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					Denver Public Schools



NETWORK MEDICAL BENEFITS
   (High Plan)



EFFECTIVE DATE: July 1, 2010




CN001
3333275




This document printed in August, 2010 takes the place of any documents previously issued to you which
described your benefits.




Printed in U.S.A.
                                                            Table of Contents
Certification....................................................................................................................................5
Special Plan Provisions..................................................................................................................7
     Case Management ..................................................................................................................................................7
How To File Your Claim ...............................................................................................................8
Accident and Health Provisions....................................................................................................8
Eligibility - Effective Date .............................................................................................................9
     Waiting Period........................................................................................................................................................9
     Employee Insurance ...............................................................................................................................................9
     Dependent Insurance ..............................................................................................................................................9
Important Information About Your Medical Plan...................................................................10
Network Medical Benefits ...........................................................................................................12
     The Schedule ........................................................................................................................................................12
     Prior Authorization/Pre-Authorized .....................................................................................................................20
     Covered Expenses ................................................................................................................................................20
Medical Conversion Privilege .....................................................................................................29
Prescription Drug Benefits..........................................................................................................31
     The Schedule ........................................................................................................................................................31
     Covered Expenses ................................................................................................................................................33
     Limitations............................................................................................................................................................33
     Your Payments .....................................................................................................................................................33
     Exclusions ............................................................................................................................................................34
     Reimbursement/Filing a Claim.............................................................................................................................34
Exclusions, Expenses Not Covered and General Limitations..................................................34
Coordination of Benefits..............................................................................................................37
Medicare Eligibles........................................................................................................................39
Expenses For Which A Third Party May Be Liable.................................................................40
Payment of Benefits .....................................................................................................................40
Termination of Insurance............................................................................................................40
     Employees ............................................................................................................................................................40
     Dependents ...........................................................................................................................................................41
     Special Continuation of Medical Insurance..........................................................................................................41
Medical Benefits Extension .........................................................................................................41
Federal Requirements .................................................................................................................42
     Notice of Provider Directory/Networks................................................................................................................42
     Qualified Medical Child Support Order (QMCSO) .............................................................................................42
     Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) ..................43
     Coverage of Students on Medically Necessary Leave of Absence.......................................................................44
     Effect of Section 125 Tax Regulations on This Plan............................................................................................44
     Eligibility for Coverage for Adopted Children.....................................................................................................45
     Federal Tax Implications for Dependent Coverage..............................................................................................45
     Coverage for Maternity Hospital Stay..................................................................................................................45
     Women’s Health and Cancer Rights Act (WHCRA) ...........................................................................................45
     Group Plan Coverage Instead of Medicaid...........................................................................................................46
     Obtaining a Certificate of Creditable Coverage Under This Plan ........................................................................46
     Requirements of Medical Leave Act of 1993 (as amended) (FMLA) ..................................................................46
     Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)....................................46
     COBRA Continuation Rights Under Federal Law ...............................................................................................47
     Notice of an Appeal or a Grievance .....................................................................................................................50
When You Have A Complaint or An Appeal ............................................................................50
Definitions.....................................................................................................................................54
                                                                                        Home Office: Bloomfield, Connecticut
                                                                             Mailing Address: Hartford, Connecticut 06152




CONNECTICUT GENERAL LIFE INSURANCE COMPANY
a CIGNA company (called CG) certifies that it insures certain Employees for the benefits provided by the
following policy(s):




POLICYHOLDER: Denver Public Schools



GROUP POLICY(S) — COVERAGE
3333275 - CIGH NETWORK MEDICAL BENEFITS



EFFECTIVE DATE: July 1, 2010

                                                         NOTICE
                                                         Any insurance benefits in this certificate will apply to an Employee
                                                         only if: a) he has elected that benefit; and b) he has a "Final
                                                         Confirmation Letter," with his name, which shows his election of that
                                                         benefit.




This certificate describes the main features of the insurance. It does not waive or alter any of the terms of
the policy(s). If questions arise, the policy(s) will govern.
This certificate takes the place of any other issued to you on a prior date which described the insurance.




                                                                                                                 CER1V17
                                                     5
                                                          Explanation of Terms
You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms
are defined in the Definitions section of your certificate.


                                                             The Schedule
The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description
of each benefit, refer to the appropriate section listed in the Table of Contents.
                                                                         4.   Following an initial assessment, the Case Manager works
Special Plan Provisions                                                       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
Case Management                                                               medical care in lieu of an extended Hospital
Case Management is a service provided through a Review                        convalescence). You are not penalized if the alternate
Organization, which assists individuals with treatment needs                  treatment program is not followed.
that extend beyond the acute care setting. The goal of Case              5.   The Case Manager arranges for alternate treatment
Management is to ensure that patients receive appropriate care                services and supplies, as needed (for example, nursing
in the most effective setting possible whether at home, as an                 services or a Hospital bed and other Durable Medical
outpatient, or an inpatient in a Hospital or specialized facility.            Equipment for the home).
Should the need for Case Management arise, a Case
Management professional will work closely with the patient,              6.   The Case Manager also acts as a liaison between the
his or her family and the attending Physician to determine                    insurer, the patient, his or her family and Physician as
appropriate treatment options which will best meet the                        needed (for example, by helping you to understand a
patient's needs and keep costs manageable. The Case Manager                   complex medical diagnosis or treatment plan).
will help coordinate the treatment program and arrange for               7.   Once the alternate treatment program is in place, the Case
necessary resources. Case Managers are also available to                      Manager continues to manage the case to ensure the
answer questions and provide ongoing support for the family                   treatment program remains appropriate to the patient's
in times of medical crisis.                                                   needs.
Case Managers are Registered Nurses (RNs) and other                      While participation in Case Management is strictly voluntary,
credentialed health care professionals, each trained in a                Case Management professionals can offer quality, cost-
clinical specialty area such as trauma, high risk pregnancy and          effective treatment alternatives, as well as provide assistance
neonates, oncology, mental health, rehabilitation or general             in obtaining needed medical resources and ongoing family
medicine and surgery. A Case Manager trained in the                      support in a time of need.
appropriate clinical specialty area will be assigned to you or
your Dependent. In addition, Case Managers are supported by
                                                                         FPCM2
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                 Additional Programs
helps coordinate needed resources, the patient's attending               We may, from time to time, offer or arrange for various
Physician remains responsible for the actual medical care.               entities to offer discounts, benefits, or other consideration to
1.   You, your dependent or an attending Physician can                   our members for the purpose of promoting the general health
     request Case Management services by calling the toll-free           and well being of our members. We may also arrange for the
     number shown on your ID card during normal business                 reimbursement of all or a portion of the cost of services
     hours, Monday through Friday. In addition, your                     provided by other parties to the Policyholder. Contact us for
     employer, a claim office or a utilization review program            details regarding any such arrangements.
     (see the PAC/CSR section of your certificate) may refer
     an individual for Case Management.
                                                                         GM6000 NOT160
2.   The Review Organization assesses each case to determine
     whether Case Management is appropriate.
3.   You or your Dependent is contacted by an assigned Case              Notice Regarding Emergency Services and Urgent Care
     Manager who explains in detail how the program works.               In the event of an Emergency, get help immediately. Go to the
     Participation in the program is voluntary - no penalty or           nearest emergency room, the nearest Hospital or call or ask
     benefit reduction is imposed if you do not wish to                  someone to call 911 or your local emergency service, police or
     participate in Case Management.                                     fire department for help. You do not need a referral from your
                                                                         PCP for Emergency Services, but you do need to call your
                                                                         PCP as soon as possible for further assistance and advice on
                                                             FPCM6
                                                                         follow-up care. If you require specialty care or a Hospital
                                                                         admission, your PCP will coordinate it and handle the



                                                                     7                                                   myCIGNA.com
necessary authorizations for care or hospitalization.                   If you have a Benefit Identification Card, present it at the
Participating Providers are on call 24 hours a day, seven days          admission office at the time of your admission. The card tells
a week to assist you when you need Emergency Services.                  the Hospital to send its bills directly to CG.
If you receive Emergency Services outside the service area,             Doctor's Bills and Other Medical Expenses
you must notify the Review Organization as soon as                      The first Medical Claim should be filed as soon as you have
reasonably possible. The Review Organization may arrange to             incurred covered expenses. Itemized copies of your bills
have you transferred to a Participating Provider for continuing         should be sent with the claim form. If you have any additional
or follow-up care, if it is determined to be medically safe to do       bills after the first treatment, file them periodically.
so.
                                                                        CLAIM REMINDERS
Urgent Care Inside the Service Area
                                                                        • BE SURE TO USE YOUR MEMBER ID AND
For Urgent Care inside the service area, you must take all                 ACCOUNT NUMBER WHEN YOU FILE CG'S CLAIM
reasonable steps to contact your PCP for direction and you                 FORMS, OR WHEN YOU CALL YOUR CG CLAIM
must receive care from a Participating Provider, unless                    OFFICE.
otherwise authorized by your PCP or the Review
                                                                            YOUR MEMBER ID IS THE ID SHOWN ON YOUR
Organization.
                                                                            BENEFIT IDENTIFICATION CARD.
Urgent Care Outside the Service Area
                                                                            YOUR ACCOUNT NUMBER IS THE 7-DIGIT POLICY
In the event you need Urgent Care while outside the service                 NUMBER SHOWN ON YOUR BENEFIT
area, you should, whenever possible, contact your PCP or the                IDENTIFICATION CARD.
CIGNA HealthCare 24-Hour Health Information Line for
                                                                        •   PROMPT FILING OF ANY REQUIRED CLAIM FORMS
direction and authorization prior to receiving services.
                                                                            RESULTS IN FASTER PAYMENT OF YOUR CLAIMS.
Continuing or Follow-up Treatment
                                                                        WARNING: Any person who knowingly presents a false or
Continuing or follow-up treatment, whether in or out of the             fraudulent claim for payment of a loss or benefit is guilty of a
service area is not covered unless it is provided or arranged for       crime and may be subject to fines and confinement in prison.
by your PCP or upon prior authorization by the Review
Organization.
                                                                        GM6000 CI 3                                               CLA9V36


GM6000 NOT91


                                                                        Accident and Health Provisions
                                                                        Claims
How To File Your Claim
                                                                        NOTICE OF CLAIM, CLAIM FORMS and PROOF OF
When you or your Dependents seek care through a                         LOSS provisions do not apply to services or supplies
Participating Provider, you are only responsible for the                recommended by and received from Participating Providers, if
applicable copayment, coinsurance or deductible amount                  that service or supply is authorized by the Provider
shown in the Schedule. You do not need to file a claim form.            Organization.
If you or your Dependents seek care through a Non-                      Notice of Claim
Participating Provider, you must submit a claim form to be
reimbursed.                                                             Written notice of claim must be given to CG within 30 days
                                                                        after the occurrence or start of the loss on which claim is
You may get the required claim forms from your Benefit Plan             based.
Administrator. All fully completed claim forms and bills
should be sent directly to your servicing CG Claim Office.              If notice is not given in that time, the claim will not be
                                                                        invalidated or reduced if it is shown that written notice was
Depending on your Group Insurance Plan benefits, file your              given as soon as was reasonably possible.
claim forms as described below.
                                                                        Claim Forms
Hospital Confinement
                                                                        When CG receives the notice of claim it will give to the
If possible, get your Group Medical Insurance claim form                claimant, or to the Policyholder for the claimant, the claim
before you are admitted to the Hospital. This form will make            forms which it uses for filing proof of loss. If the claimant
your admission easier and any cash deposit usually required             does not get these claim forms within 15 days after CG
will be waived.                                                         receives notice of claim, he will be considered to meet the
                                                                        proof of loss if he submits written proof of loss within 90 days


                                                                    8                                                   myCIGNA.com
after the date of loss. This proof must describe the occurrence,        Waiting Period
character and extent of the loss for which claim is made.
                                                                        Initial Employee Group: None.
Proof of Loss
                                                                        New Employee Group: The first day of the month following
Written proof of loss must be given to CG within 90 days after          date of hire, provided that Employee completes their
the date of the loss for which claim is made. If written proof of       enrollment form within 60 calendar days from hire date.
loss is not given in that time, the claim will not be invalidated
or reduced if it is shown that written proof of loss was given as       Classes of Eligible Employees
soon as was reasonably possible.                                        Each Employee as reported to the insurance company by your
Physical Examination                                                    Employer.
CG, at its own expense, will have the right to examine any
person for whom claim is pending as often as it may                     GM6000 EL 2                                                 V-31 M
reasonably require.                                                                                                                    ELI5

Legal Action
Where CG has followed the terms of the policy, no action at
law or in equity will be brought to recover on the policy until         Employee Insurance
at least 60 days after proof of loss has been filed with CG. No         This plan is offered to you as an Employee. To be insured, you
action will be brought at all unless brought within 3 years after       will have to pay part of the cost.
the time within which proof of loss is required.
                                                                        Effective Date of Your Insurance
                                                                        You will become insured on the date you elect the insurance
GM6000 PRO14V5                                           CLA43V34       by signing an approved payroll deduction form, but no earlier
                                                                        than the date you become eligible. If you are a Late Entrant,
                                                                        your insurance will not become effective until CG agrees to
                                                                        insure you. You will not be denied enrollment for Medical
Eligibility - Effective Date                                            Insurance due to your health status.
Eligibility for Employee Insurance                                      You will become insured on your first day of eligibility,
You will become eligible for insurance on the day you                   following your election, if you are in Active Service on that
complete the waiting period if:                                         date, or if you are not in Active Service on that date due to
•   you are in a Class of Eligible Employees; and                       your health status. However, you will not be insured for any
                                                                        loss of life, dismemberment or loss of income coverage until
•   you are an eligible, full-time or part-time Employee; who
                                                                        you are in Active Service.
    normally works at least 20 hours a week; or
                                                                        Late Entrant - Employee
If you were previously insured and your insurance ceased, you
must satisfy the New Employee Group Waiting Period to                   You are a Late Entrant if:
become insured again. If your insurance ceased because you              •   you elect the insurance more than 30 days after you become
were no longer employed in a Class of Eligible Employees,                   eligible; or
you are not required to satisfy any waiting period if you again         •   you again elect it after you cancel your payroll deduction.
become a member of a Class of Eligible Employees within
one year after your insurance ceased.
                                                                        GM6000 EF 1                                                 ELI7V82
Initial Employee Group: You are in the Initial Employee
Group if you are employed in a class of employees on the date
that class of employees becomes a Class of Eligible
Employees as determined by your Employer.                               Dependent Insurance
New Employee Group: You are in the New Employee Group                   For your Dependents to be insured, you will have to pay part
if you are not in the Initial Employee Group.                           of the cost of Dependent Insurance.
Eligibility for Dependent Insurance                                     Effective Date of Dependent Insurance
You will become eligible for Dependent insurance on the later           Insurance for your Dependents will become effective on the
of:                                                                     date you elect it by signing an approved payroll deduction
•   the day you become eligible for yourself; or                        form, but no earlier than the day you become eligible for
                                                                        Dependent Insurance. All of your Dependents as defined will
•   the day you acquire your first Dependent.
                                                                        be included.


