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SAMPLECigna Comprehensive PlanImportant InformationTHIS IS A SAMPLE DOCUMENT.NO BENEFITS ARE GUARANTEED. NO COVERAGE REPRESENTATION ISCONSIDERED TO BE ACTUAL MEDICAL BENEFITS PROVIDED TO YOU BYCIGNA.

Table of ContentsImportant Information .6Special Plan Provisions .8Important Notices .8How To File Your Claim .10Eligibility - Effective Date .11Employee Insurance . 11Waiting Period . 11Dependent Insurance . 11Comprehensive Medical Benefits .12The Schedule . 12Certification Requirements - Out-of-Network . 21Covered Expenses . 21Prescription Drug Benefits .30The Schedule . 30Covered Expenses . 32Limitations. 32Your Payments . 33Exclusions . 33Reimbursement/Filing a Claim . 33Cigna Vision .35The Schedule . 35Covered Expenses . 36Expenses Not Covered . 36Exclusions, Expenses Not Covered and General Limitations .36Coordination of Benefits.39Expenses For Which A Third Party May Be Responsible .41Payment of Benefits .43Termination of Insurance.43Employees . 43Dependents . 43Rescissions . 44Federal Requirements .44Notice of Provider Directory/Networks. 44Qualified Medical Child Support Order (QMCSO) . 44Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) . 45Effect of Section 125 Tax Regulations on This Plan . 46Eligibility for Coverage for Adopted Children . 47

Coverage for Maternity Hospital Stay . 47Women’s Health and Cancer Rights Act (WHCRA) . 47Group Plan Coverage Instead of Medicaid . 47Requirements of Medical Leave Act of 1993 (as amended) (FMLA) . 47Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) . 48Claim Determination Procedures under ERISA . 48Medical - When You Have a Complaint or an Appeal . 49COBRA Continuation Rights Under Federal Law . 51ERISA Required Information . 54Definitions .56

Important InformationTHIS IS A SAMPLE DOCUMENT.NO BENEFITS ARE GUARANTEED. NO COVERAGE REPRESENTATION IS CONSIDERED TO BEACTUAL MEDICAL BENEFITS PROVIDED TO YOU BY CIGNA.

Explanation of TermsYou will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these termsare defined in the Definitions section of your certificate.The ScheduleThe Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full descriptionof each benefit, refer to the appropriate section listed in the Table of Contents.

in lieu of an extended Hospital convalescence). You are notpenalized if the alternate treatment program is not followed.Special Plan ProvisionsCase ManagementCase Management is a service provided through a ReviewOrganization, which assists individuals with treatment needsthat extend beyond the acute care setting. The goal of CaseManagement is to ensure that patients receive appropriate carein the most effective setting possible whether at home, as anoutpatient, or an inpatient in a Hospital or specialized facility.Should the need for Case Management arise, a CaseManagement professional will work closely with the patient,his or her family and the attending Physician to determineappropriate treatment options which will best meet thepatient's needs and keep costs manageable. The Case Managerwill help coordinate the treatment program and arrange fornecessary resources. Case Managers are also available toanswer questions and provide ongoing support for the familyin times of medical crisis.The Case Manager arranges for alternate treatment servicesand supplies, as needed (for example, nursing services or aHospital bed and other Durable Medical Equipment for thehome). The Case Manager also acts as a liaison between the insurer,the patient, his or her family and Physician as needed (forexample, by helping you to understand a complex medicaldiagnosis or treatment plan). Once the alternate treatment program is in place, the CaseManager continues to manage the case to ensure thetreatment program remains appropriate to the patient'sneeds.While participation in Case Management is strictly voluntary,Case Management professionals can offer quality, costeffective treatment alternatives, as well as provide assistancein obtaining needed medical resources and ongoing familysupport in a time of need.Case Managers are Registered Nurses (RNs) and othercredentialed health care professionals, each trained in aclinical specialty area such as trauma, high risk pregnancy andneonates, oncology, mental health, rehabilitation or generalmedicine and surgery. A Case Manager trained in theappropriate clinical specialty area will be assigned to you oryour dependent. In addition, Case Managers are supported bya panel of Physician advisors who offer guidance on up-todate treatment programs and medical technology. While theCase Manager recommends alternate treatment programs andhelps coordinate needed resources, the patient's attendingPhysician remains responsible for the actual medical care. HC-SPP2V1Additional ProgramsWe may, from time to time, offer or arrange for variousentities to offer discounts, benefits, or other consideration toour members for the purpose of promoting the general healthand well being of our members. We may also arrange for thereimbursement of all or a portion of the cost of servicesprovided by other parties to the Policyholder. Contact us fordetails regarding any such arrangements.You, your dependent or an attending Physician can requestCase Management services by calling the toll-free numbershown on your ID card during normal business hours,Monday through Friday. In addition, your employer, a claimoffice or a utilization review program (see the PAC/CSRsection of your certificate) may refer an individual for CaseManagement.HC-SPP304-10V1 The Review Organization assesses each case to determinewhether Case Management is appropriate.Important Notices You or your Dependent is contacted by an assigned CaseManager who explains in detail how the program works.Participation in the program is voluntary - no penalty orbenefit reduction is imposed if you do not wish toparticipate in Case Management.Important Information 04-10Mental Health Parity and Addiction Equity ActThe Certificate is amended as stated below:In the event of a conflict between the provisions of your plandocuments and the provisions of this notice, the provisionsthat provide the better benefit shall apply.Following an initial assessment, the Case Manager workswith you, your family and Physician to determine the needsof the patient and to identify what alternate treatmentprograms are available (for example, in-home medical care8myCigna.com

