EXHIBIT “B” 

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Dobbs Equipment, LLC

OPEN ACCESS PLUS MEDICAL 

BENEFITS

Health Savings Account Low Plan

EFFECTIVE DATE: December 1, 2017

CN002

3341631

This document printed in December, 2017 takes the place of any documents previously issued to you 

which described your benefits.

Printed in U.S.A.

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Table of Contents

Certification....................................................................................................................................5

Special Plan Provisions..................................................................................................................7

Important Notices ..........................................................................................................................8

Important Information..................................................................................................................8

How To File Your Claim .............................................................................................................10

Eligibility - Effective Date ...........................................................................................................11

Employee Insurance .............................................................................................................................................11

Waiting Period......................................................................................................................................................11

Dependent Insurance ............................................................................................................................................11

Important Information About Your Medical Plan...................................................................12

Open Access Plus Medical Benefits............................................................................................13

The Schedule ........................................................................................................................................................13

Certification Requirements - Out-of-Network......................................................................................................28

Prior Authorization/Pre-Authorized .....................................................................................................................28

Covered Expenses ................................................................................................................................................29

Medical Conversion Privilege .....................................................................................................39

Prescription Drug Benefits..........................................................................................................41

The Schedule ........................................................................................................................................................41

Covered Expenses ................................................................................................................................................43

Limitations............................................................................................................................................................43

Your Payments.....................................................................................................................................................44

Exclusions ............................................................................................................................................................45

Reimbursement/Filing a Claim.............................................................................................................................46

Exclusions, Expenses Not Covered and General Limitations..................................................46

Coordination of Benefits..............................................................................................................49

Expenses For Which A Third Party May Be Responsible .......................................................51

Payment of Benefits .....................................................................................................................53

Termination of Insurance............................................................................................................53

Employees............................................................................................................................................................53

Dependents...........................................................................................................................................................54

Rescissions ...........................................................................................................................................................54

Medical Benefits Extension Upon Policy Cancellation.............................................................54

Federal Requirements .................................................................................................................55

Notice of Provider Directory/Networks................................................................................................................55

Qualified Medical Child Support Order (QMCSO) .............................................................................................55

Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) ..................56

Effect of Section 125 Tax Regulations on This Plan............................................................................................57

Eligibility for Coverage for Adopted Children.....................................................................................................58

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Coverage for Maternity Hospital Stay..................................................................................................................58

Women’s Health and Cancer Rights Act (WHCRA) ...........................................................................................58

Group Plan Coverage Instead of Medicaid...........................................................................................................58

Requirements of Medical Leave Act of 1993 (as amended) (FMLA)..................................................................58

Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)....................................59

Claim Determination Procedures under ERISA ...................................................................................................59

COBRA Continuation Rights Under Federal Law ...............................................................................................61

ERISA Required Information...............................................................................................................................64

Notice of an Appeal or a Grievance............................................................................................66

Appointment of Authorized Representative .........................................................................................................66

When You Have A Complaint Or An Appeal...........................................................................66

Definitions.....................................................................................................................................69

What You Should Know About Cigna Choice Fund®– Health Savings Account.................80

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 7 of 89
Home Office: Bloomfield, Connecticut

Mailing Address: Hartford, Connecticut 06152

CIGNA HEALTH AND LIFE INSURANCE COMPANY

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

provided by the following policy(s):

POLICYHOLDER: Dobbs Equipment, LLC

GROUP POLICY(S) — COVERAGE

3341631 - HSAFL OPEN ACCESS PLUS MEDICAL BENEFITS

EFFECTIVE DATE: December 1, 2017

THE BENEFITS IN THIS CERTIFICATE CONTAIN A DEDUCTIBLE PROVISION

This certificate describes the main features of the insurance. It does not waive or alter any of the terms of 

the policy(s). If questions arise, the policy(s) will govern.

This certificate takes the place of any other issued to you on a prior date which described the insu rance.

HC-CER5 04-10

V1

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 8 of 89
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 listed in the Table of Contents.

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 9 of 89
7 myCigna.com

Special Plan Provisions

When you select a Participating Provider, this Plan pays a 

greater share of the costs than if you select a non-Participating 

Provider. Participating Providers include Physicians, Hospitals 

and Other Health Care Professionals and Other Health Care 

Facilities. Consult your Physician Guide for a list of 

Participating Providers in your area. Participating Providers 

are committed to providing you and your Dependents 

appropriate care while lowering medical costs.

Services Available in Conjunction With Your Medical 

Plan

The following pages describe helpful services available in 

conjunction with your medical plan. You can access these 

services by calling the toll-free number shown on the back of 

your ID card.

HC-SPP1 04-10

V1

Case Management

Case Management is a service provided through a Review 

Organization, which assists individuals with treatment needs 

that extend beyond the acute care setting. The goal of Case 

Management is to ensure that patients receive appropriate care 

in the most effective setting possible whether at home, as an 

outpatient, or an inpatient in a Hospital or specialized facility. 

Should the need for Case Management arise, a Case 

Management professional will work closely with the patient, 

his or her family and the attending Physician to determine 

appropriate treatment options which will best meet the 

patient's needs and keep costs manageable. The Case Manager 

will help coordinate the treatment program and arrange for 

necessary resources. Case Managers are also available to 

answer questions and provide ongoing support for the family 

in times of medical crisis.

Case Managers are Registered Nurses (RNs) and other 

credentialed health care professionals, each trained in a 

clinical specialty area such as trauma, high risk pregnancy and 

neonates, oncology, mental health, rehabilitation or general 

medicine and surgery. A Case Manager trained in the 

appropriate clinical specialty area will be assigned to you or 

your dependent. In addition, Case Managers are supported by 

a panel of Physician advisors who offer guidance on up-todate treatment programs and medical technology. While the 

Case Manager recommends alternate treatment programs and 

helps coordinate needed resources, the patient's attending 

Physician remains responsible for the actual medical care.

 You, your dependent or an attending Physician can request 

Case Management services by calling the toll-free number

shown on your ID card during normal business hours, 

Monday through Friday. In addition, your employer, a claim 

office or a utilization review program (see the PAC/CSR 

section of your certificate) may refer an individual for Case 

Management.

 The Review Organization assesses each case to determine 

whether Case Management is appropriate.

 You or your Dependent is contacted by an assigned Case 

Manager who explains in detail how the program works. 

Participation in the program is voluntary - no penalty or 

benefit reduction is imposed if you do not wish to 

participate in Case Management.

 Following an initial assessment, the Case Manager works 

with you, your family and Physician to determine the needs 

of the patient and to identify what alternate treatment 

programs are available (for example, in-home medical care 

in lieu of an extended Hospital convalescence). You are not 

penalized if the alternate treatment program is not followed.

 The Case Manager arranges for alternate treatment services 

and supplies, as needed (for example, nursing services or a 

Hospital bed and other Durable Medical Equipment for the 

home).

 The Case Manager also acts as a liaison between the insurer, 

the patient, his or her family and Physician as needed (for 

example, by helping you to understand a complex medical 

diagnosis or treatment plan).

 Once the alternate treatment program is in place, the Case 

Manager continues to manage the case to ensure the 

treatment program remains appropriate to the patient's 

needs.

While participation in Case Management is strictly voluntary, 

Case Management professionals can offer quality, costeffective treatment alternatives, as well as provide assistance 

in obtaining needed medical resources and ongoing family 

support in a time of need.

HC-SPP2 04-10

V1

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 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 10 of 89
8 myCigna.com

provided by other parties to the Policyholder. Contact us for 

details regarding any such arrangements.

HC-SPP3 04-10

V1

Care Management and Care Coordination Services

Cigna 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.

HC-SPP27 06-15

V1

Important Notices

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, visit 

www.mycigna.com or contact customer service at the phone 

number listed on the back of your ID card.

Selection of a Primary Care Provider

This plan generally allows 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. For information on 

how to select a primary care provider, and for a list of the 

participating primary care providers, visit www.mycigna.com 

or contact customer service at the phone number listed on the 

back of your ID card.

For children, you may designate a pediatrician as the primary 

care provider.

HC-NOT5 01-11

Important Information

Rebates and Other Payments

Cigna or its affiliates may receive rebates or other 

remuneration from pharmaceutical manufacturers in 

connection with certain Medical Pharmaceuticals covered 

under your plan and Prescription Drug Products included on 

the Prescription Drug List. These rebates or remuneration are 

not obtained on you or your Employer’s or plan’s behalf or for 

your benefit. Cigna, its affiliates and the plan are not obligated 

to pass these rebates on to you, or apply them to your plan’s 

Deductible if any or take them into account in determining 

your Copayments and/or Coinsurance. Cigna and its affiliates 

or designees, conduct business with various pharmaceutical 

manufacturers separate and apart from this plan’s Medical 

Pharmaceutical and Prescription Drug Product benefits. 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 plan. Cigna and its 

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

to you, such amounts.

Coupons, Incentives and Other Communications

At various times, Cigna or its designee may send mailings to 

you or your Dependents or to your Physician that 

communicate a variety of messages, including information 

about Medical Pharmaceuticals and 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 

Medical Pharmaceutical and 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. Cigna, its affiliates and the plan 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.

If Cigna determines that a Pharmacy, pharmaceutical 

manufacturer or other third party is or has waived, reduced, or 

forgiven any portion of the charges and/or any portion of 

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

are required to pay for a Prescription Drug Product without 

Cigna’s express consent, then Cigna in its sole discretion shall 

have the right to deny the payment of plan benefits in 

connection with the Prescription Drug Product, 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 Pharmacy, pharmaceutical 

manufacturer or other third party represents that you remain 

responsible for any amounts that your plan does not cover. In 

the exercise of that discretion, Cigna shall have the right to 

require you to provide proof sufficient to Cigna that you have 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 11 of 89
9 myCigna.com

made your required cost share payment(s) prior to the payment 

of any benefits by the plan. For example, if you use a coupon 

provided by a pharmaceutical manufacturer or other third 

party that discounts the cost of a Prescription Drug Product, 

Cigna 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.

HC-IMP188 10-16

V1

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 tollfree 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 Coordinator

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 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.

HC-NOT96 07-17

Proficiency of Language Assistance Services

English – ATTENTION: Language assistance services, free 

of charge, are available to you. For current Cigna customers, 

call the number on the back of your ID card. Otherwise, call 

1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de 

idiomas, sin cargo, a su disposición. Si es un cliente actual de 

Cigna, llame al número que figura en el reverso de su tarjeta 

de identificación. Si no lo es, llame al 1.800.244.6224 (los 

usuarios de TTY deben llamar al 711).

Chinese – 注意:我們可為您免費提供語言協助服務。

對於 Cigna 的現有客戶,請致電您的 ID 卡背面的號碼。

其他客戶請致電 1.800.244.6224 (聽障專線:請撥 711)。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp 

về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của 

Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp 

khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원

서비스를 무료로 이용하실 수 있습니다. 현재 Cigna

가입자님들께서는 ID 카드 뒷면에 있는 전화번호로

연락해주십시오. 기타 다른 경우에는 1.800.244.6224

(TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa 

tulong sa wika nang libre. Para sa mga kasalukuyang customer 

ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O 

kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить 

бесплатные услуги перевода. Если вы уже участвуете в 

плане Cigna, позвоните по номеру, указанному на 

обратной стороне вашей идентификационной карточки 

участника плана. Если вы не являетесь участником одного 

из наших планов, позвоните по номеру 1.800.244.6224 

(TTY: 711).

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French Creole – ATANSYON: Gen sèvis èd nan lang ki 

disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki 

dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 

(TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous 

sont proposés gratuitement. Si vous êtes un client actuel de 

Cigna, veuillez appeler le numéro indiqué au verso de votre 

carte d’identité. Sinon, veuillez appeler le numéro 

1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de 

assistência linguística, totalmente gratuitos. Para clientes 

Cigna atuais, ligue para o número que se encontra no verso do 

seu cartão de identificação. Caso contrário, ligue para 

1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, 

bezpłatnej pomocy językowej, obecni klienci firmy Cigna 

mogą dzwonić pod numer podany na odwrocie karty 

identyfikacyjnej. Wszystkie inne osoby prosimy o 

skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese –

注意事項:日本語を話される場合、無料の言語支援サー

ビスをご利用いただけます。現在のCignaの

お客様は、IDカード裏面の電話番号まで、お電話にてご

連絡ください。その他の方は、1.800.244.6224(TTY: 

711)まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di 

assistenza linguistica gratuiti. Per i clienti Cigna attuali, 

chiamare il numero sul retro della tessera di identificazione. 

In caso contrario, chiamare il numero 1.800.244.6224 (utenti 

TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der 

Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. 

Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die 

Nummer auf der Rückseite Ihrer Krankenversicherungskarte 

an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen 

Sie 711).

HC-NOT97 07-17

Notices 

Coverage of Dependent Children for Medical Benefits

Your Employer is not required to pay any portion of the 

premium for a Dependent child after the end of the calendar 

year in which the Dependent child reaches age 25. Your 

Employer will inform you of the applicable premium 

contribution required by you.

HC-IMP22 04-10

V1

How To File Your Claim

There’s no paperwork for In-Network care. Just show your 

identification card and pay your share of the cost, if any; your 

provider will submit a claim to Cigna for reimbursement. Outof-Network claims can be submitted by the provider if the 

provider is able and willing to file on your behalf. If the 

provider is not submitting on your behalf, you must send your 

completed claim form and itemized bills to the claims address 

listed on the claim form.

You may get the required claim forms from the website listed 

on your identification card or by calling the toll-free number 

on your identification card.

CLAIM REMINDERS

 BE SURE TO USE YOUR MEMBER ID AND 

ACCOUNT/GROUP NUMBER WHEN YOU FILE 

CIGNA’S CLAIM FORMS, OR WHEN YOU CALL 

YOUR CIGNA CLAIM OFFICE.

YOUR MEMBER ID IS THE ID SHOWN ON YOUR 

BENEFIT IDENTIFICATION CARD.

YOUR ACCOUNT/GROUP NUMBER IS SHOWN ON 

YOUR BENEFIT IDENTIFICATION CARD.

 BE SURE TO FOLLOW THE INSTRUCTIONS LISTED 

ON THE BACK OF THE CLAIM FORM CAREFULLY 

WHEN SUBMITTING A CLAIM TO CIGNA.

Timely Filing of Out-of-Network Claims

Cigna will consider claims for coverage under our plans when 

proof of loss (a claim) is submitted within 180 days for Outof-Network benefits after services are rendered. If services are 

rendered on consecutive days, such as for a Hospital 

Confinement, the limit will be counted from the last date of 

service. If claims are not submitted within 180 days for Outof-Network benefits, the claim will not be considered valid 

and will be denied.

If it was not reasonably possible to give proof in the time 

required, Cigna will not reduce or deny the claim for this 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 13 of 89
11 myCigna.com

reason if the proof is submitted as soon as reasonably possible. 

In any event, the proof required must be given no later than 

one (1) year from the time specified unless the claimant was 

legally incapacitated.

WARNING: Any person who knowingly and with intent to 

defraud any insurance company or other person files an 

application for insurance or statement of claim containing any 

materially false information; or conceals for the purpose of 

misleading, information concerning any material fact thereto, 

commits a fraudulent insurance act.

HC-CLM6 01-11

V2

Eligibility - Effective Date

Employee Insurance

This plan is offered to you as an Employee.

Eligibility for Employee Insurance

You will become eligible for insurance on the day you 

complete the waiting period if:

 you are in a Class of Eligible Employees; and

 you are an eligible, full-time Employee; and

 you normally work at least 30 hours a week; and

 you pay any required contribution.

If you were previously insured and your insurance ceased, you 

must satisfy the New Employee Group Waiting Period to 

become insured again. If your insurance ceased because you 

were no longer employed in a Class of Eligible Employees, 

you are not required to satisfy any waiting period if you again 

become a member of a Class of Eligible Employees within 

one year after your insurance ceased.

Initial Employee Group: You are in the Initial Employee 

Group if you are employed in a class of employees on the date 

that class of employees becomes a Class of Eligible 

Employees as determined by your Employer.

New Employee Group: You are in the New Employee Group 

if you are not in the Initial Employee Group.

Eligibility 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.

Waiting Period

Initial Employee Group: None.

New Employee Group: The first day of the month following 

date of hire. 

Classes of Eligible Employees

Each Employee as reported to the insurance company by your 

Employer.

Effective Date of Employee Insurance

You will become insured on the date you elect the insurance 

by signing an approved payroll deduction or enrollment form, 

as applicable, but no earlier than the date you become eligible.

You will become insured on your first day of eligibility, 

following your election, if you are in Active Service on that 

date, or if you are not in Active Service on that date due to 

your health status.

Late Entrant - Employee

You are a Late Entrant if:

 you elect the insurance more than 30 days after you become 

eligible; or

 you again elect it after you cancel your payroll deduction (if 

required).

Dependent Insurance

For your Dependents to be insured, you will have to pay the 

required contribution, if any, toward the cost of Dependent 

Insurance.

Effective Date of Dependent Insurance

Insurance for your Dependents will become effective on the 

date you elect it by signing an approved payroll deduction 

form, but no earlier than the day you become eligible for 

Dependent Insurance. All of your Dependents as defined will 

be included. A newborn child will be covered for the first 31 

days of life even if you fail to enroll the child. If you enroll the 

child after the first 31 days and by the 60th day after his birth, 

coverage will be offered at an additional premium. Coverage 

for an adopted child will become effective from the date of 

placement in your home or from birth for the first 31 days 

even if you fail to enroll the child. However, if you enroll the 

adopted child between the 31st and 60th days after his birth or 

placement in your home, coverage will be offered at an 

additional premium.

Your Dependents will be insured only if you are insured.

Late Entrant – Dependent

You are a Late Entrant for Dependent Insurance if:

 you elect that insurance more than 30 days after you 

become eligible for it; or

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 14 of 89
12 myCigna.com

 you again elect it after you cancel your payroll deduction (if 

required).

Exception for Newborns

Any Dependent child born while you are insured will become 

insured on the date of his birth if you elect Dependent 

Insurance no later than 31 days after his birth. If you do not 

elect to insure your newborn child within such 31 days, 

coverage for that child will end on the 31st day. No benefits 

for expenses incurred beyond the 31st day will be payable.

If notice is given within 60 days of the birth of the child, the 

insurer may not deny coverage for a child due to the failure of 

the insured to timely notify the insurer of the birth of the child.

HC-ELG9 04-10

V1 M

Important Information About Your 

Medical Plan

Details of your medical benefits are described on the 

following pages. 

Opportunity to Select a Primary Care Physician

Choice of Primary Care Physician:

This medical plan does not require that you select a Primary 

Care Physician or obtain a referral from a Primary Care 

Physician in order to receive all benefits available to you 

under this medical plan. Notwithstanding, a Primary Care 

Physician may serve an important role in meeting your health 

care needs by providing or arranging for medical care for you 

and your Dependents. For this reason, we encourage the use of 

Primary Care Physicians and provide you with the opportunity 

to select a Primary Care Physician from a list provided by

Cigna for yourself and your Dependents. If you choose to 

select a Primary Care Physician, the Primary Care Physician 

you select for yourself may be different from the Primary Care 

Physician you select for each of your Dependents. 

Changing Primary Care Physicians:

You may request a transfer from one Primary Care Physician 

to another by contacting us at the member services number on 

your ID card. Any such transfer will be effective on the first 

day of the month following the month in which the processing 

of the change request is completed.

In addition, if at any time a Primary Care Physician ceases to 

be a Participating Provider, you or your Dependent will be 

notified for the purpose of selecting a new Primary Care 

Physician, if you choose.

HC-IMP1 04-10

V1

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Open Access Plus Medical Benefits

The Schedule

For You and Your Dependents

Open Access Plus Medical Benefits provide coverage for care In-Network and Out-of-Network. To receive Open Access 

Plus Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services 

and supplies. That portion is the Deductible or Coinsurance.

If you are unable to locate an In-Network Provider in your area who can provide you with a service or supply that is 

covered under this plan, you must call the number on the back of your I.D. card to obtain authorization for Out-ofNetwork Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, benefits for 

those services will be covered at the In-Network benefit level.

.

Coinsurance

The term Coinsurance means the percentage of charges for Covered Expenses that an insured person is required to pay 

under the plan.

Deductibles

Deductibles are expenses to be paid by you or your Dependent. 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. 

Out-of-Pocket Expenses - For In-Network Charges Only

Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan because of any 

Deductibles or Coinsurance. Such Covered Expenses accumulate to the Out-of-Pocket Maximum shown in the Schedule. 

When the Out-of-Pocket Maximum is reached, all Covered Expenses, except charges for non-compliance penalties, are 

payable by the benefit plan at 100%. 

