Summary Plan Description

ERISA REQUIRED INFORMATION

The name of the Plan is: SAMPLE PLAN

The name, address, ZIP code and business

telephone number of the sponsor of the

Plan is: SAMPLE NAME and ADDRESS

Employer Identification Number (EIN): SAMPLE EIN

Plan Number: 001

The name, address, ZIP code and

business telephone number of the Plan

administrator is: SAMPLE NAME and ADDRESS

The name, address and ZIP code of the

person designated as agent for the service

of legal process is: SAMPLE NAME and ADDRESS

The office designated to consider the

appeal of denied claims is: SAMPLE NAME and

The cost of the Plan is: EMPLOYEE CONTRIBUTES FOR ALL

The Plan's fiscal year ends on: XX/XX

The preceding pages set forth the eligibility requirements and benefits provided for you under this Plan.

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ERISA Summary Plan Description

Plan Trustees

A list of any Trustees of the Plan, which includes name,

title and address, is available upon request from the

Plan Administrator.

Plan Type

The Plan is a healthcare benefit plan.

Collective Bargaining Agreement

You may contact the Plan Administrator to determine

whether the Plan is maintained pursuant to one or

more collective bargaining agreements and if a

particular Employer is a sponsor. A copy is available

for examination from the Plan Administrator upon

written request.

Discretionary Authority

The Plan Administrator delegates to the Healthplan

the discretionary authority to interpret and apply

plan terms and to make factual determinations in

connection with its review of claims under the plan.

Such discretionary authority is intended to include, but

not limited to, the determination of the eligibility of

persons desiring to enroll in or claim benefits under the

plan, the determination of whether a person is entitled

to benefits under the plan, and the computation of any

and all benefit payments. The Plan Administrator also

delegates to the Healthplan the discretionary authority

to perform a full and fair review, as required by

ERISA, of each claim denial which has been appealed

by the claimant or his duly authorized representative.

Plan Modification, Amendment and Termination

The Employer as Plan Sponsor reserves the right to,

at any time, change or terminate benefits under the

Plan, to change or terminate the eligibility of classes

of Employees to be covered by the Plan, to amend or

eliminate any other plan term or condition, and to

terminate the whole plan or any part of it.

The procedure by which benefits may be changed

or terminated, by which the eligibility of classes of

Employees may be changed or terminated, or by

which part or all of the Plan may be terminated, is

contained in the Employer's Plan Document, which

is available for inspection and copying from the Plan

Administrator designated by the Employer. No consent

of any participant is required to terminate, modify,

amend or change the Plan.

Termination of the Plan together with termination of

the insurance policy(s) which funds the Plan benefits

will have no adverse effect on any benefits to be paid

under the policy(s) for any covered medical expenses

incurred prior to the date that policy(s) terminates.

Likewise, any extension of benefits under the policy(s)

due to your or your Dependent's total disability which

began prior to and has continued beyond the date

the policy(s) terminates will not be affected by the

Plan termination. Rights to purchase limited amounts

of life and medical insurance to replace part of the

benefits lost because the policy(s) terminated may arise

under the terms of the policy(s). A subsequent Plan

termination will not affect the extension of benefits and

rights under the policy(s).

Your coverage under the Plan's insurance policy(s)

will end on the earliest of the following dates:

the date you leave Active Service;

the date you are no longer in an eligible class;

if the Plan is contributory, the date you cease to

contribute, or;

the date the policy(s) terminates.

See your Plan Administrator to determine if any

extension of benefits or rights are available to you or

your Dependents under this policy(s). No extension of

benefits or rights will be available solely because the

Plan terminates.

Statement of Rights

As a participant in the plan you are entitled to certain

rights and protections under the Employee Retirement

Income Security Act of 1974 (ERISA). ERISA

provides that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits

examine, without charge, at the Plan Administrators

office and at other specified locations, such as

worksites and union halls, all documents governing

the plan, including insurance contracts and collective

bargaining agreements, and a copy of the latest annual

report (Form 5500 Series) filed by the plan with the

U.S. Department of Labor and available at the Public

Disclosure Room of the Pension and Welfare Benefit

Administration.

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ERISA Summary Plan Description

obtain, upon written request to the Plan Administrator,

copies of documents governing the plan, including

insurance contracts and collective-bargaining

agreements, and a copy of the latest annual report

(Form 5500 Series) and updated Summary Plan

Description. The administrator may make a reasonable

charge for the copies.

receive a summary of the plan's annual financial report.

