Mohawk ESV, Inc. Health and Welfare Benefit Plan

Mohawk ESV, Inc. Health and

Welfare Benefit Plan

LOCALPLUS MEDICAL BENEFITS

Georgia Medical Neighborhood Copay Plan

EFFECTIVE DATE: January 1, 2022

ASO26

2500322, 2500325

This document printed in July, 2022 takes the place of any documents previously issued to you which

described your benefits.

Printed in U.S.A.

Table of Contents

Important Information ..................................................................................................................5

Important Notices ..........................................................................................................................3

Completing Your Health Assessment ..................................................................................................................... 3

2022 Medical Plan Spousal Surcharge ................................................................................................................... 3

Notice of Privacy Practices ............................................................................................................4

Special Plan Provisions ................................................................................................................12

Important Notices ........................................................................................................................13

How To File Your Claim .............................................................................................................15

Eligibility - Effective Date ...........................................................................................................16

Employee Coverage.............................................................................................................................................. 16

Waiting Period .................................................................................................................................................... 16

Dependent Coverage .......................................................................................................................................... 17

Important Information About Your Medical Plan ...................................................................17

LocalPlus Medical Benefits .........................................................................................................19

The Schedule ........................................................................................................................................................ 19

Certification Requirements - Out-of-Network ...................................................................................................... 44

Prior Authorization/Pre-Authorized ..................................................................................................................... 44

Covered Expenses ................................................................................................................................................ 45

Exclusions, Expenses Not Covered and General Limitations ..................................................55

Coordination of Benefits..............................................................................................................57

Expenses For Which A Third Party May Be Responsible .......................................................59

Payment of Benefits .....................................................................................................................60

Termination of Plan Coverage ....................................................................................................61

Employees ............................................................................................................................................................ 61

Dependents ........................................................................................................................................................... 61

Rescissions ........................................................................................................................................................... 62

Medical Benefits Extension During Hospital Confinement .....................................................62

Federal Requirements .................................................................................................................62

Notice of Provider Directory/Networks................................................................................................................ 63

Continuity of Care When Provider Moves Out of Network ................................................................................. 63

Qualified Medical Child Support Order (QMCSO) ............................................................................................. 63

Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) .................. 64

Effect of Section 125 Tax Regulations on This Plan ............................................................................................ 65

Eligibility for Coverage for Adopted Children ..................................................................................................... 66

Coverage for Maternity Hospital Stay .................................................................................................................. 66

Women’s Health and Cancer Rights Act (WHCRA) ........................................................................................... 66

Group Plan Coverage Instead of Medicaid ........................................................................................................... 66

Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) ............................................... 67

Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) .................................... 67

Claim Determination Procedures under ERISA ................................................................................................... 67

Appointment of Authorized Representative ......................................................................................................... 69

Medical - When You Have a Complaint or an Appeal ......................................................................................... 69

COBRA Continuation Rights Under Federal Law ............................................................................................... 71

ERISA Required Information ............................................................................................................................... 74

Definitions .....................................................................................................................................76

Important Information

THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR

ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY MOHAWK ESV, INC. WHICH IS

RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY

(CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT

INSURE THE BENEFITS DESCRIBED.

THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE

THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO

INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "POLICY"

SHALL BE DEEMED TO MEAN "PLAN” AND "INSURED" TO MEAN "COVERED" AND

"INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."

HC-NOT89MF

Important Notices

Completing Your Health Assessment

Mohawk encourages employees and their spouses to make healthy lifestyle choices. As part of our wellness

initiative, we encourage you and your spouse, if you are going to enroll in the Mohawk medical benefit

program, to complete your biometric screening. This allows you to focus on your health and save money while

doing so!

It is your choice whether you participate in the biometric screening or not. However, if you and your covered

spouse complete the biometric screening and meet the recommended biometric standards (as outlined in your

benefits enrollment materials), you will avoid having to pay the wellness surcharge. The wellness surcharge is

an additional $28.85 per week (or $125 per month) for both you and your spouse on top of your regular

contributions for medical coverage (for a maximum surcharge of $57.70 per week, or $250 per month).

If you and your covered spouse complete the biometric screening but do not meet the recommended biometric

standards, you can still avoid the wellness surcharge by engaging in healthy lifestyle support via face-to-face,

telephonic, or online learning. Alternatively, you can work with your personal physician on a wellness plan.

You will have a total of 60 days to complete your biometric screening after your benefit effective date. If you

miss the deadline or choose not to complete this, your medical coverage contribution amount for both you and

your covered spouse will increase by $125 per month ($28.85 per week).

You may complete a biometric screening at NO COST to you at ONE of the following:

 at a Healthy Life Center in your area. Before calling, visit WWW.MYMOHAWKBENEFITS.COM to see

if a Healthy Life Center is located near you, and to locate the number for your Healthy Life Center.

 at a Quest Diagnostics facility in your area. To locate a Quest Diagnostics facility near you, visit

www.my.blueprintforwellness.com. To schedule an appointment at a Quest facility, call 1-866-908-9440.

 For participants asked to do a re-test, visit the www.mymohawkbenefits.com website for the current keycode.

Mohawk is committed to helping you achieve your best health. All employees can avoid the wellness surcharge

by participating in the wellness program described above. If you think you might be unable to meet a standard

for avoiding the wellness surcharge under this wellness program, you might qualify for an opportunity to avoid

the wellness surcharge by different means. Contact the Benefits Service Center at 1-866-481-4922 and we will

work with you (and, if you wish, with your physician) to find a wellness program with the same reward that is

right for you in light of your health status.

2022 Medical Plan Spousal Surcharge

If your spouse is eligible for medical benefits through another employer and chooses to remain on the Mohawk

medical benefit program, your spouse will be subject to a $125 surcharge each month ($28.85 per week).

You will receive a communication in the mail from Alight approximately 6 weeks after your benefits effective

date. Alight will be conducting an audit of dependent enrollments, and you will be asked to provide

documentation (birth certificate, marriage certificate, etc.). If you enroll a spouse in the Mohawk medical

benefit program, then he or she will be included in a spousal audit for other medical coverage. If your spouse’s

company offers insurance and you elect to cover him or her on Mohawk’s medical benefit program, you will

pay an additional $125 per month ($28.85 per week) in medical contributions. Alight can be contacted at 1-877-

308-9157. Failure to provide the proper documentation in a timely manner will result in benefit termination for

your dependent. Furthermore, submission of fraudulent documentation could result in disciplinary action up to

and including termination. A Mohawk employee currently married to another Mohawk employee can stay on

their current plan with no surcharge.

Effective Date: January 1, 2022

MOHAWK ESV, INC. HEALTH AND WELFARE BENEFIT PLAN

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

CAREFULLY.

If you have any questions about this Notice, please contact Mohawk’s privacy official, the Privacy Officer, who

can be contacted at Mohawk Industries, 160 South Industrial Boulevard, Calhoun, GA 30701, or by phone at

(866) 481-4922.

Who Will Follow This Notice

This Notice describes the medical privacy practices of the self-funded group health benefit programs offered

under the Mohawk ESV, Inc. Health and Welfare Benefit Plan (the “Plan”). We are giving you this Notice to

inform you of these rights and to comply with a federal law called the Health Insurance Portability and

Accountability Act of 1996. This law is also known as “HIPAA.”

Our Pledge Regarding Medical Information

We understand that medical information about you and your health is personal, and we are committed to

protecting that information. As part of that protection, we have created a record of your health care claims under

the Plan. This Notice applies to all of the medical records the Plan maintains about you. Your personal doctor or

personal health care provider may have different policies or notices regarding the uses and disclosures of your

medical information which may have been created by that doctor or health care provider. In addition, some

health benefits are provided through insurance where Mohawk does not have access to protected health

information. If you are enrolled in any insured group health benefit program sponsored by Mohawk, you will

receive a separate privacy notice from the insurer. Please note that the group health benefit programs offered

under the Mohawk ESV, Inc. Health and Welfare Benefit Plan are part of an organized health care arrangement

because they are all sponsored by Mohawk. This means that the benefit programs may share your protected

health information with each other, as needed, for the purposes of payment and health care operations.

This Notice tells you about the ways in which the Plan may use or disclose medical information about you. It

also describes the Plan’s privacy obligations to you and your rights regarding the use and disclosure of your

medical information.

The Plan is required by HIPAA to:

 make sure that medical information that identifies you is kept private;

 give you this Notice of its legal duties and privacy practices with respect to medical information about you;

and

 follow the terms of this Notice until it is changed. If it is changed, you will receive a copy of the new Notice

as long as the Plan keeps personalized health information about you.

In addition to HIPAA, special protections under state or other federal laws may apply to the use and disclosure

of your protected health information. The Plan will comply with these state or federal laws where they are more

protective of your privacy, but only to the extent these laws are not superseded by federal preemption.

How the Plan May Use and Disclose Medical Information About You

The following categories describe different ways that the Plan uses and discloses medical information about

you. For each category of uses or disclosures, we will explain what we mean and present some examples.

Obviously, we cannot list every possible use or disclosure which exists, but we will try to list the important

ones. All of the ways the Plan is permitted to use and disclose information will fall within one of the categories.

Your Treatment. The first way the Plan may use or disclose medical information about you is to help you with

medical treatment or services. The Plan may disclose medical information about you to providers, including

doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of

you. For example, the Plan might disclose information about your prior prescriptions to a pharmacist to

determine if a new prescription could cause health problems because it conflicts with prior prescriptions.

Payment of Your Claims. The Plan may use or disclose medical information about you to determine if you are

eligible for Plan benefits, to pay for treatment or services you receive from health care providers, to determine

benefit responsibility under the Plan, or to coordinate Plan coverage with other plans. For example, the Plan

may tell your health care providers about your medical history to determine if a particular treatment is

experimental, investigational, or medically necessary, or to determine if the Plan will cover the treatment. The

Plan may also share medical information with a utilization review or precertification service provider. In

addition, the Plan may share medical information with another organization to help determine if a claim should

be paid or if another person or Plan should be responsible for the claim.

Health Care Operations. The Plan may use or disclose medical information about you for other Plan health

care operations. These uses and disclosures are necessary to run the Plan. For example, the Plan may use

medical information to conduct quality assessment or improvement activities; to determine the cost of

premiums or conduct activities relating to Plan coverage; to submit claims for stop-loss coverage; to conduct or

arrange for medical review, legal services, audit services, or fraud and abuse detection programs; and to predict

the cost of future claims or manage costs. The Plan’s health care operations also include case management and

coordination of care, for example, in connection with the Plan’s wellness or disease management programs.

However, federal law prohibits the Plan from using or disclosing protected health information that is genetic

information (e.g., family medical history) for underwriting purposes, which include eligibility determinations,

calculating premiums, and any other activities related to the creation, renewal, or replacement of a health

insurance contract or health benefits.

Business Associates. The Plan may hire third parties that may need your medical information to perform

certain services on behalf of the Plan. These third parties are “Business Associates” of the Plan. Business

Associates must protect any protected health information they receive from, or create and maintain on behalf of,

the Plan. For example, the Plan may hire a third-party administrator to process claims, an auditor to review how

an insurer or third-party administrator is processing claims, or an insurance agent to assess coverages and help

with claim problems. In addition to performing services for the Plan, Business Associates may use protected

health information for their own management and legal responsibilities and for purposes of aggregating data for

Plan health care operations.

Health Information Exchange. As permitted by law, the Plan may participate in Health Information

Exchanges (“HIEs”) to provide or receive medical information for activities described in this Notice (i.e.,

treatment, payment, and health care operations purposes). HIEs are organizations where participating health

care providers or other health care entities can provide or receive information from each other related to your

care.

As Required By Law. The Plan will disclose medical information about you when required to do so by federal,

state or local law. For example, the Plan may disclose medical information when required by a court order in a

lawsuit such as a malpractice action.

To Avert a Serious Threat to Health or Safety. The Plan may use or disclose medical information about you

when necessary to prevent a serious threat to your health or safety, or to the health and safety of the public or

another person. Any disclosure, however, would only be to someone able to help prevent the threat. For

example, the Plan may disclose medical information about you in a proceeding concerning the license of a

doctor or nurse.

Special Situations

Disclosure to Mohawk or other Mohawk Plans. Your health information may be disclosed to another health

benefit program maintained by Mohawk for purposes of paying claims under that benefit program. In addition,

medical information may be disclosed to certain designated Mohawk employees who are responsible for

administering the Plan to help you with a claim or to administer benefits under the Plan, such as to determine a

claims appeal. The Plan may also disclose information to Mohawk that summarizes the claims experience of

Plan participants as a group, but without identifying specific individuals, to get new benefit insurance or to

change or terminate the Plan. For example, if Mohawk wants to consider adding or changing organ transplant

benefits, it may receive this summary health information to assess the cost of those services. The Plan may also

disclose limited health information to Mohawk in connection with the enrollment or disenrollment of

individuals into or out of the Plan.

Disclosures to Provide You With Information. The Plan or its agents may contact you to remind you about

appointments or provide information about treatment alternatives or other health-related benefits and services

that may be of interest to you.

Organ and Tissue Donation. If you are an organ donor, the Plan may release your medical information to

organizations that handle organ procurement or organ, eye or tissue transplants, or to an organ donation bank to

help with organ or tissue donation.

Military and Veterans. If you are a member of the armed forces, the Plan may release medical information

about you as required by the military. The Plan may also release medical information about foreign military

personnel to the appropriate foreign military authority.

Workers’ Compensation. The Plan may release medical information about you for workers’ compensation or

similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. The Plan may disclose medical information about you for public health purposes. This

includes disclosures:

 to prevent or control disease, injury or disability;

 to report births and deaths;

 to report child abuse or neglect;

 to report reactions to medications or problems with products;

 to notify people of recalls of products they may be using;

 to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading

a disease or condition;

 to notify the appropriate government authority if the Plan believes a patient has been the victim of abuse,

neglect or domestic violence. The Plan will only make this disclosure if you agree or if required or

authorized by law.