Out-of-Pocket Expenses - For Out-of-Network Charges Only

Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan. The following 

Expenses contribute to the Out-of-Pocket Maximum, and when the Out-of-Pocket Maximum shown in The Schedule is 

reached, they are payable by the benefit plan at 100%:

 Coinsurance.

 Plan Deductible.

The following Out-of-Pocket Expenses and charges do not contribute to the Out-of-Pocket Maximum, and they are not 

payable by the benefit plan at 100% when the Out-of-Pocket Maximum shown in The Schedule is reached:

 Non-compliance penalties.

 Any benefit deductibles.

 Provider charges in excess of the Maximum Reimbursable Charge.

.

Accumulation of Plan Deductibles and Out-of-Pocket Maximums 

Deductibles and Out-of-Pocket Maximums do not cross-accumulate (that is, In-Network will accumulate to In-Network 

and Out-of-Network will accumulate to Out-of-Network). All other plan maximums and service-specific maximums 

(dollar and occurrence) cross-accumulate between In- and Out-of-Network unless otherwise noted. 

.

Note:

For information about your health fund benefit and how it can help you pay for expenses that may not be covered under 

this plan, refer to “What You Should Know about Cigna Choice Fund”. 

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Open Access Plus Medical Benefits

The Schedule

Multiple Surgical Reduction

Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser 

charge. The most expensive procedure is paid as any other surgery.

Assistant Surgeon and Co-Surgeon Charges

Assistant Surgeon

The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed a percentage of 

the surgeon’s allowable charge as specified in Cigna Reimbursement Policies. (For purposes of this limitation, allowable 

charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.)

Co-Surgeon

The maximum amount payable for charges made by co-surgeons will be limited to the amount specified in Cigna 

Reimbursement Policies.

BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Lifetime Maximum Unlimited 

The Percentage of Covered Expenses 

the Plan Pays

80% 60% of the Maximum Reimbursable 

Charge 

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Maximum Reimbursable Charge

(Maximum Reimbursable Charge limits 

do not apply to charges for covered 

Out-of-Network Emergency Services 

provided in an emergency department 

of a Hospital)

Maximum Reimbursable Charge is 

determined based on the lesser of the 

provider’s normal charge for a similar 

service or supply; or

A percentage of a schedule that we 

have developed that is based upon a 

methodology similar to a methodology 

utilized by Medicare to determine the 

allowable fee for similar services 

within the geographic market. In some 

cases, a Medicare based schedule will 

not be used and 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

 the 80th 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 the Insurance 

Company.

Not Applicable 110%

Note:

The provider may bill you for the 

difference between the provider’s 

normal charge and the Maximum 

Reimbursable Charge, in addition to 

applicable deductibles and coinsurance.

.

Calendar Year Deductible

Individual $1,750 per person $4,000 per person

Family Maximum $3,500 per family $8,000 per family

Family Maximum Calculation

Collective Deductible:

All family members contribute 

towards the family deductible. An 

individual cannot have claims 

covered under the plan coinsurance 

until the total family deductible has 

been satisfied.

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Combined Medical/Pharmacy 

Calendar Year Deductible

Combined Medical/Pharmacy 

Deductible: includes retail and home 

delivery prescription drugs

Yes Yes

Home Delivery Pharmacy Costs 

Contribute to the Combined 

Medical/Pharmacy Deductible

Yes Yes

Out-of-Pocket Maximum 

Individual $2,750 per person $10,000 per person

Family Maximum $5,500 per family $20,000 per family 

Family Maximum Calculation

Collective Out-of-Pocket 

Maximum:

All family members contribute 

towards the family Out-of-Pocket. 

An individual cannot have claims 

covered at 100% until the total 

family Out-of-Pocket has been 

satisfied. 

Combined Medical/Pharmacy Outof-Pocket Maximum

Combined Medical/Pharmacy Outof-Pocket: includes retail and home 

delivery prescription drugs

Yes Yes 

Home Delivery Pharmacy Costs 

Contribute to the Combined 

Medical/Pharmacy Out-of-Pocket 

Maximum

Yes Yes 

.

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Physician’s Services

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visits

Consultant and Referral

Physician’s Services

Plan deductible, then 80% Plan deductible, then 60% 

Surgery Performed in the Physician’s 

Office

Primary Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Second Opinion Consultations 

(provided on a voluntary basis)

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Allergy Treatment/Injections

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Allergy Serum (dispensed by the 

Physician in the office)

Primary Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Medical Telehealth

Primary Care Physician Plan deductible, then 80% In-Network coverage only 

Specialty Care Physician Plan deductible, then 80% In-Network coverage only 

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Preventive Care

Routine Preventive Care (for 

children through age 15) 

Primary Care Physician’s Office

Visit 

100% 60% 

Specialty Care Physician’s Office 

Visit 

100% 60% 

Immunizations (for children through 

age 15) 

Primary Care Physician’s Office 

Visit 

100% 60% 

Specialty Care Physician’s Office 

Visit 

100% 60% 

Routine Preventive Care (for ages 16 

and over) 

Primary Care Physician’s Office 

Visit

100% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

100% Plan deductible, then 60% 

Immunizations (for ages 16 and 

over) 

Primary Care Physician’s Office 

Visit 

100% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit 

100% Plan deductible, then 60% 

.

Mammograms, PSA, PAP Smear 

Preventive Care Related Services 

(i.e. “routine” services)

100% Subject to the plan’s x-ray benefit & 

lab benefit; based on place of service 

Diagnostic Related Services (i.e. 

“non-routine” services)

Subject to the plan’s x-ray benefit & 

lab benefit; based on place of service 

Subject to the plan’s x-ray benefit & 

lab benefit; based on place of service 

Inpatient Hospital - Facility Services Plan deductible, then 80% Plan deductible, then 60% 

Semi-Private Room and Board Limited to the semi-private room 

negotiated rate 

Limited to the semi-private room rate

Private Room Limited to the semi-private room 

negotiated rate 

Limited to the semi-private room rate

Special Care Units (ICU/CCU) Limited to the negotiated rate Limited to the ICU/CCU daily room 

rate

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Outpatient Facility Services

Operating Room, Recovery Room, 

Procedures Room, Treatment Room 

and Observation Room 

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Hospital Physician’s 

Visits/Consultations

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Surgeon

Radiologist, Pathologist, 

Anesthesiologist

Outpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Surgeon

Radiologist, Pathologist, 

Anesthesiologist

Urgent Care Services

Urgent Care Facility or Outpatient 

Facility

Includes Outpatient Professional 

Services, X-ray and/or Lab services 

performed at the Urgent Care 

Facility and billed by the facility as 

part of the UC visit.

Plan deductible, then 80% Plan deductible, then 80%

Advanced Radiological Imaging (i.e. 

MRIs, MRAs, CAT Scans, PET 

Scans etc.) billed by the facility as 

part of the UC visit

Plan deductible, then 80% Plan deductible, then 80% 

Emergency Services

If you receive Out-of-Network Emergency Services provided in an emergency department of a Hospital and the provider 

bills you for an amount higher than the amount you owe indicated on the Explanation of Benefits (EOB), contact Cigna 

Customer Service at the phone number on your ID card.

Hospital Emergency Room

Includes Outpatient Professional 

Services, X-ray and/or Lab services 

performed at the Emergency Room 

and billed by the facility as part of 

the ER visit. 

Plan deductible, then 80% Plan deductible, then 80% 

Advanced Radiological Imaging (i.e. 

MRIs, MRAs, CAT Scans, PET 

Scans etc.) billed by the facility as 

part of the ER visit

Plan deductible, then 80% Plan deductible, then 80% 

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Ambulance Plan deductible, then 80% Plan deductible, then 80% 

Inpatient Services at Other Health 

Care Facilities

Includes Skilled Nursing Facility, 

Rehabilitation Hospital and SubAcute Facilities

Plan deductible, then 80% Plan deductible, then 60% 

Calendar Year Maximum:

60 days combined

Laboratory Services 

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Hospital Facility Plan deductible, then 80% Plan deductible, then 60% 

Independent Lab Facility Plan deductible, then 80% Plan deductible, then 60% 

Radiology Services

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60%

Outpatient Hospital Facility Plan deductible, then 80% Plan deductible, then 60% 

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Advanced Radiological Imaging (i.e. 

MRIs, MRAs, CAT Scans and PET 

Scans)

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Short-Term 

Rehabilitative Therapy and Spinal 

Manipulation Services 

Calendar Year Maximum:

20 days for all therapies combined 

Note:

The Short-Term Rehabilitative 

Therapy maximum does not apply to 

the treatment of autism. 

Includes:

Physical Therapy

Speech Therapy

Occupational Therapy

Pulmonary Rehab

Cognitive Therapy

Spinal Manipulation Services 

(includes Manipulative Services)

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

.

Outpatient Cardiac Rehabilitation

Calendar Year Maximum:

36 days

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Home Health Care

Calendar Year Maximum:

60 days (includes outpatient private 

nursing when approved as Medically 

Necessary) 

Plan deductible, then 80% Plan deductible, then 60% 

.

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Hospice

Inpatient Services Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Services

(same coinsurance level as Home 

Health Care)

Plan deductible, then 80% Plan deductible, then 60% 

.

Bereavement Counseling

Services provided as part of Hospice 

Care

Inpatient Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Plan deductible, then 80% Plan deductible, then 60% 

Services provided by Mental Health 

Professional

Covered under Mental Health Benefit Covered under Mental Health Benefit

.

Medical Pharmaceuticals

Physician’s Office Plan deductible, then 80% Plan deductible, then 60% 

Home Care Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Maternity Care Services

Initial Visit to Confirm Pregnancy

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

All subsequent Prenatal Visits, 

Postnatal Visits and Physician’s 

Delivery Charges (i.e. global 

maternity fee)

Plan deductible, then 80% Plan deductible, then 60% 

Physician’s Office Visits in addition 

to the global maternity fee when 

performed by an OB/GYN or 

Specialist

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Delivery - Facility

(Inpatient Hospital, Birthing Center)

Plan deductible, then 80% Plan deductible, then 60% 

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Abortion

Includes elective and non-elective 

procedures 

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

.

Women’s Family Planning Services

Office Visits, Lab and Radiology 

Tests and Counseling

Note:

Includes coverage for contraceptive 

devices (e.g., Depo-Provera and 

Intrauterine Devices (IUDs)) as 

ordered or prescribed by a physician. 

Diaphragms also are covered when 

services are provided in the 

physician’s office.

Primary Care Physician 100% Plan deductible, then 60% 

Specialty Care Physician 100% Plan deductible, then 60% 

Surgical Sterilization Procedures for 

Tubal Ligation (excludes reversals)

Primary Care Physician’s Office 

Visit

100% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

100% Plan deductible, then 60% 

Inpatient Facility 100% Plan deductible, then 60% 

Outpatient Facility 100% Plan deductible, then 60% 

Inpatient Professional Services 100% Plan deductible, then 60% 

Outpatient Professional Services 100% Plan deductible, then 60% 

.

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Men’s Family Planning Services

Office Visits, Lab and Radiology 

Tests and Counseling

Primary Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Surgical Sterilization Procedures for 

Vasectomy (excludes reversals)

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

.

Infertility Treatment

Coverage will be provided for the following services:

 Testing and treatment services performed in connection with an underlying medical condition.

 Testing performed specifically to determine the cause of infertility.

 Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility 

condition).

 Artificial Insemination, In-vitro, GIFT, ZIFT, etc.

.

Physician’s Office Visit (Lab and 

Radiology Tests, Counseling)

Primary Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Lifetime Maximum:

Unlimited 

Includes all related services billed 

with an infertility diagnosis (i.e. xray or lab services billed by an 

independent facility).

.

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Organ Transplants

Includes all medically appropriate, nonexperimental transplants

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 100% at 

Lifesource center, otherwise plan 

deductible, then 80%

Plan deductible, then 50% 

Inpatient Professional Services Plan deductible, then 100% at 

Lifesource center, otherwise, plan 

deductible, then 80% 

Plan deductible, then 50% 

Lifetime Travel Maximum:

$10,000 per transplant 

100% 100% 

.

Durable Medical Equipment

Calendar Year Maximum:

Unlimited

Plan deductible, then 80% Plan deductible, then 60% 

.

External Prosthetic Appliances

Calendar Year Maximum:

Unlimited 

Plan deductible, then 80% Plan deductible, then 60% 

.

Diabetic Equipment

Calendar Year Maximum:

Unlimited

Plan deductible, then 80% Plan deductible, then 60% 

Nutritional Evaluation

Calendar Year Maximum:

3 visits per person however, the 3 

visit limit will not apply to treatment 

of diabetes and/or to mental health 

and substance use disorder 

conditions. 

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

.

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Dental Care

Limited to charges made for a 

continuous course of dental treatment 

started within six months of an injury to 

teeth. 

Primary Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Specialty Care Physician’s Office 

Visit

Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Facility Plan deductible, then 80% Plan deductible, then 60% 

Inpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Outpatient Professional Services Plan deductible, then 80% Plan deductible, then 60% 

Routine Foot Disorders Not covered except for services 

associated with foot care for diabetes 

and peripheral vascular disease when 

Medically Necessary. 

Not covered except for services 

associated with foot care for diabetes 

and peripheral vascular disease when 

Medically Necessary. 

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. 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 

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

Mental Health

Inpatient 

Includes Acute Inpatient and 

Residential Treatment

Calendar Year Maximum:

Unlimited 

Plan deductible, then 80% Plan deductible, then 60% 

Outpatient

Outpatient - Office Visits 

Includes individual, family and 

group psychotherapy; medication 

management, Behavioral 

Telehealth consultation, etc.

Calendar Year Maximum:

Unlimited

Plan deductible, then 80% Plan deductible, then 60% 

Outpatient - All Other Services 

Includes Partial Hospitalization, 

Intensive Outpatient Services, 

Behavioral Telehealth 

consultation, etc.

Calendar Year Maximum:

Unlimited

Plan deductible, then 80% Plan deductible, then 60% 

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK 

Substance Use Disorder

Inpatient 

Includes Acute Inpatient 

Detoxification, Acute Inpatient 

Rehabilitation and Residential 

Treatment

Calendar Year Maximum:

Unlimited 

Plan deductible, then 80% Plan deductible, then 60% 

Outpatient

Outpatient - Office Visits 

Includes individual, family and 

group psychotherapy; medication 

management, Behavioral 

Telehealth consultation, etc.

Calendar Year Maximum:

Unlimited

Plan deductible, then 80% Plan deductible, then 60% 

Outpatient - All Other Services 

Includes Partial Hospitalization, 

Intensive Outpatient Services, 

Behavioral Telehealth 

consultation, etc.

Calendar Year Maximum:

Unlimited

Plan deductible, then 80% Plan deductible, then 60% 

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Open Access Plus Medical Benefits

Certification Requirements - Out-of-Network

For You and Your Dependents 

Pre-Admission Certification/Continued Stay Review for 

Hospital Confinement

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 require treatment in a 

Hospital:

 as a registered bed patient, except for 48/96 hour maternity 

stays;

 for a Partial Hospitalization for the treatment of Mental 

Health or Substance Use Disorder;

 for Mental Health or Substance Use Disorder Residential 

Treatment Services.

You or your Dependent should request PAC prior to any nonemergency treatment in a Hospital described above. In the 

case of an emergency admission, you should contact the 

Review Organization within 48 hours after the admission. 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 Confinement.

Covered Expenses incurred will be reduced by 50% for 

Hospital charges made for each separate admission to the 

Hospital unless PAC is received: prior to the date of 

admission; or in the case of an emergency admission, 

within 48 hours after the date of admission, or as soon as 

reasonably possible.

Covered Expenses incurred for which benefits would 

otherwise be payable under this plan for the charges listed 

below will not include: 

 Hospital charges for Bed and Board, for treatment listed 

above for which PAC was performed, which are made for 

any day in excess of the number of days certified through 

PAC or CSR; and

 any Hospital charges for treatment listed above for which 

PAC was requested, but which was not certified as 

Medically Necessary.

PAC and CSR are performed through a utilization review 

program by a Review Organization with which Cigna has 

contracted. 

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.

Outpatient Certification Requirements – Out-of-Network

Outpatient Certification refers to the process used to certify 

the Medical Necessity of outpatient diagnostic testing and 

outpatient procedures, including those listed in this section 

when performed as an outpatient in a Free-standing Surgical 

Facility, Other Health Care Facility or a Physician's office. 

You or your Dependent should call the toll-free number on the 

back of your I.D. card to determine if Outpatient Certification 

is required prior to any outpatient diagnostic testing or 

procedures. Outpatient Certification is performed through a 

utilization review program by a Review Organization with 

which Cigna has contracted. Outpatient Certification should 

only be requested for nonemergency procedures or services, 

and should be requested by you or your Dependent at least 

four working days (Monday through Friday) prior to having 

the procedure performed or the service rendered. 

Covered Expenses incurred will be reduced by 50% for 

charges made for any outpatient diagnostic testing or 

procedure performed unless Outpatient Certification is 

received prior to the date the testing or procedure is 

performed.

Covered Expenses incurred will not include expenses incurred 

for charges made for outpatient diagnostic testing or 

procedures for which Outpatient Certification was performed, 

but, 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.

Diagnostic Testing and Outpatient Procedures

 Advanced radiological imaging – CT Scans, MRI, MRA or 

PET scans.

 Hysterectomy.

HC-PAC54 11-15

Prior Authorization/Pre-Authorized

The term Prior Authorization means the approval that a 

Participating Provider must receive from the Review 

Organization, prior to services being rendered, in order for 

certain services and benefits to be covered under this policy.

Services that require Prior Authorization include:

 inpatient Hospital services, except for 48/96 hour maternity 

stays;

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 inpatient services at any participating Other Health Care 

Facility;

 residential treatment;

 outpatient facility services;

 Partial Hospitalization;

 intensive outpatient programs;

 advanced radiological imaging;

 non-emergency ambulance;

 certain Medical Pharmaceuticals; or

 transplant services.

HC-PRA28 11-16

Covered Expenses

The term Covered Expenses means the 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 

for the care and treatment of an Injury or a Sickness, as 

determined by CIGNA. Any applicable Copayments, 

Deductibles or limits are shown in The Schedule.

Covered Expenses

 charges made by a Hospital, on its own behalf, for Bed and 

Board and other Necessary Services and Supplies; except 

that for any day of Hospital Confinement, Covered 

Expenses will not include that portion of charges for Bed 

and Board which is more than the Bed and Board Limit 

shown in The Schedule.

 charges for licensed ambulance service to or from the 

nearest Hospital where the needed medical care and 

treatment can be provided.

 charges made by a Hospital, on its own behalf, for medical 

care and treatment received as an outpatient.

 charges made by a Free-Standing Surgical Facility, on its 

own behalf for medical care and treatment.

 charges made on its own behalf, by an Other Health Care 

Facility, including a Skilled Nursing Facility, a 

Rehabilitation Hospital or a subacute facility for medical 

care and treatment; except that for any day of Other Health 

Care Facility confinement, Covered Expenses will not 

include that portion of charges which are in excess of the 

Other Health Care Facility Daily Limit shown in The 

Schedule.

 charges made for Emergency Services and Urgent Care.

 charges made by a Physician or a Psychologist for 

professional services.

 charges made by a Nurse, other than a member of your 

family or your Dependent's family, for professional nursing 

service.

 charges made for anesthetics and their administration; 

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

radium, and radioactive isotope treatment; chemotherapy; 

blood transfusions; oxygen and other gases and their 

administration.

 charges made for an annual prostate-specific antigen test 

(PSA).

 charges made for laboratory services, radiation therapy and 

other diagnostic and therapeutic radiological procedures.

 charges made for Family Planning, including medical 

history, physical exam, related laboratory tests, medical 

supervision in accordance with generally accepted medical 

practices, other medical services, information and 

counseling on contraception, implanted/injected 

contraceptives, after appropriate counseling, medical 

services connected with surgical therapies (tubal ligations, 

vasectomies).

 charges made for or in connection with mammograms for 

breast cancer screening or diagnostic purposes, including, 

but not limited to: a baseline mammogram for women ages 

35 through 39; a mammogram for women ages 40 through 

49, every two years or more frequently based on the 

attending Physician's recommendations; a mammogram 

every year for women age 50 and over; and one or more 

mammograms upon the recommendation of a Physician for 

any woman who is at risk for breast cancer due to her 

family history; has biopsy proven benign breast disease; or 

has not given birth before age 30. A mammogram will be 

covered with or without a Physician’s recommendation, 

provided the mammogram is performed at an approved 

facility for breast cancer screening.

 charges made for the following preventive care services 

(detailed information is available at www.healthcare.gov.):

(1) evidence-based items or services that have in effect a 

rating of “A” or “B” in the current recommendations of 

the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation 

from the Advisory Committee on Immunization 

Practices of the Centers for Disease Control and 

Prevention with respect to the Covered Person 

involved;

(3) for infants, children, and adolescents, evidenceinformed preventive care and screenings provided for in 

the comprehensive guidelines supported by the Health 

Resources and Services Administration;

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(4) for women, such additional preventive care and 

screenings not described in paragraph (1) as provided 

for in comprehensive guidelines supported by the 

Health Resources and Services Administration.

 charges made for diagnosis and Medically Necessary 

surgical procedures to treat dysfunction of the 

temporomandibular joint. Appliances and non-surgical 

treatment including for orthodontia are not covered.

 charges for the delivery of medical and health-related 

consultations via secure telecommunications technologies, 

including telephones and internet, when delivered through a 

contracted medical telehealth provider.

 charges for the treatment of cleft lip and cleft palate 

including medical, dental, speech therapy, audiology and 

nutrition services, when prescribed by a Physician.

 charges for general anesthesia and hospitalization services 

for dental procedures for an individual who is under age 8 

and for whom it is determined by a licensed Dentist and the 

child's Physician that treatment in a Hospital or ambulatory 

surgical center is necessary due to a significantly complex 

dental condition or developmental disability in which 

patient management in the dental office has proven to be 

ineffective; or has one or more medical conditions that 

would create significant or undue medical risk if the 

procedure were not rendered in a Hospital or ambulatory 

surgical center.

 charges for the services of certified nurse-midwives, 

licensed midwives, and licensed birth centers regardless of 

whether or not such services are received in a home birth 

setting.

 charges made for 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. 