                                                                    9                                                   myCIGNA.com
If you are a Late Entrant for Dependent Insurance, the                     your ID card. Any such transfer will be effective on the first
insurance for each of your Dependents will not become                      day of the month following the month in which the processing
effective until CG agrees to insure that Dependent. Your                   of the change request is completed.
Dependent will not be denied enrollment for Medical                        In addition, if at any time a Primary Care Physician ceases to
Insurance due to health status.                                            be a Participating Provider, you or your Dependent will be
Your Dependents will be insured only if you are insured.                   notified for the purpose of selecting a new Primary Care
Late Entrant – Dependent                                                   Physician.
You are a Late Entrant for Dependent Insurance if:                         Direct Access for Ob/Gyn Services:
•   you elect that insurance more than 30 days after you                   Female insureds covered by this plan are allowed direct access
    become eligible for it; or                                             to a licensed/certified Participating Provider for covered
                                                                           ob/gyn services. There is no requirement to obtain an
•   you again elect it after you cancel your payroll deduction.            authorization of care from your Primary Care Physician for
                                                                           visits to the Participating Provider of your choice for
Exception for Newborns                                                     pregnancy, well-woman gynecological exams, primary and
                                                                           preventive gynecological care, and acute gynecological
Any Dependent child born while you are insured for Medical                 conditions.
Insurance will become insured for Medical Insurance on the
date of his birth if you elect Dependent Medical Insurance no
later than 31 days after his birth. If you do not elect to insure          GM6000 FLX143                                                  V35
your newborn child within such 31 days, coverage for that
child will end on the 31st day. No benefits for expenses
incurred beyond the 31st day will be payable.                              Continuity of Care
                                                                           If a provider terminates from participation in the plan for
                                                                           reasons other than for cause, coverage will continue for at
GM6000 EF 2                                                ELI11V44
                                                                           least 90 days from the date the provider notifies you. A
                                                                           terminated provider shall be permitted to provide health care
                                                                           services to any enrollee who: (a) was in an active course of
Important Information About Your                                           treatment prior to the notice of termination; (b) requests to
                                                                           continue receiving health care services from the provider; (c)
Medical Plan                                                               has entered into the second or third trimester of pregnancy at
Details of your medical benefits are described on the                      the time of the provider's termination. Treatment for
following pages.                                                           pregnancy shall continue through the provision of postpartum
Primary Care Physician                                                     care directly related to the delivery; or (d) is determined to be
                                                                           terminally ill and the provider was treating the terminal illness
Choice of Primary Care Physician:                                          prior to the date of the provider's termination or knowledge of
When you elect Medical Insurance, you will select a Primary                termination. Treatment for a terminally ill enrollee shall
Care Physician for yourself and your Dependents from a list                continue for the remainder of the enrollee's life for care related
provided by CG. The Primary Care Physician you select for                  directly to the treatment of the terminal illness.
yourself may be different from the Primary Care Physician
you select for each of your Dependents.
                                                                           GM6000                                                    FLX143V32
Primary Care Physician's Role/Your Responsibility:
The Primary Care Physician's role is to provide or arrange for
medical care for you and any of your Dependents.
You and your Dependents are responsible for contacting and
obtaining the authorization of the Primary Care Physician, as
required, prior to seeking medical care. (You are responsible
for obtaining such authorization on behalf of a Dependent who
is a minor.)
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



                                                                      10                                                   myCIGNA.com
Direct Access For Mental Health And Substance Abuse
Services:
Insureds covered by this plan are allowed direct access to a
licensed/certified Participating Provider for covered Mental
Health and Substance Abuse Services. There is no requirement
to obtain an authorization of care from your Primary Care
Physician for individual or group therapy visits to the
Participating Provider of your choice for Mental Health and
Substance Abuse.


GM6000 FLX142                                            V57




                                                               11   myCIGNA.com
                                   NETWORK MEDICAL BENEFITS
                                                   The Schedule
For You and Your Dependents
Network Medical Benefits provide coverage for care In-Network. To receive Network Medical Benefits, you and your
Dependents may be required to pay a portion of the Covered Expenses for services and supplies. That portion is the
Copayment, Deductible or Coinsurance.

If you are unable to locate an In-Network Provider in your area who can provide you with a service or supply that is
covered under this plan, you must call the number on the back of your I.D. card to obtain authorization for Out-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.
Copayments
Copayments are expenses to be paid by you or your Dependent for covered services. Copayments are in addition to any
Coinsurance.

Out-of-Pocket Expenses
Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan because of any:
  •   Coinsurance.
  •   inpatient hospital facility copayments.
  •   outpatient facility copayments.
Charges will not accumulate toward the Out-of-Pocket Maximum for Covered Expenses incurred for:
  •   non-compliance penalties.
When the Out-of-Pocket Maximum shown in The Schedule is reached, Injury and Sickness benefits are payable at 100%
except for:
  •   non-compliance penalties.

Contract Year
Contract Year means a twelve month period beginning on each 07/01.
Guest Privileges
If you or one of your Dependents will be residing temporarily in another location where there are In-Network Providers,
you may be eligible for Point of Service Medical Benefits at that location. However, the benefits available at the host
location may differ from those described in this certificate. Refer to your Benefit Summary from the host location or
contact your Employer for more information.




                                                           12                                                 myCIGNA.com
                                 NETWORK 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 20 percent of
the surgeon’s allowable charge. (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 will be limited to charges made by co-surgeons that do not exceed 20 percent of the
surgeon’s allowable charge plus 20 percent. (For purposes of this limitation, allowable charge means the amount payable
to the surgeons prior to any reductions due to coinsurance or deductible amounts.)

               BENEFIT HIGHLIGHTS                                               IN-NETWORK
Lifetime Maximum                                         Unlimited
Coinsurance Level                                        100%
Out-of-Pocket Maximum
  Individual                                             $2,500 per person
  Family Maximum                                         $7,500 per family
  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%.
Physician’s Services
  Primary Care Physician’s Office visit                  No charge after $25 per office visit copay; No charge if only
                                                         x-ray and lab services performed and billed.
  Specialty Care Physician's Office Visits               No charge after $45 per office visit copay; No charge if only
      Consultant and Referral Physician's Services       x-ray and lab services performed and billed.

      Note:
      OB/GYN provider is considered a Specialist.
  Surgery Performed In the Physician’s Office            No charge after the $25 PCP or $45 Specialist per office visit
                                                         copay
  Second Opinion Consultations (provided on a            No charge after the $25 PCP or $45 Specialist per office visit
  voluntary basis)                                       copay
  Allergy Treatment/Injections                           No charge after either the $25 PCP or $45 Specialist per office
                                                         visit copay or the actual charge, whichever is less
  Allergy Serum (dispensed by the Physician in the       No charge
  office)



                                                          13                                                   myCIGNA.com
              BENEFIT HIGHLIGHTS                                               IN-NETWORK
Preventive Care                                         No charge after the $25 PCP or $45 Specialist per office visit
                                                        copay
  Routine Preventive Care: Well-Baby, Well-Child,
  Adult and Well-Woman (including immunizations)
  Note:
  Well-Woman OB/GYN visits will be considered a
  Specialist visit.
  Immunizations                                         No charge
Early Intervention Services
Up to $6,036 per child per year over the 3-year program period (not applied toward any maximum lifetime or annual
benefit limits otherwise specified in the plan).
Mammograms, PSA, PAP Smear
  Preventive Care Related Services (i.e. “routine”      No charge (includes charges for the procedure itself and the
  services)                                             professional reading charge)
  Diagnostic Related Services (i.e. “non-routine”       Subject to the plan’s x-ray & lab benefit; based on place of
  services)                                             service
                                                        Note:
                                                        The associated wellness exam is subject to the $25 PCP or $45
                                                        Specialist per office visit copay
Colorectal Cancer Screening                             No charge after the $25 PCP or $45 Specialist per office visit
(i.e. "routine" preventive services)                    copay
   Contract Year Maximum:
   Unlimited
Inpatient Hospital - Facility Services                  No charge after $500 per admission copay
  Semi-Private Room and Board                           Limited to the semi-private negotiated rate
  Private Room                                          Limited to the semi-private negotiated rate
  Special Care Units (ICU/CCU)                          Limited to the negotiated rate
Outpatient Facility Services                            No charge after $250 per visit copay
 Operating Room, Recovery Room, Procedures
 Room, Treatment Room and Observation Room
 Note:
 The copay will apply as long as services billed
 include one or more of the facility room charges
 listed above.
Inpatient Hospital Physician’s Visits/Consultations     No charge
Inpatient Hospital Professional Services                No charge
  Surgeon
  Radiologist
  Pathologist
  Anesthesiologist



                                                          14                                                  myCIGNA.com
              BENEFIT HIGHLIGHTS                                                IN-NETWORK
Outpatient Professional Services                         No charge
  Surgeon
  Radiologist
  Pathologist
  Anesthesiologist
Emergency and Urgent Care Services
  Physician’s Office Visit                               No charge after the $25 PCP or $45 Specialist per office visit
                                                         copay
  Hospital Emergency Room                                No charge after $250 per visit copay** (Copay waived if
                                                         admitted)
  Outpatient Professional Services (radiology,           No charge
  pathology, ER physician)
  Urgent Care Facility or Outpatient Facility            No charge after $50 per visit copay** (Copay waived if
                                                         admitted)
  X-ray and/or Lab performed at the Emergency            No charge
  Room/Urgent Care Facility (billed by the facility as
  part of the ER/UC visit)
  Independent X-ray and/or Lab Facility in               No charge
  conjunction with an ER visit
  Advanced Radiological Imaging (i.e. MRIs, MRAs,        No charge after $100 scan copay
  CAT Scans, PET Scans etc.)
  Ambulance                                              No charge

                                                         **If not a true emergency, services are not covered
Inpatient Services at Other Health Care Facilities       No charge
  Includes Skilled Nursing Facility, Rehabilitation
  Hospital and Sub-Acute Facilities
  Contract Year Maximum:
  60 days combined
  No prior hospitalization required
Laboratory and Radiology Services (includes pre-
admission testing)
  Physician’s Office Visit                               No charge
  Outpatient Hospital Facility                           No charge for facility charges; no charge for outpatient
                                                         professional charges
  Independent X-ray and/or Lab Facility                  No charge




                                                          15                                                   myCIGNA.com
               BENEFIT HIGHLIGHTS                                            IN-NETWORK
Advanced Radiological Imaging (i.e. MRIs, MRAs,
CAT Scans and PET Scans)
  Physician’s Office Visit                            $100 Per Type of Scan Per Day
  Inpatient Facility                                  No charge
  Outpatient Facility                                 $100 Per Type of Scan Per Day
Outpatient Short-Term Rehabilitative Therapy          No charge after the $25 PCP or $45 Specialist per office visit
and Chiropractic Services                             copay; No charge if only x-ray and/or lab services performed
                                                      and billed.
  Contract Year Maximum:
  60 days for all therapies combined                  Note:
  Includes:                                           The Outpatient Short Term Rehab copay does not apply to
  Physical Therapy *                                  services provided as part of a Home Health Care visit.
  Speech Therapy *
  Occupational Therapy *                              Note:
  Pulmonary Rehab                                     Therapy days, provided as part of an approved Home Health
  Cognitive Therapy                                   Care plan, accumulate to the Outpatient Short Term Rehab
  Chiropractic Therapy (includes Chiropractors)       Therapy maximum. If multiple outpatient services are provided
                                                      on the same day, they constitute one day, but a separate copay
                                                      will apply to the services provided by each Participating
                                                      provider.
  *Note:
  Physical Therapy, Speech Therapy and
  Occupational Therapy will be subject to no less
  than 20 days per therapy per Contract Year for
  children age 3 to 6 with congenital disabilities.
.
Outpatient Cardiac Rehabilitation                     No charge after the $25 PCP or $45 Specialist per office visit
  Contract Year Maximum:                              copay; No charge if only x-ray and/or lab services performed
  36 days                                             and billed.