Health Oversight Activities. The Plan may disclose medical information to a government health agency for

activities authorized by law. These activities include, for example, audits, investigations, inspections, and

licensing. These activities are necessary for the government to monitor the health care system, government

programs, and to comply with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, the Plan may disclose medical

information about you in response to a court or administrative order. The Plan may also disclose medical

information about you in response to a subpoena, discovery request, or other lawful demand by someone else

involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order

protecting the information requested.

Law Enforcement. The Plan may release medical information if asked to do so by a law enforcement official:

 in response to a court order, subpoena, warrant, summons or similar court papers;

 to identify or locate a suspect, fugitive, material witness, or missing person;

 about the victim of a crime even if, under certain limited circumstances, the Plan is unable to obtain

your agreement;

 about a death the Plan believes may be the result of criminal conduct;

 about criminal conduct at a hospital; or

 in emergency circumstances to report a crime or the location of a crime or crime victims; or the

identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. The Plan may release medical information to a

coroner or medical examiner. This may be necessary, for example, to identify someone who has died or to

determine the cause of death. The Plan may also release medical information about individuals to funeral

directors as necessary to carry out their duties.

National Security and Intelligence Activities. The Plan may release medical information about you to

authorized federal officials for intelligence, counterintelligence, and other security activities authorized by law.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official,

the Plan may release medical information about you to the correctional institution or law enforcement official.

This release may be necessary (1) for the institution to provide you with health care; (2) to protect your health

and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Your Rights Regarding Medical Information About You

You have the following rights regarding medical information the Plan maintains about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to

make decisions about your Plan benefits. To do so, you must submit your request in writing to Mohawk

Industries, 160 South Industrial Boulevard, Calhoun, GA 30701.

The Plan may deny your request to inspect and copy your information in certain circumstances. In most cases, if

you are denied access to medical information, you may request that the denial be reviewed.

Right to Amend. If you feel that medical information the Plan has about you is incorrect or incomplete, you

may ask the Plan to amend the information. You have the right to request an amendment of your information as

long as the information is kept by or for the Plan.

To request an amendment, your request must be made in writing and submitted to Mohawk Industries, 160

South Industrial Boulevard, Calhoun, GA 30701. In addition, you must provide a reason that supports your

request.

The Plan may deny your request for an amendment if it is not in writing or does not include a reason to support

the request. In addition, the Plan may deny your request if you ask to amend information that:

 is not part of the medical information kept by or for the Plan;

 was not created by the Plan, unless the person or entity that created the information is no longer

available to make the amendment;

 is not part of the information which you would be permitted to inspect and copy; or

 is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an accounting of the prior disclosures of

your health information if the disclosure was made for any purpose other than treatment, payment, or health

care operations.

To request this list or accounting of disclosures, you must submit your request in writing to Mohawk Industries,

160 South Industrial Boulevard, Calhoun, GA 30701. Your request must state a time period which may not be

longer than six years. Your request should indicate in what form you want the list (for example, paper or

electronic). The first list you request within a 12-month period will be free. For additional lists, the Plan may

charge you for the costs of providing the list. The Plan will notify you of the cost involved, and you may choose

to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on medical information

the Plan uses or discloses about you for treatment, payment or health care operations. You also have the right to

request a limit on the medical information the Plan discloses about you to someone who is involved in your care

or the payment for your care, such as a family member or friend. For example, you could ask that the Plan not

use or disclose information about a surgery you had. Effective February 18, 2010, provided you paid out-of-

pocket in full for the services received, we will honor any request you make to restrict information about those

services from the Plan provided that such release is not necessary for your treatment. In all other circumstances,

the Plan is not required to agree to your request.

To request restrictions, you must make your request in writing to Mohawk Industries, 160 South Industrial

Boulevard, Calhoun, GA 30701. In your request, you must tell the Plan (1) what information you want to limit;

(2) whether you want to limit the Plan’s use or disclosure of this information, or both; and (3) to whom you

want the restriction to apply, for example, you don’t want information disclosed to your spouse.

Right to Request Confidential Communications. You have the right to request that the Plan communicate

with you about medical matters in a certain way or at a certain location. For example, you can ask that the Plan

only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Mohawk Industries, 160

South Industrial Boulevard, Calhoun, GA 30701. The Plan will not ask you the reason for your request, and will

accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask the

Plan to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically,

you are still entitled to a paper copy of this Notice. To obtain a paper copy of this Notice, contact the Privacy

Officer, Mohawk Industries, 160 South Industrial Boulevard, Calhoun, GA 30701.

Right to Receive Notification. You have a right to receive notification of a breach of your unsecured protected

health information.

Medical Information Not Covered by This Notice

This Notice does not cover (1) health information that does not identify you and with respect to which there is

no reasonable basis to believe that the information could be used to identify you; or (2) health information that

Mohawk can have under applicable law (e.g., the Family and Medical Leave Act, the Americans with

Disabilities Act, workers’ compensation laws, federal and state occupational health and safety laws, and other

state and federal laws), or that Mohawk properly can get for employment-related purposes through sources

other than the Plan and that is kept as part of your employment records (e.g., pre-employment physicals, drug

testing, fitness for duty examinations, etc.).

Changes to This Notice

The Plan reserves the right to change this Notice in the future, and to make the revised or changed Notice

effective for medical information the Plan already has about you as well as any information it receives in the

future. You will receive a copy of the changed Notice in the same manner that you received this Notice. The

Notice will contain the effective date on the first page in the top right-hand corner.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Plan or with the

Secretary of the United States Department of Health and Human Services. To file a complaint with the Plan,

contact the Privacy Officer, Mohawk Industries, 160 South Industrial Boulevard, Calhoun, GA 30701. All

complaints must be submitted in writing. You will not be retaliated against for filing a complaint.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to the Plan

will be made only with your written permission. This written permission is called an “Authorization.” For

example, in general and subject to specific conditions, the Plan will not use or disclose psychiatric notes about

you; will not use or disclose your protected health information for marketing; and will not sell your protected

health information. If you provide the Plan with an Authorization to use or disclose medical information about

you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, the Plan will

no longer use or disclose medical information about you for the reasons covered by your written Authorization.

You understand that the Plan is unable to take back any disclosures it has already made with your

Authorization, and that the Plan is required by law to retain records of the care that it has provided to you.

Introduction

Mohawk ESV, Inc. and its participating affiliates (together, the “Employer”) maintain the Mohawk ESV, Inc. Health and Welfare

Benefit Plan for the benefit of eligible employees and their family members. This document, which is also referred to in this document

as the “booklet,” is intended to serve as the booklet summary plan description (“SPD”) for the Open Access Plus Health Savings

Account medical and prescription drug benefit program offered under the Mohawk ESV, Inc.

Health and Welfare Benefit Plan (referred to in this booklet as the “Plan”).

This booklet describes the Plan as in effect on January 1, 2022. Please read this booklet carefully and keep it for future reference. If

you have any questions about the Plan, please contact Cigna, the claims administrator for the medical benefits provided under the

Plan, or Express Scripts, the claims administrator for the prescription drug benefits provided under the Plan, using the toll-free number

shown on the back of your ID card. For questions about the Plan’s coverage of specialty medications, please contact VIVIO, the

claims administrator for the specialty prescription drug benefits provided under the Plan, by phone at 800-470-4034 or via email at

[email protected]m. You may also log onto mymohawkbenefits.com or contact the Benefits Service Center at 1-866-481-4922.

Explanation of Terms

You will find terms starting with capital letters throughout this booklet. To help you understand your benefits, most of these terms are

defined in the Definitions section of the booklet.

The Schedule

The Schedule is a brief outline of your maximum benefits which may be payable under the Plan. For a full description of each

benefit, refer to the appropriate section listed in the Table of Contents.

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 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-SPP70 01-21

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-to-

date 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 Plan,

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, cost-

effective treatment alternatives, as well as provide assistance

in obtaining needed medical resources and ongoing family

support in a time of need.

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Additional Programs

Cigna may, from time to time, offer or arrange for various

entities to offer discounts, benefits, or other consideration to

Plan participants for the purpose of promoting the general

health and well being of participants. Cigna may also arrange

for the reimbursement of all or a portion of the cost of services

myCigna.com

provided by other parties to the Employer. Contact us for

details regarding any such arrangements.

HC-SPP3 04-10

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Care Management and Care Coordination Services

Your plan may enter into specific collaborative arrangements

with health care professionals committed to improving quality

care, patient satisfaction and affordability. Through these

collaborative arrangements, health care professionals commit

to proactively providing participants with certain care

management and care coordination services to facilitate

achievement of these goals. Reimbursement is provided at

100% for these services when rendered by designated health

care professionals in these collaborative arrangements.

HC-SPP27 06-15

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 Cigna's 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 M 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 the Plan. 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 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. 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 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.

HC-IMP304 M 01-22

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)

myCigna.com

 Provides free language services to people whose primary

language is not English, such as

 Qualified interpreters

 Information written in other languages

If you need these services, contact customer service at the toll-

free phone number shown on your ID card, and ask a

Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services

or discriminated in another way on the basis of race, color,

national origin, age, disability or sex, you can file a grievance

by sending an email to ACAG[email protected] 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 or

phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

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

Complaint forms are available at

http://www.hhs.gov/ocr/office/file/index.html.

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).

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

myCigna.com

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

Mental Health Parity and Addiction Equity Act of 2008

(MHPAEA) - Non-Quantitative Treatment Limitations

(NQTLs)

Federal MHPAEA regulations provide that a plan cannot

impose a Non-Quantitative Treatment Limitation (NQTL) on

mental health or substance use disorder (MH/SUD) benefits in

any classification unless the processes, strategies, evidentiary

standards, or other factors used in applying the NQTL to

MH/SUD benefits are comparable to, and are applied no more

stringently than, those used in applying the NQTL to

medical/surgical benefits in the same classification of benefits

as written and in operation under the terms of the plan.

Non-Quantitative Treatment Limitations (NQTLs) include:

 Medical management standards limiting or excluding

benefits based on Medical Necessity or whether the

treatment is experimental or investigative;

 Prescription drug formulary design;

 Network admission standards;

 Methods for determining in-network and out-of-network

provider reimbursement rates;

 Step therapy a/k/a fail-first requirements; and

 Exclusions and/or restrictions based on geographic location,

facility type or provider specialty.

A description of your plan’s NQTL methodologies and

processes applied to medical/surgical benefits and MH/SUD

benefits is available for review by accessing:

www.cigna.com\sp

To determine which document applies to your plan, select the

relevant health plan product; medical management model

(inpatient only or inpatient and outpatient) which can be

located in this booklet immediately following The Schedule;

and pharmacy coverage (whether or not your plan includes

pharmacy coverage).

C-NOT113 M 01-20m

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. Out-

of-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 using 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

The Plan will consider claims for coverage under the Plan

when proof of loss (a claim) is submitted within 180 days for

Out-of-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

Out-of-Network benefits, the claim will not be considered

valid and will be denied.

myCigna.com

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-CLM25 01-11

V11 M

Eligibility - Effective Date

Employee Coverage

This Plan is offered to you as an Employee.

Eligibility for Employee Coverage

You are eligible to participate in the Plan if you are classified

by the Employer as a full-time employee that is regularly

scheduled to work at least 30 hours of service per week (an

“Employee”) and you complete the Plan’s waiting period (as

described below).

You are not an Employee that is eligible to participate in the

Plan if:

 you are a leased employee;

 you are an individual classified by the Employer as an

independent contractor, a leased employee, or an employee

of a non-participating affiliate, whether or not you are an

actual employee of the Employer

 you are a union employee, unless otherwise required by a

collective bargaining agreement;

 you are a nonresident alien that does not receive U.S. source

income; or

 you are covered by a welfare plan maintained by a foreign

affiliate.

Waiting Period

As an eligible Employee, you may begin participating in the

Plan on the first of the month following 60 days of

employment as an eligible Employee as defined above.

If you are laid off and are called back within six months of

your layoff date, your benefits are reinstated as they were prior

to your layoff. The waiting period is waived. If you are laid

off and then called back more than six months after your

layoff date, you will be need to complete the Plan’s waiting

period again before you are eligible for Plan benefits.

If you leave voluntarily and have a break in service that is 13

weeks or longer, you are considered “rehired” and your

benefits are applied as any other new hire (i.e. the waiting

period applies). If you leave voluntarily and have a break in

service that is less than 13 weeks, you will be immediately

eligible for the Plan without being subject to the Plan’s

waiting period.

If you cease to be an eligible Employee for reasons other than

termination of employment and then return to eligible

Employee status, your prior service as an Employee will count

toward the Plan’s waiting period, regardless of whether you

return to eligible Employee status within 13 weeks.

Effective Date of Employee Coverage

You will become covered by the Plan on the date you satisfy

the Plan’s waiting period if you elect coverage under the Plan

through Mohawk’s online enrollment system or by calling

Mohawk’s Benefit Service Center at 1-866-481-4922 within

30 days of becoming eligible to participate in the Plan. You

will not be denied enrollment due to your health status.

You will become covered by the Plan 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.

To begin participating in the Plan, you must enroll in the Plan

by following the instructions in your enrollment materials

within 30 days of the date you complete the Plan’s waiting

period (this 30-day period is referred to as your “initial

enrollment period”). You will not be enrolled in the Plan if

you do not enroll within 30 days of the date you become

eligible, unless you qualify under the section of this booklet

entitled "Special Enrollment Rights Under the Health

Insurance Portability & Accountability Act (HIPAA)" or

experience another qualified change event (as described in the

section of this booklet entitled “Effect of Section 125 Tax

Regulations on This Plan”) and timely enroll in the Plan, or

unless you enroll during the Plan’s next open enrollment

period.