The Plan Administrator is required by law to furnish

each participant with a copy of this summary annual

report.

Continue Group Health Plan Coverage

continue health care coverage for yourself, spouse

or Dependents if there is a loss of coverage under

the plan as a result of a qualifying event. You or

your Dependents may have to pay for such coverage.

Review this Summary Plan Description and the

documents governing the plan on the rules governing

your federal continuation coverage rights.

reduction or elimination of exclusionary periods of

coverage for preexisting conditions under your group

health plan, if you have creditable coverage from

another plan. You should be provided a certificate of

creditable coverage, free of charge, from your group

health plan or health insurance issuer when you lose

coverage under the plan, when you become entitled

to elect federal continuation coverage, when your

federal continuation coverage ceases, if you request

it before losing coverage, or if you request it up to

24 months after losing coverage. Without evidence of

creditable coverage, you may be subject to a pre-

existing condition exclusion for 12 months (18 months

for late enrollees) after your enrollment date in your

coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for plan participants,

ERISA imposes duties upon the people responsible for

the operation of the Employee benefit plan. The people

who operate your plan, called "fiduciaries" of the plan,

have a duty to do so prudently and in the interest of

you and other plan participants and beneficiaries. No

one, including your Employer, your union, or any other

person, may fire you or otherwise discriminate against

you in any way to prevent you from obtaining a welfare

benefit or exercising your rights under ERISA. If your

claim for a welfare benefit is denied or ignored, in

whole or in part, you have a right to know why this

was done, to obtain copies of documents relating to

the decision without charge, and to appeal any denial,

all within certain time schedules. Under ERISA, there

are steps you can take to enforce the above rights. For

instance, if you request a copy of plan documents or the

latest annual report from the plan and do not receive

them within 30 days, you may file suit in a federal

court. In such a case, the court may require the Plan

Administrator to provide the materials and pay you up

to $110 a day until you receive the materials, unless

the materials were not sent because of reasons beyond

the control of the administrator. If you have a claim for

benefits which is denied or ignored in whole or in part,

you may file suit in a state or federal court.

Enforce Your Rights

In addition, if you disagree with the plan's decision

or lack thereof concerning the qualified status of a

domestic relations order or a medical child support

order, you may file suit in federal court. If it should

happen that plan fiduciaries misuse the plan's money,

or if you are discriminated against for asserting

your rights, you may seek assistance from the U.S.

Department of Labor, or you may file suit in a federal

court. The court will decide who should pay court costs

and legal fees. If you are successful the court may order

the person you have sued to pay these costs and fees.

If you lose, the court may order you to pay these costs

and fees, for example, if it finds your claim is frivolous.

CLAIM DETERMINATION PROCEDURES UNDER

ERISA

The following complies with federal law effective

July 1, 2002. Provisions of the laws of your state may

supersede.

Procedures Regarding Medical Necessity

Determinations

In general, health services and benefits must be

medically necessary to be covered under the plan. The

procedures for determining medical necessity vary,

according to the type of service or benefit requested,

and the type of health plan. Medical necessity

determinations are made on either a preservice,

concurrent, or postservice basis, as described below:

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ERISA Summary Plan Description

Certain services require prior authorization in order to

be covered. This prior authorization is called a

"preservice medical necessity determination." The

Agreement describes who is responsible for obtaining

this review. You or your authorized representative

(typically, your health care provider) must request

medical necessity determinations according to the

procedures described below, in the Agreement, and in

your provider's network participation documents as

applicable.

When services or benefits are determined to be not

medically necessary, you or your representative

will receive a written description of the adverse

determination, and may appeal the determination.

Appeal procedures are described in the Agreement, in

your provider's network participation documents, and

in the determination notices.

Preservice Medical Necessity Determinations

When you or your representative request a required

medical necessity determination prior to care, the

Healthplan shall notify you or your representative of

the determination within 15 days after receiving the

request. However, if more time is needed due to matters

beyond the Healthplan's control, the Healthplan will

notify you or your representative within 15 days after

receiving your request. This notice will include the

date a determination can be expected, which will be

no more than 30 days after receipt of the request. If

more time is needed because necessary information

is missing from the request, the notice will also

specify what information is needed, and you or your

representative must provide the specified information

to the Healthplan within 45 days after receiving the

notice. The determination period will be suspended on

the date the Healthplan sends such a notice of missing

information, and the determination period will resume

on the date you or your representative responds to the

notice.