Home Health Care                                      No charge
 Contract Year Maximum:
 60 days (includes outpatient private nursing when
 approved as medically necessary)
Hospice
  Inpatient Services                                  No charge
  Outpatient Services (same coinsurance level as      No charge
  Home Health Care)
Bereavement Counseling
Services Provided as part of Hospice Care
  Inpatient                                           No charge
  Outpatient                                          No charge
  Services Provided by Mental Health Professional     Covered under Mental Health benefit




                                                       16                                                   myCIGNA.com
              BENEFIT HIGHLIGHTS                                                IN-NETWORK
Maternity Care Services
  Initial Visit to Confirm Pregnancy                     No charge after the $25 PCP or $45 Specialist per office visit
                                                         copay; No charge if only x-ray and/or lab services performed
  Note:                                                  and billed.
  OB/GYN provider is considered a Specialist.
  All subsequent Prenatal Visits, Postnatal Visits and   No charge
  Physician’s Delivery Charges (i.e. global maternity
  fee)
  Physician’s Office Visits in addition to the global    No charge after the $25 PCP or $45 Specialist per office visit
  maternity fee when performed by an OB/GYN or           copay; No charge if only x-ray and/or lab services performed
  Specialist                                             and billed.
  Delivery - Facility                                    No charge after $500 per admission copay
  (Inpatient Hospital, Birthing Center)
Abortion
Includes elective and non-elective procedures
  Physician’s Office Visit                               No charge after the $25 PCP or $45 Specialist per office visit
                                                         copay; No charge if only x-ray and/or lab services performed
                                                         and billed.
  Inpatient Facility                                     No charge after $500 per admission copay
  Outpatient Facility                                    No charge after $250 per visit copay
  Physician’s Services                                   No charge
Family Planning Services
  Physician’s Office Visit (tests, counseling)           No charge after the $25 PCP or $45 Specialist per office visit
                                                         copay; No charge if only x-ray and/or lab services performed
                                                         and billed.

                                                         Note: Charges billed by a separate independent xray/lab
                                                         facility will be covered under the plan's Laboratory and
                                                         Radiology benefit.
  Surgical Sterilization Procedures for
  Vasectomy/Tubal Ligation (excludes reversals)
      Physician’s Office Visit                           No charge after the $25 PCP or $45 Specialist per office visit
                                                         copay
      Inpatient Facility                                 No charge after $500 per admission copay
      Outpatient Facility                                No charge after $250 per visit copay
      Physician’s Services                               No charge




                                                          17                                                   myCIGNA.com
                BENEFIT HIGHLIGHTS                                                   IN-NETWORK
Infertility Treatment                                         Not Covered
Services Not Covered include:
  •   Testing performed specifically to determine the
      cause of infertility.
  •   Treatment and/or procedures performed
      specifically to restore fertility (e.g. procedures to
      correct an infertility condition).
  •   Artificial means of becoming pregnant (e.g.
      Artificial Insemination, In-vitro, GIFT, ZIFT,
      etc).
  Note:
  Coverage will be provided for the treatment of an
  underlying medical condition up to the point an
  infertility condition is diagnosed. Services will be
  covered as any other illness.
Organ Transplants
Includes all medically appropriate, non-experimental
transplants
  Physician’s Office Visit                                    No charge after the $25 PCP or $45 Specialist per office visit
                                                              copay; No charge if only x-ray and/or lab services performed
                                                              and billed.
  Inpatient Facility                                          No charge after $500 per admission copay
  Inpatient Physician’s Services                              No charge
  Lifetime Travel Maximum:                                    No charge (only available when using Lifesource facility)
  $10,000 per transplant
Durable Medical Equipment                                     No charge
  Contract Year Maximum:
  $3,500
External Prosthetic Appliances                                No charge after $100 EPA deductible per Contract Year EPA
  Contract Year Maximum:                                      deductible
  Unlimited
Nutritional Evaluation
  Contract Year Maximum:
  3 visits per person, however the 3 visit limit will not
  apply to treatment of diabetes
  Physician’s Office Visit                                    No charge after the $25 PCP or $45 Specialist per office visit
                                                              copay
  Inpatient Facility                                          No charge after $500 per admission copay
  Outpatient Facility                                         No charge after $250 per visit copay
  Physician's Services                                        No charge



                                                               18                                                   myCIGNA.com
              BENEFIT HIGHLIGHTS                                                 IN-NETWORK
Dental Care
Limited to charges made for a continuous course of
dental treatment started within six months of an injury
to sound, natural teeth.
   Physician’s Office Visit                               No charge after the $25 PCP or $45 Specialist per office visit
                                                          copay
  Inpatient Facility                                      No charge after $500 per admission copay
  Outpatient Facility                                     No charge after $250 per visit copay
  Physician’s Services                                    No charge
Routine Foot Disorders                                    Not covered except for services associated with foot care for
                                                          diabetes and peripheral vascular disease.
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 abuse expense will be determined by the utilization
review Physician in accordance with the applicable mixed services claim guidelines.
Mental Health
  Inpatient                                               No charge after $500 per admission copay
  Outpatient (Includes Individual, Group and
  Intensive Outpatient)
    Physician's Office Visit                              No charge after the $25 PCP or $45 Specialist per office visit
                                                          copay
    .
Substance Abuse
  Inpatient                                               No charge after $500 per admission copay
  Outpatient (Includes Individual and Intensive
  Outpatient)
    Physician's Office Visit                              No charge after the $25 PCP or $45 Specialist per office visit
                                                          copay
    .




                                                           19                                                   myCIGNA.com
Network Medical Benefits                                                   •   charges made on its own behalf, by an Other Health Care
                                                                               Facility, including a Skilled Nursing Facility, a
Prior Authorization/Pre-Authorized                                             Rehabilitation Hospital or a subacute facility for medical
The term Prior Authorization means the approval that a                         care and treatment; except that for any day of Other Health
Participating Provider must receive from the Review                            Care Facility confinement, Covered Expenses will not
Organization, prior to services being rendered, in order for                   include that portion of charges which are in excess of the
certain services and benefits to be covered under this policy.                 Other Health Care Facility Daily Limit shown in The
                                                                               Schedule.
Services that require Prior Authorization include, but are not
limited to:                                                                •   charges made for Emergency Services and Urgent Care.
•   inpatient Hospital services;                                           •   charges made by a Physician or a Psychologist for
                                                                               professional services.
•   inpatient services at any participating Other Health Care
    Facility;                                                              •   charges made by a Nurse, other than a member of your
                                                                               family or your Dependent's family, for professional nursing
•   residential treatment;                                                     service.
•   outpatient facility services;
•   intensive outpatient programs;                                         GM6000 CM5                                              FLX107V126
•   advanced radiological imaging;
•   nonemergency ambulance; or                                             •   charges made for anesthetics and their administration;
•   transplant services.                                                       diagnostic x-ray and laboratory examinations; x-ray,
                                                                               radium, and radioactive isotope treatment; chemotherapy;
                                                                               blood transfusions; oxygen and other gases and their
GM6000 05BPT16                                                   V6
                                                                               administration.


Covered Expenses                                                           GM6000 CM6                                              FLX108V748


The term Covered Expenses means the expenses incurred by
or on behalf of a person for the charges listed below if they are          •   charges made for an annual Papanicolaou laboratory
incurred after he becomes insured for these benefits. Expenses                 screening test.
incurred for such charges are considered Covered Expenses to               •   charges for appropriate counseling, medical services
the extent that the services or supplies provided are                          connected with surgical therapies, including vasectomy and
recommended by a Physician, and are Medically Necessary                        tubal ligation.
for the care and treatment of an Injury or a Sickness, as                  •   charges made for laboratory services, radiation therapy and
determined by CG. Any applicable Copayments,                                   other diagnostic and therapeutic radiological procedures.
Deductibles or limits are shown in The Schedule.
                                                                           •   charges made for Family Planning, including medical
Covered Expenses                                                               history, physical exam, related laboratory tests, medical
• charges made by a Hospital, on its own behalf, for Bed and                   supervision in accordance with generally accepted medical
  Board and other Necessary Services and Supplies; except                      practices, other medical services, information and
  that for any day of Hospital Confinement, Covered                            counseling on contraception, implanted/injected
  Expenses will not include that portion of charges for Bed                    contraceptives.
  and Board which is more than the Bed and Board Limit                     •   charges made for Routine Preventive Care, including
  shown in The Schedule.                                                       immunizations. Routine Preventive Care means health care
•   charges for licensed ambulance service to or from the                      assessments, wellness visits and any related services.
    nearest Hospital where the needed medical care and                     •   charges made for colorectal cancer screening for the early
    treatment can be provided.                                                 detection of colorectal cancer and adenomatous polyps for
•   charges made by a Hospital, on its own behalf, for medical                 those covered persons who are asymptomatic, average risk
    care and treatment received as an outpatient.                              adults who are 50 years of age or older; and covered persons
•   charges made by a Free-Standing Surgical Facility, on its                  at high risk for colorectal cancer, including persons who
    own behalf for medical care and treatment.                                 have a family medical history of colorectal cancer; a prior



                                                                      20                                                   myCIGNA.com
    occurrence of cancer or precursor neoplastic polyps; a prior               •   the orthognathic surgery is performed prior to age 19 and
    occurrence of a chronic digestive disease condition such as                    is required as a result of severe congenital facial
    inflammatory bowel disease, Crohn’s disease, or ulcerative                     deformity or congenital condition.
    colitis; or other predisposing factors as determined by the            Repeat or subsequent orthognathic surgeries for the same
    provider. Coverage will include: (a) an annual fecal occult            condition are covered only when the previous orthognathic
    blood test, a stool-based DNA test, a CT colonoscopy; and              surgery met the above requirements, and there is a high
    either (b) a flexible sigmoidoscopy performed every five               probability of significant additional improvement as
    years; or (c) a colonoscopy performed every 10 years.                  determined by the utilization review Physician.
Early Intervention Services Program for Colorado
residents
                                                                           GM6000 06BNR10
Charges made for Medically Necessary early intervention
services for an eligible child from birth up to the child’s third
birthday, if such child has significant delays in development or           •   Phase II cardiac rehabilitation provided on an outpatient
has a diagnosed physical or mental condition that has a high                   basis following diagnosis of a qualifying cardiac condition
probability of resulting in significant delays in development,                 when Medically Necessary. Phase II is a Hospital-based
and if the service is specified in the child’s Individualized                  outpatient program following an inpatient Hospital
Family Service Plan (IFSP). Services will be delivered by a                    discharge. The Phase II program must be Physician directed
Qualified Early Intervention Service Provider which includes                   with active treatment and EKG monitoring.
a person or agency who provides early intervention services                Phase III and Phase IV cardiac rehabilitation is not covered.
and is listed on the Registry of Early Intervention Services.              Phase III follows Phase II and is generally conducted at a
Early Intervention Services do not include:                                recreational facility primarily to maintain the patient's status
                                                                           achieved through Phases I and II. Phase IV is an advancement
•   Non-emergency medical transportation;
                                                                           of Phase III which includes more active participation and
•   Respite care;                                                          weight training.
•   Service coordination other than case management services;
    and
                                                                           GM6000 06BNR7
•   Assistive technology.
Early intervention benefits are subject to the maximum shown               Clinical Trials
in the Schedule. The maximum in the Schedule does not apply
                                                                           • charges made for routine patient services associated with
to:
                                                                             cancer clinical trials approved and sponsored by the federal
•   Rehabilitation or therapeutic services that are necessary as             government. In addition the following criteria must be met:
    the result of an acute medical condition;
                                                                               •   the cancer clinical trial is listed on the NIH web site
•   Service provided to a child who is not participating in Part                   www.clinicaltrials.gov as being sponsored by the federal
    C and services that are not provided pursuant to an IFSP;                      government;
    and
                                                                               •   the trial investigates a treatment for terminal cancer and:
•   Assistive technology that is covered under the durable                         (1) the person has failed standard therapies for the
    medical equipment benefit provisions.                                          disease; (2) cannot tolerate standard therapies for the
                                                                                   disease; or (3) no effective nonexperimental treatment for
GM6000 CM6                                               FLX108V800
                                                                                   the disease exists;
                                                                               •   the person meets all inclusion criteria for the clinical trial
                                                                                   and is not treated “off-protocol”;
•   orthognathic surgery to repair or correct a severe facial
    deformity or disfigurement that orthodontics alone can not                 •   the trial is approved by the Institutional Review Board of
    correct, provided:                                                             the institution administering the treatment; and
    •   the deformity or disfigurement is accompanied by a                 Routine patient services do not include, and reimbursement
        documented clinically significant functional impairment,           will not be provided for:
        and there is a reasonable expectation that the procedure           •   the investigational service or supply itself;
        will result in meaningful functional improvement; or               •   services or supplies listed herein as Exclusions;
    •   the orthognathic surgery is Medically Necessary as a               •   services or supplies related to data collection for the clinical
        result of tumor, trauma, disease or;                                   trial (i.e., protocol-induced costs);