The benefit choices you make during your initial enrollment

period will remain in effect for the remainder of the plan year,

unless you qualify for a special enrollment period or you

experience a qualified change event (as described later in this

booklet) and you make new benefit elections.

Special Eligibility Rules

The Plan Administrator may establish different eligibility

requirements (for example, waiving the Waiting Period or

recognizing prior service) with respect to Employees who

become employed by the Employer as a result of a corporate

transaction.

myCigna.com

Dependent Coverage

For your Dependents to be covered by the Plan, you will have

to timely enroll your Dependents, provide proof of Dependent

status to the Plan, and pay the required contribution toward the

cost of Dependent coverage.

Eligible Dependents

Dependent for purposes of the Plan means:

• An Employee’s spouse, meaning the one individual with

whom the Employee has established a valid marriage

according to state law, including a common law marriage. A

divorced former spouse of an Employee is not an eligible

Dependent.

Please Note: If your spouse is eligible for benefits through

another employer and you elect coverage for him or her

under the Plan, you will pay an additional amount (as

outlined in the Plan’s enrollment materials) for the spouse’s

coverage. An eligible Employee currently married to

another eligible Employee can remain on the Plan without

the spousal surcharge.

• An Employee’s child who is less than 26 years of age.

Coverage of a Dependent child will continue until the end of

the calendar month in which the child turns age 26.

• An Employee’s child, regardless of age, who (i) is

unmarried and primarily supported by the Employee; (ii)

was continuously covered under the Plan as a Dependent

prior to attaining age 26; and (iii) is incapable of sustaining

his or her own living by reason of a mental or physical

disability. The child must have been mentally or physically

incapable of earning his or her own living due to the

disabling condition prior to attaining age 26. Written proof

of incapacity and dependency satisfactory to the Plan must

be furnished and approved by the Plan within 31 days after

the date the child reaches age 26. The Plan may require, at

reasonable intervals, subsequent proof satisfactory to the

Plan of the child’s continuing disability.

“Child” for purposes of the Plan means an Employee’s natural

child, stepchild, legally adopted child, foster child, or any

other child for whom the Employee has been named legal

guardian. The term “child” will also include an Employee’s

grandchild who is considered the Employee’s dependent for

federal income tax purposes. For purposes of this definition, a

legally adopted child shall include a child placed in an

Employee’s physical custody in anticipation of adoption.

“Child” shall also mean a covered Employee’s child who is an

Alternate Recipient under a Qualified Medical Child Support

Order, as required by the Federal Omnibus Budget

Reconciliation Act of 1993.

Residents of a country other than the United States are not

eligible for Dependent coverage under the Plan.

To establish a Dependent relationship, the Plan reserves the

right to require documentation satisfactory to the Plan

Administrator.

An individual may be enrolled in the Plan as an Employee or a

Dependent, but not both. No one may be considered as a

Dependent of more than one Employee.

Effective Date of Dependent Coverage

Insurance for your Dependents will become effective on the

date you complete the Plan’s waiting period, if you timely

elect Dependent coverage during your initial enrollment

period in the manner outlined in the Plan’s enrollment

materials..

Your Dependents will be covered only if you are enrolled in

the Plan.

If you do not enroll your eligible Dependents during your

initial enrollment period, you will not be able to enroll them in

the Plan until the next open enrollment period, unless you

qualify for a special enrollment period or you experience

another qualified change event (as described later in this

booklet) and you make new benefit elections.

Exception for Newborns

Any Dependent child born while you are enrolled in the Plan

will become covered by the Plan on the date of his birth if you

elect Dependent coverage no later than 31 days after his birth.

If you do not elect to insure your newborn child within such

31 days, no benefits for expenses incurred will be payable for

that child.

HC-ELG274 M 01-19

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 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 Plan.

However, 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

myCigna.com

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.

HC-IMP212 M 01-18

myCigna.com

LocalPlus My Medical Neighborhood Medical Benefits

The Schedule

For You and Your Dependents

The Plan provides coverage for care In-Network and Out-of-Network. To receive Plan benefits, you and your Dependents

may be required to pay a portion of the Covered Expenses for services and supplies. That portion is the Copayment,

Deductible or Coinsurance.

When you receive services from an In-Network Provider, remind your provider to utilize In-Network Providers for x-rays,

lab tests and other services to ensure the cost may be considered at the In-Network level.

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-of-

Network 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.

Copayments/Deductibles

Copayments are expenses to be paid by you or your Dependent for covered services. Deductibles are also expenses to be

paid by you or your Dependent. Deductible amounts are separate from and not reduced by Copayments. Copayments and

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 for In-Network charges are Covered Expenses incurred for charges that are not paid by the Plan

because of any Deductibles, Copayments or Coinsurance. Such Covered Expenses accumulate to the the In-Network Out-

of-Pocket Maximum shown in The Schedule. When the In-Network Out-of-Pocket Maximum is reached, all In-Network

Covered Expenses, except charges for non-compliance penalties, are payable by the Plan at 100%.

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.

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.

myCigna.com

LocalPlus My Medical Neighborhood Medical Benefits

The Schedule

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.

Out-of-Network Charges for Certain Services

Charges for services furnished by an Out-of-Network provider in an In-Network hospital or ambulatory surgical center

while you are receiving In-Network services at that In-Network facility: (i) are payable at the In-Network cost-sharing

level; and (ii) the cost-sharing payments that you pay to the Out-of-Network provider will count toward the Plan’s In-

Network Deductible and Out-of-Pocket Maximum. Your cost-sharing requirements for these Out-of-Network services will

be determined based on the lesser of (i) the median amount negotiated by the Plan with In-Network providers for the

services in the geographic area where the services are provided, or (ii) the amount billed by the provider.

The member is only responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance),

determined as described above. The member is not responsible for any charges that may be made in excess of these

amounts, and the Out-of-Network provider is not permitted to balance bill you for these amounts. If the Out-of-Network

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

contact Cigna Customer Service at the phone number on your ID card.

Please Note: The Plan is not required to apply the special cost-sharing rules above if you provide specific informed

consent, as provided by law, to treatment by the Out-of-Network provider. In this case, the Out-of-Network provider is

also not prohibited from balance billing you for any amounts not paid by the Plan. This consent exception does not apply

to “ancillary services” or to items or services furnished as a result of unforeseen, urgent medical needs arising at the time

an item or service is provided. “Ancillary services” for this purpose are (i) items and services related to emergency

medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician

practitioner; (ii) items and services provided by assistant surgeons, hospitalists, and intensivists; (iii) diagnostic services

(including radiology and laboratory services); and (iv) items and services provided by an Out-of-Network provider if there

is no In-Network provider who can furnish such item or service at the facility.

myCigna.com

LocalPlus My Medical Neighborhood Medical Benefits

The Schedule

Out-of-Network Emergency Services Charges

1. Emergency Services are covered, without the need for any prior authorization, at the In-Network cost-sharing level if

services are received from a non-Participating (Out-of-Network) provider or facility.

2. The cost-sharing payments that you pay to the Out-of-Network provider or facility for Emergency Services will count

toward the Plan’s In-Network Deductible and Out-of-Pocket Maximum.

3. Your cost-sharing requirements for Emergency Services furnished by an Out-of-Network provider or facility will be

determined based on the lesser of the median amount negotiated by the Plan with In-Network providers or facilities for

the services in the geographic area where the Emergency Services are provided, or (ii) the amount billed by the

provider or facility.

4. The Plan will not impose any administrative requirement or coverage limitation for Emergency Services furnished by

an Out-of-Network provider or facility that are more restrictive than the requirements or limitations that apply to

Emergency Services received from an In-Network provider or facility.

The member is only responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance),

determined as described above. The member is not responsible for any charges that may be made in excess of these

amounts, and the Out-of-Network provider or facility is not permitted to balance bill you for these amounts. If the Out-of-

Network provider or facility bills you for an amount higher than the amount you owe as indicated on the Explanation of

Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card.

Charges for Air Ambulance Services

Charges for Air Ambulance Services: (i) are payable at the In-Network cost-sharing level, regardless of the provider’s

network status; and (ii) the cost-sharing payments that you pay to any Out-of-Network provider for Air Ambulance

Services will count toward the Plan’s In-Network Deductible and Out-of-Pocket Maximum. Your cost-sharing

requirements for Out-of-Network Air Ambulance Services will be determined based on the lesser of (i) the median

amount negotiated by the Plan with In-Network providers for the services in the geographic area where the services are

provided, or (ii) the amount billed by the provider.

The member is only responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance),

determined as described above. The member is not responsible for any charges that may be made in excess of the these

amounts, and the Out-of-Network provider is not permitted to balance bill you for these amounts. If the Out-of-Network

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

contact Cigna Customer Service at the phone number on your ID card.

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Lifetime Maximum

Unlimited

The Percentage of Covered Expenses

the Plan Pays

80%

50% of the Maximum Reimbursable

Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Maximum Reimbursable Charge

The Maximum Reimbursable Charge

for Out-of-Network services, other than

those described in the Schedule

sections “Out-of-Network Charges for

Certain Services,” “Out-of-Network

Emergency Services Charges,” and

“Charges for Air Ambulance Services”

above, is determined based on the

lesser of (i) the provider's normal

charge for a similar service or supply;

or (ii) the amount agreed to by the Out-

of-Network provider and Cigna, or (iii)

an Employer-selected percentage of a

fee schedule Cigna has developed that

is based upon a methodology similar to

a methodology utilized by Medicare to

determine the allowable fee for the

same or 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 amount agreed to by the Out-of-

Network provider and Cigna; 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.

Not Applicable

110%

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Note:

The provider may bill you for the

difference between the provider’s

normal charge and the Maximum

Reimbursable Charge, in addition to

applicable copayment, deductibles

and/or coinsurance.

Note:

Some providers forgive or waive the

cost share obligation (e.g. your

deductible and/or coinsurance) that this

Plan requires you to pay. Waiver of

your required cost share obligation can

jeopardize your coverage under this

Plan. For more details, see the

Exclusions Section.

Calendar Year Deductible

Individual

$1,000 per person

$3,300 per person

Family Maximum

$2,500 per family

$6,600 per family

Family Maximum Calculation

Individual Calculation:

Family members meet only their

individual deductible and then their

claims will be covered under the plan

coinsurance; if the family deductible

has been met prior to their individual

deductible being met, their claims

will be paid at the plan coinsurance.

Out-of-Pocket Maximum

Individual

$5,000 per person

Unlimited

Family Maximum

$13,000 per family

Unlimited

Family Maximum Calculation

Individual Calculation:

Family members meet only their

individual Out-of-Pocket and then

their claims will be covered at 100%;

if the family Out-of-Pocket has been

met prior to their individual Out-of-

Pocket being met, their claims will

be paid at 100%.

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Physician’s Services

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

Consultant and Referral

Physician’s Services

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Note:

OB/GYN providers will be

considered either as a PCP or

Specialist, depending on how

the provider contracts with

Cigna on an In-Network basis.

Out-of-Network OB/GYN

providers will be considered a

Specialist.

Surgery Performed in the Physician’s

Office

Primary Care Physician

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Second Opinion Consultations

(provided on a voluntary basis)

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Allergy Treatment/Injections

Primary Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Allergy Serum (dispensed by the

Physician in the office)

Primary Care Physician

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Convenience Care Clinic

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Virtual Care

Virtual Physician Services

Services available through Physicians

as medically appropriate.

Note:

Preventive services covered at the

preventive level.

Primary Care Physician’s Office Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Preventive Care

Note:

Includes coverage of additional

services, such as urinalysis, EKG,

and other laboratory tests,

supplementing the standard

Preventive Care benefit.

Routine Preventive Care - all ages

Primary Care Physician’s Office

Visit

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Immunizations - all ages

Primary Care Physician’s Office

Visit

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Mammograms

Preventive Care Related Services

(i.e. “routine” services)

Note: Preventive 3D mammograms

are limited to $285 payment

maximum per occurrence and all

other preventive mammograms are

limited to $225 payment maximum

per occurence. Maximum applies to

technical component only.

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Diagnostic Related Services (i.e.

“non-routine” services)

Note: Includes all related charges

including professional services.

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

PSA, PAP Smear

Preventive Care Related Services

(i.e. “routine” services)

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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

Early Cancer Detection Colon/Rectal

Note: Preventive colonoscopies are

limited to $2,250 payment maximum

per occurrence. Includes all related

charges including professional services.

Maximum applies to technical

component only.

Preventive Care Related Services

(i.e. “routine” services)

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Diagnostic Related Services (i.e.

“non-routine” services)

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Hospital - Facility Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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

Outpatient Facility Services

Operating Room, Recovery Room,

Procedures Room, Treatment Room

and Observation Room

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Hospital Physician’s

Visits/Consultations

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge*

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge*

Surgeon

Radiologist, Pathologist,

Anesthesiologist

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

* Charges for certain services furnished by an Out-of-Network provider in an In-Network hospital or ambulatory surgical

center while you are receiving In-Network services at that In-Network facility are payable at the In-Network cost-sharing

level. Please see the section of the Schedule titled “Out-of-Network Charges for Certain Services” above for more

information.

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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.

$25 per visit copay, then 100%

$25 per visit copay, then 100% of the

Maximum Reimbursable Charge

Advanced Radiological Imaging (i.e.

MRIs, MRAs, CAT Scans, PET

Scans etc.) billed by the facility as

part of the UC visit

100%

100% of the Maximum Reimbursable

Charge

Emergency Services

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%

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%

Air Ambulance

Plan deductible, then 80%

Ambulance

Plan deductible, then 80%

Plan deductible, then 80% of the

Maximum Reimbursable Charge

Inpatient Services at Other Health

Care Facilities

Includes Skilled Nursing Facility,

Rehabilitation Hospital and Sub-

Acute Facilities

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Calendar Year Maximum:

Unlimited

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Laboratory Services

Primary Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Hospital Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Independent Lab Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Radiology Services

Primary Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Hospital Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Advanced Radiological Imaging (i.e.