If the determination periods above would (a) seriously

jeopardize your life or health, your ability to regain

maximum function, or (b) in the opinion of a Physician

with knowledge of your health condition, cause you

severe pain which cannot be managed without the

requested services, the Healthplan will make the

preservice determination on an expedited basis. The

Healthplan Physician reviewer, in consultation with the

treating Physician, will decide if an expedited appeal

is necessary. The Healthplan will notify you or your

representative of an expedited determination within 72

hours after receiving the request. However, if necessary

information is missing from the request, the Healthplan

will notify you or your representative within 24 hours

after receiving the request to specify what information

is needed. You or your representative must provide

the specified information to the Healthplan within

48 hours after receiving the notice. The Healthplan

will notify you or your representative of the expedited

benefit determination within 48 hours after you or

your representative responds to the notice. Expedited

determinations may be provided orally, followed within

3 days by written or electronic notification.

If you or your representative fails to follow the

Healthplan's procedures for requesting a required

preservice medical necessity determination, the

Healthplan will notify you or your representative of

the failure and describe the proper procedures for

filing within five days (or 24 hours, if an expedited

determination is required, as described above) after

receiving the request. This notice may be provided

orally, unless you or your representative requests

written notification.

Concurrent Medical Necessity Determinations

When an ongoing course of treatment has been

approved for you and you wish to extend the approval,

you or your representative must request a required

concurrent medical necessity determination at least 24

hours prior to the expiration of the approved period

of time or number of treatments. When you or your

representative requests such a determination, the

Healthplan will notify you or your representative of

the determination within 24 hours after receiving the

request.

Postservice Medical Necessity Determinations

When you or your representative requests a medical

necessity determination after services have been

rendered, the Healthplan will notify you or your

representative of the determination within 30 days

after receiving the request. However, if more time

is needed to make a determination due to matters

beyond the Healthplan's control the Healthplan will

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ERISA Summary Plan Description

notify you or your representative within 30 days after

receiving the request. This notice will include the

date a determination can be expected, which will be

no more than 45 days after receipt of the request.

If more time is needed because necessary information

is missing from the request, the notice will also

specify what information is needed, and you or your

representative must provide the specified information

to the Healthplan within 45 days after receiving the

notice. The determination period will be suspended on

the date the Healthplan sends such a notice of missing

information, and the determination period will resume

on the date you or your representative responds to the

notice.

Postservice Claim Determinations

When you or your representative requests payment

for services which have been rendered, the Healthplan

will notify you or your representative of the claim

payment determination within 30 days after receiving

the request. However, if more time is needed to

make a determination due to matters beyond the

Healthplan's control the Healthplan will notify you

or your representative within 30 days after receiving

the request. This notice will include the date a

determination can be expected, which will be no

more than 45 days after receipt of the request.

If more time is needed because necessary information

is missing from the request, the notice will also

specify what information is needed, and you or your

representative must provide the specified information

to the Healthplan within 45 days after receiving the

notice. The determination period will be suspended on

the date the Healthplan sends such a notice of missing

information, and the determination period will resume

on the date you or your representative responds to the

notice.

Notice of Adverse Determination

Every notice of an adverse benefit determination

will be provided in writing or electronically, and

will include all of the following that pertain to the

determination: (1) the specific reason or reasons for the

adverse determination; (2) reference to the specific plan

provisions on which the determination is based; (3) a

description of any additional material or information

necessary to perfect the claim and an explanation of

why such material or information is necessary; (4) a

description of the plan's review procedures and the time

limits applicable, including a statement of a claimant's

rights to bring a civil action under section 502(a) of

ERISA following an adverse benefit determination

on appeal; (5) upon request and free of charge, a

copy of any internal rule, guideline, protocol or other

similar criterion that was relied upon in making the

adverse determination regarding your claim, and an

explanation of the scientific or clinical judgment for

a determination that is based on a medical necessity,

experimental treatment or other similar exclusion or

limit; (6) in the case of a claim involving urgent care, a

description of the expedited review process applicable

to such claim.

Assistance with Your Questions.

If you have any questions about your plan, you should

contact the Plan Administrator. If you have any

questions about this statement or about your rights

under ERISA, or if you need assistance in obtaining

documents from the Plan Administrator, you should

contact the nearest office of the Employee Benefits

Security Administration, U.S. Department of Labor,

listed in your telephone directory or the Division of

Technical Assistance and Inquiries, Employee Benefits

Security Administration, U.S. Department of Labor,

200 Constitution Avenue N.W, Washington, D.C.

20210. You may also obtain certain publications about

your rights and responsibilities under ERISA by calling

the publications hotline of the Employee Benefits

Security Administration. The Healthplan will provide

administrative services of the following nature: Claim

Administration; Cost Containment; Financial; Banking

and Billing Administration. Benefits provided under

this Agreement are fully guaranteed by the Healthplan.