                                                                      21                                                        myCIGNA.com
•   services or supplies which, in the absence of private health                    Schedule and any Full Payment Area exceptions for Mental
    care coverage, are provided by a clinical trial sponsor or                      Illness will not apply to Biologically-Based Mental Illness;
    other party (e.g., device, drug, item or service supplied by                •   charges made for Medical Foods to treat inherited metabolic
    manufacturer and not yet FDA approved) without charge to                        disorders: “Medical Foods” means prescription metabolic
    the trial participant.                                                          formulas and their modular counterparts, obtained through a
Genetic Testing                                                                     pharmacy, that are specifically designated and manufactured
• charges made for genetic testing that uses a proven testing                       for the treatment of inherited enzymatic disorders caused by
  method for the identification of genetically-linked                               single gene defects involved in the metabolism of amino,
  inheritable disease. Genetic testing is covered only if:                          organic, and fatty acids and for which medically standard
                                                                                    methods of diagnosis, treatment, and monitoring exist. Such
    •   a person has symptoms or signs of a genetically-linked                      formulas are specifically processed or formulated to be
        inheritable disease;                                                        deficient in one or more nutrients and are to be consumed or
    •   it has been determined that a person is at risk for carrier                 administered enterally either via tube or orally under the
        status as supported by existing peer-reviewed, evidence-                    direction of a participating Physician. This definition does
        based, scientific literature for the development of a                       not apply to cystic fibrosis patients or lactose-intolerant or
        genetically-linked inheritable disease when the results                     soy-intolerant patients.
        will impact clinical outcome; or
                                                                                GM6000 CM6
GM6000 05BPT1                                                                                                                              INDEM106V1



    •   the therapeutic purpose is to identify specific genetic                 •   charges by a Hospital for a mother and newborn for
        mutation that has been demonstrated in the existing peer-                   inpatient care for 48 hours following a vaginal delivery and
        reviewed, evidence-based, scientific literature to directly                 96 hours of care following a cesarian section. No
        impact treatment options.                                                   authorization of care will be required for these time frames.
Pre-implantation genetic testing, genetic diagnosis prior to                        For longer stays, guidelines prepared by the American
embryo transfer, is covered when either parent has an                               Academy of Pediatrics and the American College of
inherited disease or is a documented carrier of a genetically-                      Obstetricians and Gynecologists will be used. A shorter
linked inheritable disease.                                                         length of stay is acceptable if the decision for early
                                                                                    discharge is made by the mother and the Physician.
Genetic counseling is covered if a person is undergoing
approved genetic testing, or if a person has an inherited                       •   charges for or in connection with cleft lip/cleft palate for
disease and is a potential candidate for genetic testing. Genetic                   newborns and where appropriate, to older children and
counseling is limited to 3 visits per contract year for both pre-                   adults when considered Medically Necessary. Benefits will
and postgenetic testing.                                                            include: (a) oral and facial surgery, surgical management,
                                                                                    and follow-up care by plastic and oral surgeons; (b)
Nutritional Evaluation                                                              prosthetic treatments such as obturators, speech appliances,
• charges made for nutritional evaluation and counseling                            and feeding appliances; (c) prosthodontic treatment; (d)
  when diet is a part of the medical management of a                                rehabilitative speech therapy; (e) otolaryngology treatment;
  documented organic disease.                                                       and (f) audiological assessments and treatments.
Internal Prosthetic/Medical Appliances                                              If dental coverage is in effect at the time of the newborn's
• charges made for internal prosthetic/medical appliances that                      birth or if it becomes effective after the birth of a child with
  provide permanent or temporary internal functional supports                       this birth defect, orthodontic coverage will be provided.
  for nonfunctional body parts are covered. Medically                               Dental coverage must be proven to be Medically Necessary
  Necessary repair, maintenance or replacement of a covered                         as a result of cleft lip and/or cleft palate.
  appliance is also covered.
                                                                                GM6000 CM6                                                 INDEM107V1

GM6000 05BPT2                                                         V1

                                                                                •   charges for general anesthesia and for associated Hospital or
•   charges made for treatment of Biologically-Based Mental                         facility charges for dental care for your Dependent child, if
    Illness. Such Covered Expenses will be payable the same as                      the following apply: (a) the child has a physical, mental or
    for other illnesses. Any Mental Illness Maximums in The                         medically compromising condition; (b) local anesthesia is



                                                                           22                                                      myCIGNA.com
    ineffective for the child because of acute infection, anatomic             condition causing the disability is acute or chronic; (b)
    variations or allergy; (c) the child or adolescent is extremely            improvement can be demonstrated; (c) the therapy is needed
    uncooperative, unmanageable, anxious or uncommunicative                    to attain or maintain functional capacity; or (d) the therapy
    with dental demands, and it is deemed sufficiently important               visits will be spaced throughout the year.
    that dental care cannot be deferred; or (d) the child has
    sustained extensive orofacial and dental trauma;
                                                                           GM6000 CM5                                              INDEM229V1
•   charges for hearing aids for a Dependent child up to age 18,
    who has a hearing loss that has been verified by both a
    licensed Physician and a licensed audiologist, provided the            The following benefits will apply to insulin and noninsulin-
    hearing aids are medically appropriate to meet the needs of            dependent diabetics as well as covered individuals who have
    the child according to accepted professional standards.                elevated blood sugar levels due to pregnancy or other medical
    Benefits are payable for (a) the purchase of initial hearing           conditions:
    aids, and replacement hearing aids not more frequently than            •   charges for Durable Medical Equipment, including podiatric
    every 5 years; (b) a new hearing aid when alterations to an                appliances, related to diabetes. A special maximum will not
    existing hearing aid cannot adequately meet the needs of the               apply.
    child; (c) services and supplies including, but not limited to,
                                                                           •   charges for training by a Physician, including a podiatrist
    the initial assessment, fitting, adjustments, and auditory
                                                                               with recent education in diabetes management, but limited
    training that is provided in accordance with acceptable
                                                                               to the following:
    professional standards. Benefits payable under this part will
    not be used to reduce any durable medical equipment                        (a) Medically Necessary visits when diabetes is
    maximum provided by this plan.                                                 diagnosed;
    A hearing aid is defined as amplification technology that                  (b) visits following a diagnosis of a significant change in
    optimizes audibility and listening skills in the environments                  the symptoms or conditions that warrant change in
    commonly experienced by the patient, including a wearable                      self-management;
    instrument or device designed to aid or compensate for                     (c) visits when reeducation or refresher training is
    impaired human hearing. A hearing aid shall include any                        prescribed by the Physician; and
    part or ear molds.                                                         (d) Medical Nutrition therapy related to diabetes
                                                                                   management.
GM6000 CM6                                               INDEM108V1

                                                                           GM6000 CM6                                              INDEM110V1

•   charges made for or in connection with management of pain
    for which a cause or cure can not be found through                     In addition, Covered Expenses will include charges made for
    reasonable efforts made by a Physician or specialist.                  Preventive Child Health Supervision Services for a Dependent
•   charges for the treatment of autism.                                   child on or before his 13th birthday, at any of the Approximate
•   charges made for an annual prostate-specific antigen test              Age Intervals shown below. Charges made for Preventive
    (PSA) and digital rectal exam in men over age 50 and in                Child Health Supervision Services consist of the following
    men over age 40 who are in high risk categories;                       services, provided in keeping with prevailing medical
                                                                           standards by a Physician or a Physician's Assistant, or by a
•   charges made for mammograms for breast cancer screening
                                                                           Registered Nurse with additional training in child health
    according to the following guidelines: (a) annual
                                                                           assessment who is working in collaboration with a Physician:
    mammograms for women ages 35 to 39 and over age 50; (b)
    every two years for women ages 40 to 49, or more                       •   a history;
    frequently if recommended by a Physician;                              •   an age-appropriate physical examination;
•   Substance Abuse Rehabilitation Services will be provided               •   anticipatory guidance; and
    regardless of whether the treatment is voluntary or court-             •   appropriate immunizations and laboratory tests;
    ordered as a result of contact with the criminal justice or
    legal system. Coverage will be provided for services that are          excluding any charges for:
    Medically Necessary and otherwise covered under this plan.             •   more than one visit to one provider for Preventive Child
•   charges made for physical, occupational, and speech therapy                Health Supervision Services at each of the Approximate
    for children ages 3 to 6 with congenital disabilities. Therapy             Age Intervals, up to a total of 16 visits for each child;
    will be provided without regard to whether: (a) a birth


                                                                      23                                                   myCIGNA.com
•   services for which benefits are otherwise provided under                  to the benefit limitations described under Short-term
    this Medical Benefits plan; and                                           Rehabilitative Therapy Maximum shown in The Schedule.
•   services for which benefits are not payable according to the
    Expenses Not Covered section.                                         GM6000 05BPT104

It is provided that the Deductible that would otherwise apply
will be waived for those Covered Expenses incurred for                    Hospice Care Services
Preventive Child Health Supervision Services.
                                                                          • charges made for a person who has been diagnosed as
Approximate Age Intervals are: birth, 2 months, 4 months, 6                 having six months or fewer to live, due to Terminal Illness,
months, 9 months, 12 months, 15 months, 18 months, 2 years,                 for the following Hospice Care Services provided under a
3 years, 4 years, 5 years, 6 years, 8 years, 10 years and 12                Hospice Care Program:
years.
                                                                              •   by a Hospice Facility for Bed and Board and Services and
                                                                                  Supplies;
GM6000 CM6
                                                                              •   by a Hospice Facility for services provided on an
                                                          INDEM111
                                                                                  outpatient basis;
                                                                              •   by a Physician for professional services;
Home Health Services                                                          •   by a Psychologist, social worker, family counselor or
• charges made for Home Health Services when you: (a)                             ordained minister for individual and family counseling;
  require skilled care; (b) are unable to obtain the required                 •   for pain relief treatment, including drugs, medicines and
  care as an ambulatory outpatient; and (c) do not require                        medical supplies;
  confinement in a Hospital or Other Health Care Facility.
                                                                              •   by an Other Health Care Facility for:
    Home Health Services are provided only if CG has
    determined that the home is a medically appropriate setting.                  •   part-time or intermittent nursing care by or under the
    If you are a minor or an adult who is dependent upon others                       supervision of a Nurse;
    for nonskilled care and/or custodial services (e.g., bathing,                 •   part-time or intermittent services of an Other Health
    eating, toileting), Home Health Services will be provided                         Care Professional;
    for you only during times when there is a family member or
    care giver present in the home to meet your nonskilled care
                                                                          GM6000 CM34                                                  FLX124V38
    and/or custodial services needs.
    Home Health Services are those skilled health care services
    that can be provided during visits by Other Health Care                       •   physical, occupational and speech therapy;
    Professionals. The services of a home health aide are                         •   medical supplies; drugs and medicines lawfully
    covered when rendered in direct support of skilled health                         dispensed only on the written prescription of a
    care services provided by Other Health Care Professionals.                        Physician; and laboratory services; but only to the
    A visit is defined as a period of 2 hours or less. Home                           extent such charges would have been payable under the
    Health Services are subject to a maximum of 16 hours in                           policy if the person had remained or been Confined in a
    total per day. Necessary consumable medical supplies and                          Hospital or Hospice Facility.
    home infusion therapy administered or used by Other
                                                                          The following charges for Hospice Care Services are not
    Health Care Professionals in providing Home Health
                                                                          included as Covered Expenses:
    Services are covered. Home Health Services do not include
    services by a person who is a member of your family or                •   for the services of a person who is a member of your family
    your Dependent's family or who normally resides in your                   or your Dependent's family or who normally resides in your
    house or your Dependent's house even if that person is an                 house or your Dependent's house;
    Other Health Care Professional. Skilled nursing services or           •   for any period when you or your Dependent is not under the
    private duty nursing services provided in the home are                    care of a Physician;
    subject to the Home Health Services benefit terms,
                                                                          •   for services or supplies not listed in the Hospice Care
    conditions and benefit limitations. Physical, occupational,
                                                                              Program;
    and other Short-Term Rehabilitative Therapy services
    provided in the home are not subject to the Home Health               •   for any curative or life-prolonging procedures;
    Services benefit limitations in the Schedule, but are subject