MRIs, MRAs, CAT Scans and PET

Scans)

Note: MRIs are limited to $2,300

payment maximum per scan. CAT

Scans are limited to $2,000 payment

maximum per scan. Maximum applies

to physician’s office, outpatient free

standing imaging center and Outpatient

Imaging Department at a Hospital (non-

ER location/non-urgent care.

Primary Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Outpatient Therapy Services

(The limit is not applicable to mental

health conditions.)

Calendar Year Maximum:

60 days

Includes:

Physical Therapy

Calendar Year Maximum:

30 days per therapy for each

additional therapy

Includes:

Cardiac Rehab

Speech Therapy

Occupational Therapy

Pulmonary Rehab

Cognitive Therapy

Primary Care Physician’s Office

Visit

$35 per visit copay*, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay*, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

*Note:

Outpatient Therapy Services copay

applies, regardless of place of

service, including the home.

Chiropractic Care

Calendar Year Maximum:

12 days

Primary Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Home Health Care Services

Calendar Year Maximum:

120 days (includes outpatient private

nursing when approved as Medically

Necessary)

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Dialysis visits in the home setting

will not accumulate to the Home

Health Care maximum

(The limit is not applicable to Mental

Health and Substance Use Disorder

conditions.)

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Hospice

Inpatient Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Services

(same coinsurance level as Home

Health Care Services)

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Bereavement Counseling

Services provided as part of Hospice

Care

Inpatient

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Services provided by Mental Health

Professional

Covered under Mental Health benefit

Medical Pharmaceuticals

Physician’s Office

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Home Care

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Gene Therapy

Includes prior authorized gene therapy

products and services directly related to

their administration, when Medically

Necessary.

Gene therapy must be received at an In-

Network facility specifically contracted

with Cigna to provide the specific gene

therapy. Gene therapy at other In-

Network facilities is not covered.

Gene Therapy Product

Covered same as Medical

Pharmaceuticals

In-Network coverage only

Inpatient Facility

Plan deductible, then 80%

In-Network coverage only

Outpatient Facility

Plan deductible, then 80%

In-Network coverage only

Inpatient Professional Services

Plan deductible, then 80%

In-Network coverage only

Outpatient Professional Services

Plan deductible, then 80%

In-Network coverage only

Travel Maximum:

$10,000 per episode of gene therapy

100% (available only for travel when

prior authorized to receive gene

therapy at a participating In-Network

facility specifically contracted with

Cigna to provide the specific gene

therapy)

In-Network coverage only

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Maternity Care Services

Initial Visit to Confirm Pregnancy

Note:

OB/GYN providers will be

considered either as a PCP or

Specialist, depending on how the

provider contracts with Cigna on

an In-Network basis. Out-of-

Network OB/GYN providers will

be considered a Specialist.

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

All subsequent Prenatal Visits,

Postnatal Visits and Physician’s

Delivery Charges (i.e. global

maternity fee)

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Delivery - Facility

(Inpatient Hospital)

Delivery - Facility

(Birthing Center)

Plan deductible, then 80%

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Abortion

Includes only non-elective procedures

Surgery Performed in the Physician’s

Office

Primary Care Physician

Specialty Care Physician

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

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 50% of the

Maximum Reimbursable Charge

Specialty Care Physician

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Surgical Sterilization Procedures for

Tubal Ligation (excludes reversals)

Primary Care Physician’s Office

Visit

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Men’s Family Planning Services

Note: Applies to employees and

spouses only.

Office Visits, Lab and Radiology

Tests and Counseling

Primary Care Physician

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Surgical Sterilization Procedures for

Vasectomy (excludes reversals)

Primary Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Infertility Services

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).

Surgical Treatment: Limited to procedures for the correction of infertility (excludes Artificial Insemination, In-vitro,

GIFT, ZIFT, etc.)

Physician’s Office Visit (Lab and

Radiology Tests, Counseling)

Primary Care Physician

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Transplant Services and Related

Specialty Care

Includes all medically appropriate, non-

experimental transplants

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

In-Network coverage only

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

In-Network coverage only

Inpatient Facility

100% at LifeSOURCE center,

otherwise not covered

In-Network coverage only

Inpatient Professional Services

100% at LifeSOURCE center,

otherwise not covered

In-Network coverage only

Travel Maximum:

$10,000 per transplant

100% (only available when using

LifeSOURCE facility)

In-Network coverage only

Durable Medical Equipment

Calendar Year Maximum:

Unlimited

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Outpatient Dialysis Services

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Home Setting

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Breast Feeding Equipment and

Supplies

Note:

Includes the rental of one breast

pump per birth as ordered or

prescribed by a physician. Includes

related supplies.

100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

External Prosthetic Appliances

Calendar Year Maximum:

Unlimited

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Nutritional Counseling

Calendar Year Maximum:

3 visits per person however, the 3

visit limit will not apply to treatment

of mental health and substance use

disorder conditions.

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

myCigna.com

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Genetic Counseling

Calendar Year Maximum:

3 visits per person for Genetic

Counseling for both pre- and post-

genetic testing; however, the 3 visit

limit will not apply to Mental Health

and Substance Use Disorder

conditions.

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Dental Care

Limited to charges made for a

continuous course of dental treatment

started within twelve months of an

injury to teeth.

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

External Breast Prosthesis

Calendar Year Maximum:

Two mastectomy bras

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Wigs

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Calendar Year Maximum:

One wig

TMJ Surgical and Non-Surgical

Includes appliances and orthodontia if

specifically for the treatment of TMJ

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Facility

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Inpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient Professional Services

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Obesity/Bariatric Surgery

Note:

Coverage is provided subject to

medical necessity and clinical

guidelines subject to any limitations

shown in the “Exclusions, Expenses

Not Covered and General Limitations”

section of this certificate.

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

In-Network coverage only

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

In-Network coverage only

Inpatient Facility

Plan deductible, then 80%

In-Network coverage only

Outpatient Facility

Plan deductible, then 80%

In-Network coverage only

Inpatient Professional Services

Plan deductible, then 80%

In-Network coverage only

Outpatient Professional Services

Plan deductible, then 80%

In-Network coverage only

Surgical Professional Services

Lifetime Maximum:

$10,000

Note:

 Includes charges for surgeon only;

does not include radiologist,

anesthesiologist, etc.

Routine Foot Disorders

Calendar Year Maximum:

$1,000

Primary Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Specialty Care Physician’s Office

Visit

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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.

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BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Mental Health

Inpatient

Includes Acute Inpatient and

Residential Treatment

Calendar Year Maximum:

Unlimited

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient

Outpatient - Office Visits

Includes individual, family and

group psychotherapy; medication

management, virtual care, etc.

Calendar Year Maximum:

Unlimited

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient - All Other Services

Includes Partial Hospitalization,

Intensive Outpatient Services,

virtual care, etc.

Calendar Year Maximum:

Unlimited

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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 50% of the

Maximum Reimbursable Charge

Outpatient

Outpatient - Office Visits

Includes individual, family and

group psychotherapy; medication

management, virtual care, etc.

Calendar Year Maximum:

Unlimited

$35 per visit copay, then 100%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

Outpatient - All Other Services

Includes Partial Hospitalization,

Intensive Outpatient Services,

virtual care, etc.

Calendar Year Maximum:

Unlimited

Plan deductible, then 80%

Plan deductible, then 50% of the

Maximum Reimbursable Charge

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LocalPlus 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 Mental Health or Substance Use Disorder Residential

Treatment Services.

You or your Dependent should request PAC prior to any non-

emergency 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 except for 48/96 hour

maternity stays, 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.

PAC and CSR are performed through a utilization review

program by a Review Organization with which Cigna has

contracted.

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, but not limited to, 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 outpatient 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 non-emergency 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 not include the first $500 for

charges made for any outpatient diagnostic testing or

outpatient procedure performed unless Outpatient Certification

is received prior to the date the testing or procedure is

performed.

Covered Expenses incurred will not include the first $500 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.

Outpatient Diagnostic Testing and Outpatient Procedures

Including, but not limited to:

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

PET scans.

 Home Health Care Services.

 Medical Pharmaceuticals.

 Radiation Therapy.

HC-PAC122 M 01-21

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 Plan.

Services that require Prior Authorization include, but are not

limited to:

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

stays.

 inpatient services at any participating Other Health Care

Facility.

 residential treatment.

 outpatient facility services.

 partial hospitalization.

 advanced radiological imaging.

 non-emergency Ambulance.

 certain Medical Pharmaceuticals.

 home health care services.

 radiation therapy.

 transplant services.

HC-PRA55 M 01-21

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Covered Expenses

The term Covered Expenses means expenses incurred by a

person while covered under this Plan for the charges listed

below for:

 preventive care services; and

 services or supplies that are Medically Necessary for the

care and treatment of an Injury or a Sickness, as determined

by Cigna.

As determined by Cigna, Covered Expenses may also include

all charges made by an entity that has directly or indirectly

contracted with Cigna to arrange, through contracts with

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

services and/or supplies listed below. Any applicable

Copayments, Deductibles or limits are shown in The

Schedule.

Covered Expenses

 charges for inpatient Room and Board and other Necessary

Services and Supplies made by a Hospital, subject to the

limits as shown in The Schedule.

 charges for inpatient Room and Board and other Necessary

Services and Supplies made by an Other Health Care

Facility, including a Skilled Nursing Facility, a

Rehabilitation Hospital or a subacute facility as shown in

The Schedule.

 charges for licensed Ambulance service to the nearest

Hospital where the needed medical care and treatment can

be provided.

 charges for outpatient medical care and treatment received

at a Hospital.

 charges for outpatient medical care and treatment received

at a Free-Standing Surgical Facility.

 charges for Emergency Services.

 charges for Urgent Care.

 charges by a Physician or a Psychologist for professional

services.

 charges by a Nurse for professional nursing service.

 charges for anesthetics, including, but not limited to

supplies and their administration.

 charges for diagnostic x-ray.

 charges for advanced radiological imaging, including for

example CT Scans, MRI, MRA and PET scans and

laboratory examinations, x-ray, radiation therapy and

radium and radioactive isotope treatment and other

therapeutic radiological procedures.

 charges for chemotherapy.

 charges for blood transfusions.

 charges for oxygen and other gases and their administration.

 charges for Medically Necessary foot care for diabetes,

peripheral neuropathies, and peripheral vascular disease.

 charges for diagnosis and treatment of: corns, calluses, flat

feet, chronic foot strain or instability or imbalance of the

feet, and toenail maintenance.

 charges for screening prostate-specific antigen (PSA)

testing.

 charges 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 for abortion when a Physician certifies in writing

that the pregnancy would endanger the life of the mother, or

when the expenses are incurred to treat medical

complications due to abortion.

 charges for the following preventive care services as

defined by recommendations from the following:

 the U.S. Preventive Services Task Force (A and B

recommendations);

 the Advisory Committee on Immunization Practices

(ACIP) for immunizations;

 the American Academy of Pediatrics’ Periodicity

Schedule of the Bright Futures Recommendations for

Pediatric Preventive Health Care;

 the Uniform Panel of the Secretary’s Advisory Committee

on Heritable Disorders in Newborns and Children; and

 with respect to women, evidence-informed preventive

care and screening guidelines supported by the Health

Resources and Services Administration.

Detailed information is available at www.healthcare.gov.

For additional information on immunizations, visit the

immunization schedule section of www.cdc.gov.

 charges for surgical and non-surgical treatment of

Temporomandibular Joint Dysfunction (TMJ).

 Medically Necessary orthognathic surgery to repair or

correct a severe facial deformity or disfigurement.

Virtual Care

Virtual Physician Services

Charges for the delivery of medical and health-related services

and consultations as medically appropriate through audio,

video, and secure internet-based technologies that are similar

to office visit services provided in a face-to-face setting.

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Charges for behavioral consultations and services via secure

telecommunications technologies that shall include video

capability, including telephones and internet, when delivered

through a behavioral provider.

Convenience Care Clinic

Convenience Care Clinics provide for common ailments and

routine services, including but not limited to, strep throat, ear

infections or pink eye, immunizations and flu shots.

Nutritional Counseling

Charges for nutritional counseling when diet is a part of the

medical management of a medical or behavioral condition.

Enteral Nutrition

Enteral Nutrition means medical foods that are specially

formulated for enteral feedings or oral consumption.

Coverage includes medically approved formulas prescribed by

a Physician for treatment of inborn errors of metabolism (e.g.,

disorders of amino acid or organic acid metabolism).

Internal Prosthetic/Medical Appliances

Charges for internal prosthetic/medical appliances that provide

permanent or temporary internal functional supports for non-

functional body parts are covered. Medically Necessary repair,

maintenance or replacement of a covered appliance is also

covered.

HC-COV1122 01-22

Obesity Treatment

 charges made for medical and surgical services only at

approved centers for the treatment or control of clinically

severe (morbid) obesity as defined below and if the services

are demonstrated, through existing peer reviewed, evidence

based, scientific literature and scientifically based

guidelines, to be safe and effective for the treatment or

control of the condition. Clinically severe (morbid) obesity

is defined by the National Heart, Lung and Blood Institute

(NHLBI) as a Body Mass Index (BMI) of 40 or greater

without comorbidities, or a BMI of 35-39 with

comorbidities. The following items are specifically

excluded:

 medical and surgical services to alter appearances or

physical changes that are the result of any medical or

surgical services performed for the treatment or control of

obesity or clinically severe (morbid) obesity; and

 weight loss programs or treatments, whether or not they

are prescribed or recommended by a Physician or under

medical supervision.