Services provided to you by a certified nurse-midwife or a 

licensed midwife, in a home setting or in a licensed birthing 

center. Coverage for a mother and her newborn 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. Post delivery care for a 

mother and her newborn shall be covered. Post delivery care 

includes: a postpartum assessment and newborn assessment, 

which can be provided at the hospital, the attending 

Physician’s office, and outpatient maternity center or in the 

home by an Other Health Care Professional trained in 

mother and newborn care. The services may include 

physical assessment of the newborn and mother, and the 

performance of any clinical tests and immunizations in 

keeping with prevailing medical standards.

 coverage for diagnosis and treatment of autism spectrum 

disorder to include autistic disorder, Asperger's Syndrome 

and pervasive developmental disorder not otherwise 

specified, when prescribed by a treating Physician in 

accordance with a treatment plan for individuals diagnosed 

at age 8 or younger. Coverage is provided for Dependents to 

age 18, or older if attending High School. Treatment 

includes well-baby and well-child screening for diagnosis 

and treatment through speech therapy, occupational therapy, 

physical therapy and applied behavior analysis. Day or visit 

maximums applied to such treatment for other causes will 

not apply to treatment of autism spectrum disorder.

 charges for or in connection with Medically Necessary 

diagnosis and treatment of osteoporosis for high risk 

individuals. This includes, but is not limited to individuals 

who: have vertebral abnormalities; are receiving long-term 

glucocorticoid (steroid) therapy; have primary 

hyperparathyroidism; have a family history of osteoporosis; 

and/or are estrogen-deficient individuals who are at clinical 

risk for osteoporosis.

 charges for a drug that has been prescribed for the treatment 

of a type of cancer for which it has not been approved by 

the Food and Drug Administration (FDA). Such drug must 

be covered, provided: it is recognized for the treatment of 

the specific type of cancer for which the drug has been 

prescribed in one of the following reference compendia: the 

United States Pharmacopeia Drug Information; the 

American Medical Association Drug Evaluations; the 

American Hospital Formulary Service Drug Information; or 

the drug is recommended by one review article in a U.S. 

peer-reviewed national professional journal; it has been 

otherwise approved by the FDA; and its use for the specific 

type of cancer treatment prescribed has not been 

contraindicated by the FDA.

 charges made by a Physician, certified diabetes educator or 

licensed dietitian for a program which provides instruction 

on an outpatient basis for a person who has been diagnosed 

as having diabetes, for the purpose of instructing such 

person about the condition and its control;

 charges for or in connection with a bone marrow transplant 

when recommended by a Physician and deemed acceptable 

by the appropriate oncological specialty. This treatment 

cannot be considered experimental under the rules of the 

Secretary of Health and Rehabilitative Services. Please call 

your Claims Office prior to receiving any treatment in order 

to determine your benefits.

 charges for an inpatient Hospital stay following a 

mastectomy will be covered for a period determined to be 

Medically Necessary by the Physician and in consultation 

with the patient. Postsurgical follow-up care may be 

provided at the Hospital, Physician's office, outpatient 

center, or at the home of the patient.

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 charges for newborn and infant hearing screening and 

Medically Necessary follow-up evaluations. When ordered 

by the treating Physician, a newborn’s hearing screening 

must include auditory brainstem responses or evoked 

otacoustic emissions or other appropriate technology 

approved by the FDA. All screenings shall be conducted by 

a licensed audiologist, Physician, or supervised individual 

who has training specific to newborn hearing screening.

Newborn means an age range from birth through 29 days. 

Infant means an age range from 30 days through 12 months.

In addition, Covered Expenses will include expenses incurred 

at any of the Approximate Age Intervals shown below, for a 

Dependent child who is age 15 or less, for charges made for 

Child Preventive Care Services consisting of the following 

services delivered or supervised by a Physician, in keeping 

with prevailing medical standards:

 a history;

 physical examination;

 development assessment;

 anticipatory guidance; and

 appropriate immunizations and laboratory tests;

excluding any charges for:

 more than one visit to one provider for Child 

Preventive Care Services at each of the Approximate 

Age Intervals, up to a total of 18 visits for each 

Dependent child;

 services for which benefits are otherwise provided 

under this Covered Expenses section;

 services for which benefits are not payable, according 

to the Expenses Not Covered section.

It is provided that any Deductible that would otherwise apply 

will be waived for those Covered Expenses incurred for Child 

Preventive Care Services. Approximate Age Intervals are: 

Birth, 2 months, 4 months, 6 months, 9 months, 12 months, 15 

months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years, 

8 years, 10 years, 12 years, 14 years and 15 years.

Covered Expenses – Mental Health and Substance Use 

Disorder

 behavioral consultations and services via secure 

telecommunications technologies that shall include video 

capability, including telephones and internet, when 

delivered through a behavioral provider.

Clinical Trials

This benefit plan covers routine patient care costs related to a 

qualified clinical trial for an individual who meets the 

following requirements:

(a) is eligible to participate in an approved clinical trial 

according to the trial protocol with respect to treatment of 

cancer or other life-threatening disease or condition; and 

(b) either

 the referring health care professional is a participating 

health care provider and has concluded that the 

individual’s participation in such trial would be 

appropriate based upon the individual meeting the 

conditions described in paragraph (a); or

 the individual provides medical and scientific information 

establishing that the individual’s participation in such trial 

would be appropriate based upon the individual meeting 

the conditions described in paragraph (a).

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.

The clinical trial must meet the following requirements:

 The study or investigation must: 

 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 care costs are costs associated with the 

provision of health care items and services including drugs, 

items, devices and services otherwise covered by this benefit 

plan for an individual who is not enrolled in a clinical trial 

and, in addition:

 services required solely for the provision of the

investigational drug, item, device or service;

 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 care costs do not include:

 the investigational drug, item, device, or service, itself; or

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 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.

If your plan includes In-Network providers, Clinical trials 

conducted by non-participating providers will be covered at 

the In-Network benefit level if:

 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.

Genetic Testing

Charges made for genetic testing that uses a proven testing 

method for the identification of genetically-linked inheritable 

disease. Genetic testing is covered only if:

 a person has symptoms or signs of a genetically-linked 

inheritable disease;

 it has been determined that a person is at risk for carrier 

status as supported by existing peer-reviewed, evidencebased, 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 peerreviewed, 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 geneticallylinked inheritable disease.

Genetic counseling is covered if a person is undergoing 

approved genetic testing, or if a person has an inherited 

disease and is a potential candidate for genetic testing. Genetic 

counseling is limited to 3 visits per calendar year for both preand post-genetic testing.

Nutritional Evaluation

Charges made for nutritional evaluation and counseling when 

diet is a part of the medical management of a documented 

organic disease.

Internal Prosthetic/Medical Appliances

Charges made for internal prosthetic/medical appliances that 

provide permanent or temporary internal functional supports 

for nonfunctional body parts are covered. Medically 

Necessary repair, maintenance or replacement of a covered 

appliance is also covered.

HC-COV458 07-15

HC-COV321 04-14

Orthognathic Surgery

 orthognathic surgery to repair or correct a severe facial 

deformity or disfigurement that orthodontics alone can not 

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

 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, and there is a high 

probability of significant additional improvement as 

determined by the utilization review Physician.

HC-COV3 04-10

V1

Cardiac Rehabilitation

 Phase II cardiac rehabilitation 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.

HC-COV4 04-10

V1

Home Health Services

 charges made for Home Health Services when you: require 

skilled care; are unable to obtain the required care as an 

ambulatory outpatient; and do not require confinement in a 

Hospital or Other Health Care Facility.

Home Health Services are provided only if Cigna has 

determined that the home is a medically appropriate setting. 

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

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for nonskilled care and/or custodial services (e.g., bathing, 

eating, toileting), Home Health Services will be provided 

for you only during times when there is a family member or 

care giver present in the home to meet your nonskilled 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. Home 

Health 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 

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 limitations in the Schedule, but are subject 

to the benefit limitations described under Short-term 

Rehabilitative Therapy Maximum shown in The Schedule.

HC-COV5 04-10

V1

Hospice Care Services

 charges made for a person who has been diagnosed as 

having six months or fewer to live, due to Terminal Illness, 

for the following Hospice Care Services provided under a 

Hospice Care Program:

 by a Hospice Facility for Bed and Board and Services and 

Supplies;

 by a Hospice Facility for services provided on an 

outpatient basis;

 by a Physician for professional services;

 by a Psychologist, social worker, family counselor or 

ordained minister for individual and family counseling; 

 for pain relief treatment, including drugs, medicines and 

medical supplies;

 by an Other Health Care Facility for:

 part-time or intermittent nursing care by or under the 

supervision of a Nurse;

 part-time or intermittent services of an Other Health 

Care Professional;

 physical, occupational and speech therapy;

 medical supplies; drugs and medicines lawfully dispensed 

only on the written prescription of a Physician; and 

laboratory services; but only to the extent such charges 

would have been payable under the policy if the person 

had remained or been Confined in a Hospital or Hospice 

Facility.

The following charges for Hospice Care Services are not 

included as Covered Expenses:

 for the 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;

 for any period when you or your Dependent is not under the 

care of a Physician;

 for services or supplies not listed in the Hospice Care 

Program;

 for any curative or life-prolonging procedures;

 to the extent that any other benefits are payable for those 

expenses under the policy;

 for services or supplies that are primarily to aid you or your 

Dependent in daily living.

HC-COV6 04-10

V1

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

Services that are provided by a Hospital while you or your 

Dependent is Confined in a Hospital for the treatment and 

evaluation of Mental Health. Inpatient Mental Health Services 

include Mental Health Residential Treatment Services. 

Mental Health Residential Treatment Services are services

provided by a Hospital for the evaluation and treatment of the 

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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 Physicians; 

provides 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 person 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 Physician.

Outpatient Mental Health Services

Services of Providers who are qualified to treat Mental Health 

when treatment is provided on an outpatient basis, while you 

or your Dependent is not Confined in a Hospital, and is 

provided in an individual, group or Mental Health Partial 

Hospitalization or Intensive Outpatient Therapy Program. 

Covered services include, but are not limited to, outpatient 

treatment of conditions such as: anxiety or depression which 

interfere 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 and relapse prevention) and outpatient testing and 

assessment.

Mental Health Partial Hospitalization Services are rendered 

not less than 4 hours and not more than 12 hours in any 24-

hour period by a certified/licensed Mental Health program in 

accordance with the laws of the appropriate legally authorized 

agency.

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 or more hours in a week.

Inpatient Substance Use Disorder Rehabilitation Services

Services provided for rehabilitation, while you or your 

Dependent is Confined in a 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 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 

Physicians; provides 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 person 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.

Outpatient Substance Use Disorder Rehabilitation Services

Services provided for the diagnosis and treatment of 

Substance Use Disorder or addiction to alcohol and/or drugs, 

while you or your Dependent is not Confined in a Hospital, 

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 no less than 4 hours and not more than 12 hours in 

any 24-hour period by a certified/licensed Substance Use 

Disorder program in accordance with the laws of the 

appropriate legally authorized agency.

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, or more hours in a week.

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. Cigna will decide, based on 

the Medical Necessity of each situation, whether such services 

will be provided in an inpatient or outpatient setting.

Exclusions

The following are specifically excluded from Mental Health 

and Substance Use Disorder Services:

 treatment of disorders which have been diagnosed as 

organic mental disorders associated with permanent 

dysfunction of the brain.

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 developmental disorders, including but not limited to, 

developmental reading disorders, developmental arithmetic 

disorders, developmental language disorders or 

developmental articulation disorders.

 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.

 occupational/recreational therapy programs even if 

combined with supportive therapy for age-related cognitive 

decline.

HC-COV481 12-15

Durable Medical Equipment

 charges made for purchase or rental of Durable Medical 

Equipment that is ordered or prescribed by a Physician and 

provided by a vendor approved by Cigna for use outside a 

Hospital or Other 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 

person’s misuse are the person’s responsibility. Coverage 

for Durable Medical Equipment is limited to the lowest-cost 

alternative as determined by the utilization review 

Physician.

Durable Medical Equipment is defined as items which are 

designed for and able to withstand repeated use by more than 

one person; customarily serve a medical purpose; generally 

are not useful in the absence of Injury or Sickness; 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 nonpower mattresses, custom mattresses and 

posturepedic mattresses.

 Bath Related Items: bath lifts, nonportable 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-person transfer), and auto 

tilt chairs.

 Fixtures to Real Property: ceiling lifts and wheelchair 

ramps.

 Car/Van Modifications.

 Air Quality Items: room humidifiers, vaporizers, air 

purifiers and electrostatic machines.

 Blood/Injection Related Items: blood pressure cuffs, 

centrifuges, nova pens and needleless 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 adaptors, enuresis alarms, magnetic 

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

saunas, any exercise equipment and diathermy machines.

HC-COV8 04-10

V2

External Prosthetic Appliances and Devices

 charges made or ordered by a Physician for: the initial 

purchase and fitting of external prosthetic appliances and 

devices available only by prescription which are necessary 

for the alleviation or correction of Injury, Sickness or 

congenital defect. Coverage for External Prosthetic 

Appliances is limited to the most appropriate and cost 

effective alternative as determined by the utilization review 

Physician. 

External prosthetic appliances and devices shall 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:

 basic limb prostheses;

 terminal devices such as hands or hooks; and

 speech prostheses.

Orthoses and Orthotic Devices

Orthoses and orthotic devices are defined as orthopedic 

appliances or apparatuses used to support, align, prevent or 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 38 of 89
36 myCigna.com

correct deformities. Coverage is provided for custom foot 

orthoses and other orthoses as follows:

 Nonfoot orthoses – only the following nonfoot orthoses are 

covered:

 rigid and semirigid custom fabricated orthoses;

 semirigid prefabricated and flexible orthoses; and

 rigid prefabricated orthoses including preparation, fitting 

and basic additions, such as bars and joints.

 Custom foot orthoses – custom foot orthoses are only 

covered as follows:

 for persons with impaired peripheral sensation and/or 

altered peripheral circulation (e.g. diabetic neuropathy 

and peripheral vascular disease);

 when the foot orthosis is an integral part of a leg brace 

and is necessary for the proper functioning of the brace;

 when the foot orthosis is for use as a replacement or 

substitute for missing parts of the foot (e.g. amputated 

toes) and is necessary for the alleviation or correction of 

Injury, Sickness or congenital defect; and

 for persons 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.

The following are specifically excluded orthoses and orthotic 

devices:

 prefabricated foot orthoses;

 cranial banding and/or 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;

 orthoses primarily used for cosmetic rather than functional 

reasons; and

 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 a joint 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 person will not be covered.

 replacement will be provided when anatomic change has 

rendered the external prosthetic appliance or device 

ineffective. Anatomic change includes significant weight 

gain or loss, atrophy and/or growth.

 Coverage for replacement is limited as follows:

 no more than once every 24 months for persons 19 years 

of age and older;

 no more than once every 12 months for persons 18 years 

of age and under; and 

 replacement due to a surgical alteration or revision of the 

site.

The following are specifically excluded external prosthetic 

appliances and devices:

 external and internal power enhancements or power controls 

for prosthetic limbs and terminal devices; and

 myoelectric prostheses peripheral nerve stimulators.

HC-COV9 04-10

V2

Infertility Services

 charges made for services related to diagnosis of infertility 

and treatment of infertility once a condition of infertility has 

been diagnosed. Services include, but are not limited to: 

infertility drugs which are administered or provided by a 

Physician; approved surgeries and other therapeutic 

procedures that have been demonstrated in existing peerreviewed, evidence-based, scientific literature to have a 

reasonable likelihood of resulting in pregnancy; laboratory 

tests; sperm washing or preparation; artificial insemination; 

diagnostic evaluations; gamete intrafallopian transfer 

(GIFT); in vitro fertilization (IVF); zygote intrafallopian 

transfer (ZIFT); and the services of an embryologist.

Infertility is defined as the inability of opposite sex partners to 

achieve conception after one year of unprotected intercourse; 

or the inability of a woman to achieve conception after six 

trials of artificial insemination over a one-year period. This 

benefit includes diagnosis and treatment of both male and 

female infertility.

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 39 of 89
37 myCigna.com

However, the following are specifically excluded infertility 

services:

 reversal of male and female voluntary sterilization;

 infertility services when the infertility is caused by or 

related to voluntary sterilization;

 donor charges and services;

 cryopreservation of donor sperm and eggs; and

 any experimental, investigational or unproven infertility 

procedures or therapies.

HC-COV11 04-10

V2

Short-Term Rehabilitative Therapy and Spinal 

Manipulation Care Services

 charges made for Short-term Rehabilitative Therapy that is 

part of a rehabilitative program, including physical, speech, 

occupational, cognitive, osteopathic manipulative, and 

pulmonary rehabilitation therapy, when provided in the 

most medically appropriate setting. Also included are 

services that are provided by a Spinal Manipulation 

Physician when provided in an outpatient setting. Services 

of a Spinal Manipulation Physician include the conservative 

management of acute neuromusculoskeletal conditions 

through manipulation and ancillary physiological treatment 

that is rendered to restore motion, reduce pain and improve 

function.

The following limitation applies to Short-term Rehabilitative 

Therapy and Spinal Manipulation Care Services:

 occupational therapy is provided only for purposes of 

enabling persons to perform the activities of daily living 

after an Injury or Sickness.

Short-term Rehabilitative Therapy and Spinal Manipulation 

Care 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;

 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;

The following are specifically excluded from Spinal 

Manipulation Care Services:

 services of a Spinal Manipulation Physician which are not 

within his scope of practice, as defined by state law;

 charges for care not provided in an office setting;

 vitamin therapy.

If multiple outpatient services are provided on the same day 

they constitute one day.

HC-COV53 04-10

V1

Breast Reconstruction and Breast Prostheses

 charges made for reconstructive surgery following a

mastectomy; benefits include: surgical services for 

reconstruction of the breast on which surgery was 

performed; surgical services for reconstruction of the 

nondiseased breast to produce symmetrical appearance; 

postoperative 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.

Reconstructive Surgery

 charges made for 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 conditions related to TMJ 

disorder) provided that: the surgery or therapy restores or 

improves function; reconstruction is required as a result of 

Medically Necessary, noncosmetic 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 utilization review 

Physician.

HC-COV14 04-10

V1

Transplant Services

 charges made for human organ and tissue Transplant 

services which include solid organ and bone marrow/stem 

cell procedures at designated facilities throughout the 

United States or its territories. This coverage is subject to 

the following conditions and limitations.

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 40 of 89
38 myCigna.com

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 intestine 

which includes small bowel-liver or multi-visceral.

All Transplant services, other than cornea, are covered at 

100% when received at Cigna LIFESOURCE Transplant 

Network® facilities. Cornea transplants are not covered at 

Cigna LIFESOURCE Transplant Network® facilities. 

Transplant services, including cornea, received at participating 

facilities specifically contracted with Cigna for those 

Transplant services, other than Cigna LIFESOURCE 

Transplant Network® facilities, are payable at the In-Network 

level. Transplant services received at any other facilities, 

including Non-Participating Providers and Participating 

Providers not specifically contracted with Cigna for 

Transplant services, are covered at the Out-of-Network level.