                                                                     24                                                       myCIGNA.com
•   to the extent that any other benefits are payable for those              in an open setting; and (d) is licensed in accordance with the
    expenses under the policy;                                               laws of the appropriate legally authorized agency as a
•   for services or supplies that are primarily to aid you or your           residential treatment center.
    Dependent in daily living;                                               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
GM6000 CM35                                                FLX124V27
                                                                             the recommendation of a Physician.
                                                                             Outpatient Mental Health Services
Mental Health and Substance Abuse Services
                                                                             Services of Providers who are qualified to treat Mental Health
Mental Health Services are services that are required to treat               when treatment is provided on an outpatient basis, while you
a disorder that impairs the behavior, emotional reaction or                  or your Dependent is not Confined in a Hospital, and is
thought processes. In determining benefits payable, charges                  provided in an individual, group or Mental Health Intensive
made for the treatment of any physiological conditions related               Outpatient Therapy Program. Covered services include, but
to Mental Health will not be considered to be charges made                   are not limited to, outpatient treatment of conditions such as:
for treatment of Mental Health.                                              anxiety or depression which interfere with daily functioning;
Substance Abuse is defined as the psychological or physical                  emotional adjustment or concerns related to chronic
dependence on alcohol or other mind-altering drugs that                      conditions, such as psychosis or depression; emotional
requires diagnosis, care, and treatment. In determining                      reactions associated with marital problems or divorce;
benefits payable, charges made for the treatment of any                      child/adolescent problems of conduct or poor impulse control;
physiological conditions related to rehabilitation services for              affective disorders; suicidal or homicidal threats or acts; eating
alcohol or drug abuse or addiction will not be considered to be              disorders; or acute exacerbation of chronic mental health
charges made for treatment of Substance Abuse.                               conditions (crisis intervention and relapse prevention) and
                                                                             outpatient testing and assessment.
Inpatient Mental Health Services
                                                                             A Mental Health Intensive Outpatient Therapy Program
Services that are provided by a Hospital while you or your
                                                                             consists of distinct levels or phases of treatment that are
Dependent is Confined in a Hospital for the treatment and
                                                                             provided by a certified/licensed Mental Health program.
evaluation of Mental Health. Inpatient Mental Health Services
                                                                             Intensive Outpatient Therapy Programs provide a combination
include Partial Hospitalization and Mental Health Residential
                                                                             of individual, family and/or group therapy in a day, totaling 9
Treatment Services.
                                                                             or more hours in a week. Mental Health Intensive Outpatient
Inpatient Mental Health services are exchangeable with                       Therapy Program services are exchanged with Outpatient
Partial Hospitalization sessions when services are provided                  Mental Health services at a rate of one visit of Mental Health
for at least 3 hours and not more than 12 hours in any 24-hour               Intensive Outpatient Therapy being equal to one visit of
period. The exchange for services will be two Partial                        Outpatient Mental Health Services.
Hospitalization sessions are equal to one day of inpatient care.
Mental Health Residential Treatment Services are services
                                                                             GM6000 INDEM10                                                 V49
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 services are exchanged                   Inpatient Substance Abuse Rehabilitation Services
with Inpatient Mental Health services at a rate of two days of               Services provided for rehabilitation, while you or your
Mental Health Residential Treatment being equal to one day                   Dependent is Confined in a Hospital, when required for the
of Inpatient Mental Health Treatment.                                        diagnosis and treatment of abuse or addiction to alcohol and/or
                                                                             drugs. Inpatient Substance Abuse Services include Partial
                                                                             Hospitalization sessions and Residential Treatment services.
GM6000 INDEM9                                                     V55
                                                                             Inpatient Substance Abuse services are exchangeable with
                                                                             Partial Hospitalization sessions when services are provided
Mental Health Residential Treatment Center means an                          for not less than 4 hours and not more than 12 hours in any 24-
institution which (a) specializes in the treatment of                        hour period. The exchange for services will be two Partial
psychological and social disturbances that are the result of                 Hospitalization sessions are equal to one day of inpatient care.
Mental Health conditions; (b) provides a subacute, structured,
                                                                             Substance Abuse Residential Treatment Services are
psychotherapeutic treatment program, under the supervision of
                                                                             services provided by a Hospital for the evaluation and
Physicians; (c) provides 24-hour care, in which a person lives


                                                                        25                                                   myCIGNA.com
treatment of the psychological and social functional                    Exclusions
disturbances that are a result of subacute Substance Abuse              The following are specifically excluded from Mental Health
conditions.                                                             and Substance Abuse Services:
Substance Abuse Residential Treatment services are                      •   any court ordered treatment or therapy, or any treatment or
exchanged with Inpatient Substance Abuse services at a rate of              therapy ordered as a condition of parole, probation or
two days of Substance Abuse Residential Treatment being                     custody or visitation evaluations unless Medically
equal to one day of Inpatient Substance Abuse Treatment.                    Necessary and otherwise covered under this policy or
Substance Abuse Residential Treatment Center means an                       agreement.
institution which (a) specializes in the treatment of                   •   treatment of disorders which have been diagnosed as
psychological and social disturbances that are the result of                organic mental disorders associated with permanent
Substance Abuse; (b) provides a subacute, structured,                       dysfunction of the brain.
psychotherapeutic treatment program, under the supervision of
Physicians; (c) provides 24-hour care, in which a person lives          •   developmental disorders, including but not limited to,
in an open setting; and (d) is licensed in accordance with the              developmental reading disorders, developmental arithmetic
laws of the appropriate legally authorized agency as a                      disorders, developmental language disorders or
residential treatment center.                                               developmental articulation disorders.
A person is considered confined in a Substance Abuse                    •   counseling for activities of an educational nature.
Residential Treatment Center when she/he is a registered bed            •   counseling for borderline intellectual functioning.
patient in a Substance Abuse Residential Treatment Center               •   counseling for occupational problems.
upon the recommendation of a Physician.
                                                                        •   counseling related to consciousness raising.
Outpatient Substance Abuse Rehabilitation Services
                                                                        •   vocational or religious counseling.
Services provided for the diagnosis and treatment of abuse or
addiction to alcohol and/or drugs, while you or your                    •   I.Q. testing.
Dependent is not Confined in a Hospital, including outpatient           •   custodial care, including but not limited to geriatric day
rehabilitation in an individual, or a Substance Abuse Intensive             care.
Outpatient Therapy Program.                                             •   psychological testing on children requested by or for a
A Substance Abuse Intensive Outpatient Therapy Program                      school system.
consists of distinct levels or phases of treatment that are             •   occupational/recreational therapy programs even if
provided by a certified/licensed Substance Abuse program.                   combined with supportive therapy for age-related cognitive
Intensive Outpatient Therapy Programs provide a combination                 decline.
of individual, family and/or group therapy in a day, totaling
nine, or more hours in a week. Substance Abuse Intensive
Outpatient Therapy Program services are exchanged with                  GM6000 INDEM12                                                   V61

Outpatient Substance Abuse services at a rate of one visit of
Substance Abuse Intensive Outpatient Therapy being equal to
one visit of Outpatient Substance Abuse Rehabilitation                  Durable Medical Equipment
Services.
                                                                        • charges made for purchase or rental of Durable Medical
                                                                          Equipment that is ordered or prescribed by a Physician and
GM6000 INDEM11                                               V70          provided by a vendor approved by CG for use outside a
                                                                          Hospital or Other Health Care Facility. Coverage for repair,
                                                                          replacement or duplicate equipment is provided only when
Substance Abuse Detoxification Services
                                                                          required due to anatomical change and/or reasonable wear
Detoxification and related medical ancillary services provided            and tear. All maintenance and repairs that result from a
when required for the diagnosis and treatment of addiction to             person’s misuse are the person’s responsibility. Coverage
alcohol and/or drugs. CG will decide, based on the Medical                for Durable Medical Equipment is limited to the lowest-cost
Necessity of each situation, whether such services will be                alternative as determined by the utilization review
provided in an inpatient or outpatient setting.                           Physician.
                                                                        Durable Medical Equipment is defined as items which are
                                                                        designed for and able to withstand repeated use by more than
                                                                        one person; customarily serve a medical purpose; generally
                                                                        are not useful in the absence of Injury or Sickness; are


                                                                   26                                                      myCIGNA.com
appropriate for use in the home; and are not disposable. Such              Prostheses/Prosthetic Appliances and Devices
equipment includes, but is not limited to, crutches, hospital              Prostheses/prosthetic appliances and devices are defined as
beds, respirators, wheel chairs, and dialysis machines.                    fabricated replacements for missing body parts.
Durable Medical Equipment items that are not covered include               Prostheses/prosthetic appliances and devices include, but are
but are not limited to those that are listed below:                        not limited to:
•   Bed Related Items: bed trays, over the bed tables, bed                 •   basic limb prostheses;
    wedges, pillows, custom bedroom equipment, mattresses,                 •   terminal devices such as hands or hooks; and
    including nonpower mattresses, custom mattresses and
                                                                           • speech prostheses.
    posturepedic mattresses.
                                                                           Orthoses and Orthotic Devices
•   Bath Related Items: bath lifts, nonportable whirlpools,
    bathtub rails, toilet rails, raised toilet seats, bath benches,        Orthoses and orthotic devices are defined as orthopedic
    bath stools, hand held showers, paraffin baths, bath mats,             appliances or apparatuses used to support, align, prevent or
    and spas.                                                              correct deformities. Coverage is provided for custom foot
                                                                           orthoses and other orthoses as follows:
•   Chairs, Lifts and Standing Devices: computerized or
    gyroscopic mobility systems, roll about chairs, geriatric              •   Nonfoot orthoses – only the following nonfoot orthoses are
    chairs, hip chairs, seat lifts (mechanical or motorized),                  covered:
    patient lifts (mechanical or motorized – manual hydraulic                  •   rigid and semirigid custom fabricated orthoses,
    lifts are covered if patient is two-person transfer), and auto             •   semirigid prefabricated and flexible orthoses; and
    tilt chairs.
                                                                               •   rigid prefabricated orthoses including preparation, fitting
•   Fixtures to Real Property: ceiling lifts and wheelchair                        and basic additions, such as bars and joints.
    ramps.
                                                                           •   Custom foot orthoses – custom foot orthoses are only
•   Car/Van Modifications.                                                     covered as follows:
•   Air Quality Items: room humidifiers, vaporizers, air                       •   for persons with impaired peripheral sensation and/or
    purifiers and electrostatic machines.                                          altered peripheral circulation (e.g. diabetic neuropathy
•   Blood/Injection Related Items: blood pressure cuffs,                           and peripheral vascular disease);
    centrifuges, nova pens and needleless injectors.                           •   when the foot orthosis is an integral part of a leg brace
•   Other Equipment: heat lamps, heating pads, cryounits,                          and is necessary for the proper functioning of the brace;
    cryotherapy machines, electronic-controlled therapy units,                 •   when the foot orthosis is for use as a replacement or
    ultraviolet cabinets, sheepskin pads and boots, postural                       substitute for missing parts of the foot (e.g. amputated
    drainage board, AC/DC adaptors, enuresis alarms, magnetic                      toes) and is necessary for the alleviation or correction of
    equipment, scales (baby and adult), stair gliders, elevators,                  Injury, Sickness or congenital defect; and
    saunas, any exercise equipment and diathermy machines.
                                                                               •   for persons with neurologic or neuromuscular condition
                                                                                   (e.g. cerebral palsy, hemiplegia, spina bifida) producing
GM6000 05BPT3                                                                      spasticity, malalignment, or pathological positioning of
                                                                                   the foot and there is reasonable expectation of
                                                                                   improvement.
External Prosthetic Appliances and Devices
• charges made or ordered by a Physician for: the initial
  purchase and fitting of external prosthetic appliances and               GM6000 06BNR5

  devices available only by prescription which are necessary
  for the alleviation or correction of Injury, Sickness or                 The following are specifically excluded orthoses and orthotic
  congenital defect. Coverage for External Prosthetic                      devices:
  Appliances is limited to the most appropriate and cost
  effective alternative as determined by the utilization review            •   prefabricated foot orthoses;
  Physician.                                                               •   cranial banding and/or cranial orthoses. Other similar
External prosthetic appliances and devices shall include                       devices are excluded except when used postoperatively for
prostheses/prosthetic appliances and devices, orthoses and                     synostotic plagiocephaly. When used for this indication, the
orthotic devices; braces; and splints.                                         cranial orthosis will be subject to the limitations and
                                                                               maximums of the External Prosthetic Appliances and
                                                                               Devices benefit;



                                                                      27                                                      myCIGNA.com
•   orthosis shoes, shoe additions, procedures for foot                        Physician include the conservative management of acute
    orthopedic shoes, shoe modifications and transfers;                        neuromusculoskeletal conditions through manipulation and
•   orthoses primarily used for cosmetic rather than functional                ancillary physiological treatment that is rendered to restore
    reasons; and                                                               motion, reduce pain and improve function.
•   orthoses primarily for improved athletic performance or                The following limitation applies to Short-term Rehabilitative
    sports participation.                                                  Therapy and Chiropractic Care Services:
Braces                                                                     •   Occupational therapy is provided only for purposes of
                                                                               enabling persons to perform the activities of daily living
A Brace is defined as an orthosis or orthopedic appliance that                 after an Injury or Sickness.
supports or holds in correct position any movable part of the
body and that allows for motion of that part.                              Short-term Rehabilitative Therapy and Chiropractic Care
                                                                           Services that are not covered include but are not limited to:
The following braces are specifically excluded: Copes
scoliosis braces.                                                          •   sensory integration therapy, group therapy; treatment of
                                                                               dyslexia; behavior modification or myofunctional therapy
Splints                                                                        for dysfluency, such as stuttering or other involuntarily
A Splint is defined as an appliance for preventing movement                    acted conditions without evidence of an underlying medical
of a joint or for the fixation of displaced or movable parts.                  condition or neurological disorder;
Coverage for replacement of external prosthetic appliances                 •   treatment for functional articulation disorder such as
and devices is limited to the following:                                       correction of tongue thrust, lisp, verbal apraxia or
•   Replacement due to regular wear. Replacement for damage                    swallowing dysfunction that is not based on an underlying
    due to abuse or misuse by the person will not be covered.                  diagnosed medical condition or Injury;
•   Replacement will be provided when anatomic change has                  •   maintenance or preventive treatment consisting of routine,
    rendered the external prosthetic appliance or device                       long-term or non-Medically Necessary care provided to
    ineffective. Anatomic change includes significant weight                   prevent recurrences or to maintain the patient’s current
    gain or loss, atrophy and/or growth.                                       status;
•   Coverage for replacement is limited as follows:
    •   No more than once every 24 months for persons 19 years             GM6000 07BNR1

        of age and older and
    •   No more than once every 12 months for persons 18 years             The following are specifically excluded from Chiropractic
        of age and under.                                                  Care Services:
    •   Replacement due to a surgical alteration or revision of the        •   services of a chiropractor which are not within his scope of
        site.                                                                  practice, as defined by state law;
The following are specifically excluded external prosthetic                •   charges for care not provided in an office setting;
appliances and devices:                                                    •   vitamin therapy.
•   External and internal power enhancements or power                      A separate Copayment will apply to the services provided by
    controls for prosthetic limbs and terminal devices; and                each provider.
•   Myoelectric prostheses peripheral nerve stimulators.
                                                                           GM6000 07BNR2
GM6000 05BPT5