HC-COV2 04-10

Home Health Care Services

Charges for skilled care provided by certain health care

providers during a visit to the home, when the home is

determined to be a medically appropriate setting for the

services. A visit is defined as a period of 2 hours or less.

Home Health Care Services are subject to a maximum of 16

hours in total per day.

Home Health Care Services are covered when skilled care is

required under any of the following conditions:

 the required skilled care cannot be obtained in an outpatient

facility.

 confinement in a Hospital or Other Health Care Facility is

not required.

 the patient’s home is determined by Cigna to be the most

medically appropriate place to receive specific services.

Covered services include:

 skilled nursing services provided by a Registered Nurse

(RN), Licensed Practical Nurse (LPN), Licensed Vocational

Nurse (LVN) and an Advanced Practice Registered Nurse

(APRN).

 services provided by health care providers such as physical

therapist, occupational therapist and speech therapist.

 services of a home health aide when provided in direct

support of those nurses and health care providers.

 necessary consumable medical supplies and home infusion

therapy administered or used by a health care provider.

Note: Physical, occupational, and other Outpatient Therapy

Services provided in the home are covered under the

Outpatient Therapy Services benefit shown in The Schedule.

The following are excluded from coverage:

 services provided by a person who is a member of the

patient’s family, even when that person is a health care

provider.

 services provided by a person who normally resides in the

patient’s house, even when that person is a health care

provider.

 non-skilled care, Custodial Services, and assistance in the

activities of daily living, including but not limited to eating,

bathing, dressing or other services; self-care activities;

homemaker services; and services primarily for rest,

domiciliary or convalescent care.

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Home Health Care Services, for a patient who is dependent

upon others for non-skilled care and/or Custodial Services, is

provided only when there is a family member or caregiver

present in the home at the time of the health care visit to

provide the non-skilled care and/or Custodial Services.

HC-COV1123 01-22

Hospice Care Services

 charges 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 Room 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

Professional;

 charges for physical, occupational and speech therapy;

 charges for 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-COV980 01-21

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

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

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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.

 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

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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.

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, ventilators, insulin pumps and wheel chairs.

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.

 Fixtures to Real Property: ceiling lifts and wheelchair

ramps.

 Car/Van Modifications.

 Air Quality Items: room humidifiers, vaporizers and air

purifiers.

 Other Equipment: centrifuges, needleless injectors, heat

lamps, heating pads, cryounits, cryotherapy machines,

ultraviolet cabinets, that emit Ultraviolet A (UVA) rays

sheepskin pads and boots, postural drainage board, AC/DC

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

saunas, cervical and lumbar traction devices, exercise

equipment and diathermy machines.

HC-COV1124 02-21

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.

External prosthetic appliances and devices include

prostheses/prosthetic appliances and devices; orthoses and

orthotic devices; braces; and splints.

Prostheses/Prosthetic Appliances and Devices

Prostheses/prosthetic appliances and devices are defined as

fabricated replacements for missing body parts.

Prostheses/prosthetic appliances and devices include, but are

not limited to:

 limb prostheses;

 terminal devices such as hands or hooks;

 speech prostheses; and

 facial prostheses.

Orthoses and Orthotic Devices

Orthoses and orthotic devices are defined as orthopedic

appliances or apparatuses used to support, align, prevent or

correct deformities. Coverage is provided for custom foot

orthoses and other orthoses as follows:

 Non-foot orthoses – only the following non-foot orthoses

are covered:

 rigid and semi-rigid custom fabricated orthoses;

 semi-rigid 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;

 orthosis shoes, shoe additions, procedures for foot

orthopedic shoes, shoe modifications and transfers;

 non-foot orthoses primarily used for cosmetic rather than

functional reasons; and

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 non-foot orthoses primarily for improved athletic

performance or sports participation.

Braces

A Brace is defined as an orthosis or orthopedic appliance that

supports or holds in correct position any movable part of the

body and that allows for motion of that part.

The following braces are specifically excluded: Copes

scoliosis braces.

Splints

A Splint is defined as an appliance for preventing movement

of 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 required because anatomic change has rendered

the external prosthetic appliance or device ineffective.

Anatomic change includes significant weight gain or loss,

atrophy and/or growth.

 replacement due to a surgical alteration or revision of the

impacted site.

Coverage for replacement is limited as follows:

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

age and older.

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

age and under.

The following are specifically excluded external prosthetic

appliances and devices:

 external and internal power enhancements for external

prosthetic devices; or

 microprocessor controlled prostheses and orthoses; and

 myoelectric and orthoses.

HC-COV1125 M 01-22

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:

approved surgeries and other therapeutic procedures that

have been demonstrated in existing peer-reviewed,

evidence-based, scientific literature to have a reasonable

likelihood of resulting in pregnancy; laboratory tests; sperm

washing or preparation; artificial insemination; and

diagnostic evaluations.

Infertility is defined as:

 the inability of opposite-sex partners to achieve

conception after at least one year of unprotected

intercourse;

 the inability of opposite-sex partners to achieve

conception after six months of unprotected intercourse,

when the female partner trying to conceive is age 35 or

older;

 the inability of a woman, with or without an opposite-sex

partner, to achieve conception after at least six trials of

medically supervised artificial insemination over a one-

year period; and

 the inability of a woman, with or without an opposite-sex

partner, to achieve conception after at least three trials of

medically supervised artificial insemination over a six-

month period of time, when the female partner trying to

conceive is age 35 or older.

This benefit includes diagnosis and treatment of both male and

female infertility.

However, the following are specifically excluded infertility

services:

 Infertility drugs;

 Artificial Insemination;

 In vitro fertilization (IVF); gamete intrafallopian transfer

(GIFT); zygote intrafallopian transfer (ZIFT) and variations

of these procedures;

 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-COV733 M 01-19

Outpatient Therapy Services

Charges for the following therapy services:

Cognitive Therapy, Occupational Therapy, Osteopathic

Manipulation, Physical Therapy, Pulmonary

Rehabilitation, Speech Therapy

 Charges for therapy services are covered when provided as

part of a program of treatment.

Cardiac Rehabilitation

 Charges for Phase II cardiac rehabilitation provided on an

outpatient basis following diagnosis of a qualifying cardiac

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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.

Chiropractic Care Services

 Charges for diagnostic and treatment services utilized in an

office setting by chiropractic Physicians. Chiropractic

treatment includes the conservative management of acute

neuromusculoskeletal conditions through manipulation and

ancillary physiological treatment rendered to specific joints

to restore motion, reduce pain, and improve function. For

these services you have direct access to qualified

chiropractic Physicians.

Coverage is provided when Medically Necessary in the most

medically appropriate setting to:

 Restore function (called “rehabilitative”):

 To restore function that has been impaired or lost.

 To reduce pain as a result of Sickness, Injury, or loss of a

body part.

 Improve, adapt or attain function (sometimes called

“habilitative”):

 To improve, adapt or attain function that has been

impaired or was never achieved as a result of congenital

abnormality (birth defect).

 To improve, adapt or attain function that has been

impaired or was never achieved because of mental health

and substance use disorder conditions. Includes

conditions such as autism and intellectual disability, or

mental health and substance use disorder conditions that

result in a developmental delay.

Coverage is provided as part of a program of treatment when

the following criteria are met:

 The individual’s condition has the potential to improve or is

improving in response to therapy, and maximum

improvement is yet to be attained.

 There is an expectation that the anticipated improvement is

attainable in a reasonable and generally predictable period

of time.

 The therapy is provided by, or under the direct supervision

of, a licensed health care professional acting within the

scope of the license.

 The therapy is Medically Necessary and medically

appropriate for the diagnosed condition.

Coverage for occupational therapy is provided only for

purposes of enabling individuals to perform the activities of

daily living after an Injury or Sickness.

Therapy services that are not covered include:

 sensory integration therapy.

 treatment of dyslexia.

 maintenance or preventive treatment provided to prevent

recurrence or to maintain the patient’s current status.

 charges for Chiropractic Care not provided in an office

setting.

 vitamin therapy.

Coverage is administered according to the following:

 Multiple therapy services provided on the same day

constitute one day of service for each therapy type.

 A separate Copayment applies to the services provided by

each provider for each therapy type per day.

HC-COV982 01-21

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 non-

diseased breast to produce symmetrical appearance;

postoperative breast prostheses; and mastectomy bras and

prosthetics, limited to the lowest cost alternative available

that meets prosthetic placement needs. During all stages of

mastectomy, treatment of physical complications, including

lymphedema therapy, are covered.

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, non-cosmetic surgery; or the surgery

or therapy is performed prior to age 19 and is required as a

result of the congenital absence or agenesis (lack of

formation or development) of a body part. Repeat or

subsequent surgeries for the same condition are covered

only when there is the probability of significant additional

improvement as determined by the utilization review

Physician.

HC-COV631 12-17

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Transplant Services and Related Specialty Care

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.

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.

Implantation procedures are also covered for artificial heart,

percutaneous ventricular assist device (PVAD), extracorporeal

membrane oxygenation (ECMO) ventricular assist device

(VAD) and intra-aortic balloon pump (IABP) are also covered.

 All transplant services and related specialty care services,

other than cornea transplants, are covered when received at

Cigna LifeSOURCE Transplant Network® facilities.

 Transplant services and related specialty care services

received at Participating Provider facilities specifically

contracted with Cigna for those transplant services and

related specialty care services, other than Cigna

LifeSOURCE Transplant Network® facilities, are payable

at the In-Network level.

 Transplant services and related specialty care services

received at any other facility, including non-Participating

Provider facilities and Participating Provider facilities not

specifically contracted with Cigna for transplant services

and related specialty care services, are not covered.

 Cornea transplants received at a facility that is specifically

contracted with Cigna for this type of transplant are payable

at the In-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

hospitalization and surgery necessary for removal of an organ

and transportation of a live donor (refer to Transplant and

Related Specialty Care Travel Services). 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.

Advanced cellular therapy, including but not limited to,

immune effector cell therapies and Chimeric Antigen Receptor

Therapy (CAR-T) cellular therapy, is covered when performed

at a Cigna LifeSOURCE Transplant Network® facility with

an approved stem cell transplant program. Advanced cellular

therapy received at facilities other than Cigna LifeSOURCE

Transplant Network® facilities, are not covered.

Transplant and Related Specialty Care 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 and related specialty care travel benefits are not

available for cornea transplants.

 Benefits for transportation and lodging are available to the

recipient of a preapproved organ/tissue transplant and/or

related specialty care 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

designated Cigna LifeSOURCE Transplant Network®

facility (including charges for a rental car used during a

period of care at the designated Cigna LifeSOURCE

Transplant Network® facility); and lodging while at, or

traveling to and from, the designated Cigna LifeSOURCE

Transplant Network® facility.

 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 for Transplant Services and Related Specialty

Care, and for Transplant and Related Specialty Care Travel

Services 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 transplant and related specialty care services or

travel benefits are available when the covered person is the

donor for an organ/tissue transplant, the transplant recipient’s

plan would cover all donor costs.

HC-COV1126 M 01-22

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Medical Pharmaceuticals

The Plan’s medical benefit program 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 provided under the Plan’s prescription

drug benefit program are described in the section of this

booklet entitled “Prescription Drug Benefits.”

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 or Other Health Professional. Benefits

payable under this section include Medical Pharmaceuticals

whose administration may initially, or typically, require

Physician or Other Health Professional 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.

Utilization management requirements or other coverage

conditions are based on a number of factors, which may

include 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

certain supply limits or other 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. 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-COV1168 M 01-22

Gene Therapy

Charges for gene therapy products and services directly

related to their administration are covered when Medically

Necessary. Gene therapy is a category of pharmaceutical

products approved by the U.S. Food and Drug Administration

(FDA) to treat or cure a disease by:

 replacing a disease-causing gene with a healthy copy of the

gene.

 inactivating a disease-causing gene that may not be

functioning properly.

 introducing a new or modified gene into the body to help

treat a disease.

Each gene therapy product is specific to a particular disease

and is administered in a specialized manner. Cigna determines

which products are in the category of gene therapy, based in

part on the nature of the treatment and how it is distributed

and administered.

Coverage includes the cost of the gene therapy product;

medical, surgical, and facility services directly related to

administration of the gene therapy product; and professional

services.

Gene therapy products and their administration are covered

when prior authorized to be received at In-Network facilities

specifically contracted with Cigna for the specific gene

therapy service. Gene therapy products and their

administration received at other facilities are not covered.

Gene Therapy Travel Services

Charges made for non-taxable travel expenses incurred by you

in connection with a prior authorized gene therapy procedure

are covered subject to the following conditions and

limitations.

Benefits for transportation and lodging are available to you

only when you are the recipient of a prior authorized gene

therapy; and when the gene therapy products and services

directly related to their administration are received at a

participating In-Network facility specifically contracted with

Cigna for the specific gene therapy service. The term recipient

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is defined to include a person receiving prior authorized gene

therapy related services during any of the following:

evaluation, candidacy, event, or post care.

Travel expenses for the person receiving the gene therapy

include charges for: transportation to and from the gene

therapy site (including charges for a rental car used during a

period of care at the facility); and lodging while at, or

traveling to and from, the site.

In addition to your coverage for the charges associated with

the items above, such charges will also be considered covered

travel expenses for one companion to accompany you. The

term companion includes your spouse, a member of your

family, your legal guardian, or any person not related to you,

but actively involved as your caregiver who is at least 18 years

of age.

The following are specifically excluded travel expenses: any

expenses that if reimbursed would be taxable income, travel

costs incurred due to travel within 60 miles of your home;

food and meals; laundry bills; telephone bills; alcohol or

tobacco products; and charges for transportation that exceed

coach class rates.