This Agreement is issued by the Healthplan.

GSA-ERISA

6/05

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Federal Rider

FEDERAL REQUIREMENTS

The following pages explain your rights and responsibilities under certain federal laws and regulations. Some states may

have similar requirements. If a similar provision appears elsewhere in this agreement, the provision which provides the

better benefit will apply.

Coverage of Students on Medically Necessary Leave of Absence

If your Dependent child is covered by this plan as a student, coverage will remain active for that child if the child is on a

medically necessary leave of absence from a postsecondary educational institution (such as a college, university or trade

school).

Coverage will terminate on the earlier of:

(a) The date that is one year after the first day of the medically necessary leave of absence; or

(b) The date on which coverage would otherwise terminate under the terms of the plan.

The child must be a Dependent under the terms of the plan and must have been enrolled in the plan on the basis of being

a student at a postsecondary educational institution immediately before the first day of the medically necessary leave of

absence.

The plan must receive written certification from the treating physician that the child is suffering from a serious illness or

injury and that the leave of absence (or other change in enrollment) is medically necessary.

A "medically necessary leave of absence" is a leave of absence from a postsecondary educational institution, or any other

change in enrollment of the child at the institution that: (1) starts while the child is suffering from a serious illness or

condition; (2) is medically necessary; and (3) causes the child to lose student status under the terms of the plan.

(GSA) Federal.1 10/09

Special Enrollment Rights Under the Health Insurance Portability & Accountability Act

(HIPAA)

If you or your eligible Dependent(s) experience a special enrollment event as described below, you or your eligible

Dependent(s) may be entitled to enroll in the Plan outside of a designated enrollment period upon the occurrence of one

of the special enrollment events listed below. If you are already enrolled in the Plan, you may request enrollment for you

and your eligible Dependent(s) under a different option offered by the Employer for which you are currently eligible.

If you are not already enrolled in the Plan, you must request special enrollment for yourself in addition to your eligible

Dependent(s). You and all of your eligible Dependent(s) must be covered under the same option. The special enrollment

events include:

Acquiring a new Dependent. If you acquire a new Dependent(s) through marriage, birth, adoption or placement

for adoption, you may request special enrollment for any of the following combinations of individuals if not already

enrolled in the Plan: Employee only; spouse only; Employee and spouse; Dependent child(ren) only; Employee and

Dependent child(ren); Employee, spouse and Dependent child(ren). Enrollment of Dependent children is limited

to the newborn or adopted children or children who became Dependent children of the Employee due to marriage.

Dependent children who were already Dependents of the Employee but not currently enrolled in the Plan are not

entitled to special enrollment.

Loss of eligibility for State Medicaid or Children's Health Insurance Program (CHIP). If you and/or your

Dependent(s) were covered under a state Medicaid or CHIP plan and the coverage is terminated due to a loss of

eligibility, you may request special enrollment for yourself and any affected Dependent(s) who are not already enrolled

in the Plan. You must request enrollment within 60 days after termination of Medicaid or CHIP coverage.

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Federal Rider

Loss of eligibility for other coverage (excluding continuation coverage). If coverage was declined under this

Plan due to coverage under another plan, and eligibility for the other coverage is lost, you and all of your eligible

Dependent(s) may request special enrollment in this Plan. If required by the Plan, when enrollment in this Plan was

previously declined, it must have been declined in writing with a statement that the reason for declining enrollment

was due to other health coverage. This provision applies to loss of eligibility as a result of any of the following:

divorce or legal separation;

cessation of Dependent status (such as reaching the limiting age);

death of the Employee;

termination of employment;

reduction in work hours to below the minimum required for eligibility;

you or your Dependent(s) no longer reside, live or work in the other plan's network service area and no other coverage

is available under the other plan;

you or your Dependent(s) incur a claim which meets or exceeds the lifetime maximum limit that is applicable to all

benefits offered under the other plan; or

the other plan no longer offers any benefits to a class of similarly situated individuals.

Termination of employer contributions (excluding continuation coverage). If a current or former employer ceases

all contributions toward the Employee's or Dependent's other coverage, special enrollment may be requested in this

Plan for you and all of your eligible Dependent(s).