                                                                           Transplant Services
Short-Term Rehabilitative Therapy and Chiropractic                         • charges made for human organ and tissue Transplant
Care Services
                                                                             services which include solid organ and bone marrow/stem
• charges made for Short-term Rehabilitative Therapy that is                 cell procedures at designated facilities throughout the
  part of a rehabilitative program, including physical, speech,              United States. This coverage is subject to the following
  occupational, cognitive, osteopathic manipulative and                      conditions and limitations.
  pulmonary rehabilitation therapy, when provided in the
                                                                           Transplant services include the recipient’s medical, surgical
  most medically appropriate setting. Also included are
                                                                           and Hospital services; inpatient immunosuppressive
  services that are provided by a chiropractic Physician when
                                                                           medications; and costs for organ or bone marrow/stem cell
  provided in an outpatient setting. Services of a chiropractic


                                                                      28                                                    myCIGNA.com
procurement. Transplant services are covered only if they are           These benefits are only available when the covered person is
required to perform any of the following human to human                 the recipient of an organ transplant. No benefits are available
organ or tissue transplants: allogeneic bone marrow/stem cell,          when the covered person is a donor.
autologous bone marrow/stem cell, cornea, heart, heart/lung,
kidney, kidney/pancreas, liver, lung, pancreas or intestine
                                                                        GM6000 05BPT7                                                 V11
which includes small bowel-liver or multi-visceral.
All Transplant services, other than cornea, must be received at
a CIGNA LIFESOURCE Transplant Network® facility.                        Breast Reconstruction and Breast Prostheses
Cornea transplants are payable when received from                       • charges made for reconstructive surgery following a
Participating Provider facilities other than CIGNA                        mastectomy; benefits include: (a) surgical services for
LIFESOURCE Transplant Network® facilities. Transplant                     reconstruction of the breast on which surgery was
services received at any other facilities are not covered.                performed; (b) surgical services for reconstruction of the
Coverage for organ procurement costs are limited to costs                 nondiseased breast to produce symmetrical appearance; (c)
directly related to the procurement of an organ, from a cadaver           postoperative breast prostheses; and (d) mastectomy bras
or a live donor. Organ procurement costs shall consist of                 and external prosthetics, limited to the lowest cost
surgery necessary for organ removal, organ transportation and             alternative available that meets external prosthetic
the transportation, hospitalization and surgery of a live donor.          placement needs. During all stages of mastectomy,
Compatibility testing undertaken prior to procurement is                  treatment of physical complications, including lymphedema
covered if Medically Necessary. Costs related to the search               therapy, are covered.
for, and identification of a bone marrow or stem cell donor for         Reconstructive Surgery
an allogeneic transplant are also covered.                              • charges made for reconstructive surgery or therapy to repair
Transplant Travel Services                                                or correct a severe physical deformity or disfigurement
Charges made for reasonable travel expenses incurred by you               which is accompanied by functional deficit; (other than
in connection with a preapproved organ/tissue transplant are              abnormalities of the jaw or conditions related to TMJ
covered subject to the following conditions and limitations.              disorder) provided that: (a) the surgery or therapy restores
Transplant travel benefits are not available for cornea                   or improves function; (b) reconstruction is required as a
transplants. Benefits for transportation, lodging and food are            result of Medically Necessary, noncosmetic surgery; or (c)
available to you only if you are the recipient of a preapproved           the surgery or therapy is performed prior to age 19 and is
organ/tissue transplant from a designated CIGNA                           required as a result of the congenital absence or agenesis
LIFESOURCE Transplant Network® facility. The term                         (lack of formation or development) of a body part. Repeat
recipient is defined to include a person receiving authorized             or subsequent surgeries for the same condition are covered
transplant related services during any of the following: (a)              only when there is the probability of significant additional
evaluation, (b) candidacy, (c) transplant event, or (d) post-             improvement as determined by the utilization review
transplant care. Travel expenses for the person receiving the             Physician.
transplant will include charges for: transportation to and from
the transplant site (including charges for a rental car used            GM6000 05BPT2                                                     V2
during a period of care at the transplant facility); lodging
while at, or traveling to and from the transplant site; and food
while at, or traveling to and from the transplant site.
In addition to your coverage for the charges associated with            Medical Conversion Privilege
the items above, such charges will also be considered covered           For You and Your Dependents
travel expenses for one companion to accompany you. The                 When a person's Medical Expense Insurance ceases, he may
term companion includes your spouse, a member of your                   be eligible to be insured under an individual policy of medical
family, your legal guardian, or any person not related to you,          care benefits (called the Converted Policy). A Converted
but actively involved as your caregiver. The following are              Policy will be issued by CG only to a person who is Entitled to
specifically excluded travel expenses:                                  Convert, and only if he applies in writing and pays the first
  travel costs incurred due to travel within 60 miles of your           premium for the Converted Policy to CG within 31 days after
  home; laundry bills; telephone bills; alcohol or tobacco              the date his insurance ceases. Evidence of good health is not
  products; and charges for transportation that exceed coach            needed.
  class rates.




                                                                   29                                                  myCIGNA.com
If a person does not receive notice of the Conversion Privilege                Benefits are: (a) those for which the person is covered by
at least 15 days before the 31-day application period deadline,                another hospital, surgical or medical expense insurance
the deadline will be extended to the earlier of:                               policy, or a hospital, or medical service subscriber contract,
•   15 days after the person receives the written notice; or                   or a medical practice or other prepayment plan or by any
                                                                               other plan or program; (b) those for which the person is
•   up to 60 days after the initial 31-day application period                  eligible, whether or not covered, under any plan of group
    expired.                                                                   coverage on an insured or uninsured basis; or (c) those
Employees Entitled to Convert                                                  available for the person by or through any state, provincial
You are Entitled to Convert Medical Expense Insurance for                      or federal law.
yourself and all of your Dependents who were insured when                    Converted Policy
your insurance ceased, except a Dependent who is eligible for                The Converted Policy will be one of CG's current offerings at
Medicare or would be Overinsured, but only if:                               the time the first premium is received based on its rules for
•   you have been insured for at least three consecutive months              Converted Policies. It will comply with the laws of the
    under the policy or under it and a prior policy issued to the            jurisdiction where the group medical policy is issued.
    Policyholder.                                                            However, if the applicant for the Converted Policy resides
•   your insurance ceased because you were no longer in Active               elsewhere, the Converted Policy will be on a form which
    Service or no longer eligible for Medical Expense                        meets the conversion requirements of the jurisdiction where he
    Insurance.                                                               resides. The Converted Policy offering may include medical
                                                                             benefits on a group basis. The Converted Policy need not
•   you are not eligible for Medicare.                                       provide major medical coverage unless it is required by the
•   you would not be Overinsured.                                            laws of the jurisdiction in which the Converted Policy is
If you retire you may apply for a Converted Policy within 31                 issued.
days after your retirement date in place of any continuation of
your insurance that may be available under this plan when you                GM6000 CP3
retire, if you are otherwise Entitled to Convert.                                                                                      CON26V3
Dependents Entitled to Convert
The following Dependents are also Entitled to Convert:                       The Converted Policy will be issued to you if you are Entitled
•   a child whose insurance under this plan ceases because he                to Convert, insuring you and those Dependents for whom you
    no longer qualifies as a Dependent or because of your death;             may convert. If you are not Entitled to Convert and your
•   a spouse whose insurance under this plan ceases due to                   spouse and children are, it will be issued to the spouse,
    divorce, annulment of marriage or your death;                            covering all such Dependents. Otherwise, a Converted Policy
                                                                             will be issued to each Dependent who is Entitled to Convert.
                                                                             The Converted Policy will take effect on the day after the
GM6000 CP1                                                                   person's insurance under this plan ceases. The premium on its
GM6000 CP2                                                                   effective date will be based on: (a) class of risk and age; and
                                                               CON1V4        (b) benefits.
                                                                             The Converted Policy may not exclude any pre-existing
•   your Dependents, if you are not Entitled to Convert solely               condition not excluded by this plan. During the first 12 months
    because you are eligible for Medicare;                                   the Converted Policy is in effect, the amount payable under it
but only if that Dependent: (a) was insured when your                        will be reduced so that the total amount payable under the
insurance ceased; (b) is not eligible for Medicare; and (c)                  Converted Policy and the Medical Benefits Extension of this
would not be Overinsured.                                                    plan will not be more than the amount that would have been
                                                                             payable under this plan if the person's insurance had not
Overinsured                                                                  ceased. After that, the amount payable under the Converted
A person will be considered Overinsured if either of the                     Policy will be reduced by any amount still payable under the
following occurs.                                                            Medical Benefits Extension of this plan.
•   His insurance under this plan is replaced by similar group               CG or the Policyholder will give you, on request, further
    coverage within 31 days.                                                 details of the Converted Policy.
•   The benefits under the Converted Policy, combined with
    Similar Benefits, result in an excess of insurance based on              GM6000 CON29
    CG's underwriting standards for individual policies. Similar


                                                                        30                                                  myCIGNA.com
                                 PRESCRIPTION DRUG BENEFITS
                                                  The Schedule
For You and Your Dependents
This plan provides Prescription Drug benefits for Prescription Drugs and Related Supplies provided by Pharmacies as
shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a
portion of the Covered Expenses for Prescription Drugs and Related Supplies for each 30-day supply at a retail pharmacy
or each 90-day supply at a mail order pharmacy. That portion includes any applicable Copayment, Deductible and/or
Coinsurance.
Copayments
Copayments are expenses to be paid by you or your Dependent for covered Prescription Drugs and Related Supplies.
Copayments are in addition to any Coinsurance.

                                                   PARTICIPATING                         Non-PARTICIPATING
      BENEFIT HIGHLIGHTS
                                                     PHARMACY                                PHARMACY
Prescription Drugs
Tier 1
  Generic* drugs on the Prescription     No charge after $15 per prescription     In-network coverage only
  Drug List                              order or refill

Tier 2
  Brand-Name* drugs designated as        No charge after $30 per prescription     In-network coverage only
  preferred on the Prescription Drug     order or refill
  List with no Generic equivalent
Tier 3
  Brand-Name* drugs with a Generic       No charge after $50 per prescription     In-network coverage only
  equivalent and drugs designated as     order or refill
  non-preferred on the Prescription
  Drug List
Tier 4
  Self-Administered Injectable Drugs     20% per prescription order or refill,    In-network coverage only
  (e.g. injectable drugs used to treat   subject to a maximum of $100, then
  rheumatoid arthritis, hepatitis C,     the plan pays 100%
  multiple sclerosis, asthma)

                       * Designated as per generally-accepted industry sources and adopted by CG
Mail-Order Drugs
Tier 1
  Generic* drugs on the Prescription     No charge after $38 per prescription     In-network coverage only
  Drug List                              order or refill




                                                           31                                                myCIGNA.com
                                                   PARTICIPATING                        Non-PARTICIPATING
     BENEFIT HIGHLIGHTS
                                                     PHARMACY                               PHARMACY
Tier 2
  Brand-Name* drugs designated as        No charge after $75 per prescription    In-network coverage only
  preferred on the Prescription Drug     order or refill
  List with no Generic equivalent
Tier 3
  Brand-Name* drugs with a Generic       No charge after $125 per prescription   In-network coverage only
  equivalent and drugs designated as     order or refill
  non-preferred on the Prescription
  Drug List
Tier 4
  Self-Administered Injectable Drugs     20% per prescription order or refill,   In-network coverage only
  (e.g. injectable drugs used to treat   subject to a maximum of $250, then
  rheumatoid arthritis, hepatitis C,     the plan pays 100%
  multiple sclerosis, asthma)
                       * Designated as per generally-accepted industry sources and adopted by CG