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 for, and 

identification of a bone marrow or stem cell donor for an 

allogeneic transplant are also covered.

Transplant Travel Services

Charges made for non-taxable travel expenses incurred by you 

in connection with a preapproved 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 preapproved 

organ/tissue transplant from a designated Cigna

LIFESOURCE Transplant Network®facility. The term 

recipient is defined to include a person receiving authorized 

transplant related services during any of the following: 

evaluation, candidacy, transplant event, or post-transplant 

care. Travel expenses for the person 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 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.

These benefits are only available when the covered person 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 when the covered person is 

a donor.

HC-COV482 12-15

Medical Pharmaceuticals

The plan covers charges made for Medical Pharmaceuticals 

that are administered in an Inpatient setting, Outpatient 

setting, Physician’s office, or in a covered person's home.

Benefits under this section are provided only for Medical 

Pharmaceuticals which, due to their characteristics (as 

determined by Cigna), are required to be administered, or the 

administration of which must be directly supervised, by a 

qualified Physician. Benefits payable under this section

include Medical Pharmaceuticals whose administration may 

initially, or typically, require Physician oversight but may be 

self-administered under certain conditions specified in the 

product’s FDA labeling.

Certain Medical Pharmaceuticals are subject to prior 

authorization requirements or other coverage conditions. 

Additionally, certain Medical Pharmaceuticals are subject to 

step therapy requirements. This means that in order to receive 

benefits for such Medical Pharmaceuticals, you are required to 

try a different Medical Pharmaceutical and/or Prescription 

Drug Product first.

The Cigna Business Decision Team determines whether 

utilization management requirements or other coverage 

conditions should apply to a Medical Pharmaceutical 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 Medical 

Pharmaceuticals as well as whether utilization management 

requirements should apply. Economic factors may include, but 

are not limited to, the Medical Pharmaceutical’s cost 

including, but not limited to, assessments on the cost 

effectiveness of the Medical Pharmaceuticals and available 

rebates. When considering a Medical Pharmaceutical for a 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 41 of 89
39 myCigna.com

coverage status, the Business Decision Team reviews clinical 

and economic factors regarding enrollees as a general 

population across its book-of-business. Regardless of its 

eligibility for coverage under your plan, whether a particular 

Prescription Drug Product is appropriate for you or any of 

your Dependents is a determination that is made by you (or 

your Dependent) and the prescribing Physician.

The coverage criteria for a Medical Pharmaceutical may 

change periodically for various reasons. For example, a 

Medical Pharmaceutical may be removed from the market, a 

new Medical Pharmaceutical in the same therapeutic class as a 

Medical Pharmaceutical may become available, or other 

market events may occur. Market events that may affect the 

coverage status of a Medical Pharmaceutical include, but are 

not limited to, an increase in the cost of a Medical 

Pharmaceutical.

HC-COV526 10-16

Medical Conversion Privilege

For You and Your Dependents

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 Cigna only to a person 

who:

 resides in a state that requires offering a conversion policy,

 is Entitled to Convert, and 

 applies in writing and pays the first premium for the 

Converted Policy to Cigna within 31 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 but only if:

 you are not eligible for other individual insurance 

coverage on a guaranteed issue basis.

 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.

 you are not eligible for Medicare.

 you would not be Overinsured.

 you have paid all required premium or contribution.

 you have not performed an act or practice that constitutes 

fraud in connection with the coverage.

 you have not made an intentional misrepresentation of a

material fact under the terms of the coverage.

 your insurance did not cease because the policy in its 

entirety canceled.

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 who is not eligible for other individual insurance 

coverage on a guaranteed issue basis, and whose 

insurance under this plan ceases because he no longer 

qualifies as a Dependent or because of your death;

 a spouse who is not eligible for other individual insurance 

coverage on a guaranteed issue basis, and whose 

insurance under this plan ceases due to divorce, 

annulment of marriage or your death;

 your Dependents whose insurance under this plan ceases 

because your insurance ceased solely because you are 

eligible for Medicare;

but only if that Dependent: is not eligible for other individual 

insurance coverage on a guaranteed issue basis, is not eligible 

for Medicare, would not be Overinsured, has paid all required 

premium or contribution, has not performed an act or practice 

that constitutes fraud in connection with the coverage, and has 

not made an intentional misrepresentation of a material fact 

under the terms of the coverage.

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 

Cigna's underwriting standards for individual policies.

Similar Benefits are: 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; those for which the person is eligible, 

whether or not covered, under any plan of group coverage on 

an insured or uninsured basis; or those available for the person 

by or through any state, provincial or federal law.

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40 myCigna.com

Converted Policy

If you reside in a state that requires the offering of a 

conversion policy, the Converted Policy will be one of Cigna's 

current conversion policy offerings available in the state 

where you reside, as determined based upon Cigna's rules.

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 Entitled to Convert, 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: class of risk 

and age; and benefits.

During the first 12 months the Converted Policy is in effect, 

the amount payable under it will be reduced so that the total 

amount payable under the Converted Policy and the Medical 

Benefits Extension of this plan (if any) 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 (if any). Cigna or the Policyholder will give you, on 

request, further details of the Converted Policy.

HC-CNV28 04-14

V1

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Prescription Drug Benefits

The Schedule

For You and Your Dependents

This plan provides Prescription Drug benefits for Prescription Drug Products provided by Pharmacies as shown in this 

Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the 

Covered Expenses for Prescription Drug Products. That portion includes any applicable Copayment, Deductible and/or 

Coinsurance.

As applicable, your Deductible or Coinsurance payment will be based on the Prescription Drug Charge when the 

Pharmacy is a Network Pharmacy, and the Usual and Customary Charge when the Pharmacy is a non-Network Pharmacy.

Coinsurance

The term Coinsurance means the percentage of Charges for covered Prescription Drug Products that you or your 

Dependent are required to pay under this plan.

Charges

The term Charges means the Prescription Drug Charge when the Pharmacy is a Network Pharmacy, and it means the 

Usual and Customary Charge when the Pharmacy is a non-Network Pharmacy.

Copayments (Copay)

Copayments are expenses to be paid by you or your Dependent for Covered Prescription Drug Products.

.

Oral Chemotherapy Medication

Prescription oral chemotherapy medication that is used to kill or slow the growth of cancerous cells is covered at 

participating pharmacies at 100% after deductible and if applicable at non-participating pharmacies, is covered at the 

lower of the pharmacy cost share for oral chemotherapy medication or the out of network medical cost share for 

injectable/IV chemotherapy.

BENEFIT HIGHLIGHTS NETWORK 

PHARMACY

NON-NETWORK 

PHARMACY

Lifetime Maximum Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Calendar Year Deductible 

Individual Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Family Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Out-of-Pocket Maximum

Individual Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Family Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

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42 myCigna.com

BENEFIT HIGHLIGHTS NETWORK 

PHARMACY

NON-NETWORK 

PHARMACY

Certain Preventive Care Medications covered under this plan and required as part of preventive care services (detailed 

information is available at www.healthcare.gov) are payable at 100% with no Copayment or Deductible, when purchased 

from a Network Pharmacy. A written prescription is required.

Note: Preventive generic Prescription medications used to prevent any of the following medical conditions are covered at 

100% and are not subject to the individual and/or family plan deductible: Hypertension, high cholesterol, diabetes, asthma, 

osteoporosis, stroke and prenatal nutrient deficiency.

.

Prescription Drug Products at 

Retail Pharmacies

The amount you pay for up to a 

consecutive 30-day supply at a 

Network Pharmacy

The amount you pay for up to a 

consecutive 30-day supply at a nonNetwork Pharmacy

Tier 1

Generic Drugs on the Prescription 

Drug List 

No charge after $10 copay after plan 

Deductible 

50% after plan Deductible 

Tier 2

Brand Drugs designated as 

preferred on the Prescription Drug 

List 

No charge after $35 copay after plan 

Deductible 

50% after plan Deductible

Tier 3

Brand Drugs designated as nonpreferred on the Prescription Drug 

List 

No charge after $60 copay after plan 

Deductible 

50% after plan Deductible

.

Prescription Drug Products at 

Home Delivery Pharmacies

The amount you pay for up to a 

consecutive 90-day supply at a 

Network Pharmacy

The amount you pay for up to a 

consecutive 90-day supply at a nonNetwork Pharmacy

Tier 1

Generic Drugs on the Prescription 

Drug List 

No charge after $25 copay after plan 

Deductible 

50% after plan Deductible 

Tier 2

Brand Drugs designated as 

preferred on the Prescription Drug 

List 

No charge after $88 copay after plan 

Deductible 

50% after plan Deductible 

Tier 3

Brand Drugs designated as nonpreferred on the Prescription Drug 

List 

No charge after $150 copay after plan 

Deductible 

50% after plan Deductible 

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43 myCigna.com

Prescription Drug Benefits

For You and Your Dependents

Covered Expenses

Your plan provides benefits for Prescription Drug Products 

dispensed by a Pharmacy. Details regarding your plan’s 

Covered Expenses, Limitations and Exclusions are provided 

below and are shown in The Schedule.

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, Cigna will provide coverage 

for those expenses as shown in The Schedule. 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 plan’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 are issued a Prescription Order or 

Refill for Medically Necessary Prescription Drug Products as 

part of the rendering of Emergency Services and Cigna 

determines that it cannot reasonably be filled by a Network 

Pharmacy, the prescription will be covered by Cigna as if 

filled by a Network Pharmacy. Your payment will be based on 

the Usual and Customary Charge submitted by the nonNetwork Pharmacy.

Prescription Drug List Management

The Prescription Drug List (or formulary) offered under your 

Employer’s plan is managed by the Cigna Business Decision 

Team. Your plan’s Prescription Drug List 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 on the 

Prescription Drug List and decides whether utilization 

management requirements or other coverage conditions should 

apply to a Prescription Drug Product by considering a number 

of factors including clinical and economic factors. Clinical 

factors include 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 include the Prescription Drug 

Product's acquisition cost, including the assessments on the 

cost effectiveness of the Prescription Drug Product and 

available rebates. When considering a Prescription Drug 

Product for tier placement on the Prescription Drug List or 

other coverage conditions, the Business Decision Team 

reviews clinical and economic factors regarding enrollees as a 

general population across its book-of-business. Regardless of 

its eligibility for coverage under the plan, whether a particular 

Prescription Drug Product is appropriate for you or any of 

your Dependents 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 an 

increase in the acquisition cost of a Prescription Drug Product. 

As a result of coverage changes, for the purposes of benefits 

the plan 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 

the internet through the website shown on your ID card 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.

HC-PHR163 10-16

Limitations

Prior Authorization Requirements

Coverage for certain Prescription Drug Products prescribed to 

you requires your Physician to obtain prior authorization from 

Cigna or its Review Organization. The reason for obtaining 

prior authorization from Cigna is to determine whether the 

Prescription Drug Product is Medically Necessary in 

accordance with Cigna'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 Cigna or its Review Organization reviews the 

documentation provided and determines that the Prescription 

Drug Product is not Medically Necessary or otherwise 

excluded, your plan will not cover the Prescription Drug 

Product. Cigna, or its Review Organization, will not review 

claims for excluded Prescription Drug Products or other 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 46 of 89
44 myCigna.com

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 Cigna. 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 the 

website shown on your ID card.

If a prior authorization request is approved, your Physician 

will receive confirmation. The authorization will be processed 

in the claim system to allow you to have coverage for the 

Prescription Drug Product. The length of the authorization 

may depend on the diagnosis and the Prescription Drug 

Product. The authorization will at all times be subject to the 

plan’s terms of coverage for the Prescription Drug Product, 

which may change from time to time. When your Physician 

advises you that coverage for the Prescription Drug Product 

has been approved, you can contact a Pharmacy to fill the 

covered Prescription Order or Refill.

If the prior authorization request is denied, your Physician and 

you will be notified that coverage for the Prescription Drug 

Product is not authorized. If you disagree with a coverage 

decision, you may appeal that decision in accordance with the 

provisions of the plan by submitting a written request stating 

why the Prescription Drug Product should be covered.

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 plan's exception criteria. You may identify whether a 

particular Prescription Drug Product is subject to step therapy 

requirements at the website shown on your ID card 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. 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 have 

been approved based on consideration of the P&T 

Committee’s clinical findings. Coverage criteria are 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 the website shown on your ID card or by 

calling member 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, 

you may be directed to a Designated Pharmacy with whom 

Cigna has an arrangement to provide those Specialty 

Prescription Drug Products.

Designated Pharmacies

If you require certain Prescription Drug Products, including 

Specialty Prescription Drug Products, we 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 

may not receive coverage for the Prescription Drug Product or 

be subject to the non-Network Pharmacy Benefit, if any, for 

that Prescription Drug Product. Refer to The Schedule for 

further information.

New Prescription Drug Products

The Business Decision Team may or may not place a New 

Prescription Drug Product on the 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 Cigna 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.

HC-PHR164 10-16

Your Payments

Covered Prescription Drug Products purchased at a Pharmacy 

are subject to any applicable Deductible, Copayments or 

Coinsurance shown in The Schedule. Please refer to The 

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Schedule for any required Copayments, Coinsurance, 

Deductibles or Out-of-Pocket Maximums.

After satisfying the plan Deductible, if any, your responsibility 

for a covered Prescription Drug Product will always be the 

lowest of:

 the Copayment or Coinsurance for the Prescription Drug 

Product; or

 the Pharmacy’s Usual and Customary (U&C) Charge 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 

or Coinsurance may apply to each Prescription Drug Product.

Any Prescription Drug Product not listed on the Prescription 

Drug List that is not otherwise excluded and Cigna or its 

Review Organization approves as Medically Necessary 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, and any 

negotiated Prescription Drug Charge will not be available to 

you.

HC-PHR138 10-16

Exclusions

Coverage exclusions listed under the “Exclusions, Expenses 

Not Covered and General Limitations” section also apply to 

benefits for Prescription Drug Products. In addition, the 

exclusions listed below apply to benefits for Prescription Drug 

Products. When an exclusion or limitation applies to only 

certain Prescription Drug Products, you can access the internet 

through the website shown on your ID card or call member 

services at the telephone number on your ID card for 

information on which Prescription Drug Products are 

excluded.

 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, or which exceeds quantity limit(s) 

or dosage limit(s) 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.

 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).

 any product dispensed for the purpose of appetite 

suppression (anorectics) or weight loss.

 Prescription and non-prescription supplies other than 

supplies covered as Prescription Drug Products. 

 vitamins, except prenatal vitamins that require a 

Prescription Order or Refill, unless coverage for such 

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

 medications used for cosmetic 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.

 Prescription Drug Products as a replacement for a 

previously dispensed Prescription Drug Product that was 

lost, stolen, broken or destroyed.

 Medical Pharmaceuticals covered solely under the plan’s 

medical benefits.

 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.

 any ingredient(s) in a compounded Prescription Drug 

Product that has not been approved by the U.S. Food and 

Drug Administration (FDA).

 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 over-the-counter 

medication has been designated 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-thecounter drug(s), or are available in over-the-counter form. 

Such coverage determinations may be made periodically, 

and benefits for a Prescription Drug Product that was 

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previously excluded under this provision may be reinstated 

at any time. 

 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. 

 immunization agents, biological products for allergy 

immunization, biological sera, blood, blood plasma and 

other blood products or fractions and medications used for 

travel prophylaxis. 

 smoking cessation medications except those required by 

federal law to be covered as Preventive Care Medications.

 certain Prescription Drug Products that are a Therapeutic 

Equivalent or Therapeutic Alternative to another covered 

Prescription Drug Product(s). Such coverage determinations 

may be made periodically, and benefits for a Prescription 

Drug Product that was previously excluded under this 

provision may be reinstated at any time.

 medications that are experimental investigational or 

unproven as described under the “General Exclusion and 

Limitations” section of your plan’s certificate.

HC-PHR149 10-16

Reimbursement/Filing a Claim

Retail Pharmacy

When you or your Dependents purchase your Prescription 

Drug Products through a retail Network Pharmacy, you pay 

any applicable Copayment, Coinsurance or Deductible shown 

in The Schedule 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.

HC-PHR140 10-16

Exclusions, Expenses Not Covered and 

General Limitations

Exclusions and Expenses Not Covered

Additional coverage limitations determined by plan or 

provider type are shown in the Schedule. Payment for the 

following is specifically excluded from this plan:

 care for health conditions that are required by state or local 

law to be treated in a public facility.

 care required by state or federal law to be supplied by a 

public school system or school district.

 care for military service disabilities treatable through 

governmental services if you are legally entitled to such 

treatment and facilities are reasonably available.

 treatment of an Injury or Sickness which is due to war, 

declared, or undeclared.

 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 Cigna 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) without 

Cigna's express consent, then Cigna 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, 

Cigna shall have the right to require you to provide proof 

sufficient to Cigna that you have made your required cost 

share payment(s) prior to the payment of any benefits by 

Cigna. This exclusion includes charges of a NonParticipating 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, Cigna 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.

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 49 of 89
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 charges arising out of or relating to any violation of a 

healthcare-related state or federal law or which themselves 

are a violation of a healthcare- related state or federal law.

 assistance in the activities of daily living, including 

eating, bathing, dressing or other Custodial Services or 

self-care activities, homemaker services and services 

primarily for rest, domiciliary or convalescent care.

 for or in connection with experimental, investigational or 

unproven services.

Experimental, investigational and unproven services are 

medical, surgical, diagnostic, psychiatric, Substance Use 

Disorder or other health care technologies, supplies, 

treatments, procedures, 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” section(s) 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” 

section(s) of this plan.

In determining whether drug or Biologic therapies are 

experimental, investigational and unproven, the utilization 

review Physician may review, without limitation U.S. Food 

and Drug Administration-approved labeling, the standard 

medical reference compendia and peer-reviewed evidencebased scientific literature. The plan or policy shall not deny 

coverage for a drug or Biologic therapy as experimental, 

investigational and unproven if the drug or Biologic therapy is 

otherwise approved by the FDA to be lawfully marketed, has 

not been contraindicated by the FDA for the use for which the 

drug or Biologic has been prescribed, and is recognized for the 

treatment of cancer in any one of the following: American 

Medical Association Drug Evaluations; American Hospital 

Formulary Service Drug Information; U.S. Pharmacopeia 

Drug Information; or a U.S. peer-reviewed national 

professional journal.

 cosmetic surgery and therapies. Cosmetic surgery or therapy 

is defined as surgery or therapy performed to improve or 

alter appearance or self-esteem.

 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.

 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. Charges 

made for services or supplies provided for or in connection 

with an accidental Injury to teeth are covered provided a 

continuous course of dental treatment is started within six 

months of an accident.

 for 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 appearance or 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.

 unless otherwise covered in this plan, for reports, 

evaluations, physical examinations, or hospitalization not 

required for health reasons including, but not limited to, 

employment, insurance or government licenses, and courtordered, forensic or custodial evaluations.

 court-ordered treatment or hospitalization, unless such 

treatment is prescribed by a Physician and listed as covered 

in this plan.

 any services or supplies for the treatment of male or female 

sexual dysfunction such as, but not limited to, treatment of 

erectile dysfunction (including penile implants), anorgasmy, 

and premature ejaculation.

 medical and Hospital care and costs for the infant child of a 

Dependent, unless this infant child is otherwise eligible 

under this plan.

 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 nonmedical ancillary services 

for learning disabilities, developmental delays, or 

intellectual disabilities.

 therapy or treatment intended primarily to improve or 

maintain general physical condition or for the purpose of 

enhancing job, school, athletic or recreational performance, 

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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.

 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 

“Home Health Services” or “Breast Reconstruction and 

Breast Prostheses” section(s) of this plan.

 private Hospital rooms and/or private duty nursing except as 

provided under the Home Health Services provision.

 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 an Injury or Sickness.

 artificial aids including corrective orthopedic shoes, arch 

supports, elastic stockings, garter belts, corsets, dentures 

and wigs.

 hearing aids, including semi-implantable hearing devices, 

audiant bone conductors and Bone Anchored Hearing Aids 

(BAHAs). A hearing aid is any device that amplifies sound.

 aids or devices that assist with non-verbal communications, 

including communication boards, prerecorded speech 

devices, laptop computers, desktop computers, Personal 

Digital Assistants (PDAs), Braille typewriters, visual alert 

systems for the deaf and memory books.

 eyeglass lenses and frames and contact lenses (except for 

the first pair of contact lenses for treatment of keratoconus 

or post-cataract surgery).

 routine refractions, eye exercises and surgical treatment for 

the correction of a refractive error, including radial 

keratotomy.

 treatment by acupuncture.

 All noninjectable prescription drugs unless Physician 

administration or oversight is required, injectable 

prescription drugs to the extent they do not require 

Physician supervision and are typically considered selfadministered drugs, nonprescription drugs and 

investigational and experimental drugs, except as provided 

in this plan.