Exhaustion of COBRA or other continuation coverage. Special enrollment may be requested in this Plan for

you and all of your eligible Dependent(s) upon exhaustion of COBRA or other continuation coverage. If you or

your Dependent(s) elect COBRA or other continuation coverage following loss of coverage under another plan, the

COBRA or other continuation coverage must be exhausted before any special enrollment rights exist under this Plan.

An individual is considered to have exhausted COBRA or other continuation coverage only if such coverage ceases:

(a) due to failure of the employer or other responsible entity to remit premiums on a timely basis; (b) when the person

no longer resides or works in the other plan's service area and there is no other COBRA or continuation coverage

available under the plan; or (c) when the individual incurs a claim that would meet or exceed a lifetime maximum limit

on all benefits and there is no other COBRA or other continuation coverage available to the individual. This does not

include termination of an employer's limited period of contributions toward COBRA or other continuation coverage as

provided under any severance or other agreement.

Eligibility for employment assistance under State Medicaid or Children's Health Insurance Program (CHIP).

If you and/or your Dependent(s) become eligible for assistance with group health plan premium payments under a

state Medicaid or CHIP plan, you may request special enrollment for yourself and any affected Dependent(s) who are

not already enrolled in the Plan. You must request enrollment within 60 days after the date you are determined to be

eligible for assistance.

Except as stated above, special enrollment must be requested within 30 days after the occurrence of the special

enrollment event. If the special enrollment event is the birth or adoption of a Dependent child, coverage will be

effective immediately on the date of birth, adoption or placement for adoption. Coverage with regard to any other

special enrollment event will be effective on the first day of the calendar month following receipt of the request for

special enrollment.

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Federal Rider

If your plan contains out-of-network benefits, individuals within that plan who enroll due to a special enrollment event

will not be considered Late Entrants. Any Pre-existing Condition limitation will be applied upon enrollment, reduced by

prior Creditable Coverage, but will not be extended as for a Late Entrant.

Domestic Partners and their children (if not legal children of the Employee) are not eligible for special enrollment.

(GSA) Federal.2 4/09

Effect of Section 125 Tax Regulations on This Plan

If your Employer has chosen to administer this Plan in accordance with Section 125 regulations of the Internal Revenue

Code. Per this regulation, you may agree to a pretax salary reduction put toward the cost of your benefits. Otherwise, you

will receive your taxable earnings as cash (salary).

A. Coverage Elections

Per Section 125 regulations, you are generally allowed to enroll for or change coverage only before each annual

benefit period. However, exceptions are allowed if your Employer agrees and you enroll for or change coverage within

30 days of the following:

the date you meet the Special Enrollment criteria described above; or

the date you meet the criteria shown in the following Sections B through F.

B. Change of Status

A change in status is defined as:

1. change in legal marital status due to marriage, death of a spouse, divorce, annulment or legal separation;

2. change in number of Dependents due to birth, adoption, placement for adoption, or death of a Dependent;

3. change in employment status of Employee, spouse or Dependent due to termination or start of employment,

strike, lockout, beginning or end of unpaid leave of absence, including under the Family and Medical Leave Act

(FMLA), or change in worksite;

4. changes in employment status of Employee, spouse or Dependent resulting in eligibility or ineligibility for

coverage;

5. change in residence of Employee, spouse or Dependent to a location outside of the Employer's network service

area; and

6. changes which cause a Dependent to become eligible or ineligible for coverage.

C. Court Order

A change in coverage due to and consistent with a court order of the Employee or other person to cover a Dependent.

D. Medicare or Medicaid Eligibility/Entitlement

The Employee, spouse or Dependent cancels or reduces coverage due to entitlement to Medicare or Medicaid, or

enrolls or increases coverage due to loss of Medicare or Medicaid eligibility.

E. Change in Cost of Coverage

If the cost of benefits increases or decreases during a benefit period, your Employer may, in accordance with plan

terms, automatically change your elective contribution.

When the change in cost is significant, you may either increase your contribution or elect less-costly coverage. When

a significant overall reduction is made to the benefit option you have elected, you may elect another available benefit

option. When a new benefit option is added, you may change your election to the new benefit option.

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Federal Rider

F. Changes in Coverage of Spouse or Dependent Under Another Employer's Plan

You may make a coverage election change if the plan of your spouse or Dependent: (a) incurs a change such as adding

or deleting a benefit option; (b) allows election changes due to Special Enrollment, Change in Status, Court Order or

Medicare or Medicaid Eligibility/Entitlement; or (c) this Plan and the other plan have different periods of coverage or

open enrollment periods.

(GSA) Federal.3 1/09

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