                                                           32                                               myCIGNA.com
Prescription Drug Benefits                                                 If the request is approved, your Physician will receive
                                                                           confirmation. The authorization will be processed in our claim
For You and Your Dependents                                                system to allow you to have coverage for those Prescription
                                                                           Drugs or Related Supplies. The length of the authorization
Covered Expenses                                                           will depend on the diagnosis and Prescription Drugs or
If you or any one of your Dependents, while insured for                    Related Supplies. When your Physician advises you that
Prescription Drug Benefits, incurs expenses for charges made               coverage for the Prescription Drugs or Related Supplies has
by a Pharmacy, for Medically Necessary Prescription Drugs or               been approved, you should contact the Pharmacy to fill the
Related Supplies ordered by a Physician, CG will provide                   prescription(s).
coverage for those expenses as shown in the Schedule.                      If the request is denied, your Physician and you will be
Coverage also includes Medically Necessary Prescription                    notified that coverage for the Prescription Drugs or Related
Drugs and Related Supplies dispensed for a prescription                    Supplies is not authorized.
issued to you or your Dependents by a licensed dentist for the             If you disagree with a coverage decision, you may appeal that
prevention of infection or pain in conjunction with a dental               decision in accordance with the provisions of the Policy, by
procedure.                                                                 submitting a written request stating why the Prescription
When you or a Dependent is issued a prescription for                       Drugs or Related Supplies should be covered.
Medically Necessary Prescription Drugs or Related Supplies                 If you have questions about a specific prior authorization
as part of the rendering of Emergency Services and that                    request, you should call Member Services at the toll-free
prescription cannot reasonably be filled by a Participating                number on the ID card.
Pharmacy, the prescription will be covered by CG, as if filled
by a Participating Pharmacy.                                               All drugs newly approved by the Food and Drug
                                                                           Administration (FDA) are designated as either non-Preferred
                                                                           or non-Prescription Drug List drugs until the P & T
Limitations                                                                Committee clinically evaluates the Prescription Drug for a
Each Prescription Order or refill shall be limited as follows:             different designation.
•   up to a consecutive 30-day supply, at a retail Pharmacy,               Prescription Drugs that represent an advance over available
    unless limited by the drug manufacturer's packaging: or                therapy according to the FDA will be reviewed by the P&T
•   up to a consecutive 90-day supply at a mail-order                      Committee within six months after FDA approval.
    Participating Pharmacy, unless limited by the drug                     Prescription Drugs that appear to have therapeutic qualities
    manufacturer's packaging; or                                           similar to those of an already marketed drug according to the
                                                                           FDA, will not be reviewed by the P&T Committee for at least
•   to a dosage and/or dispensing limit as determined by the               six months after FDA approval. In the case of compelling
    P&T Committee.
                                                                           clinical data, an ad hoc group will be formed to make an
                                                                           interim decision on the merits of a Prescription Drug.
GM6000 PHARM128                                                  V7
                                                                           Your Payments
Coverage for certain Prescription Drugs and Related Supplies               Coverage for Prescription Drugs and Related Supplies
requires your Physician to obtain authorization prior to                   purchased at a Pharmacy is subject to the Copayment or
prescribing. Prior authorization may include, for example, a               Coinsurance shown in the Schedule, after you have satisfied
step therapy determination. Step therapy determines the                    your Prescription Drug Deductible, if applicable. Please refer
specific usage progression of therapeutically equivalent drug              to the Schedule for any required Copayments, Coinsurance,
products or supplies appropriate for treatment of a specific               Deductibles or Maximums if applicable.
condition. If your Physician wishes to request coverage for                When a treatment regimen contains more than one type of
Prescription Drugs or Related Supplies for which prior                     Prescription Drugs which are packaged together for your, or
authorization is required, your Physician may call or complete             your Dependent's convenience, a Copayment will apply to
the appropriate prior authorization form and fax it to CG to               each Prescription Drug.
request prior authorization for coverage of the Prescription
Drugs or Related Supplies. Your Physician should make this
request before writing the prescription.                                   GM6000 PHARM129                                                V1




                                                                      33                                                  myCIGNA.com
Exclusions                                                                   other blood products or fractions and medications used for
                                                                             travel prophylaxis;
No payment will be made for the following expenses:
                                                                         •   replacement of Prescription Drugs and Related Supplies due
•   drugs available over the counter that do not require a
                                                                             to loss or theft;
    prescription by federal or state law;
                                                                         •   drugs used to enhance athletic performance;
•   any drug that is a pharmaceutical alternative to an over-the-
    counter drug other than insulin;                                     •   drugs which are to be taken by or administered to you while
                                                                             you are a patient in a licensed Hospital, Skilled Nursing
•   a drug class in which at least one of the drugs is available
                                                                             Facility, rest home or similar institution which operates on
    over the counter and the drugs in the class are deemed to be
                                                                             its premises or allows to be operated on its premises a
    therapeutically equivalent as determined by the P&T
                                                                             facility for dispensing pharmaceuticals;
    Committee;
                                                                         •   prescriptions more than one year from the original date of
•   injectable infertility drugs and any injectable drugs that
                                                                             issue.
    require Physician supervision and are not typically
    considered self-administered drugs. The following are                Other limitations are shown in the Medical "Exclusions"
    examples of Physician supervised drugs: Injectables used to          section.
    treat hemophilia and RSV (respiratory syncytial virus),
    chemotherapy injectables and endocrine and metabolic                 GM6000 PHARM88                                          PHARM104V16
    agents.                                                              GM6000 PHARM89
•   any drugs that are experimental or investigational as                GM6000 PHARM105
    described under the Medical "Exclusions" section of your
    certificate;
•   Food and Drug Administration (FDA) approved drugs used               Reimbursement/Filing a Claim
    for purposes other than those approved by the FDA unless
                                                                         When you or your Dependents purchase your Prescription
    the drug is recognized for the treatment of the particular
                                                                         Drugs or Related Supplies through a retail Participating
    indication in one of the standard reference compendia (The
                                                                         Pharmacy, you pay any applicable Copayment, Coinsurance or
    United States Pharmacopeia Drug Information, The
                                                                         Deductible shown in the Schedule at the time of purchase.
    American Medical Association Drug Evaluations; or The
                                                                         You do not need to file a claim form.
    American Hospital Formulary Service Drug Information)
    or in medical literature. Medical literature means scientific        To purchase Prescription Drugs or Related Supplies from a
    studies published in a peer-reviewed national professional           mail-order Participating Pharmacy, see your mail-order drug
    medical journal;                                                     introductory kit for details, or contact member services for
                                                                         assistance.
•   prescription and nonprescription supplies (such as ostomy
    supplies), devices, and appliances other than Related                See your Employer's Benefit Plan Administrator to obtain the
    Supplies;                                                            appropriate claim form.
•   implantable contraceptive products;
•   any fertility drug;                                                  GM6000 PHARM94                                                    V17

•   drugs used for the treatment of sexual dysfunction,
    including, but not limited to erectile dysfunction, delayed
    ejaculation, anorgasmy, and decreased libido;                        Exclusions, Expenses Not Covered and
•   prescription vitamins (other than prenatal vitamins), dietary        General Limitations
    supplements, and fluoride products;
                                                                         Additional coverage limitations determined by plan or
•   drugs used for cosmetic purposes such as drugs used to               provider type are shown in the Schedule. Payment for the
    reduce wrinkles, drugs to promote hair growth as well as             following is specifically excluded from this plan:
    drugs used to control perspiration and fade cream products;
                                                                         •   expenses for supplies, care, treatment, or surgery that are
•   diet pills or appetite suppressants (anorectics);                        not Medically Necessary.
•   prescription smoking cessation products;                             •   to the extent that you or any one of your Dependents is in
•   immunization agents, biological products for allergy                     any way paid or entitled to payment for those expenses by
    immunization, biological sera, blood, blood plasma and                   or through a public program, other than Medicaid.




                                                                    34                                                    myCIGNA.com
•   to the extent that payment is unlawful where the person                 •   for or in connection with treatment of the teeth or
    resides when the expenses are incurred.                                     periodontium unless such expenses are incurred for: (a)
•   charges made by a Hospital owned or operated by or which                    charges made for a continuous course of dental treatment
    provides care or performs services for, the United States                   started within six months of an Injury to sound natural teeth;
    Government, if such charges are directly related to a                       (b) charges made by a Hospital for Bed and Board or
    military-service-connected Injury or Sickness.                              Necessary Services and Supplies; (c) charges made by a
                                                                                Free-Standing Surgical Facility or the outpatient department
•   for or in connection with an Injury or Sickness which is due                of a Hospital in connection with surgery.
    to war, declared or undeclared.
                                                                            •   for medical and surgical services, initial and repeat,
•   charges which you are not obligated to pay or for which you                 intended for the treatment or control of obesity including
    are not billed or for which you would not have been billed                  clinically severe (morbid) obesity, including: medical and
    except that they were covered under this plan.                              surgical services to alter appearance or physical changes
•   assistance in the activities of daily living, including but not             that are the result of any surgery performed for the
    limited to eating, bathing, dressing or other Custodial                     management of obesity or clinically severe (morbid)
    Services or self-care activities, homemaker services and                    obesity; and weight loss programs or treatments, whether
    services primarily for rest, domiciliary or convalescent care.              prescribed or recommended by a Physician or under
•   for or in connection with experimental, investigational or                  medical supervision.
    unproven services.                                                      •   unless otherwise covered in this plan, for reports,
    Experimental, investigational and unproven services are                     evaluations, physical examinations, or hospitalization not
    medical, surgical, diagnostic, psychiatric, substance abuse                 required for health reasons including, but not limited to,
    or other health care technologies, supplies, treatments,                    employment, insurance or government licenses, and court-
    procedures, drug therapies or devices that are determined by                ordered, forensic or custodial evaluations.
    the utilization review Physician to be:                                 •   court-ordered treatment or hospitalization, unless such
    •   not demonstrated, through existing peer-reviewed,                       treatment is prescribed by a Physician and listed as covered
        evidence-based, scientific literature to be safe and                    in this plan.
        effective for treating or diagnosing the condition or               •   infertility services including infertility drugs, surgical or
        sickness for which its use is proposed;                                 medical treatment programs for infertility, including in vitro
    •   not approved by the U.S. Food and Drug Administration                   fertilization, gamete intrafallopian transfer (GIFT), zygote
        (FDA) or other appropriate regulatory agency to be                      intrafallopian transfer (ZIFT), variations of these
        lawfully marketed for the proposed use;                                 procedures, and any costs associated with the collection,
                                                                                washing, preparation or storage of sperm for artificial
    •   the subject of review or approval by an Institutional                   insemination (including donor fees). Cryopreservation of
        Review Board for the proposed use except as provided in                 donor sperm and eggs are also excluded from coverage.
        the “Clinical Trials” section of this plan; or
                                                                            •   reversal of male or female voluntary sterilization
    •   the subject of an ongoing phase I, II or III clinical trial,
                                                                                procedures.
        except as provided in the “Clinical Trials” section of this
        plan.                                                               •   transsexual surgery including medical or psychological
                                                                                counseling and hormonal therapy in preparation for, or
•   cosmetic surgery and therapies. Cosmetic surgery or therapy
                                                                                subsequent to, any such surgery.
    is defined as surgery or therapy performed to improve or
    alter appearance or self-esteem or to treat psychological               •   any services or supplies for the treatment of male or female
    symptomatology or psychosocial complaints related to                        sexual dysfunction such as, but not limited to, treatment of
    one’s appearance.                                                           erectile dysfunction (including penile implants), anorgasmy,
                                                                                and premature ejaculation.
•   regardless of clinical indication for macromastia or
    gynecomastia surgeries; surgical treatment of varicose                  •   medical and Hospital care and costs for the infant child of a
    veins; abdominoplasty/panniculectomy; rhinoplasty;                          Dependent, unless this infant child is otherwise eligible
    blepharoplasty; redundant skin surgery; removal of skin                     under this plan.
    tags; acupressure; craniosacral/cranial therapy; dance                  •   nonmedical counseling or ancillary services, including but
    therapy, movement therapy; applied kinesiology; rolfing;                    not limited to Custodial Services, education, training,
    prolotherapy; and extracorporeal shock wave lithotripsy                     vocational rehabilitation, behavioral training, biofeedback,
    (ESWL) for musculoskeletal and orthopedic conditions.                       neurofeedback, hypnosis, sleep therapy, employment
•   surgical or nonsurgical treatment of TMJ dysfunction.                       counseling, back school, return to work services, work
                                                                                hardening programs, driving safety, and services, training,


                                                                       35                                                    myCIGNA.com
    educational therapy or other nonmedical ancillary services                associated with foot care for diabetes and peripheral
    for learning disabilities, developmental delays, autism or                vascular disease are covered when Medically Necessary.
    mental retardation.                                                   •   membership costs or fees associated with health clubs,
•   therapy or treatment intended primarily to improve or                     weight loss programs and smoking cessation programs.
    maintain general physical condition or for the purpose of             •   genetic screening or pre-implantations genetic screening.
    enhancing job, school, athletic or recreational performance,              General population-based genetic screening is a testing
    including but not limited to routine, long term, or                       method performed in the absence of any symptoms or any
    maintenance care which is provided after the resolution of                significant, proven risk factors for genetically linked
    the acute medical problem and when significant therapeutic                inheritable disease.
    improvement is not expected.
                                                                          •   dental implants for any condition.
•   consumable medical supplies other than ostomy supplies
    and urinary catheters. Excluded supplies include, but are not         •   fees associated with the collection or donation of blood or
    limited to bandages and other disposable medical supplies,                blood products, except for autologous donation in
    skin preparations and test strips, except as specified in the             anticipation of scheduled services where in the utilization
    “Home Health Services” or “Breast Reconstruction and                      review Physician’s opinion the likelihood of excess blood
    Breast Prostheses” sections of this plan.                                 loss is such that transfusion is an expected adjunct to
                                                                              surgery.
•   private Hospital rooms and/or private duty nursing except as
    provided under the Home Health Services provision.                    •   blood administration for the purpose of general
                                                                              improvement in physical condition.
•   personal or comfort items such as personal care kits
    provided on admission to a Hospital, television, telephone,           •   cost of biologicals that are immunizations or medications
    newborn infant photographs, complimentary meals, birth                    for the purpose of travel, or to protect against occupational
    announcements, and other articles which are not for the                   hazards and risks.
    specific treatment of an Injury or Sickness.                          •   cosmetics, dietary supplements and health and beauty aids.
•   artificial aids including, but not limited to, corrective             •   nutritional supplements and formulae except for infant
    orthopedic shoes, arch supports, elastic stockings, garter                formula needed for the treatment of inborn errors of
    belts, corsets, dentures and wigs.                                        metabolism.
•   hearing aids except as provided under “Covered Expenses.”             •   medical treatment for a person age 65 or older, who is
•   aids or devices that assist with nonverbal communications,                covered under this plan as a retiree, or their Dependent,
    including but not limited to communication boards,                        when payment is denied by the Medicare plan because
    prerecorded speech devices, laptop computers, desktop                     treatment was received from a nonparticipating provider.
    computers, Personal Digital Assistants (PDAs), Braille                •   medical treatment when payment is denied by a Primary
    typewriters, visual alert systems for the deaf and memory                 Plan because treatment was received from a
    books.                                                                    nonparticipating provider.
•   medical benefits for eyeglasses, contact lenses or                    •   for or in connection with an Injury or Sickness arising out
    examinations for prescription or fitting thereof, except that             of, or in the course of, any employment for wage or profit.
    Covered Expenses will include the purchase of the first pair          •   telephone, e-mail, and Internet consultations, and
    of eyeglasses, lenses, frames or contact lenses that follows              telemedicine.
    keratoconus or cataract surgery.
                                                                          •   massage therapy.
•   charges made for or in connection with routine refractions,
    eye exercises and for surgical treatment for the correction of        •   for charges which would not have been made if the person
                                                                              had no insurance.
    a refractive error, including radial keratotomy, when
    eyeglasses or contact lenses may be worn.                             •   for medical plans to the extent that they are more than the
•   treatment by acupuncture.                                                 Maximum Reimbursable Charges applicable to care, if any
                                                                              received out of network (for example, emergency care).
•   all noninjectable prescription drugs, injectable prescription
    drugs that do not require Physician supervision and are               •   expenses incurred outside the United States or Canada,
    typically considered self-administered drugs,                             unless you or your Dependent is a U.S. or Canadian resident
                                                                              and the charges are incurred while traveling on business or
    nonprescription drugs, and investigational and experimental
    drugs, except as provided in this plan.                                   for pleasure.