HC-COV873 01-20

Clinical Trials

This plan covers routine patient care costs and services related

to an approved clinical trial for a qualified individual. The

individual must be eligible to participate according to the trial

protocol and either of the following conditions must be met:

 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; or

 the individual provides medical and scientific information

establishing that the individual’s participation in the clinical

trial would be appropriate.

In addition to qualifying as an individual, the clinical trial

must also meet certain criteria in order for patient care costs

and services to be covered.

The clinical trial must be a phase I, phase II, phase III, or

phase IV clinical trial conducted in relation to the prevention,

detection, or treatment of cancer or other life-threatening

disease or condition that meets any of the following criteria:

 it is a federally funded trial. The study or investigation is

approved or funded (which may include funding through in-

kind contributions) by one or more of the following:

 National Institutes of Health (NIH).

 Centers for Disease Control and Prevention (CDC).

 Agency for Health Care Research and Quality (AHRQ).

 Centers for Medicare and Medicaid Services (CMS).

 a cooperative group or center of any of the entities

described above or the Department of Defense (DOD) or

the Department of Veterans Affairs (VA).

 a qualified non-governmental research entity identified in

NIH guidelines for center support grants.

 any of the following: Department of Energy, Department

of Defense, Department of Veterans Affairs, if both of

the following conditions are met:

 the study or investigation has been reviewed and

approved through a system of peer review comparable

to the system of peer review of studies and

investigations used by the National Institutes of Health

(NIH); and

 the study or investigation assures unbiased review of

the highest scientific standards by qualified individuals

who have no interest in the outcome of the review.

 the study or investigation is conducted under an

investigational new drug application reviewed by the U.S.

Food and Drug Administration (FDA).

 the study or investigation is a drug trial that is exempt

from having such an investigational new drug application.

The plan does not cover any of the following services

associated with a clinical trial:

 services that are not considered routine patient care costs

and services, including the following:

 the investigational drug, device, item, or service that is

provided solely to satisfy data collection and analysis

needs.

 an item or service that is not used in the direct clinical

management of the individual.

 a service that is clearly inconsistent with widely accepted

and established standards of care for a particular

diagnosis.

 an item or service provided by the research sponsors free of

charge for any person enrolled in the trial.

 travel and transportation expenses, unless otherwise covered

under the plan, including but not limited to the following:

 fees for personal vehicle, rental car, taxi, medical van,

ambulance, commercial airline, train.

 mileage reimbursement for driving a personal vehicle.

 lodging.

 meals.

 routine patient costs obtained out-of-network when Out-of-

Network benefits do not exist under the plan.

Examples of routine patient care costs and services include:

 radiological services.

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 laboratory services.

 intravenous therapy.

 anesthesia services.

 Physician services.

 office services.

 Hospital services.

 Room and Board, and medical supplies that typically would

be covered under the plan for an individual who is not

enrolled in a clinical trial.

Clinical trials conducted by Out-of-Network providers will be

covered only when the following conditions are met:

 In-Network providers are not participating in the clinical

trial; or

 the clinical trial is conducted outside the individual’s state

of residence.

HC-COV1128 01-22

Exclusions, Expenses Not Covered and

General Limitations

Exclusions and Expenses Not Covered

Additional coverage limitations 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

the 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 the

Plan. This exclusion includes, but is not limited to, charges

of a non-Participating Provider who has agreed to charge

you or charged you at an in-network benefits level or some

other benefits level not otherwise applicable to the services

received.

 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 but not

limited to eating, bathing, dressing or other Custodial

Services or self-care activities, homemaker services and

services primarily for rest, domiciliary or convalescent care.

 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” sections of this booklet; or

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

except for routine patient care costs related to qualified

clinical trials as provided in the “Clinical Trials” sections

of this booklet.

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, evidence-

based scientific literature.

 cosmetic surgery and therapies. Cosmetic surgery or therapy

is defined as surgery or therapy performed to improve or

alter appearance or self-esteem.

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 the following services are excluded from coverage

regardless of clinical indications: 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

twelve months of an accident. Additionally, charges made

by a Physician for any of the following Surgical Procedures

are covered: excision of unerupted impacted tooth,

including removal of alveolar bone and sectioning of tooth;

removal of residual root (when performed by a Dentist other

than the one who extracted the tooth).

 medical and surgical services, initial and repeat, intended

for the treatment or control of obesity, except for treatment

of clinically severe (morbid) obesity as shown in Covered

Expenses, 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 booklet, for reports,

evaluations, physical examinations, or hospitalization not

required for health reasons, including but not limited to

employment, insurance or government licenses, and court-

ordered, forensic or custodial evaluations.

 court-ordered treatment or hospitalization, unless such

treatment is prescribed by a Physician and listed as covered

in this booklet.

 any medications, drugs, 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 for

coverage as an eligible Dependent and is timely enrolled in

the Plan.

 non-medical counseling and/or ancillary services, including

but not limited to Custodial Services, educational services,

vocational counseling, training and, rehabilitation services,

behavioral training, biofeedback, neurofeedback, hypnosis,

sleep therapy, return to work services, work hardening

programs and driver safety courses.

 therapy or treatment intended primarily to improve or

maintain general physical condition or for the purpose of

enhancing job, school, athletic or recreational performance,

including but not limited to routine, long term, or

maintenance care which is provided after the resolution of

the acute medical problem and when significant therapeutic

improvement is not expected.

 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 Care Services” or “Breast Reconstruction

and Breast Prostheses” sections of this booklet.

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

provided under the Home Health Care 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 but not limited to corrective

orthopedic shoes, arch supports, elastic stockings, garter

belts, corsets and dentures.

 hearing aids, including but not limited to semi-implantable

hearing devices, audiant bone conductors and Bone

Anchored Hearing Aids (BAHAs). A hearing aid is any

device that amplifies sound.

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

including but not limited to communication boards, pre-

recorded speech devices, laptop computers, desktop

computers, Personal Digital Assistants (PDAs), Braille

typewriters, visual alert systems for the deaf and memory

books.

 eyeglass lenses and frames and contact lenses (except for

the first pair of contact lenses or the first set of eyeglass

lenses and frames, and associated services, for treatment of

keratoconus or following cataract surgery).

 routine refractions, eye exercises and surgical treatment for

the correction of a refractive error, including radial

keratotomy.

 treatment by acupuncture.

 all non-injectable 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 self-

administered drugs, non-prescription drugs, and

investigational and experimental drugs, except as provided

in this booklet.

 membership costs or fees associated with health clubs,

weight loss programs and smoking cessation programs.

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 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.

 enteral feedings, supplies and specially formulated medical

foods that are prescribed and non-prescribed, except for

infant formula needed for the treatment of inborn errors of

metabolism.

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

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

 massage therapy.

 abortions, unless a Physician certifies in writing that the

pregnancy would endanger the life of the mother, or the

expenses are incurred to treat medical complications due to

abortion.

 for or in connection with the pregnancy of a Dependent

child, other than Complications of Pregnancy.

 expenses incurred by a participant to the extent

reimbursable under automobile insurance coverage.

Coverage under this plan is secondary to automobile no-

fault insurance or similar coverage. The coverage provided

under this plan does not constitute “Qualified Health

Coverage” under Michigan law and therefore does not

replace Personal Injury Protection (PIP) coverage provided

under an automobile insurance policy issued to a Michigan

resident. This Plan will cover expenses only not otherwise

covered by the PIP coverage.

General Limitations

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

one of your Dependents:

 for charges 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.

 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 booklet.

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

not Medically Necessary.

 charges 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-EXC466 M 01-22

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.

Coverage under this Plan plus another Plan will not

guarantee 100% reimbursement.

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.

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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 which 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.

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 if rendered under

similar or comparable circumstances by other health care

providers located within the immediate geographic area where

the health care service was delivered.

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 a person as an enrollee or an employee

shall be the Primary Plan and the Plan that covers that

person as a Dependent shall be the Secondary Plan;

 For 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;

 For 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 noncustodial parent 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, the benefits that would be

payable under this Plan in the absence of Coordination will be

reduced by the benefits payable under all other Plans for the

expense covered under this Plan.

When a Plan provides benefits in the form of services, the

Reasonable Cash Value of each service rendered will be

considered both an expense incurred and a benefit payable.

Recovery of Excess Benefits

If the Plan pays charges for services and supplies that should

have been paid by the Primary Plan, the Plan will have the

right to recover such payments.

The Plan 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 were made by any

insurance company, healthcare plan or other organization. If

requested by the Plan, you shall execute and deliver to the

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Plan such instruments and documents as the Plan determines

are necessary to secure the right of recovery.

Right to Receive and Release Information

The Plan, 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 the Plan with any

information requested 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 55 days of the request, the claim will be

closed. If the requested information is subsequently received,

the claim will be processed.

Medicare Eligibles

The Plan 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 due to age

or disability and whose Plan coverage is continued for any

reason as provided in this booklet (for example, due to

electing COBRA continuation coverage);

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

spouse or child, who is eligible for Medicare due to age or

disability and whose Plan coverage is continued for any

reason as provided in this booklet (for example, due to

electing COBRA continuation coverage);

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 (c) above.

HC-COB274 M 01-21

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.

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 the paragraph immediately

above, 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

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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-SUB128 M 03-20

Payment of Benefits

Prohibition on 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, to file lawsuits

or assert any causes of action under ERISA, or to assert any

other rights or remedies under this Plan. Any attempt to assign

such rights and/or benefits shall be void and unenforceable

under all circumstances. The foregoing prohibition on

assignments applies to both Plan participants and their

Dependents.

You may, however, authorize Cigna to pay any healthcare

benefits under this Plan to a Participating or Non-Participating

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 the Plan, it is the provider’s

responsibility to reimburse the overpayment to you. The Plan

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 directly to a

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Participating or Non-Participating Provider as the authority to

assign any rights or benefits under this Plan to any party,

including, but not limited to, a provider of healthcare

services/items, or as a waiver of the Plan’s prohibition against

assignments.

Even if the payment of healthcare benefits to a Non-

Participating Provider has been authorized by you, the Plan

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 a Plan participant passes away, Cigna may receive

notice that an executor of the estate has been established.

Benefit payments for claims properly filed and payable under

the terms of the Plan should be made payable to the executor.

Payment as described above will release the Plan from all

liability to the extent of any payment made.

Recovery of Overpayment

When an overpayment has been made by the Plan, the Plan

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 from the Plan. In addition, your acceptance of

benefits under this Plan separately creates an equitable lien by

agreement pursuant to which the Plan may seek recovery of

any overpayment. You agree that the Plan, 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-POB132 M 01-19

Termination of Plan Coverage

Employees

Your coverage under the Plan will cease on the earliest date

below:

 the date you cease to be an eligible Employee under the

Plan for any reason.

 the last day for which you have made any required

contribution for the Plan.

 the date the Plan is terminated.

 as soon as administratively practicable following the date

you request that such coverage be terminated due to a

qualified change event.

 the last day of the current plan year, if you voluntarily

cancel your participation in the Plan during an open

enrollment period.

Temporary Layoff or Leave of Absence

If your Active Service ends due to temporary layoff or leave

of absence, your coverage under the Plan will be continued for

a period of up to 90 days (with the exception of FMLA leave,

in which case your insurance will terminate on the last day of

your approved FMLA leave, if longer than 90 days).

Dependents

Your coverage under the Plan for all of your Dependents will

cease on the earliest date below:

 the date your coverage ceases.

 the date the individual is no longer an eligible Dependent,

even if the Plan learns of the ineligibility at a later date

(your child will continue to be an eligible Dependent, if all

other criteria are met, until the end of the month in which

your child turns age 26).

 the last day of the current plan year, if you voluntarily

cancel your eligible Dependent’s participation in the Plan

during an open enrollment period.

 as soon as administratively practicable after you voluntarily

cancel your Dependent’s participation in the Plan due to a

qualifying change event.

 the last day for which you have made any required

contribution for the coverage.

 the date the Plan or Dependent coverage under the Plan is

terminated.

HC-TRM128 M 12-17

Please Note: If you commit fraud or make a material

misrepresentation in applying for or obtaining coverage under

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the Plan, or in obtaining benefits under the Plan, then the Plan

may terminate coverage for you and/or any other individual

you have enrolled in the Plan as of a date to be determined at

the Plan Administrator’s discretion, consistent with applicable

law including the rules regarding rescission.

Rescissions

Your coverage may not be rescinded (retroactively terminated)

by the Plan unless an individual (or a person seeking coverage

on behalf of the individual) performs an act, practice or

omission that constitutes fraud; or the individual (or a person

seeking coverage on behalf of the individual) makes an

intentional misrepresentation of material fact. Failure to

inform the Plan that an individual is no longer eligible for

coverage under the Plan is considered an intentional

misrepresentation of material fact entitling the Plan to

retroactively cancel the individual’s coverage. The Plan has

the right to recover from you any payments the Plan makes on

behalf of the ineligible individual.

HC-TRM80 M 01-11

Medical Benefits Extension During

Hospital Confinement

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

Dependent, and you or your Dependent is Confined in a

Hospital on that date, Medical Benefits will be paid for

Covered Expenses incurred in connection with that Hospital

Confinement. 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 you are covered for medical benefits under another

group Plan;

 the date you or your Dependent is no longer Hospital

Confined; or

 3 months from the date your Medical Benefits cease.

The terms of this Medical Benefits Extension will not apply to

a child born as a result of a pregnancy which exists when your

Medical Benefits cease or your Dependent's Medical Benefits

cease.

Note: Limited Extension of Benefits applies to Inpatient

Hospital Facility Claims Only, No Professional Charges.

HC-BEX44 M 01-13

Federal Requirements

The following pages explain your rights and responsibilities

under federal laws and regulations.