 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.

 membership costs or fees associated with health clubs, 

weight loss programs and smoking cessation programs.

 genetic screening or pre-implantations 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.

 dental implants for any condition.

 fees associated with the collection or donation of blood or 

blood products, except for autologous donation in 

anticipation of scheduled services where in the utilization 

review Physician’s opinion the likelihood of excess blood 

loss is such that transfusion is an expected adjunct to 

surgery.

 blood administration for the purpose of general 

improvement in physical condition.

 cost of biologicals that are immunizations or medications 

for the purpose of travel, or to protect against occupational 

hazards and risks.

 cosmetics, dietary supplements and health and beauty aids.

 all nutritional supplements and formulae except for infant 

formula needed for the treatment of inborn errors of 

metabolism.

 medical treatment for a person age 65 or older, who is 

covered under this plan as a retiree, or their Dependent, 

when payment is denied by the Medicare plan because 

treatment was received from a non-participating provider.

 medical treatment when payment is denied by a Primary 

Plan because treatment was received from a nonparticipating provider.

 for or in connection with an Injury or Sickness arising out 

of, or in the course of, any employment for wage or profit.

 charges for the delivery of medical and health-related 

services via telecommunications technologies, including 

telephone and internet, unless provided as specifically 

described under Covered Expenses.

 massage therapy.

General Limitations

No payment will be made for expenses incurred for you or any 

one of your Dependents:

 for charges made by a Hospital owned or operated by or 

which provides care or performs services for, the United 

States Government, if such charges are directly related to a 

military-service-connected Injury or Sickness.

 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.

 to the extent that payment is unlawful where the person 

resides when the expenses are incurred.

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49 myCigna.com

 for charges which would not have been made if the person 

had no insurance.

 to the extent that they are more than Maximum 

Reimbursable Charges.

 to the extent of the exclusions imposed by any certification 

requirement shown in this plan.

 expenses for supplies, care, treatment, or surgery that are 

not Medically Necessary.

 charges made by any covered provider who is a member of 

your family or your Dependent's family.

 expenses incurred outside the United States other than 

expenses for Medically Necessary urgent or emergent care 

while temporarily traveling abroad.

HC-EXC236 10-16

Coordination of Benefits

This section applies if you or any one of your Dependents is 

covered under more than one Plan 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:

 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 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 or dental 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.

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 from the 

Primary Plan the Reasonable Cash Value of any services it 

provided to you.

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 Cigna 

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 Cigna 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 Allowable 

Expenses include, but are not limited to the following:

 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.

 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.

 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.

 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.

 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. Such Plan 

provisions include second surgical opinions and 

precertification of admissions or services.

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50 myCigna.com

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:

 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;

 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;

 If you are the Dependent of divorced or separated parents, 

benefits for the Dependent shall be determined in the 

following order:

 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;

 then, the Plan of the parent with custody of the child;

 then, the Plan of the spouse of the parent with custody of 

the child;

 then, the Plan of the parent not having custody of the 

child, and

 finally, the Plan of the spouse of the parent not having 

custody of the child.

 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.

 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.

 If one of the Plans that covers 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 100% of the 

total of all Allowable Expenses.

The difference between the amount 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. Cigna will 

use this benefit reserve to pay any Allowable Expense not 

otherwise paid during the Claim Determination Period.

As each claim is submitted, Cigna will determine the 

following:

 Cigna's obligation to provide services and supplies under 

this policy;

 whether a benefit reserve has been recorded for you; and

 whether there are any unpaid Allowable Expenses during 

the Claims Determination Period.

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

recorded for you to pay up to 100% of the total of all 

Allowable Expenses. At the end of the Claim Determination 

Period, your benefit reserve will return to zero and a new 

benefit reserve will be calculated for each new Claim 

Determination Period.

Recovery of Excess Benefits

If Cigna pays charges for benefits that should have been paid 

by the Primary Plan, or if Cigna pays charges in excess of 

those for which we are obligated to provide under the Policy, 

Cigna will have the right to recover the actual payment made 

or the Reasonable Cash Value of any services.

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Cigna will have 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 made by any 

insurance company, healthcare plan or other organization. If 

we request, you must 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

Cigna, without consent or notice to you, may obtain 

information from and release information to any other Plan 

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. This request may occur in connection 

with a submitted claim; if so, you will be advised that the 

"other coverage" information, (including an Explanation of 

Benefits paid under the Primary Plan) is required before the 

claim will be processed for payment. If no response is 

received within 90 days of the request, the claim will be 

denied. If the requested information is subsequently received, 

the claim will be processed.

Medicare Eligibles

Cigna will pay as the Secondary Plan as permitted by the 

Social Security Act of 1965 as amended for the following:

(a) a former Employee who is eligible for Medicare and 

whose insurance is continued for any reason as 

provided in this plan;

(b) a former Employee's Dependent, or a former 

Dependent Spouse, who is eligible for Medicare and 

whose insurance is continued for any reason as 

provided in this plan;

(c) an Employee whose Employer and each other 

Employer participating in the Employer's plan have 

fewer than 100 Employees and that Employee is 

eligible for Medicare due to disability;

(d) the Dependent of an Employee whose Employer and 

each other Employer participating in the Employer's 

plan have fewer than 100 Employees and that 

Dependent is eligible for Medicare due to disability;

(e) an Employee or a Dependent of an Employee of an 

Employer who has fewer than 20 Employees, if that 

person is eligible for Medicare due to age;

(f) an Employee, retired Employee, Employee's 

Dependent or retired Employee's Dependent who is 

eligible for Medicare due to End Stage Renal Disease 

after that person has been eligible for Medicare for 30 

months;

Cigna will assume the amount payable under:

 Part A of Medicare for a person who is eligible for that Part 

without premium payment, but has not applied, to be the 

amount he would receive if he had applied.

 Part B of Medicare for a person who is entitled to be 

enrolled in that Part, but is not, to be the amount he would 

receive if he were enrolled.

 Part B of Medicare for a person who has entered into a 

private contract with a provider, to be the amount he would 

receive in the absence of such private contract.

A person is considered eligible for Medicare on the earliest 

date any coverage under Medicare could become effective for 

him.

This reduction will not apply to any Employee and his 

Dependent or any former Employee and his Dependent unless 

he is listed under (a) through (f) above.

Domestic Partners

Under federal law, the Medicare Secondary Payer Rules do 

not apply to Domestic Partners covered under a group health 

plan when Medicare coverage is due to age. Therefore, when 

Medicare coverage is due to age, Medicare is always the 

Primary Plan for a person covered as a Domestic Partner, and 

Cigna is the Secondary Plan. However, when Medicare 

coverage is due to disability, the Medicare Secondary Payer 

rules explained above will apply.

HC-COB135 01-17

Expenses For Which A Third Party May 

Be Responsible

This plan does not cover:

 Expenses incurred by you or your Dependent (hereinafter 

individually and collectively referred to as a "Participant,") 

for which another party may be responsible as a result of 

having caused or contributed to an Injury or Sickness.

 Expenses incurred by a Participant to the extent any

payment is received for them either directly or indirectly 

from a third party tortfeasor or as a result of a settlement, 

judgment or arbitration award in connection with any 

automobile medical, automobile no-fault, uninsured or 

underinsured motorist, homeowners, workers' 

compensation, government insurance (other than Medicaid), 

or similar type of insurance or coverage. The coverage 

under this plan is secondary to any automobile no-fault or 

similar coverage.

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Subrogation/Right of Reimbursement

If a Participant incurs a Covered Expense for which, in the 

opinion of the plan or its claim administrator, another party 

may be responsible or for which the Participant may receive 

payment as described above:

 Subrogation: The plan shall, to the extent permitted by law,

be subrogated to all rights, claims or interests that a 

Participant may have against such party and shall 

automatically have a lien upon the proceeds of any recovery 

by a Participant from such party to the extent of any benefits 

paid under the plan. A Participant or his/her representative 

shall execute such documents as may be required to secure 

the plan’s subrogation rights.

 Right of Reimbursement: The plan is also granted a right of 

reimbursement from the proceeds of any recovery whether 

by settlement, judgment, or otherwise. This right of 

reimbursement is cumulative with and not exclusive of the 

subrogation right granted in paragraph 1, but only to the 

extent of the benefits provided by the plan.

Lien of the Plan

By accepting benefits under this plan, a Participant:

 grants a lien and assigns to the plan an amount equal to the 

benefits paid under the plan against any recovery made by 

or on behalf of the Participant which is binding on any 

attorney or other party who represents the Participant 

whether or not an agent of the Participant or of any 

insurance company or other financially responsible party 

against whom a Participant may have a claim provided said 

attorney, insurance carrier or other party has been notified 

by the plan or its agents;

 agrees that this lien shall constitute a charge against the 

proceeds of any recovery and the plan shall be entitled to 

assert a security interest thereon;

 agrees to hold the proceeds of any recovery in trust for the 

benefit of the plan to the extent of any payment made by the 

plan.

Additional Terms

 No adult Participant hereunder may assign any rights that it 

may have to recover medical expenses from any third party 

or other person or entity to any minor Dependent of said 

adult Participant without the prior express written consent 

of the plan. The plan’s right to recover shall apply to 

decedents’, minors’, and incompetent or disabled persons’ 

settlements or recoveries.

 No Participant shall make any settlement, which specifically 

reduces or excludes, or attempts to reduce or exclude, the 

benefits provided by the plan.

 The plan’s right of recovery shall be a prior lien against any 

proceeds recovered by the Participant. This right of 

recovery shall not be defeated nor reduced by the 

application of any so-called “Made-Whole Doctrine”, 

“Rimes Doctrine”, or any other such doctrine purporting to 

defeat the plan’s recovery rights by allocating the proceeds 

exclusively to non-medical expense damages.

 No Participant hereunder shall incur any expenses on behalf 

of the plan in pursuit of the plan’s rights hereunder, 

specifically; no court costs, attorneys' fees or other 

representatives' fees may be deducted from the plan’s 

recovery without the prior express written consent of the 

plan. This right shall not be defeated by any so-called “Fund 

Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund 

Doctrine”.

 The plan shall recover the full amount of benefits provided 

hereunder without regard to any claim of fault on the part of 

any Participant, whether under comparative negligence or 

otherwise.

 The plan hereby disavows all equitable defenses in pursuit 

of its right of recovery. The plan’s subrogation or recovery 

rights are neither affected nor diminished by equitable 

defenses.

 In the event that a Participant shall fail or refuse to honor its

obligations hereunder, then the plan shall be entitled to 

recover any costs incurred in enforcing the terms hereof 

including, but not limited to, attorney’s fees, litigation, court 

costs, and other expenses. The plan shall also be entitled to 

offset the reimbursement obligation against any entitlement 

to future medical benefits hereunder until the Participant has 

fully complied with his reimbursement obligations 

hereunder, regardless of how those future medical benefits 

are incurred. 

 Any reference to state law in any other provision of this 

plan shall not be applicable to this provision, if the plan is 

governed by ERISA. By acceptance of benefits under the 

plan, the Participant agrees that a breach hereof would cause 

irreparable and substantial harm and that no adequate 

remedy at law would exist. Further, the Plan shall be 

entitled to invoke such equitable remedies as may be 

necessary to enforce the terms of the plan, including, but not 

limited to, specific performance, restitution, the imposition 

of an equitable lien and/or constructive trust, as well as 

injunctive relief. 

 Participants must assist the plan in pursuing any subrogation 

or recovery rights by providing requested information.

HC-SUB77 01-17

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Payment of Benefits

Assignment and Payment of Benefits

You may not assign to any party, including, but not limited to, 

a provider of healthcare services/items, your right to benefits 

under this plan, nor may you assign any administrative, 

statutory, or legal rights or causes of action you may have 

under ERISA, including, but not limited to, any right to make 

a claim for plan benefits, to request plan or other documents, 

to file appeals of denied claims or grievances, or to file 

lawsuits under ERISA. Any attempt to assign such rights shall 

be void and unenforceable under all circumstances.

You may, however, authorize Cigna to pay any healthcare

benefits under this policy to a Participating or NonParticipating Provider. When you authorize the payment of 

your healthcare benefits to a Participating or Non-Participating 

Provider, you authorize the payment of the entire amount of 

the benefits due on that claim. If a provider is overpaid 

because of accepting duplicate payments from you and Cigna, 

it is the provider’s responsibility to reimburse the 

overpayment to you. Cigna may pay all healthcare benefits for 

Covered Services directly to a Participating Provider without 

your authorization. You may not interpret or rely upon this 

discrete authorization or permission to pay any healthcare 

benefits to a Participating or Non-Participating Provider as the 

authority to assign any other rights under this policy to any 

party, including, but not limited to, a provider of healthcare 

services/items.

Even if the payment of healthcare benefits to a NonParticipating Provider has been authorized by you, Cigna may, 

at its option, make payment of benefits to you. When benefits 

are paid to you or your Dependent, you or your Dependents 

are responsible for reimbursing the Non-Participating 

Provider. 

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

the opinion of Cigna 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, Cigna may, at its option, make payment to the 

person or institution appearing to have assumed his custody 

and support.

When one of our participants passes away, Cigna may receive 

notice that an executor of the estate has been established. The 

executor has the same rights as our insured and benefit 

payments for unassigned claims should be made payable to the 

executor.

Payment as described above will release Cigna from all 

liability to the extent of any payment made.

Recovery of Overpayment

When an overpayment has been made by Cigna, Cigna will 

have the right at any time to: recover that overpayment from 

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

the amount of that overpayment from a future claim payment. 

In addition, your acceptance of benefits under this plan and/or 

assignment of Medical Benefits separately creates an equitable 

lien by agreement pursuant to which Cigna may seek recovery 

of any overpayment. You agree that Cigna, in seeking 

recovery of any overpayment as a contractual right or as an 

equitable lien by agreement, may pursue the general assets of 

the person or entity to whom or on whose behalf the 

overpayment was made.

Calculation of Covered Expenses

Cigna, in its discretion, will calculate Covered Expenses 

following evaluation and validation of all provider billings in 

accordance with:

 the methodologies in the most recent edition of the Current 

Procedural terminology.

 the methodologies as reported by generally recognized 

professionals or publications.

HC-POB89 01-17

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.

 the date your Active Service ends except as described 

below.

Any continuation of insurance must be based on a plan which 

precludes individual selection.

Temporary Layoff or Leave of Absence

If your Active Service ends due to temporary layoff or leave 

of absence, your insurance will be continued until the date 

your Employer: stops paying premium for you; or otherwise 

cancels your insurance. However, your insurance will not be 

continued for more than 60 days past the date your Active 

Service ends.

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Injury or Sickness

If your Active Service ends due to an Injury or Sickness, your 

insurance will be continued while you remain totally and 

continuously disabled as a result of the Injury or Sickness for a 

period not longer than 12 months. 

Dependents

Your insurance for all of your Dependents will cease on the 

earliest 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.

The insurance for any one of your Dependents will cease on 

the date that Dependent no longer qualifies as a Dependent.

Special Continuation of Medical Insurance For 

Dependents of Military Reservists

If your insurance ceases because you are called to active 

military duty in: the Florida National Guard; or the United 

States military reserves, you may elect to continue Dependent 

insurance. You must pay the required premiums to the 

Policyholder if you choose to continue Dependent insurance. 

In no event will coverage be continued beyond the earliest of 

the following dates:

 the expiration of 30 days from the date the Employee's 

military service ends;

 the last day for which the required contribution for 

Dependent insurance has been made;

 the date the Dependent becomes eligible for insurance 

under another group policy. Coverage under the Civilian 

Health and Medical Program of the Uniformed Services 

(CHAMPUS) is excluded from this provision;

 the date the Dependent becomes eligible for Medicare;

 the date the group policy cancels;

 the date the Dependent ceases to be an eligible 

Dependent.

Reinstatement of Medical Insurance - Employees and 

Dependents

Upon completion of your active military duty in: the Florida 

National Guard; or the United States military reserves, you are 

entitled to the reinstatement of your insurance and that of your 

Dependents if continuation of Dependent insurance was not 

elected. Such reinstatement will be without the application of: 

any new waiting periods; or the Pre-existing Condition 

Limitation to any new condition that you or your Dependent 

may have developed during the period that coverage was 

interrupted due to active military duty. 

Provisions Applicable to Reinstatement

 You must notify your Employer, before reporting for 

military duty, that you intend to return to Active Service 

with that Employer; and

 You must notify your Employer that you elect such 

reinstatement within 30 days after returning to Active 

Service with that Employer and pay any required premium.

Conversion Available Following Continuation

The provisions of the "Medical Conversion Privilege" section 

will apply when the insurance ceases.

HC-TRM25 04-10

V1

Rescissions

Your coverage may not be rescinded (retroactively terminated) 

by Cigna or the plan sponsor unless 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 the plan sponsor or individual (or a 

person seeking coverage on behalf of the individual) makes an 

intentional misrepresentation of material fact.

HC-TRM80 01-11

Medical Benefits Extension Upon Policy 

Cancellation

If the Medical Benefits under this plan cease for you or your 

Dependent due to cancellation of the policy, and you or your 

Dependent is Totally Disabled on that date due to an Injury, 

Sickness or pregnancy, Medical Benefits will be paid for 

Covered Expenses incurred in connection with that Injury, 

Sickness or pregnancy. However, no benefits will be paid after 

the earliest of:

 the date you exceed the Maximum Benefit, if any, shown in 

the Schedule;

 the date a succeeding carrier agrees to provide coverage 

without limitation for the disabling condition;

 the date you are no longer Totally Disabled;

 12 months from the date the policy is canceled; or

 for pregnancy, until delivery.

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Totally Disabled

You will be considered Totally Disabled if, because of an 

Injury or a Sickness:

 you are unable to perform the basic duties of your 

occupation; and

 you are not performing any other work or engaging in any 

other occupation for wage or profit.

Your Dependent will be considered Totally Disabled if, 

because of an Injury or a Sickness:

 he is unable to engage in the normal activities of a person of 

the same age, sex and ability; or

 in the case of a Dependent who normally works for wage or 

profit, he is not performing such work.

HC-BEX42 04-11

Federal Requirements

The following pages explain your rights and responsibilities 

under federal laws and regulations. Some states may have 

similar requirements. If a similar provision appears elsewhere 

in this booklet, the provision which provides the better benefit 

will apply.

HC-FED1 10-10

Notice of Provider Directory/Networks

Notice Regarding Provider Directories and Provider 

Networks

A list of network providers is available to you without charge 

by visiting the website or by calling the phone number on your 

ID card. The network consists of providers, including 

hospitals, of varied specialties as well as general practice, 

affiliated or contracted with Cigna or an organization 

contracting on its behalf.

Notice Regarding Pharmacy Directories and Pharmacy 

Networks

A list of network pharmacies is available to you without 

charge by visiting the website or by calling the phone number 

on your ID card. The network consists of pharmacies affiliated 

or contracted with Cigna or an organization contracting on its 

behalf.

HC-FED78 10-10

Qualified Medical Child Support Order 

(QMCSO)

Eligibility for Coverage Under a QMCSO

If a Qualified Medical Child Support Order (QMCSO) is 

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

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, and yourself if you are not already enrolled, within 31 

days of the QMCSO being issued.

Qualified Medical Child Support Order Defined

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:

 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 requirements 

above.

The QMCSO may not require the health insurance policy to 

provide coverage for any type or form of benefit or option not 

otherwise provided under the policy, except that an order may 

require a plan to comply with State laws regarding health care 

coverage.

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Payment of Benefits

Any payment of benefits in reimbursement for Covered 

Expenses paid by the child, or the child’s custodial parent or 

legal guardian, shall be made to the child, the child’s custodial 

parent or legal guardian, or a state official whose name and

address have been substituted for the name and address of the 

child.

HC-FED4 10-10

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. 

 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.

 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: due to 

failure of the Employer or other responsible entity to remit

premiums on a timely basis; 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 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.

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57 myCigna.com

 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 31 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 no later than the 

first day of the first calendar month following receipt of 

the request for special enrollment.

Domestic Partners and their children (if not legal children of 

the Employee) are not eligible for special enrollment.

HC-FED90 04-17

Effect of Section 125 Tax Regulations on This 

Plan

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 31 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 H.

B. Change of Status

A change in status is defined as:

 change in legal marital status due to marriage, death of a 

spouse, divorce, annulment or legal separation;

 change in number of Dependents due to birth, adoption, 

placement for adoption, or death of a Dependent;

 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;

 changes in employment status of Employee, spouse or 

Dependent resulting in eligibility or ineligibility for 

coverage;

 change in residence of Employee, spouse or Dependent to a 

location outside of the Employer’s network service area; 

and

 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.