chronic conditions, such as psychosis or depression; emotionalreactions associated with marital problems or divorce;child/adolescent problems of conduct or poor impulse control;affective disorders; suicidal or homicidal threats or acts; eatingdisorders; or acute exacerbation of chronic Mental Healthconditions (crisis intervention and relapse prevention) andoutpatient testing and assessment.The Schedule and Mental Health and Substance AbuseCovered Expenses:Partial Hospitalization charges for Mental Health andSubstance Abuse will be paid at the Outpatient level. CoveredExpenses are changed as follows:Mental Health and Substance Abuse ServicesMental Health Services are services that are required to treata disorder that impairs the behavior, emotional reaction orthought processes. In determining benefits payable, chargesmade for the treatment of any physiological conditions relatedto Mental Health will not be considered to be charges madefor treatment of Mental Health.Partial Hospitalization sessions are services that are providedfor not less than 4 hours and not more than 12 hours in any 24hour period.Inpatient Substance Abuse Rehabilitation ServicesServices provided for rehabilitation, while you or yourDependent is Confined in a Hospital, when required for thediagnosis and treatment of abuse or addiction to alcohol and/ordrugs. Inpatient Substance Abuse Services include ResidentialTreatment services.Substance Abuse is defined as the psychological or physicaldependence on alcohol or other mind-altering drugs thatrequires diagnosis, care, and treatment. In determiningbenefits payable, charges made for the treatment of anyphysiological conditions related to rehabilitation services foralcohol or drug abuse or addiction will not be considered to becharges made for treatment of Substance Abuse.Substance Abuse Residential Treatment Services areservices provided by a Hospital for the evaluation andtreatment of the psychological and social functionaldisturbances that are a result of subacute Substance Abuseconditions.Inpatient Mental Health ServicesServices that are provided by a Hospital while you or yourDependent is Confined in a Hospital for the treatment andevaluation of Mental Health. Inpatient Mental Health Servicesinclude Mental Health Residential Treatment Services.Substance Abuse Residential Treatment Center means aninstitution which specializes in the treatment of psychologicaland social disturbances that are the result of Substance Abuse;provides a subacute, structured, psychotherapeutic treatmentprogram, under the supervision of Physicians; provides 24hour care, in which a person lives in an open setting; and islicensed in accordance with the laws of the appropriate legallyauthorized agency as a residential treatment center.Mental Health Residential Treatment Services are servicesprovided by a Hospital for the evaluation and treatment of thepsychological and social functional disturbances that are aresult of subacute Mental Health conditions.Mental Health Residential Treatment Center means aninstitution which specializes in the treatment of psychologicaland social disturbances that are the result of Mental Healthconditions; provides a subacute, structured, psychotherapeutictreatment program, under the supervision of Physicians;provides 24-hour care, in which a person lives in an opensetting; and is licensed in accordance with the laws of theappropriate legally authorized agency as a residentialtreatment center.A person is considered confined in a Substance AbuseResidential Treatment Center when she/he is a registeredbed patient in a Substance Abuse Residential TreatmentCenter upon the recommendation of a Physician.Outpatient Substance Abuse Rehabilitation ServicesServices provided for the diagnosis and treatment of abuse oraddiction to alcohol and/or drugs, while you or yourDependent is not Confined in a Hospital, including outpatientrehabilitation in an individual, or a Substance Abuse IntensiveOutpatient Therapy Program and for Partial Hospitalizationsessions.A person is considered confined in a Mental HealthResidential Treatment Center when she/he is a registered bedpatient in a Mental Health Residential Treatment Center uponthe recommendation of a Physician.Partial Hospitalization sessions are services that are providedfor not less than 4 hours and not more than 12 hours in any 24hour period.Outpatient Mental Health Services are Services of Providerswho are qualified to treat Mental Health when treatment isprovided on an outpatient basis, while you or your Dependentis not Confined in a Hospital, or for Partial Hospitalizationsessions, and is provided in an individual, group or MentalHealth Intensive Outpatient Therapy Program. Coveredservices include, but are not limited to, outpatient treatment ofconditions such as: anxiety or depression which interfere withdaily functioning; emotional adjustment or concerns related toA Substance Abuse Intensive Outpatient Therapy Programconsists of distinct levels or phases of treatment that areprovided by a certified/licensed Substance Abuse program.Intensive Outpatient Therapy Programs provide a combinationof individual, family and/or group therapy in a day, totalingnine, or more hours in a week.9myCigna.com