HC-FED1 M 10-10

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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 for the medical benefits under the Plan

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. The network for

the prescription drug benefits under the Plan, other than

specialty medications, are the retail and mail order pharmacies

affiliated or contracted with Express Scripts. The Plan does

not include a network of pharmacies or providers for specialty

medications. Instead, you will be directed by the Plan’s

specialty pharmacy vendor, VIVIO, to use a specific

pharmacy or provider that has agreed to accept the Plan’s

offered pricing for specialty drugs. The use of any other

pharmacy or provider generally will not be reimbursed by the

Plan.

The Plan will keep its provider directory up to date in

accordance with applicable federal law. If you unintentionally

receive items or services from an Out-of-Network provider or

facility after receiving incorrect information from the Plan’s

provider directory about that provider’s or facility’s network

status, you will only be responsible for the cost-sharing

amount that would have applied if the items or services had

been provided by an In-Network provider or facility, and the

Plan will count those cost-sharing amounts towards the Plan’s

In-Network Deductible and Out-of-Pocket Maximum.

Continuity of Care When Provider Moves Out of

Network

If you are a “continuing care patient” with respect to an In-

Network provider or facility and the contractual relationship

between Cigna and the provider or facility is terminated for

reasons other than cause, the Plan will notify you of the

termination on a timely basis and allow you the opportunity to

elect continued transitional care from the provider or facility

under the same terms and conditions as would have applied

had the termination not occurred, for up to 90 days.

An individual will be considered a “continuing care patient”

with respect to a provider or facility if the individual (i) is

undergoing a course of treatment for a serious and complex

condition from the provider or facility; (ii) is undergoing a

course of institutional or inpatient care from the provider or

facility; (iii) is scheduled to undergo nonelective surgery from

the provider, including receipt of postoperative care from such

provider or facility with respect to such a surgery; (iv) is

pregnant and undergoing a course of treatment for the

pregnancy from the provider or facility; or (v) is or was

determined to be terminally ill and is receiving treatment for

such illness from such provider or facility.

HC-FED78 M 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 be entitled to enroll

yourself and your child as required by the order outside of the

Plan’s open enrollment period.

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 plan or

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.

Participants and beneficiaries can obtain, without charge, a

copy of the Plan’s procedures governing QMCSO

determinations from the Plan Administrator.

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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 M 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) by calling the Benefits Service Center at 1-866-

481-4922. 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. You must request enrollment within 31 days of

the marriage, birth, adoption, or placement for

adoption, regardless of whether the enrollment will

result in an increase in your benefit contributions (i.e.,

you are already enrolled in Employee + Children or

Family coverage).

 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 for yourself and your Dependents 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. 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 another employer ceases all

contributions toward the Employee’s or Dependent’s other

coverage, special enrollment may be requested in this Plan

for you and 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

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coverage as provided under any severance or other

agreement.

 Eligibility for employment assistance under State

Medicaid or Children’s Health Insurance Program

(CHIP). If you and/or your Dependent(s) become eligible

for assistance with group health Plan premium payments

under a state Medicaid or CHIP Plan, you may request

special enrollment for yourself and any affected

Dependent(s) who are not already enrolled in the Plan. You

must request enrollment within 60 days after the date you

are determined to be eligible for assistance.

Except as stated above, special enrollment must be

requested within 31 days after the occurrence of the

special enrollment event by calling the Benefits Service

Center at 1-866-481-4922. 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 if enrollment is timely requested.

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.

If you have any questions about your special enrollment rights

under the Plan, please contact the Benefits Service Center at 1-

866-481-4922.

HC-FED96 M 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 you meet Special Enrollment criteria and enroll as

described in the Special Enrollment section; or

 if you meet the criteria shown in the following Sections B

through G and enroll for or change coverage within 31 days

of the qualifying change event.

To make an election change, you must call the Benefits

Service Center at 1-866-481-4922 within 31 days of the

qualifying change event.

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 plan year

by an insignificant amount (as determined by the Plan

Administrator), your Employer may, in accordance with Plan

terms, automatically change your elective contribution.

When the change in cost is significant, you may either

increase your contribution or elect less-costly coverage. When

a significant overall reduction is made to the benefit option

you have elected, you may elect another available benefit

option. When a new benefit option is added, you may change

your election to the new benefit option.

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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. Enrollment in a 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 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 under the Plan.

HC-FED95 M 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

coverage under the plan, 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 this document that describe requirements for

enrollment and effective date of coverage for a newborn child

will also apply to an adopted child or a child placed with you

for adoption.

HC-FED67 M 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

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Requirements of Family and Medical Leave Act

of 1993 (as amended) (FMLA)

Any provisions of the Plan that provide for: continuation of

coverage during a leave of absence; and reinstatement of

coverage 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 coverage under the Plan 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.

Your Plan coverage will be continued on the same terms and

conditions as if you were still active (that is, the Employer will

continue to pay its share of the contributions). If you are on a

paid FMLA leave of absence, your share of the benefit

contributions will be paid by the method normally used during

any paid leave (i.e., on a pre-tax salary reduction basis). If you

are on an unpaid FMLA leave of absence, then the Employer

will fund coverage during the leave and withhold “catch-up”

amounts from your pay when you return to work.

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-FED93 M 10-17

Uniformed Services Employment and Re-

Employment 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 coverage under the Plan for you

and your Dependents.

Continuation of Coverage

For leaves of less than 91 days, coverage will continue as

described in the Termination section regarding Leave of

Absence.

For leaves of 91 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 Plan is terminated.

Your Employer may charge you and your Dependents up to

102% of the total premium for continuation coverage that

extends beyond 90 days of qualified military leave.

Reinstatement of Benefits (applicable to all coverages)

If your coverage ends during the leave of absence because you

do not elect USERRA 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 M 10-10

Claim Determination Procedures under ERISA

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 booklet 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 booklet, and in your provider’s network participation

documents as applicable.

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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 booklet, in your

provider’s network participation documents as applicable, and

in the determination notices.

Note: An oral statement made to you by a representative of

Cigna or its designee that indicates, for example, a particular

service is a Covered Expense, is authorized for coverage by

the Plan, or that you are eligible for coverage is not a

guarantee that you will receive benefits for services under this

Plan. Cigna will make a benefit determination after a claim is

received from you or your authorized representative, and the

benefit determination will be based on, your eligibility as of

the date services were rendered to you and the terms and

conditions of the Plan in effect as of the date services were

rendered to you.

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

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 (or the date your time to

respond to the request for additional information expires, if

you fail to respond).

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 attempts to request a preservice

determination, but 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 (or the

date your time to respond to the request for additional

information expires, if you fail to respond).

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,

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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; 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-FED104 M 01-19

Appointment of Authorized Representative

For the purposes of this section, any reference to "you" or

"your" also refers to a representative or provider designated by

you to act on your behalf; unless otherwise noted.

You may appoint an authorized representative to assist you in

submitting a claim or appealing a claim denial under the

Plan’s administrative claim and appeal procedures. 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-FED88 01-17

Medical - When You Have a Complaint or an

Appeal

For the purposes of this section, any reference to "you" or

"your" 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 services 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 may call the toll-

free number on your ID card, explanation of benefits, or

claim form and explain your concern to one of our Customer

Service representatives. You may also express that concern

in writing.

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 may start the appeals

procedure.

Internal Appeals Procedure

To initiate an appeal of an adverse benefit determination, you

must submit a request for an appeal to Cigna within 180 days

of receipt of a denial notice. If you appeal a reduction or

termination in coverage for an ongoing course of treatment

that Cigna previously approved, you will receive, as required

by applicable law, continued coverage pending the outcome of

an appeal.

You should state the reason why you feel your appeal should

be approved and include any information supporting your

appeal. If you are unable or choose not to write, you may ask

Cigna to register your appeal by telephone. Call or write us at

the toll-free number on your ID card, explanation of benefits,

or claim form.

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.

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We will respond in writing with a decision within 30 calendar

days after we receive an appeal for a required preservice or

concurrent care coverage determination or a postservice

Medical Necessity determination. We will respond within 60

calendar days after we receive an appeal for any other

postservice coverage determination. If more time or

information is needed to make a postservice Medical

Necessity 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 appeal, this information will be provided

automatically 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 may request that the appeal process be expedited if, (a)

the time frames under this process would seriously jeopardize

your life, health or ability to regain maximum functionality or

in the opinion of your health care provider 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 review at

the same time, if the time to complete an expedited review

would be detrimental to your medical condition and your

claim is eligible for external review (as described in “External

Review Procedure” below).

When an appeal is expedited, Cigna will respond orally with a

decision within 72 hours, followed up in writing.

External Review Procedure

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

internal appeal review and the appeal involves (i) medical

judgment; (ii) consideration of whether the Plan is complying

with the surprise billing and cost-sharing protections set forth

in the federal No Surprises Act; or (iii) a rescission of

coverage, you may request that your appeal be referred to an

Independent Review Organization (IRO). The IRO is

composed of persons who are not employed by Cigna or the

Employer, or any of their affiliates. A decision to request an

external review to an IRO will not affect the claimant's rights

to any other benefits under the Plan.

There is no charge for you to initiate an external review. Cigna

and the Plan will abide by the decision of the IRO.

To request an external review, you must notify the Appeals

Coordinator within 4 months of your receipt of Cigna's

appeal review denial. Cigna will then forward the file to a

randomly selected IRO. The IRO will render an opinion

within 45 days.

When requested, and if a delay would be detrimental to your

medical condition, as determined by Cigna's 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 a facility, the external review shall be

completed within 72 hours.

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 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 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 below; 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 an adverse determination

will include a discussion of the decision.

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

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 for

the claimant's diagnosis, without regard to whether such

advice or statement was relied upon in making the benefit

determination.

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Legal Action

After you have exhausted the Plan’s internal appeal

procedures, 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.

If you wish to file an action in court, you must do so within

one year of completing the Plan’s claim and appeal

procedures (including, if applicable, external review).

Any action arising out of or in connection with the Plan may

only be brought or filed in Federal District Court for the

Northern District of Georgia, Atlanta Division.

HC-FED110 M 01-21

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. 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.

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, to the

extent that such an event would have caused your Dependent

to lose coverage under the Plan had the first qualifying event

not occurred.

This extension due to a second qualifying event is available

only if you notify the COBRA Administrator in writing of the

second qualifying event within 60 days after the date of the

second qualifying event. If you fail to provide notice of a

second qualifying event during this 60-day notice period, then

there will be no extension of coverage due to a second

qualifying event.

All causes for “Termination of COBRA Continuation” listed

below will also apply to the period of extension due to a

second qualifying event.

Disability Extension

If, prior to or 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 be eligible to 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

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 A copy of the written SSA determination must be provided

to the COBRA Administrator within 60 calendar days (1)

after the latest of (i) the date the SSA determination is

made; (ii) the date of the qualifying event (i.e., the

employee’s termination of employment or reduction of

hours); and (iii) the date on which the qualified beneficiary

loses (or would lose) coverage under the Plan as a result of

the qualifying event AND (2) 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 COBRA 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

the qualifying event, COBRA continuation coverage for your

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

became enrolled in Medicare. This COBRA coverage period is

available only if the covered employee becomes entitled to

Medicare within 18 months before the termination or

reduction of hours and you notify the COBRA Administrator

of your entitlement to the extension when electing COBRA

continuation coverage. 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;

 the Employer ceases to provide any group health coverage

for its employees;

 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 pre-

existing 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 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 COBRA Administrator of your

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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.

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 COBRA 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

also 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.).

COBRA Administrator

Please contact the COBRA Administrator with any questions

about COBRA continuation coverage under the Plan at the

following:

TaxSaver Plan

P. O. Box 609002

Dallas, TX 75360

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Phone: 1-800-328-4337

Website/Email: csr@taxsaverplan.com

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. 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.

Are There Other Coverage Options Besides COBRA

Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage,

there may be other coverage options for you and your family

through the Health Insurance Marketplace, Medicaid, or other

group health plan coverage options (such as a spouse’s plan)

through what is called a “special enrollment period.” Some of

these options may cost less than COBRA continuation

coverage. You can learn more about many of these options at

www.healthcare.gov.

If You Have Questions

Questions concerning your Plan or your COBRA continuation

coverage rights should be addressed to the COBRA

Administrator identified above. For more information about

your rights under the Employee Retirement Income Security

Act (ERISA), including COBRA, the Patient Protection and

Affordable Care Act, and other laws affecting group health

plans, contact the nearest Regional or District Office of the

U.S. Department of Labor’s Employee Benefits Security

Administration (EBSA) in your area or visit

www.dol.gov/agencies/ebsa. (Addresses and phone numbers

of Regional and District EBSA Offices are available through

EBSA’s website.) For more information about the

Marketplace, visit www.healthcare.gov.

Keep the Plan Informed of Address Changes

To protect your family’s rights, let the COBRA Administrator

know about any changes in the addresses of family members.

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

you send to the COBRA Administrator.

HC-FED66 M 07-14

ERISA Required Information

The name of the Plan is:

Mohawk ESV, Inc. Health and Welfare Benefit Plan

The LocalPlus Account is a medical and prescription drug

benefit program offered under the

Mohawk ESV, Inc. Health and Welfare Benefit Plan.

References in this booklet to the “Plan” refer to LocalPlus

Account benefit program only.

The name, address, ZIP code and business telephone number

of the sponsor of the Plan is:

Mohawk ESV, Inc.

160 South Industrial Boulevard

Calhoun, GA 30701

706-629-7721

Employer Identification

Number (EIN):

Plan Number:

20-1880191

501

The name, address, ZIP code and business telephone number

of the Plan Administrator is:

Benefits Committee of Mohawk ESV, Inc.

160 South Industrial Boulevard

Calhoun, GA 30701

706-629-7721

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

agent for service of legal process is:

Mohawk ESV, Inc.

Attn: Director of Benefits

160 South Industrial Boulevard

Calhoun, GA 30701

706-629-7721

Service of process may also be made on the Plan

Administrator.