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: incurs a change such as adding or 

deleting a benefit option; allows election changes due to

Special Enrollment, Change in Status, Court Order or 

Medicare or Medicaid Eligibility/Entitlement; or this Plan and 

the other plan have different periods of coverage or open 

enrollment periods.

G. Reduction in work hours

If an Employee’s work hours are reduced below 30 

hours/week (even if it does not result in the Employee losing 

eligibility for the Employer’s coverage); and the Employee 

(and family) intend to enroll in another plan that provides 

Minimum Essential Coverage (MEC). The new coverage must 

be effective no later than the 1st day of the 2nd month following 

the month that includes the date the original coverage is 

revoked.

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H. Enrollment in Qualified Health Plan (QHP)

The Employee must be eligible for a Special Enrollment 

Period to enroll in a QHP through a Marketplace or the 

Employee wants to enroll in a QHP through a Marketplace 

during the Marketplace’s annual open enrollment period; and 

the disenrollment from the group plan corresponds to the 

intended enrollment of the Employee (and family) in a QHP 

through a Marketplace for new coverage effective beginning 

no later than the day immediately following the last day of the 

original coverage.

HC-FED91 04-17

Eligibility for Coverage for Adopted Children

Any child who is adopted by you, including a child who is 

placed with you for adoption, will be eligible for Dependent 

Insurance, if otherwise eligible as a Dependent, 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 “Exception for Newborns” section of 

this document 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.

HC-FED67 09-14

Coverage for Maternity Hospital Stay

Group health plans and health insurance issuers offering group 

health insurance coverage generally may not, under a federal 

law known as the “Newborns’ and Mothers’ Health Protection 

Act”: 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 you and your Dependents.

HC-FED11 10-10

Women’s Health and Cancer Rights Act 

(WHCRA)

Do you know that your plan, as required by the Women’s 

Health and Cancer Rights Act of 1998, provides benefits for 

mastectomy-related services including all stages of 

reconstruction and surgery to achieve symmetry between the 

breasts, prostheses, and complications resulting from a 

mastectomy, including lymphedema? Call Member Services at 

the toll free number listed on your ID card for more 

information.

HC-FED12 10-10

Group Plan Coverage Instead of Medicaid

If your income and liquid resources do not exceed certain 

limits established by law, the state may decide to pay 

premiums for this coverage instead of for Medicaid, if it is 

cost effective. This includes premiums for continuation 

coverage required by federal law.

HC-FED13 10-10

Requirements of Medical Leave Act of 1993 (as 

amended) (FMLA)

Any provisions of the policy that provide for: continuation of 

insurance during a leave of absence; and 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, as amended, where applicable:

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, as amended; 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.

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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, as amended, 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 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, as amended.

HC-FED17 10-10

Uniformed Services Employment and ReEmployment Rights Act of 1994 (USERRA)

The Uniformed Services Employment and Re-employment 

Rights Act of 1994 (USERRA) sets requirements for 

continuation of health coverage and re-employment in regard 

to an Employee’s military leave of absence. These 

requirements apply to medical and dental coverage for you 

and your Dependents. They do not apply to any Life, Shortterm or Long-term Disability or Accidental Death & 

Dismemberment coverage you may have.

Continuation of Coverage

For leaves of less than 31 days, coverage will continue as 

described in the Termination section regarding Leave of 

Absence.

For leaves of 31 days or more, 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 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 (applicable to all coverages)

If your coverage ends during the leave of absence 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 you gave your Employer advance written or 

verbal notice of your military service leave, and 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 waiting period 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.

If your coverage under this plan terminates as a result of your 

eligibility for military medical and dental coverage and your 

order to active duty is canceled before your active duty service 

commences, these reinstatement rights will continue to apply.

HC-FED18 10-10

Claim Determination Procedures under ERISA 

The following complies with federal law. Provisions of 

applicable 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 a preservice, 

concurrent, or postservice basis, as described below:

Certain services require prior authorization in order to be 

covered. The Certificate describes who is responsible for 

obtaining this review. You or your authorized representative 

(typically, your health care professional) must request prior 

authorization according to the procedures described below, in 

the Certificate, and in your provider’s network participation 

documents as applicable.

When services or benefits are determined to be not covered, 

you or your representative will receive a written description of 

the adverse determination, and may appeal the determination. 

Appeal procedures are described in the Certificate, in your 

provider’s network participation documents as applicable, and 

in the determination notices.

Preservice Determinations

When you or your representative requests a required prior 

authorization, Cigna will 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 

Cigna’s control, Cigna 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 

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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 Cigna within 45 days after receiving 

the notice. The determination period will be suspended on the 

date Cigna 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 seriously jeopardize 

your life or health, your ability to regain maximum function, 

or in the opinion of a health care professional with knowledge 

of your health condition, cause you severe pain which cannot 

be managed without the requested services, Cigna will make 

the preservice determination on an expedited basis. Cigna will 

defer to the determination of the treating health care 

professional regarding whether an expedited determination is 

necessary. Cigna 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, Cigna 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 Cigna within 48 hours after receiving the 

notice. Cigna 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 Cigna’s

procedures for requesting a required preservice determination, 

Cigna will notify you or your representative of the failure and 

describe the proper procedures for filing within 5 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 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 coverage

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, Cigna 

will notify you or your representative of the determination 

within 24 hours after receiving the request.

Postservice Determinations

When you or your representative requests a coverage

determination or a claim payment determination after services 

have been rendered, Cigna 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 Cigna’s control,

Cigna 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 Cigna within 45 days 

after receiving the notice. The determination period will be 

suspended on the date Cigna 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: information 

sufficient to identify the claim including, if applicable, the 

date of service, provider and claim amount; diagnosis and 

treatment codes, and their meanings; the specific reason or 

reasons for the adverse determination including, if applicable, 

the denial code and its meaning and a description of any 

standard that was used in the denial; reference to the specific 

plan provisions on which the determination is based; a 

description of any additional material or information necessary 

to perfect the claim and an explanation of why such material 

or information is necessary; 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, (if applicable); 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; a 

description of any available internal appeal and/or external 

review process(es); information about any office of health 

insurance consumer assistance or ombudsman available to 

assist you with the appeal process; and in the case of a claim 

involving urgent care, a description of the expedited review 

process applicable to such claim.

HC-FED79 03-13

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COBRA Continuation Rights Under Federal 

Law

For You and Your Dependents

What is COBRA Continuation Coverage?

Under federal law, you and/or your Dependents must be given 

the opportunity to continue health insurance when there is a 

“qualifying event” that would result in loss of coverage under 

the Plan. You and/or your Dependents will be permitted to 

continue the same coverage under which you or your 

Dependents were covered on the day before the qualifying 

event occurred, unless you move out of that plan’s coverage 

area or the plan is no longer available. You and/or your 

Dependents cannot change coverage options until the next 

open enrollment period.

When is COBRA Continuation Available?

For you and your Dependents, COBRA continuation is 

available for up to 18 months from the date of the following 

qualifying events if the event would result in a loss of 

coverage under the Plan:

 your termination of employment for any reason, other than 

gross misconduct; or

 your reduction in work hours.

For your Dependents, COBRA continuation coverage is 

available for up to 36 months from the date of the following 

qualifying events if the event would result in a loss of 

coverage under the Plan:

 your death;

 your divorce or legal separation; or

 for a Dependent child, failure to continue to qualify as a 

Dependent under the Plan.

Who is Entitled to COBRA Continuation?

Only a “qualified beneficiary” (as defined by federal law) may 

elect to continue health insurance coverage. A qualified 

beneficiary may include the following individuals who were 

covered by the Plan on the day the qualifying event occurred: 

you, your spouse, and your Dependent children. Each 

qualified beneficiary has their own right to elect or decline 

COBRA continuation coverage even if you decline or are not 

eligible for COBRA continuation.

The following individuals are not qualified beneficiaries for 

purposes of COBRA continuation: domestic partners, 

grandchildren (unless adopted by you), stepchildren (unless 

adopted by you). Although these individuals do not have an 

independent right to elect COBRA continuation coverage, if 

you elect COBRA continuation coverage for yourself, you 

may also cover your Dependents even if they are not 

considered qualified beneficiaries under COBRA. However, 

such individuals’ coverage will terminate when your COBRA 

continuation coverage terminates. The sections titled 

“Secondary Qualifying Events” and “Medicare Extension For 

Your Dependents” are not applicable to these individuals.

Secondary Qualifying Events

If, as a result of your termination of employment or reduction 

in work hours, your Dependent(s) have elected COBRA 

continuation coverage and one or more Dependents experience 

another COBRA qualifying event, the affected Dependent(s) 

may elect to extend their COBRA continuation coverage for 

an additional 18 months (7 months if the secondary event 

occurs within the disability extension period) for a maximum 

of 36 months from the initial qualifying event. The second 

qualifying event must occur before the end of the initial 18 

months of COBRA continuation coverage or within the 

disability extension period discussed below. Under no 

circumstances will COBRA continuation coverage be 

available for more than 36 months from the initial qualifying 

event. Secondary qualifying events are: your death; your 

divorce or legal separation; or, for a Dependent child, failure 

to continue to qualify as a Dependent under the Plan.

Disability Extension

If, after electing COBRA continuation coverage due to your 

termination of employment or reduction in work hours, you or 

one of your Dependents is determined by the Social Security 

Administration (SSA) to be totally disabled under Title II or 

XVI of the SSA, you and all of your Dependents who have 

elected COBRA continuation coverage may extend such 

continuation for an additional 11 months, for a maximum of 

29 months from the initial qualifying event.

To qualify for the disability extension, all of the following 

requirements must be satisfied:

 SSA must determine that the disability occurred prior to or 

within 60 days after the disabled individual elected COBRA 

continuation coverage; and

 A copy of the written SSA determination must be provided 

to the Plan Administrator within 60 calendar days after the 

date the SSA determination is made AND before the end of 

the initial 18-month continuation period.

If the SSA later determines that the individual is no longer 

disabled, you must notify the Plan Administrator within 30 

days after the date the final determination is made by SSA. 

The 11-month disability extension will terminate for all 

covered persons on the first day of the month that is more than 

30 days after the date the SSA makes a final determination 

that the disabled individual is no longer disabled.

All causes for “Termination of COBRA Continuation” listed 

below will also apply to the period of disability extension.

Medicare Extension for Your Dependents

When the qualifying event is your termination of employment 

or reduction in work hours and you became enrolled in 

Medicare (Part A, Part B or both) within the 18 months before 

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the qualifying event, COBRA continuation coverage for your 

Dependents will last for up to 36 months after the date you 

became enrolled in Medicare. Your COBRA continuation 

coverage will last for up to 18 months from the date of your 

termination of employment or reduction in work hours.

Termination of COBRA Continuation

COBRA continuation coverage will be terminated upon the 

occurrence of any of the following:

 the end of the COBRA continuation period of 18, 29 or 36 

months, as applicable;

 failure to pay the required premium within 30 calendar days 

after the due date;

 cancellation of the Employer’s policy with Cigna;

 after electing COBRA continuation coverage, a qualified 

beneficiary enrolls in Medicare (Part A, Part B, or both);

 after electing COBRA continuation coverage, a qualified 

beneficiary becomes covered under another group health 

plan, unless the qualified beneficiary has a condition for 

which the new plan limits or excludes coverage under a preexisting condition provision. In such case coverage will 

continue until the earliest of: the end of the applicable 

maximum period; the date the pre-existing condition 

provision is no longer applicable; or the occurrence of an 

event described in one of the first three bullets above;

 any reason the Plan would terminate coverage of a 

participant or beneficiary who is not receiving continuation 

coverage (e.g., fraud).

Moving Out of Employer’s Service Area or Elimination of 

a Service Area

If you and/or your Dependents move out of the Employer’s 

service area or the Employer eliminates a service area in your 

location, your COBRA continuation coverage under the plan 

will be limited to out-of-network coverage only. In-network 

coverage is not available outside of the Employer’s service 

area. If the Employer offers another benefit option through 

Cigna or another carrier which can provide coverage in your 

location, you may elect COBRA continuation coverage under 

that option.

Employer’s Notification Requirements

Your Employer is required to provide you and/or your 

Dependents with the following notices:

 An initial notification of COBRA continuation rights must 

be provided within 90 days after your (or your spouse’s) 

coverage under the Plan begins (or the Plan first becomes 

subject to COBRA continuation requirements, if later). If 

you and/or your Dependents experience a qualifying event 

before the end of that 90-day period, the initial notice must 

be provided within the time frame required for the COBRA 

continuation coverage election notice as explained below.

 A COBRA continuation coverage election notice must be 

provided to you and/or your Dependents within the 

following timeframes:

 if the Plan provides that COBRA continuation coverage 

and the period within which an Employer must notify the 

Plan Administrator of a qualifying event starts upon the 

loss of coverage, 44 days after loss of coverage under the 

Plan;

 if the Plan provides that COBRA continuation coverage 

and the period within which an Employer must notify the 

Plan Administrator of a qualifying event starts upon the 

occurrence of a qualifying event, 44 days after the 

qualifying event occurs; or

 in the case of a multi-employer plan, no later than 14 days 

after the end of the period in which Employers must 

provide notice of a qualifying event to the Plan 

Administrator.

How to Elect COBRA Continuation Coverage

The COBRA coverage election notice will list the individuals 

who are eligible for COBRA continuation coverage and 

inform you of the applicable premium. The notice will also 

include instructions for electing COBRA continuation 

coverage. You must notify the Plan Administrator of your 

election no later than the due date stated on the COBRA 

election notice. If a written election notice is required, it must 

be post-marked no later than the due date stated on the 

COBRA election notice. If you do not make proper 

notification by the due date shown on the notice, you and your 

Dependents will lose the right to elect COBRA continuation 

coverage. If you reject COBRA continuation coverage before 

the due date, you may change your mind as long as you 

furnish a completed election form before the due date.

Each qualified beneficiary has an independent right to elect 

COBRA continuation coverage. Continuation coverage may 

be elected for only one, several, or for all Dependents who are 

qualified beneficiaries. Parents may elect to continue coverage 

on behalf of their Dependent children. You or your spouse 

may elect continuation coverage on behalf of all the qualified 

beneficiaries. You are not required to elect COBRA 

continuation coverage in order for your Dependents to elect 

COBRA continuation.

How Much Does COBRA Continuation Coverage Cost?

Each qualified beneficiary may be required to pay the entire 

cost of continuation coverage. The amount may not exceed 

102% of the cost to the group health plan (including both 

Employer and Employee contributions) for coverage of a 

similarly situated active Employee or family member. The 

premium during the 11-month disability extension may not 

exceed 150% of the cost to the group health plan (including 

both employer and employee contributions) for coverage of a 

similarly situated active Employee or family member.

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For example: If the Employee alone elects COBRA 

continuation coverage, the Employee will be charged 102%

(or 150%) of the active Employee premium. If the spouse or 

one Dependent child alone elects COBRA continuation 

coverage, they will be charged 102% (or 150%) of the active 

Employee premium. If more than one qualified beneficiary 

elects COBRA continuation coverage, they will be charged 

102% (or 150%) of the applicable family premium.

When and How to Pay COBRA Premiums

First payment for COBRA continuation

If you elect COBRA continuation coverage, you do not have 

to send any payment with the election form. However, you 

must make your first payment no later than 45 calendar days 

after the date of your election. (This is the date the Election 

Notice is postmarked, if mailed.) If you do not make your first 

payment within that 45 days, you will lose all COBRA 

continuation rights under the Plan.

Subsequent payments

After you make your first payment for COBRA continuation 

coverage, you will be required to make subsequent payments 

of the required premium for each additional month of 

coverage. Payment is due on the first day of each month. If 

you make a payment on or before its due date, your coverage 

under the Plan will continue for that coverage period without 

any break.

Grace periods for subsequent payments

Although subsequent payments are due by the first day of the 

month, you will be given a grace period of 30 days after the 

first day of the coverage period to make each monthly

payment. Your COBRA continuation coverage will be 

provided for each coverage period as long as payment for that 

coverage period is made before the end of the grace period for 

that payment. However, if your payment is received after the 

due date, your coverage under the Plan may be suspended 

during this time. Any providers who contact the Plan to 

confirm coverage during this time may be informed that 

coverage has been suspended. If payment is received before 

the end of the grace period, your coverage will be reinstated 

back to the beginning of the coverage period. This means that 

any claim you submit for benefits while your coverage is 

suspended may be denied and may have to be resubmitted 

once your coverage is reinstated. If you fail to make a 

payment before the end of the grace period for that coverage 

period, you will lose all rights to COBRA continuation 

coverage under the Plan.

You Must Give Notice of Certain Qualifying Events

If you or your Dependent(s) experience one of the following 

qualifying events, you must notify the Plan Administrator

within 60 calendar days after the later of the date the 

qualifying event occurs or the date coverage would cease as a 

result of the qualifying event:

 Your divorce or legal separation; or

 Your child ceases to qualify as a Dependent under the Plan.

 The occurrence of a secondary qualifying event as discussed 

under “Secondary Qualifying Events” above (this notice 

must be received prior to the end of the initial 18- or 29-

month COBRA period).

(Also refer to the section titled “Disability Extension” for 

additional notice requirements.)

Notice must be made in writing and must include: the name of 

the Plan, name and address of the Employee covered under the 

Plan, name and address(es) of the qualified beneficiaries 

affected by the qualifying event; the qualifying event; the date 

the qualifying event occurred; and supporting documentation 

(e.g., divorce decree, birth certificate, disability determination, 

etc.).

Newly Acquired Dependents 

If you acquire a new Dependent through marriage, birth, 

adoption or placement for adoption while your coverage is 

being continued, you may cover such Dependent under your 

COBRA continuation coverage. However, only your newborn 

or adopted Dependent child is a qualified beneficiary and may 

continue COBRA continuation coverage for the remainder of 

the coverage period following your early termination of 

COBRA coverage or due to a secondary qualifying event. 

COBRA coverage for your Dependent spouse and any 

Dependent children who are not your children (e.g., 

stepchildren or grandchildren) will cease on the date your 

COBRA coverage ceases and they are not eligible for a 

secondary qualifying event.

COBRA Continuation for Retirees Following Employer’s 

Bankruptcy

If you are covered as a retiree, and a proceeding in bankruptcy 

is filed with respect to the Employer under Title 11 of the 

United States Code, you may be entitled to COBRA 

continuation coverage. If the bankruptcy results in a loss of 

coverage for you, your Dependents or your surviving spouse 

within one year before or after such proceeding, you and your 

covered Dependents will become COBRA qualified 

beneficiaries with respect to the bankruptcy. You will be 

entitled to COBRA continuation coverage until your death. 

Your surviving spouse and covered Dependent children will 

be entitled to COBRA continuation coverage for up to 36 

months following your death. However, COBRA continuation 

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coverage will cease upon the occurrence of any of the events 

listed under “Termination of COBRA Continuation” above.

Conversion Available Following Continuation

If your or your Dependents’ COBRA continuation ends due to 

the expiration of the maximum 18-, 29- or 36-month period, 

whichever applies, you and/or your Dependents may be 

entitled to convert to the coverage in accordance with the 

Medical Conversion benefit then available to Employees and 

the Dependents. Please refer to the section titled “Conversion 

Privilege” for more information.

Interaction With Other Continuation Benefits

You may be eligible for other continuation benefits under state 

law. Refer to the Termination section for any other 

continuation benefits.

HC-FED66 07-14

ERISA Required Information

The name of the Plan is:

Dobbs Equipment, LLC

The name, address, ZIP code and business telephone number 

of the sponsor of the Plan is:

Dobbs Equipment, LLC

2730 S. Falkenburg Rd

Riverview, FL 33578

813-635-2368

Employer Identification

Number (EIN):

Plan Number:

822505079 501

The name, address, ZIP code and business telephone number 

of the Plan Administrator is:

Employer named above

The name, address and ZIP code of the person designated as 

agent for service of legal process is:

Employer named above

The office designated to consider the appeal of denied claims 

is:

The Cigna Claim Office responsible for this Plan

The cost of the Plan is shared by Employee and Employer.

The Plan’s fiscal year ends on 12/31.

The preceding pages set forth the eligibility requirements and 

benefits provided for you under this Plan.

Plan Trustees

A list of any Trustees of the Plan, which includes name, title 

and address, is available upon request to the Plan 

Administrator.

Plan Type

The plan is a healthcare benefit plan.

Collective Bargaining Agreements

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 Cigna 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 Cigna 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. 

Contact the Employer for 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. 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 you 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).

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Your coverage under the Plan’s insurance policy(s) will end 

on the earliest of the following dates:

 the date you leave Active Service (or later as explained in 

the Termination Section;)

 the date you are no longer in an eligible class;

 if the Plan is contributory, the date you cease to contribute;

 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 Administrator’s 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 Employee Benefits Security 

Administration.