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 benefits provided under the Plan are paid from the general

assets of the Employer and Employee contributions.

The Employee cost of the Plan will be stated in the enrollment

materials provided to you when you are first eligible for the

Plan and each year during open enrollment. The portion of the

enrollment materials listing the amount of Employee

contributions for the Plan is considered part of this booklet

only for the purpose of identifying the amount of the

Employee contributions required each plan year.

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 Type

The Mohawk ESV, Inc. Health and Welfare Benefit Plan is a

welfare benefit plan.

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The LocalPlus Account benefit program described in this

booklet is a medical and prescription drug benefit program

offered under the Mohawk ESV, Inc. Health and Welfare

Benefit Plan.

The Mohawk ESV, Inc. Health and Welfare Benefit Plan also

provides other welfare benefit programs, which are described

in separate summaries.

Funding Type and Plan Administration

The Plan is funded from the general assets of the Employer

and Employee contributions. The Benefits Committee of

Mohawk ESV, Inc. serves as the Plan Administrator of the

Plan. The Plan Administrator has delegated its discretionary

authority and fiduciary duties with respect to initial and final

internal claims determinations under the Plan to the claims

administrators for the Plan. Cigna serves as the claims

administrator for medical benefit claims and appeals, and

Express Scripts serves as the claims administrator for all

prescription drug benefit claims and appeals, other than those

involving specialty medications. VIVIO is the claims

administrator for benefit claims and appeals involving

specialty medications covered under the pharmacy benefit.

Discretionary Authority

The operation and administration of the medical benefit Plan,

with full discretionary authority to: interpret the Plan;

determine the amount of benefits available under the Plan,

including the discretionary authority to grant or deny internal

claims and appeals; gather needed information; prescribe

forms; and to employ or appoint persons to help or advise in

any administrative functions to administer the Plan. The Plan

Administrator has the necessary discretionary authority and

control over the Plan to require deferential judicial review

with respect to internal claim and appeal determinations.

Therefore, the Plan Administrator’s exercise of discretion in

its interpretation of the Plan’s written terms and its findings of

fact in its role as the Plan Administrator will not be overturned

unless a court determines they are arbitrary and capricious.

The Plan Administrator has delegated to Cigna with respect to

medical claims its complete discretionary authority to interpret

and apply Plan terms and to make factual determinations in

connection with their review of benefit claims and first-level

internal appeal under the Plan. Such discretionary authority is

intended to include, but is not limited to, 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 has also delegated to Cigna with respect to

medical claims its complete 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. These claims administrators have

the full extent of the Plan Administrator’s discretionary

authority and duties with respect to those responsibilities

delegated to them, including full discretionary authority to

interpret the Plan; the amount of benefits under the Plan,

including the discretionary authority to grant or deny claims

and first-level internal appeal; and exercise all of the power

and discretionary authority contemplated by ERISA with

respect to making initial claim and final internal appeal

determinations under the Plan. Therefore, the claims

administrator’s exercise of discretion in their interpretation of

the Plan’s written terms and their finding of fact in their role

as the Plan’s claims fiduciary will not be overturned unless a

court determines they are arbitrary and capricious.

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.

Any amendment will be in writing and duly adopted in

accordance with the Plan’s amendment procedures. No

consent of any participant or beneficiary is required to

terminate, modify, amend or change the Plan.

If the Plan is terminated, the rights of participants and

beneficiaries will be limited to claims incurred before the

Plan’s termination. In connection with the termination, the

Plan Administrator may establish a deadline by which all

claims must be submitted for consideration. Benefits will be

paid only for covered claims incurred prior to the termination

date and submitted in accordance with the rules established by

the Plan Administrator. Nothing in this booklet, the Plan

document, or any other communications describing the Plan

shall be construed to provide vested, non-forfeitable, non-

terminable, or non-changeable benefits or rights thereto.

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.

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 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 this booklet and 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 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 federal

court but only after you have exhausted (or are deemed to

have exhausted) the Plan’s administrative claim and appeal

procedures.

In addition, if you disagree with the Plan’s decision or lack

thereof concerning the qualified status of 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.

You must file your claim in federal court before the expiration

of the Plan’s limitations period, as described in the “Medical –

When You Have a Complaint or an Appeal” section above, or

your claim will be dismissed. In addition, any action arising

out of or in connection with the Plan may only be filed in the

United States District Court, Northern District of Georgia.

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 M 05-15

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-DFS1095 12-17

Air Ambulance Service

Medical transport by a rotary wing air ambulance or fixed

wing ambulance.

Ambulance

Licensed ambulance transportation services involve the use of

specially designed and equipped vehicles for transporting ill or

injured patients. It includes ground, air, or sea transportation

when Medically Necessary and clinically appropriate.

HC-DFS1480 01-21

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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

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 effect changes regarding coverage

treatment of Medical Pharmaceuticals based on clinical

findings provided by the P&T Committee, including, but not

limited to, changes regarding tier placement and application of

utilization management to Medical Pharmaceuticals.

HC-DFS1494 07-20

Charges

The term charges means the actual billed charges; except

when Cigna has contracted directly or indirectly for a different

amount including where Cigna has directly or indirectly

contracted with an entity to arrange for the provision of

services and/or supplies through contracts with providers of

such services and/or supplies.

HC-DFS1193 01-19

Chiropractic Care

The term Chiropractic 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-DFS55 04-10

Cigna Care Network

The term Cigna Care Network refers to a designation given to

Participating Providers who meet independently-established

criteria determining efficiency and quality.

HC-RDR4 04-10

HC-DFS371

Convenience Care Clinics

Convenience Care Clinics are staffed by nurse practitioners

and physician assistants and offer customers convenient,

professional walk-in care for common ailments and routine

services. Convenience Care Clinics have extended hours and

are located in or near easy-to-access, popular locations

(pharmacies, grocery and free-standing locations) with or

without appointment.

HC-DFS1629 07-21

Complications of Pregnancy - For Medical Insurance

Expenses will be considered to be incurred for Complications

of Pregnancy if they are incurred for: (a) an extrauterine

pregnancy; (b) a pregnancy which ends by Caesarean section

or miscarriage (other than elective abortion); or (c) a Sickness

resulting from pregnancy.

DFS19

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.

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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

Dependent

Dependents are defined in the “Eligibility – Effective Date”

section of this booklet under the subheading “Eligible

Dependents.”

HC-DFS872 M 10-16

Emergency Medical Condition

Emergency medical condition means a medical condition,

including a mental health condition or substance use disorder,

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 M 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 or an independent freestanding emergency

department, 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 or independent

freestanding emergency department, to stabilize the patient.

Emergency services also include additional services covered

under the Plan that are furnished by an Out-of-Network

provider or Our-of-Network emergency facility after the

patient is stabilized and as part of outpatient observation or an

inpatient or outpatient stay with respect to the visit in which

the initial emergency services were provided, unless you

receive these services after your provider determines that you

are stable and able to travel to an In-Network facility by non-

emergency transport, and you provide informed consent to the

continuing services as provided by law. If you continue to

receive services from the Out-of-Network provider or facility

after you are stabilized and have provided informed consent,

you will no longer be considered to be receiving emergency

services for purposes of the Plan’s special coverage rules for

these services.

HC-DFS1482 M 01-21

Employee

The term Employee is defined in the “Eligibility – Effective

Date” section of this booklet under the subheading “Eligibility

for Employee Coverage.”

HC-DFS1094 M 12-17

Employer

The term Employer means Mohawk ESV, Inc., the plan

sponsor self-insuring the benefits described in this booklet,

and its affiliates that participate in the Plan on whose behalf

Cigna is providing claim administration services.

HC-DFS1615 M 01-22

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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

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.

A Free-Standing Surgical Facility, unless specifically noted

otherwise, is covered with the same cost share as an

Outpatient Facility.

HC-DFS1484 01-21

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

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

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

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

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services under Medicare, if such institution is accredited as

a hospital by the Joint Commission on the Accreditation of

Healthcare Organizations; 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 does not include an institution which is

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

home.

HC-DFS1485 01-21

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

Maintenance Treatment

The term Maintenance Treatment means:

 treatment rendered to keep or maintain the patient's current

status.

HC-DFS56 04-10

Maximum Reimbursable Charge - Medical

The Maximum Reimbursable Charge for covered services for

Local Plus, other than those Out-of-Network services

described in the Schedule sections “Out-of-Network Charges

for Certain Services,” “Out-of-Network Emergency Services

Charges,” and “Charges for Air Ambulance Services” is

determined based on the lesser of:

 the provider’s normal charge for a similar service or supply;

 the amount agreed to by the Out-of-Network provider and

Cigna; or

 an Employer-selected percentage of a fee schedule Cigna

has developed that is based upon a methodology similar to a

methodology utilized by Medicare to determine the

allowable reimbursement 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;

 the amount agreed to by the Out-of-Network provider and

Cigna; 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. If sufficient

charge data is unavailable in the database for that

geographic area to determine the Maximum Reimbursable

Charge, then data in the database for similar services may

be used.

HC-DFS1631 M 01-22

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

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 Professional within the

scope of the provider's license. This definition includes certain

pharmaceutical products whose administration may initially or

typically require Physician or Other Health Professional

oversight but may be self-administered under certain

conditions specified in the product’s FDA labeling.

HC-DFS1632 01-22

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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 Professional;

 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.

In determining whether health care services, supplies, or

medications are Medically Necessary, the Medical Director or

Review Organization may rely on the clinical coverage

policies maintained by Cigna or the Review Organization.

Clinical coverage policies may incorporate, without limitation

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

Administration-approved labeling, the standard medical

reference compendia and peer-reviewed, evidence-based

scientific literature or guidelines.

HC-DFS1486 01-21

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

Necessary Services and Supplies

The term Necessary Services and Supplies includes any

charges, except charges for Room and Board, made by a

Hospital for medical services and supplies actually used

during Hospital Confinement.

The term Necessary Services and Supplies will not include

any charges for special nursing fees, dental fees or medical

fees.

HC-DFS1488 01-21

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

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

makes a Prescription Drug List coverage status decision.

HC-DFS1498 07-20

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

Other Health Care Facility

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.

HC-DFS1489 01-21

Other Health Professional

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

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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-DFS1490 01-21

Participating Provider

The term Participating Provider means a person or entity that

has a direct or indirect contractual arrangement with Cigna to

provide covered services and/or supplies, the Charges for

which are Covered Expenses. It includes an entity that has

directly or indirectly contracted with Cigna to arrange, through

contracts with providers of services and/or supplies, for the

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

which are Covered Expenses.

HC-DFS1194 01-19

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 & Therapeutics (P&T) Committee

A committee comprised of physicians and an independent

pharmacist that represent a range of clinical specialties. The

committee regularly reviews Medical Pharmaceuticals for

safety and efficacy, the findings of which clinical reviews

inform coverage determinations 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-DFS1495 07-20

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

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). This list is 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.

HC-DFS1496 07-20

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. For the purpose of benefits under

the Plan, this definition may also include products in the

following categories if specifically identified in the

Prescription Drug List:

 Certain durable products and supplies that support drug

therapy;

 Certain diagnostic testing and screening services that

support drug therapy;

 Certain medication consultation and other medication

administration services that support drug therapy; and

 Certain digital products, applications, electronic devices,

software and cloud based service solutions used to predict,

detect and monitor health conditions in support of drug

therapy.

HC-DFS1633 01-22

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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 Treatment

The term Preventive Treatment means treatment rendered to

prevent disease or its recurrence.

HC-DFS57 04-10

Primary Care Physician

The term Primary Care Physician means a Physician who

qualifies as a Participating Provider in general practice,

internal medicine, family practice OB/GYN or pediatrics; and

who has been voluntarily selected by you and is contracted as

a Primary Care Physician with, as authorized by Cigna, to

provide or arrange for medical care for you or any of your

insured Dependents.

HC-DFS40 04-10

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

Retirement

Under certain circumstances, Employees can continue to

participate in the Mohawk ESV, Inc. Health Care Plan (the

"Mohawk Plan") after they retire from employment.

If you retire after you reach age 60 and prior to turning age 65

with ten (10) years of service your benefits may continue

until:

A. The date that you become covered under another Group

Health Plan or the date you become eligible for the Federal

Medicare Program (other than for end-stage renal failure);

B. The date in which COBRA payment is not made;

C. The date that a covered Dependent no longer meets the

definition of Dependent;

D. The last day of the month following your death.

Once you or any of your covered eligible Dependent(s) reach

age 65 or become eligible for any other group medical

coverage, including becoming eligible for the Federal

Medicare Program (other than for end-stage renal failure),

your medical coverage under the Mohawk Plan will end.

However, if you are eligible for Medicare, but your spouse is

not, your spouse can still be covered under the Mohawk Plan

until he/she turns 65 or becomes eligible for other group

medical coverage or Medicare (other than for end-stage renal

failure).

Your benefits under the Mohawk Plan will be the same as

those provided to active covered Employees. The premiums

for this medical coverage will be equal to equivalent COBRA

premiums under the Mohawk Plan. This amount can change

annually and you are responsible for payment of these

premiums.

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 M 12-15

Room and Board

The term Room and Board includes all charges made by a

Hospital for room and meals and for all general services and

activities needed for the care of registered bed patients.

HC-DFS1481 01-21

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Sickness – For Medical Insurance

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

includes pregnancy for you or your spouse and complications

of pregnancy for your dependent child. 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 M

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

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

Specialty Prescription Drug Product

A 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

Medical Pharmaceutical is prescribed and used for the

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

Medical Pharmaceutical has a high acquisition cost; and,

whether the 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 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

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

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

Therapeutic Alternative

A 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

Medical Pharmaceutical or over-the-counter medication.

HC-DFS859 10-16

Therapeutic Equivalent

A Medical Pharmaceutical that is a pharmaceutical equivalent

to another 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,

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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