 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 person 

under the Plan with a copy of this summary financial report.

Continue Group Health Plan Coverage

 continue health care coverage for yourself, your 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 the documents 

governing the Plan on the rules governing your federal 

continuation coverage rights.

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 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.

Enforce Your Rights

Under ERISA, there are steps you can take to enforce the 

above rights. For instance, if you request a copy of documents 

governing the plan 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.

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.

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.

HC-FED72 05-15

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Notice of an Appeal or a Grievance

The appeal or grievance provision in this certificate may be 

superseded by the law of your state. Please see your 

explanation of benefits for the applicable appeal or grievance 

procedure.

HC-SPP4 04-10

V1

Appointment of Authorized Representative

You may appoint an authorized representative to assist you in 

submitting a claim or appealing a claim denial. However, 

Cigna may require you to designate your authorized 

representative in writing using a form approved by Cigna. At 

all times, the appointment of an authorized representative is 

revocable by you. To ensure that a prior appointment remains 

valid, Cigna may require you to re-appoint your authorized 

representative, from time to time. 

Cigna reserves the right to refuse to honor the appointment of 

a representative if Cigna 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 Cigna does not honor your designation, you may appoint a 

new authorized representative at any time, in writing, using a 

form approved by Cigna. 

HC-AAR1 01-17

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 is why we have established a process for 

addressing your concerns and solving your problems.

Start with Customer Service

We are here to listen and help. If you have a concern regarding 

a person, a service, the quality of care, contractual benefits, or 

a rescission of coverage, you can call our toll-free number and 

explain your concern to one of our Customer Service 

representatives. You can also express that concern in writing. 

Please call, or write to us at the following:

Cigna

National Appeals Organization (NAO)

PO Box 188011

Chattanooga, TN 37422

We will do our best to resolve the matter on your initial 

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

concern, we will get back to you as soon as possible, but in 

any case within 30 days.

If you are not satisfied with the results of a coverage decision, 

you can start the appeals procedure.

Appeals Procedure

Cigna has a two step appeals procedure for coverage 

decisions. To initiate an appeal, you must submit a request for 

an appeal in writing within 365 days of receipt of a denial 

notice. 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 telephone. Call us at the toll-free 

number on your Benefit Identification card, explanation of 

benefits or claim form.

Cigna has a single level appeals procedure for Florida Adverse 

Determination appeals which are Medical Necessity appeals 

received in writing within 30 calendar days of the initial 

Medical Necessity denial. Cigna has a two step appeals 

procedure for the appeal of coverage decisions which are not 

Florida Adverse Determinations. To initiate an appeal, you 

must submit a request for an appeal in writing within 365 days 

of receipt of a denial notice. 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 

telephone. Call us at the toll-free number on your Benefit 

Identification card, explanation of benefits or claim form.

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 15 calendar days after we receive an appeal 

for a required preservice or concurrent care coverage 

determination (decision). We will respond within 30 calendar 

days after we receive an appeal for a postservice coverage 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 69 of 89
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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 15 calendar days and to specify any 

additional information needed to complete the review.

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 function 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 nonauthorization of an admission or 

continuing inpatient Hospital stay.

If you request that your appeal be expedited based on (a) 

above, you may also ask for an expedited external 

Independent Review at the same time, if the time to complete 

an expedited level one appeal would be detrimental to your 

medical condition.

Cigna’s Physician Reviewer, 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 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 start 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 Cigna’s Physician Reviewer. 

For all other coverage plan-related appeals, a second-level 

review will be conducted by someone who was not involved 

in any previous decision related to your appeal, and not a 

subordinate of previous decision makers. Provide all relevant 

documentation with your second-level appeal request.

For required preservice and concurrent care coverage 

determinations, Cigna’s review will be completed within 15 

calendar days. For postservice claims, Cigna’s review will be 

completed within 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 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 Cigna in connection with the level two appeal, 

Cigna 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 Cigna, Cigna will provide the 

rationale 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 

working days after the decision is made, and within the review 

time frames above if Cigna does not approve the requested 

coverage.

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 function or in 

the opinion of your Physician would cause you severe pain 

which cannot be managed without the requested services; or 

your appeal involves nonauthorization of an admission or 

continuing inpatient Hospital stay. Cigna’s Physician 

Reviewer, 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 72 

hours, followed up in writing.

Independent Review Procedure

If you are not fully satisfied with the decision of Cigna’s level 

two appeal review and the appeal involves medical judgment 

or a rescission of coverage, 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 or any of its affiliates. A 

decision to request an appeal to an 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. Cigna will abide by the decision of the Independent 

Review Organization.

To request a review, you must notify the Appeals Coordinator 

within 180 days of your receipt of Cigna’s level two appeal 

review denial. Cigna 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 delay would be 

detrimental to your condition, as determined by Cigna’s 

Physician Reviewer, or if 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 the facility, the review shall 

be completed within 72 hours.

Florida Adverse Determination Medical Necessity Appeal

To initiate an Adverse Determination appeal, you must submit 

a request in writing to Cigna within 30 days of receipt of a 

denial notice. You should state the reason why you feel your 

appeal should be approved and include any information 

supporting your appeal. If you are unable to write, you may 

ask Cigna to assist so that you may register your written 

appeal. Call us at the toll-free number on your Benefit 

Identification card, explanation of benefits or claim form.

Your appeal will be reviewed and the decision made by 

individuals not involved in the initial decision. Appeals 

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involving Medical Necessity or clinical appropriateness will 

be considered by an Internal Panel of health care 

professionals. For appeals involving Medical Necessity or 

clinical appropriateness, the Internal Panel will include at least 

one Physician in the same or similar specialty as the care 

under consideration, as determined by the Cigna Physician 

Reviewer.

For Adverse Determination Medical Necessity Appeals, we 

will acknowledge in writing that we have received your 

request and schedule a panel review. For preservice and 

concurrent care coverage determinations, the panel review will 

be completed within 30 calendar days and for postservice 

claims, the panel review will be completed within 60 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 15 calendar days and to specify any 

additional information needed by the Internal Panel to 

complete the review. 

In the event any new or additional information (evidence) is 

considered, relied upon or generated by Cigna in connection 

with the appeal, Cigna 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 Cigna, Cigna will 

provide the rationale 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 Internal Panel's decision 

within five working days after the panel considers your 

request.

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 function 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 nonauthorization of an admission or 

continuing inpatient Hospital stay. 

If you request that your appeal be expedited based on (a) 

above, you may also ask for an expedited external 

Independent Review at the same time, if the time to complete 

an expedited Medical Necessity appeal would be detrimental 

to your medical condition.

The Cigna Physician Reviewer, in consultation with the 

treating Physician, will decide if an expedited appeal is 

necessary. When an appeal is expedited, Cigna will respond 

orally with a decision within 72 hours, followed up in writing.

Appeal to the State of Florida

You have the right to contact the state regulators for assistance 

at any time. The state regulators may be contacted at the 

following addresses and telephone numbers:

The Agency for Health Care Administration

Fort Knox Building One, Room 339

2727 Mahan Drive

Tallahassee, FL 32308

1-888-419-3456

Florida Office of Insurance Regulation

200 East Gaines St.

Tallahassee, FL 32399-0300

1-800-342-2762

Notice of Benefit Determination on Appeal

Every notice of a determination on appeal will be provided in 

writing or electronically and, if an adverse determination, will 

include: information sufficient to identify the claim; the 

specific reason or reasons for the adverse determination;

reference to the specific plan provisions on which the 

determination is based; 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; 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); 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 

information about any office of health insurance consumer 

assistance or ombudsman available to assist you in the appeal 

process. A final notice of 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 was relied upon in making the benefit 

determination; 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; demonstrates 

compliance with the administrative processes and safeguards 

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required by federal law in making the benefit determination; 

or constitutes a statement of policy or guidance with respect to 

the plan concerning the denied treatment option or benefit or 

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 Cigna

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. However, no action will be brought at all unless 

brought within five years after a claim is submitted for InNetwork services or within five years after proof of claim is 

required under the Plan for Out-of-Network services.

HC-APL242 01-15

V1

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.

HC-DFS1 04-10

V1

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.

HC-DFS2 04-10

V2

Biologic

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).

HC-DFS840 10-16

Biosimilar

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).

HC-DFS841 10-16

Brand Drug

A Prescription Drug Product that Cigna 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 

plan.

HC-DFS842 10-16

Business Decision Team

A committee comprised of voting and non-voting 

representatives across various Cigna business units such as 

clinical, medical and business leadership that is duly 

authorized by Cigna to make decisions regarding coverage 

treatment of Prescription Drug Products or Medical 

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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. 

HC-DFS843 10-16

Charges 

The term "charges" means the actual billed charges; except 

when the provider has contracted directly or indirectly with 

Cigna for a different amount.

HC-DFS3 04-10

V1

Cigna Home Delivery Pharmacy

A home delivery Network Pharmacy owned and operated by 

licensed Pharmacy affiliates of Cigna Health and Life 

Insurance Company.

HC-DFS844 10-16

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: walking, 

grooming, bathing, dressing, getting in or out of bed, 

toileting, eating, preparing foods, or taking medications that 

can be self administered, and

 Services not required to be performed by trained or skilled 

medical or paramedical personnel.

HC-DFS4 04-10

V1

Dependent – For Medical Insurance

Dependents are: 

 your lawful spouse; or

 your Domestic Partner; and

 any child of yours who is:

 less than 26 years old.

 from 26 years until the end of the calendar year in which 

the child reaches the age of 30, provided the child is 

unmarried and does not have a dependent of his own, is a 

Florida state resident or a full-time or part-time student, 

and is not covered under a plan of his own or entitled to 

benefits under Title XVIII of the Social Security Act. 

Cigna may require such proof at least once each year until 

the end of the calendar year in which he attains age 30; 

and

 who is 26 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 may be required to be 

submitted to the plan as a condition of coverage after the 

date the child ceases to qualify above. However, if a claim 

is denied, proof must be submitted by the Employee that 

the child is and has continued to be mentally or physically 

handicapped. 

A child includes a legally adopted child, including that child 

from the date of placement in the home or from birth provided 

that a written agreement to adopt such child has been entered 

into prior to the birth of such child. Coverage for a legally 

adopted child will include the necessary care and treatment of 

an Injury or a Sickness existing prior to the date of placement 

or adoption. A child also includes a foster child or a child 

placed in your custody by a court order from the date of 

placement in the home. Coverage is not required if the adopted 

or foster child is ultimately not placed in your home. It also 

includes:

 a stepchild or a child for whom you are the legal guardian; 

 a child born to an insured Dependent child of yours until 

such child is 18 months old. 

If your Domestic Partner has a child, that child will also be 

included as a Dependent.

Benefits for a Dependent child will continue until the last day 

of the calendar year in which the limiting age is reached. 

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 

an Employee. 

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No one may be considered as a Dependent of more than one 

Employee.

HC-DFS912 10-16

Designated Pharmacy

A Network Pharmacy that has entered into an agreement with 

Cigna, or with an entity contracting on Cigna’s behalf, to 

provide Prescription Drug Products or services, including, 

without limitation, specific Prescription Drug Products, to plan 

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. 

HC-DFS845 10-16

Domestic Partner

A Domestic Partner is defined as a person of the same sex 

who:

 shares your permanent residence;

 has resided with you for no less than one year;

 is no less than 18 years of age;

 is financially interdependent with you and has proven such 

interdependence by providing documentation of at least two 

of the following arrangements: common ownership of real 

property or a common leasehold interest in such property; 

community ownership of a motor vehicle; a joint bank 

account or a joint credit account; designation as a 

beneficiary for life insurance or retirement benefits or under 

your partner's will; assignment of a durable power of 

attorney or health care power of attorney; or such other 

proof as is considered by Cigna to be sufficient to establish 

financial interdependency under the circumstances of your 

particular case;

 is not a blood relative any closer than would prohibit legal 

marriage; and

 has signed jointly with you, a notarized affidavit attesting to 

the above which can be made available to Cigna upon 

request.

In addition, you and your Domestic Partner will be considered 

to have met the terms of this definition as long as neither you 

nor your Domestic Partner: 

 has signed a Domestic Partner affidavit or declaration with 

any other person within twelve months prior to designating 

each other as Domestic Partners hereunder;

 is currently legally married to another person; or

 has any other Domestic Partner, spouse or spouse equivalent 

of the same or opposite sex.

You and your Domestic Partner must have registered as

Domestic Partners, if you reside in a state that provides for 

such registration.

The section of this certificate entitled "COBRA Continuation 

Rights Under Federal Law" will not apply to your Domestic 

Partner and his or her Dependents.

HC-DFS47 04-10

V1

Emergency Medical Condition

Emergency medical condition means a medical condition 

which manifests 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.

HC-DFS394 11-10

Emergency Services

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, including ancillary services routinely available to the 

emergency department to evaluate the 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, to stabilize the 

patient.

HC-DFS393 11-10

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Employee

The term Employee means a full-time employee of the 

Employer who is currently in Active Service. The term does 

not include employees who are part-time or temporary or who 

normally work less than 30 hours a week for the Employer.

HC-DFS7 04-10

V3

Employer

The term Employer means the Policyholder and all Affiliated 

Employers.

HC-DFS8 04-10

V1

Essential Health Benefits

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 and wellness services and chronic disease 

management and pediatric services, including oral and vision

care.

HC-DFS411 01-11

Expense Incurred

An expense is incurred when the service or the supply for 

which it is incurred is provided.

HC-DFS10 04-10

V1

Free-Standing Surgical Facility

The term Free-standing Surgical Facility means an institution 

which meets all of the following requirements:

 it has a medical staff of Physicians, Nurses and licensed 

anesthesiologists;

 it maintains at least two operating rooms and one recovery 

room;

 it maintains diagnostic laboratory and x-ray facilities;

 it has equipment for emergency care;

 it has a blood supply;

 it maintains medical records;

 it has agreements with Hospitals for immediate acceptance 

of patients who need Hospital Confinement on an inpatient 

basis; and

 it is licensed in accordance with the laws of the appropriate 

legally authorized agency.

HC-DFS11 04-10

V1

Generic Drug

A Prescription Drug Product that Cigna 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 plan. A Biosimilar may be classified as a 

Generic Drug for the purposes of benefits under the plan even 

if it is identified as a “brand name” drug by the manufacturer, 

Pharmacy or your Physician. 

HC-DFS846 10-16

Hospice Care Program

The term Hospice Care Program means:

 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;

 a program for persons who have a Terminal Illness and for 

the families of those persons.

HC-DFS51 04-10

V1

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Hospice Care Services

The term Hospice Care Services means any services provided 

by: a Hospital, a Skilled Nursing Facility or a similar 

institution, a Home Health Care Agency, a Hospice Facility, 

or any other licensed facility or agency under a Hospice Care 

Program.

HC-DFS52 04-10

V1

Hospice Facility

The term Hospice Facility means an institution or part of it 

which:

 primarily provides care for Terminally Ill patients;

 is accredited by the National Hospice Organization;

 meets standards established by Cigna; and

 fulfills any licensing requirements of the state or locality in 

which it operates.

HC-DFS53 04-10

V1

Hospital

The term Hospital means:

 an institution licensed as a hospital, which: maintains, on 

the premises, all facilities necessary for medical and 

surgical treatment; provides such treatment on an inpatient 

basis, for compensation, under the supervision of 

Physicians; and provides 24-hour service by Registered 

Graduate Nurses;

 an institution which qualifies as a hospital, a psychiatric 

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 

Healthcare Organizations; or

 an Ambulatory Surgical Center; or

 an institution which: specializes in treatment of Mental 

Health and Substance Use Disorder or other related illness; 

provides residential treatment programs; and 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.

HC-DFS818 12-15

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;

 receiving treatment for Mental Health and Substance Use 

Disorder Services in a Mental Health or Substance Use 

Disorder Residential Treatment Center.

HC-DFS807 12-15

Injury

The term Injury means an accidental bodily injury.

HC-DFS12 04-10

V1

Maximum Reimbursable Charge - Medical

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 percentage of a schedule developed 

by Cigna that is based upon a methodology similar to a 

methodology utilized by Medicare to determine the 

allowable fee for the same or similar service within the 

geographic market.

The percentage used to determine the Maximum Reimbursable 

Charge is listed in The Schedule.

In some cases, a Medicare based schedule will not be used and 

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

 the 80th 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 Cigna.

The Maximum Reimbursable Charge is subject to all other 

benefit limitations and applicable coding and payment 

methodologies determined by Cigna. Additional information 

about how Cigna determines the Maximum Reimbursable 

Charge is available upon request.

HC-DFS792 05-15

V1

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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.

HC-DFS16 04-10

V1

Medical Pharmaceutical

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 selfadministered 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.

HC-DFS848 10-16

Medically Necessary/Medical Necessity

Health care services, supplies and medications provided for 

the purpose of preventing, evaluating, diagnosing or treating a 

Sickness, Injury, condition, disease or its symptoms, that are 

all of the following as determined by a Medical Director or 

Review Organization:

 required to diagnose or treat an illness, Injury, disease or its 

symptoms; 

 in accordance with generally accepted standards of medical 

practice; 

 clinically appropriate in terms of type, frequency, extent, 

site and duration; 

 not primarily for the convenience of the patient, Physician 

or other health care provider;

 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, supplies or medications. Where 

applicable, the Medical Director or Review Organization 

may compare the cost-effectiveness of alternative services, 

supplies, medications or settings when determining least 

intensive setting.

HC-DFS839 10-16

Medicare

The term Medicare means the program of medical care 

benefits provided under Title XVIII of the Social Security Act 

of 1965 as amended.

HC-DFS17 04-10

V1

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.

HC-DFS21 04-10

V1

Network Pharmacy

A retail or home delivery Pharmacy that has:

 entered into an agreement with Cigna or an entity 

contracting on Cigna's behalf to provide Prescription Drug 

Products to plan 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 Employer’s plan. 

HC-DFS849 10-16

New Prescription Drug Product

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 

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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 

Cigna's Business Decision Team makes a Prescription Drug 

List coverage status decision. 

HC-DFS850 10-16

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."

HC-DFS22 04-10

V1

Other Health Care Facility/Other Health Professional

The term Other Health Care Facility means a facility 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 subacute 

facilities. The term Other Health Professional means an 

individual other than a Physician who is licensed or otherwise 

authorized under the applicable state law to deliver medical 

services and supplies. Other Health Professionals include, but 

are not limited to physical therapists, registered nurses and 

licensed practical nurses. Other Health Professionals do not 

include providers such as Certified First Assistants, Certified 

Operating Room Technicians, Certified Surgical 

Assistants/Technicians, Licensed Certified Surgical 

Assistants/Technicians, Licensed Surgical Assistants, 

Orthopedic Physician Assistants and Surgical First Assistants.

HC-DFS23 04-10

V1

Participating Provider

The term Participating Provider means a hospital, a Physician 

or any other health care practitioner or entity that has a direct 

or indirect contractual arrangement with Cigna to provide 

covered services with regard to a particular plan under which 

the participant is covered. 

HC-DFS45 04-10

V1

Patient Protection and Affordable Care Act of 2010 

(“PPACA”)

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).

HC-DFS412 01-11

Pharmacy

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 Drug Products through mail order.

HC-DFS851 10-16

Pharmacy & Therapeutics (P&T) Committee

A committee comprised of both voting and non-voting Cignaemployed clinicians, Medical Directors and Pharmacy 

Directors and non-employees such as Participating Providers 

that represent a range of clinical specialties. The committee 

regularly reviews Medical Pharmaceuticals or 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.

HC-DFS852 10-16

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.

HC-DFS25 04-10

V1

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Prescription Drug Charge

The amount the plan pays to Cigna, including the applicable 

dispensing fee and any applicable sales tax, for a Prescription 

Drug Product dispensed at a Network Pharmacy. Cigna may 

pay a Network Pharmacy a different amount for a Prescription 

Drug Product than the plan pays to Cigna.

HC-DFS853 10-16

Prescription Drug List

A list that categorizes drugs, Biologics (including Biosimilars) 

or other products covered under the plan’s Prescription Drug 

benefits that have been approved by the U.S. Food and Drug 

Administration (FDA) into coverage tiers. This list is 

developed by Cigna's Business Decision Team based on 

clinical factors communicated by the P&T Committee, and 

adopted by your Employer as part of the plan. The list is 

subject to periodic review and change, and is subject to the 

limitations and exclusions of the plan. You may determine to 

which tier a particular Prescription Drug Product has been 

assigned through the website shown on your ID card or by 

calling customer service at the telephone number on your ID 

card.

HC-DFS854 10-16

Prescription Drug Product

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 Prescription Drug 

benefit; and

 Inhaler assistance devices and accessories, peak flow 

meters.

This definition does not include any charges for mobile, webbased or other electronic applications or software, even if 

approved for marketing as a prescription product by the FDA.

HC-DFS855 10-16

Prescription Order or Refill

The lawful directive to dispense a Prescription Drug Product 

issued by a Physician whose scope of practice permits issuing 

such a directive.

HC-DFS856 10-16

Preventive Care Medications

The Prescription Drug Products or other medications 

(including over-the-counter medications) designated as 

payable by the plan at 100% of the cost (without application of 

any Deductible, Copayment or Coinsurance) as required by 

applicable law under any of the following:

 Evidence-based items or services that have in effect a rating 

of "A" or "B" in the current recommendations of the United 

States Preventive Services Task Force.

 With respect to infants, children and adolescents, evidenceinformed preventive care and screenings provided for in the 

comprehensive guidelines supported by the Health 

Resources and Services Administration.

 With respect to women, such additional preventive care and 

screenings as provided for in comprehensive guidelines 

supported by the Health Resources and Services 

Administration.

A written prescription is required to process a claim for a 

Preventive Care Medication. You may determine whether a 

drug is a Preventive Care Medication through the internet 

website shown on your ID card or by calling member services 

at the telephone number on your ID card.

HC-DFS857 10-16

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Primary Care Physician

The term Primary Care Physician means a Physician who 

qualifies as a Participating Provider in general practice, 

internal medicine, family practice or pediatrics; and who has 

been selected by you, as authorized by Cigna, to provide or 

arrange for medical care for you or any of your insured 

Dependents. 

HC-DFS40 04-10

V1

Psychologist

The term Psychologist means a person who is licensed or 

certified as a clinical psychologist. Where no licensure or 

certification exists, the term Psychologist means a person who 

is considered qualified as a clinical psychologist by a 

recognized psychological association. It will also include any 

other licensed counseling 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 Psychologist.

HC-DFS26 04-10

V1

Review Organization

The term Review Organization refers to an affiliate of Cigna

or another entity to which Cigna 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.

HC-DFS808 12-15

Sickness – For Medical Insurance

The term Sickness means a physical or mental illness. It also 

includes pregnancy. Expenses incurred for routine Hospital 

and pediatric care of a newborn child prior to discharge from 

the Hospital nursery will be considered to be incurred as a 

result of Sickness.

HC-DFS50 04-10

V1

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: maintains on the premises all 

facilities necessary for medical treatment; provides such 

treatment, for compensation, under the supervision of 

Physicians; and provides Nurses' services.

HC-DFS31 04-10

V1

Specialist

The term Specialist means a Physician who provides 

specialized services, and is not engaged in general practice, 

family practice, internal medicine, obstetrics/gynecology or 

pediatrics.

HC-DFS33 04-10

V1

Specialty Prescription Drug Product

A Prescription Drug Product or Medical Pharmaceutical 

considered by Cigna to be a Specialty Prescription Drug 

Product based on consideration of the following factors, 

subject to applicable law: whether the Prescription Drug 

Product or Medical Pharmaceutical is prescribed and used for 

the treatment of a complex, chronic or rare condition; whether 

the Prescription Drug Product or Medical Pharmaceutical has 

a high acquisition cost; and, whether the Prescription Drug 

Product or Medical Pharmaceutical 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 or Medical Pharmaceutical will 

be considered a Specialty Prescription Drug Product. Specialty 

Prescription Drug Products may vary by plan 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 website shown on your 

ID card or by calling member services at the telephone 

number on your ID card.

HC-DFS858 10-16

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Spinal Manipulation Care

The term Spinal Manipulation Care means the conservative 

management of neuromusculoskeletal conditions through 

manipulation and ancillary physiological treatment rendered to 

specific joints to restore motion, reduce pain and improve 

function.

HC-DFS164 01-11

V1

Stabilize

Stabilize means, with respect to an emergency medical 

condition, to provide such medical treatment of the condition 

as may be necessary to assure, within reasonable medical 

probability that no material deterioration of the condition is 

likely to result from or occur during the transfer of the 

individual from a facility.

HC-DFS413 01-11

Terminal Illness

A Terminal Illness will be considered to exist if a person 

becomes terminally ill with a prognosis of six months or less 

to live, as diagnosed by a Physician.

HC-DFS54 04-10

V1

Therapeutic Alternative

A Prescription Drug Product or Medical Pharmaceutical that is 

of the same therapeutic or pharmacological class, and usually 

can be expected to have similar outcomes and adverse reaction 

profiles when administered in therapeutically equivalent doses 

as, another Prescription Drug Product, Medical 

Pharmaceutical or over-the-counter medication.

HC-DFS859 10-16

Therapeutic Equivalent

A Prescription Drug Product or Medical Pharmaceutical that is 

a pharmaceutical equivalent to another Prescription Drug 

Product, Medical Pharmaceutical or over-the-counter 

medication.

HC-DFS860 10-16

Urgent Care

Urgent Care is medical, surgical, Hospital or related health 

care services and testing which are not Emergency Services, 

but which are determined by Cigna, 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 were 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 the insured should not travel due to any medical 

condition.

HC-DFS34 04-10

V1

Usual and Customary (U&C) Charge

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. 

HC-DFS861 10-16

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The following pages describe the features of your Cigna Choice Fund - Health Savings Account. Please read 

them carefully.

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 82 of 89
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What You Should Know About Cigna

Choice Fund®– Health Savings Account

Cigna Choice Fund is designed to give you:

Control

You decide how much you’d like to contribute (up to federal 

limits) to your Health Savings Account. You decide how and 

when to access your account. And the money in the account is 

yours until you spend it. Unused dollars remain in your 

account from year to year and earn interest.

Choice

You have the freedom to choose any licensed doctor, even 

those who do not participate with Cigna. Your costs are 

lower for services from Cigna contracted health care 

professionals and facilities because they have agreed to accept 

discounted payments to help you make the most of your health 

care dollars.

Easy Access to your HSA Dollars

You can draw money directly from your health savings 

account using your HSA debit card, checkbook (if purchased) 

or online bill pay. Or, you may choose automatic claim 

forwarding, which allows qualified medical claims to pay

directly from your account to your doctor or hospital.

Flexibility and Tax Savings

You can also choose to pay for medical expenses out of your 

pocket until you reach the deductible, allowing you to save for 

qualified health care expenses in future years or retirement. 

You are not taxed on your HSA withdrawals unless you use 

the money to pay for nonqualified expenses.

Health Information and Education

Call the toll-free number on your ID card to reach Cigna's 24-

Hour Health Information LineSM, giving you access to trained

nurses and an audio library of health topics 24 hours a day. In 

addition, the Cigna Healthy Pregnancies, Healthy Babies®

program provides prenatal education and support for mothersto-be.

Tools & Support

We help you keep track of your health and coverage with 

online benefits information, transactions, and account activity; 

medical and drug cost comparisons; monthly statements; and 

more. You also have 24/7/365 toll-free access to a dedicated 

Customer Service team, specially trained to answer your 

questions and address your needs.

Savings on Health and Wellness Products and Services

Through Cigna Healthy Rewards®, you can save money on a 

variety of health-related products and services. Offerings 

include laser vision correction, acupuncture, chiropractic care, 

weight loss programs, fitness club and equipment discounts, 

and more.

The Basics

Who is eligible?

You are eligible to open a Health Savings Account only if you 

are covered under a federally qualified high deductible health 

plan, such as the one described in this booklet. You cannot be 

covered by Medicare or any other individual or group health 

plan that is not a federally qualified high deductible health 

plan. You can no longer contribute to the HSA once you: 

become entitled to Medicare due to age; or are no longer 

covered under a high deductible health plan. However, you 

will still be able to use the HSA funds for qualified health care

expenses.

How does it work?

The Health Savings Account combines a health care plan with 

a tax-free savings account.

1. You, your employer or both may contribute to your 

account. Contributions are tax-free up to federal limits.

2. You choose how to pay for qualified health care

expenses:

 You may pay for qualified expenses on your own using a 

debit card, checkbook (if purchased) or online bill pay 

that draws from your health savings account.

 You may choose the Automatic Claim Forwarding option, 

allowing qualifying medical expenses to be paid directly 

to your doctor, hospital, or other facility from your HSA. 

You can change your election at any time during the year.

 You may choose to cover your expenses using other

personal funds. This allows you to save the money in your 

HSA for qualified health care expenses in future years or 

at retirement. The balance in your savings account will 

earn interest.

3.Once you meet your deductible, you and your plan share 

the costs. Depending on your plan, you pay pre-determined 

coinsurance or copayments for certain services. Your 

employer determines the maximum amount of out-of-pocket 

expenses you pay each year. Once you meet the maximum, 

the plan pays covered expenses at 100%.

Your HSA can be a tax-sheltered savings tool. Because your 

HSA rolls over year after year, and unused money 

accumulates tax-deferred interest, you have the option to pay 

for current qualified health care expenses out of your pocket 

and use the account to save for future qualified expenses.

Please note: Your HSA contributions are not taxable under 

federal and most state laws. However, your contributions to 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 83 of 89
81 myCigna.com

your HSA may be taxable as income in certain states. Please 

consult your tax advisor for guidance.

Which services are covered by my Cigna Choice Fund 

Health Savings Account?

Money in your HSA can be used only to cover qualified health 

care expenses for you and your dependents as allowed under 

federal tax law. In addition, your HSA may be used to cover 

COBRA continuation premiums, qualified long-term care 

insurance premiums, health plan premiums when you are 

receiving unemployment compensation, or Medicare or retiree 

health plan premiums (excluding Medicare Supplement or 

Medigap premiums) once you reach age 65. If you use your 

HSA funds for expenses that are not allowed under federal tax 

law, the withdrawal will be subject to tax, and you will incur a 

20 percent tax penalty. The 20 percent penalty is not 

applicable once you reach age 65. A list of qualified health 

care expenses is available through www.myCigna.com.

Which services are covered by my Cigna medical plan, and 

which will I have to pay out of my own pocket?

Covered services vary depending on your plan, so visit 

www.myCigna.com or check your plan materials in this 

booklet for specific information. In addition to your monthly 

premiums deducted from your paycheck, you’ll be responsible 

for paying:

 Any health care services not covered by your plan. 

 Costs for any services you receive until you meet your 

deductible, if you choose not to use your health savings 

account, or after you spend all the money in your account.

 Your share of the cost for your covered health care expenses 

(coinsurance or copayments) after you meet the deductible 

and your medical plan coverage begins.

Tools and Resources at Your Fingertips

If you’re not sure where to begin, you have access to health 

advocates.

You now have access to health specialists, including 

individuals trained as nurses, coaches, nutritionists and 

clinicians, who will listen, understand your needs and help you 

find solutions, even when you’re not sure where to begin. 

Partner with a health coach and get help to maintain good 

eating and exercise habits; support and encouragement to set 

and reach health improvement goals; and guidance to better 

manage conditions, including coronary artery disease, low 

back pain, osteoarthritis, high blood pressure, high cholesterol 

and more. From quick answers to health questions to 

assistance with managing more serious health needs, call the 

toll-free number on your Cigna ID card or visit 

www.myCigna.com. See your benefits administrator for more 

details about all of the services you have access to through 

your plan.

Wherever you go in the U.S., you take the Cigna 24-Hour 

Health Information Line with you.

Whether it’s late at night, or your child has a fever, or you’re 

traveling and you’re not sure where to get care, or you don’t 

feel well and you’re unsure about the symptoms, you can call 

the Cigna 24-Hour Health Information Line whenever you 

have a question. Call the toll-free number on your Cigna ID 

card and you will speak to a nurse who will help direct you to 

the appropriate care.

www.myCigna.com

www.myCigna.com provides fast, reliable and personalized 

information and service, including:

 Online access to your current account balance, past 

transactions and claim status, as well as your Explanation of 

Benefits and health statements.

 Medical cost and drug cost information, including cost 

estimates specific to you and your plan.

 Explanations of other Cigna products and services, what 

they are and how you can use them.

 Frequently asked questions about health care in general and 

Cigna Choice Fund specifically.

 A number of convenient, helpful tools that let you:

Compare costs

Use tools to compare costs and help you decide where to get 

care. You can compare out-of-pocket estimates, specific to 

your coverage plan, for actual treatment and procedures and 

costs.

Find out more about your local hospitals

Learn how hospitals rank by number of procedures 

performed, patients’ average length of stay, and cost. Go to 

our online healthcare professional directory for estimated 

costs for certain procedures, including total charges and 

your out-of-pocket expense, based on your Cigna plan. You 

can also find hospitals that earn the Centers of Excellence 

designation based on effectiveness in treating selected 

procedures/conditions and cost.

Get the facts about your medication, cost, treatment 

options and side effects

Use the pharmacy tools to: check your prescription drug 

costs, listed by specific pharmacy and location (including 

Cigna Home Delivery Pharmacy); and review your claims 

history for the past 16 months. Look at condition-specific 

drug treatments and compare characteristics of more than 

200 common medications. Evaluate up to 10 medications at 

once to better understand side effects, drug interactions and 

alternatives.

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 84 of 89
82 myCigna.com

Take control of your health

Take the health assessment, an online questionnaire that can 

help you identify and monitor your health status. You can 

learn about preventive care and check your progress toward 

healthy goals. And if your results show that you may benefit 

from other services, you can learn about related Cigna 

programs on the same site.

Explore topics on medicine, health and wellness

Get information on more than 5,000 health conditions, 

health and wellness, first aid and medical exams through 

Healthwise® Medical Encyclopedia, an interactive library.

Keep track of your personal health information

Health Record is your central, secure location for your 

medical conditions, medications, allergies, surgeries, 

immunizations, and emergency contacts. You can add your 

health assessment results to Health Record, so you can 

easily print and share the information with your doctor. 

Your lab results from certain facilities can be automatically 

entered into your Personal Health Record.

Chart progress of important health indicators

Input key data such as blood pressure, blood sugar, 

cholesterol (Total/LDL/HDL), height and weight, and 

exercise regimen. Health Tracker makes it easy to chart 

the results and share them with your doctor.

Getting the Most from Your HSA

As a consumer, you make decisions every day, from buying 

the family car to choosing the breakfast cereal. Make yourself 

a more educated health care consumer and you’ll find that 

you, too, can make a difference in the health care services you 

receive and what you ultimately pay.

If you choose to see a Cigna participating health care 

professional, the cost is based on discounted rates, so your 

costs will be lower. If you visit a health care professional or 

facility not in the network, you may still use your HSA to pay 

for the cost of those services, but you will pay a higher rate, 

and you may have to file claims.

If you need hospital care, there are several tools to help 

you make informed decisions about quality and cost.

 With the Hospital Comparison tool on www.myCigna.com, 

you can learn how hospitals rank by number of procedures 

performed, patients’ average length of stay, and cost.

 Visit our healthcare professional directory for Cigna Centers 

of Excellence, providing hospital scores for specific 

procedures/conditions, such as cardiac care, hip and knee 

replacement, and bariatric surgery. Scores are based on cost 

and effectiveness in treating the procedure/condition, based 

on publicly available data.

 www.myCigna.com also includes a Healthcare Professional

Excellence Recognition Directory. This directory includes 

information on:

 Participating physicians who have achieved recognition 

from the National Committee for Quality Assurance 

(NCQA) for diabetes and/or heart and stroke care. 

 Hospitals that fully meet The Leapfrog Group patient 

safety standards.

A little knowledge goes a long way.

Getting the facts about your care, such as treatment options 

and health risks is important to your health and well-being,

and your pocketbook. For instance:

 Getting appropriate preventive care is key to staying 

healthy. Visit www.myCigna.com to learn more about 

proper preventive care and what’s covered under your plan.

 When it comes to medications, talk to your doctor about 

whether generic drugs are right for you. The brand-name

drugs you are prescribed may have generic alternatives that 

could lower your costs. If a generic version of your brandname drug is not available, other generic drugs with the 

same treatment effect may meet your needs.

 Tools on www.myCigna.com can help you take control of 

your health and health care spending. You can learn about 

medical topics and wellness, and keep track of your 

personal health information. You can also print personalized 

reports to discuss with your doctor.

NOT153 V5

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 85 of 89
1 myCigna.com

Home Office: Bloomfield, Connecticut

Mailing Address: Hartford, Connecticut 06152

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

called Cigna)

CERTIFICATE RIDER

No. CR7SI002-1

Policyholder: Dobbs Equipment, LLC

Rider Eligibility: Each Employee as reported to the insurance compay by your Employer

Policy No. or Nos. 3341631-HSAFL/HSAIL

EFFECTIVE DATE: December 1, 2017

You will become insured on the date you become eligible if you are in Active Service on that date or if you are 

not in Active Service on that date due to your health status. If you are not insured for the benefits described in 

your certificate on that date, the effective date of this certificate rider will be the date you become insured.

This certificate rider forms a part of the certificate issued to you by Cigna describing the benefits provided under 

the policy(ies) specified above.

HC-RDR1 04-10

V1

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2 myCigna.com

THE SCHEDULE — Prescription Drug Benefits— section in your certificate is changed to read as attached.

 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 87 of 89
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Prescription Drug Benefits

The Schedule

For You and Your Dependents

This plan provides Prescription Drug benefits for Prescription Drug Products provided by Pharmacies as shown in this 

Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the 

Covered Expenses for Prescription Drug Products. That portion includes any applicable Copayment, Deductible and/or 

Coinsurance.

As applicable, your Deductible or Coinsurance payment will be based on the Prescription Drug Charge when the 

Pharmacy is a Network Pharmacy, and the Usual and Customary Charge when the Pharmacy is a non-Network Pharmacy.

Coinsurance

The term Coinsurance means the percentage of Charges for covered Prescription Drug Products that you or your 

Dependent are required to pay under this plan.

Charges

The term Charges means the Prescription Drug Charge when the Pharmacy is a Network Pharmacy, and it means the 

Usual and Customary Charge when the Pharmacy is a non-Network Pharmacy.

Copayments (Copay)

Copayments are expenses to be paid by you or your Dependent for Covered Prescription Drug Products.

.

Oral Chemotherapy Medication

Prescription oral chemotherapy medication that is used to kill or slow the growth of cancerous cells is covered at 

participating pharmacies at 100% after deductible and if applicable at non-participating pharmacies, is covered at the 

lower of the pharmacy cost share for oral chemotherapy medication or the out of network medical cost share for 

injectable/IV chemotherapy.

BENEFIT HIGHLIGHTS NETWORK 

PHARMACY

NON-NETWORK 

PHARMACY

Lifetime Maximum Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Calendar Year Deductible 

Individual Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Family Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Out-of-Pocket Maximum

Individual Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Family Refer to the Medical Benefits 

Schedule

Refer to the Medical Benefits 

Schedule

Certain Preventive Care Medications covered under this plan and required as part of preventive care services (detailed 

information is available at www.healthcare.gov) are payable at 100% with no Copayment or Deductible, when purchased 

from a Network Pharmacy. A written prescription is required.

.

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 88 of 89
4 myCigna.com

BENEFIT HIGHLIGHTS NETWORK 

PHARMACY

NON-NETWORK 

PHARMACY

Prescription Drug Products at 

Retail Pharmacies

The amount you pay for up to a 

consecutive 30-day supply at a 

Network Pharmacy

The amount you pay for up to a 

consecutive 30-day supply at a nonNetwork Pharmacy

Tier 1

Generic Preventive Drugs on the 

Prescription Drug List 

No charge No charge 

Generic Non-Preventive Drugs on 

the Prescription Drug List 

No charge after $10 copay after plan 

Deductible 

50% after plan Deductible 

Tier 2

Brand Drugs designated as 

preferred on the Prescription Drug 

List 

No charge after $35 copay after plan 

Deductible 

50% after plan Deductible

Tier 3

Brand Drugs designated as nonpreferred on the Prescription Drug 

List 

No charge after $60 copay after plan 

Deductible 

50% after plan Deductible

.

Prescription Drug Products at 

Home Delivery Pharmacies

The amount you pay for up to a 

consecutive 90-day supply at a 

Network Pharmacy

The amount you pay for up to a 

consecutive 90-day supply at a nonNetwork Pharmacy

Tier 1

Generic Preventive Drugs on the 

Prescription Drug List 

No charge No charge 

Generic Non-Preventive Drugs on 

the Prescription Drug List 

No charge after $10 copay after plan 

Deductible 

50% after plan Deductible 

Tier 2

Brand Drugs designated as 

preferred on the Prescription Drug 

List 

No charge after $88 copay after plan 

Deductible 

50% after plan Deductible 

Tier 3

Brand Drugs designated as nonpreferred on the Prescription Drug 

List 

No charge after $150 copay after plan 

Deductible 

50% after plan Deductible 

Case 1:22-cv-23355-JEM Document 1-2 Entered on FLSD Docket 10/14/2022 Page 89 of 89