•   routine foot care, including the paring and removing of               •   charges made by any covered provider who is a member of
                                                                              your family or your Dependent’s family.
    corns and calluses or trimming of nails. However, services


                                                                     36                                                    myCIGNA.com
•   to the extent of the exclusions imposed by any certification           Secondary Plan
    requirement shown in this plan.                                        A Plan that determines, and may reduce its benefits after
                                                                           taking into consideration, the benefits provided or paid by the
GM6000 05BPT14                                                 V143
                                                                           Primary Plan. A Secondary Plan may also recover from the
GM6000 05BPT105
                                                                           Primary Plan the Reasonable Cash Value of any services it
GM6000 06BNR2                                                  V112        provided to you.


                                                                           GM6000 COB11

Coordination of Benefits
This section applies if you or any one of your Dependents is               Allowable Expense
covered under more than one Plan and determines how                        A necessary, reasonable and customary service or expense,
benefits payable from all such Plans will be coordinated. You              including deductibles, coinsurance or copayments, that is
should file all claims with each Plan.                                     covered in full or in part by any Plan covering you. When a
Definitions                                                                Plan provides benefits in the form of services, the Reasonable
For the purposes of this section, the following terms have the             Cash Value of each service is the Allowable Expense and is a
meanings set forth below:                                                  paid benefit.
Plan                                                                       Examples of expenses or services that are not Allowable
                                                                           Expenses include, but are not limited to the following:
Any of the following that provides benefits or services for
medical care or treatment:                                                 (1) An expense or service or a portion of an expense or
                                                                               service that is not covered by any of the Plans is not an
(1) Group insurance and/or group-type coverage, whether                        Allowable Expense.
    insured or self-insured which neither can be purchased by
    the general public, nor is individually underwritten,                  (2) If you are confined to a private Hospital room and no Plan
    including closed panel coverage.                                           provides coverage for more than a semiprivate room, the
                                                                               difference in cost between a private and semiprivate room
(2) Coverage under Medicare and other governmental benefits                    is not an Allowable Expense.
    as permitted by law, excepting Medicaid and Medicare
    supplement policies.                                                   (3) If you are covered by two or more Plans that provide
                                                                               services or supplies on the basis of reasonable and
(3) Medical benefits coverage of group, group-type, and                        customary fees, any amount in excess of the highest
    individual automobile contracts.                                           reasonable and customary fee is not an Allowable
Each Plan or part of a Plan which has the right to coordinate                  Expense.
benefits will be considered a separate Plan.                               (4) If you are covered by one Plan that provides services or
Closed Panel Plan                                                              supplies on the basis of reasonable and customary fees
A Plan that provides medical or dental benefits primarily in                   and one Plan that provides services and supplies on the
the form of services through a panel of employed or                            basis of negotiated fees, the Primary Plan's fee
contracted providers, and that limits or excludes benefits                     arrangement shall be the Allowable Expense.
provided by providers outside of the panel, except in the case             (5) If your benefits are reduced under the Primary Plan
of emergency or if referred by a provider within the panel.                    (through the imposition of a higher copayment amount,
Primary Plan                                                                   higher coinsurance percentage, a deductible and/or a
                                                                               penalty) because you did not comply with Plan provisions
The Plan that determines and provides or pays benefits
                                                                               or because you did not use a preferred provider, the
without taking into consideration the existence of any other
                                                                               amount of the reduction is not an Allowable Expense.
Plan.
                                                                               Such Plan provisions include second surgical opinions
                                                                               and precertification of admissions or services.
                                                                           Claim Determination Period
                                                                           A calendar year, but does not include any part of a year during
                                                                           which you are not covered under this policy or any date before
                                                                           this section or any similar provision takes effect.


                                                                           GM6000 COB12




                                                                      37                                                  myCIGNA.com
                                                                                Secondary Plan and the Plan that covers you as an active
Reasonable Cash Value                                                           employee or retiree (or as that employee's Dependent)
                                                                                shall be the Primary Plan. If the other Plan does not have
An amount which a duly licensed provider of health care                         a similar provision and, as a result, the Plans cannot agree
services usually charges patients and which is within the range                 on the order of benefit determination, this paragraph shall
of fees usually charged for the same service by other health                    not apply.
care providers located within the immediate geographic area
where the health care service is rendered under similar or                 (6) If one of the Plans that covers you is issued out of the
comparable circumstances.                                                      state whose laws govern this Policy, and determines the
                                                                               order of benefits based upon the gender of a parent, and as
Order of Benefit Determination Rules                                           a result, the Plans do not agree on the order of benefit
A Plan that does not have a coordination of benefits rule                      determination, the Plan with the gender rules shall
consistent with this section shall always be the Primary Plan.                 determine the order of benefits.
If the Plan does have a coordination of benefits rule consistent
                                                                           If none of the above rules determines the order of benefits, the
with this section, the first of the following rules that applies to
                                                                           Plan that has covered you for the longer period of time shall
the situation is the one to use:
                                                                           be primary.
(1) The Plan that covers you as an enrollee or an employee
                                                                           When coordinating benefits with Medicare, this Plan will be
    shall be the Primary Plan and the Plan that covers you as a
                                                                           the Secondary Plan and determine benefits after Medicare,
    Dependent shall be the Secondary Plan;
                                                                           where permitted by the Social Security Act of 1965, as
(2) If you are a Dependent child whose parents are not                     amended. However, when more than one Plan is secondary to
    divorced or legally separated, the Primary Plan shall be               Medicare, the benefit determination rules identified above,
    the Plan which covers the parent whose birthday falls first            will be used to determine how benefits will be coordinated.
    in the calendar year as an enrollee or employee;                       Effect on the Benefits of This Plan
(3) If you are the Dependent of divorced or separated parents,             If this Plan is the Secondary Plan, this Plan may reduce
    benefits for the Dependent shall be determined in the                  benefits so that the total benefits paid by all Plans during a
    following order:                                                       Claim Determination Period are not more than 100% of the
     (a) first, if a court decree states that one parent is                total of all Allowable Expenses.
         responsible for the child's healthcare expenses or                The difference between the amount that this Plan would have
         health coverage and the Plan for that parent has actual           paid if this Plan had been the Primary Plan, and the benefit
         knowledge of the terms of the order, but only from                payments that this Plan had actually paid as the Secondary
         the time of actual knowledge;                                     Plan, will be recorded as a benefit reserve for you. CG will use
     (b) then, the Plan of the parent with custody of the child;           this benefit reserve to pay any Allowable Expense not
     (c) then, the Plan of the spouse of the parent with custody           otherwise paid during the Claim Determination Period.
         of the child;
     (d) then, the Plan of the parent not having custody of the            GM6000 COB14
         child, and
     (e) finally, the Plan of the spouse of the parent not having          As each claim is submitted, CG will determine the following:
         custody of the child.
                                                                           (1) CG's obligation to provide services and supplies under
                                                                               this policy;
GM6000 COB13
                                                                           (2) whether a benefit reserve has been recorded for you; and
                                                                           (3) whether there are any unpaid Allowable Expenses during
(4) The Plan that covers you as an active employee (or as that                 the Claims Determination Period.
    employee's Dependent) shall be the Primary Plan and the                If there is a benefit reserve, CG will use the benefit reserve
    Plan that covers you as laid-off or retired employee (or as            recorded for you to pay up to 100% of the total of all
    that employee's Dependent) shall be the secondary Plan.                Allowable Expenses. At the end of the Claim Determination
    If the other Plan does not have a similar provision and, as            Period, your benefit reserve will return to zero and a new
    a result, the Plans cannot agree on the order of benefit               benefit reserve will be calculated for each new Claim
    determination, this paragraph shall not apply.                         Determination Period.
(5) The Plan that covers you under a right of continuation
    which is provided by federal or state law shall be the



                                                                      38                                                   myCIGNA.com
Recovery of Excess Benefits                                                Employees and that Employee is eligible for
If CG pays charges for benefits that should have been paid by              Medicare due to disability;
the Primary Plan, or if CG pays charges in excess of those for
which we are obligated to provide under the Policy, CG will            (d) the Dependent of an Employee whose
have the right to recover the actual payment made or the                   Employer and each other Employer
Reasonable Cash Value of any services.
                                                                           participating in the Employer's plan have
CG will have sole discretion to seek such recovery from any
person to, or for whom, or with respect to whom, such
                                                                           fewer than 100 Employees and that
services were provided or such payments made by any                        Dependent is eligible for Medicare due to
insurance company, healthcare plan or other organization. If               disability;
we request, you must execute and deliver to us such
instruments and documents as we determine are necessary to             (e) an Employee or a Dependent of an
secure the right of recovery.                                              Employee of an Employer who has fewer
Right to Receive and Release Information                                   than 20 Employees, if that person is eligible
CG, without consent or notice to you, may obtain information               for Medicare due to age;
from and release information to any other Plan with respect to
you in order to coordinate your benefits pursuant to this              (f) an Employee, retired Employee, Employee's
section. You must provide us with any information we request               Dependent or retired Employee's Dependent
in order to coordinate your benefits pursuant to this section.             who is eligible for Medicare due to End
This request may occur in connection with a submitted claim;
if so, you will be advised that the "other coverage"                       Stage Renal Disease after that person has
information, (including an Explanation of Benefits paid under              been eligible for Medicare for 30 months;
the Primary Plan) is required before the claim will be
processed for payment. If no response is received within 90
                                                                       GM6000 MEL23                                     V4
days of the request, the claim will be denied. If the requested
information is subsequently received, the claim will be
processed.                                                             CG will assume the amount payable under:
                                                                       • Part A of Medicare for a person who is
GM6000 COB15
                                                                         eligible for that Part without premium
                                                                         payment, but has not applied, to be the
Medicare Eligibles                                                       amount he would receive if he had applied.
                                                                       • Part B of Medicare for a person who is
CG will pay as the Secondary Plan as permitted
by the Social Security Act of 1965 as amended                            entitled to be enrolled in that Part, but is not,
for the following:                                                       to be the amount he would receive if he were
                                                                         enrolled.
(a) a former Employee who is eligible for
                                                                       • Part B of Medicare for a person who has
    Medicare and whose insurance is continued
    for any reason as provided in this plan;                             entered into a private contract with a provider,
                                                                         to be the amount he would receive in the
(b) a former Employee's Dependent, or a former
                                                                         absence of such private contract.
    Dependent Spouse, who is eligible for
    Medicare and whose insurance is continued                          A person is considered eligible for Medicare on
    for any reason as provided in this plan;                           the earliest date any coverage under Medicare
                                                                       could become effective for him.
(c) an Employee whose Employer and each
    other Employer participating in the                                This reduction will not apply to any Employee
    Employer's plan have fewer than 100                                and his Dependent or any former Employee and



                                                                  39                                        myCIGNA.com
his Dependent unless he is listed under (a)                                  Medical Benefits are not assignable unless agreed to by CG.
                                                                             CG may, at its option, make payment to you for the cost of
through (f) above.                                                           any Covered Expenses received by you or your Dependent
Domestic Partners                                                            from a Non-Participating Provider even if benefits have been
                                                                             assigned. When benefits are paid to you or your Dependent,
Under federal law, the Medicare Secondary                                    you or your Dependent is responsible for reimbursing the
Payer Rules do not apply to Domestic Partners                                Provider. If any person to whom benefits are payable is a
covered under a group health plan. Therefore,                                minor or, in the opinion of CG, is not able to give a valid
                                                                             receipt for any payment due him, such payment will be made
Medicare is always the Primary Plan for a                                    to his legal guardian. If no request for payment has been made
person covered as a Domestic Partner, and                                    by his legal guardian, CG may, at its option, make payment to
CIGNA is the Secondary Plan.                                                 the person or institution appearing to have assumed his
                                                                             custody and support.
                                                                             If you die while any of these benefits remain unpaid, CG may
GM6000 MEL45                                                       V3
                                                                             choose to make direct payment to any of your following living
                                                                             relatives: spouse, mother, father, child or children, brothers or
                                                                             sisters; or to the executors or administrators of your estate.
Expenses For Which A Third Party May                                         Payment as described above will release CG from all liability
Be Liable                                                                    to the extent of any payment made.
This policy does not cover expenses for which another party                  Time of Payment
may be responsible as a result of having caused or contributed               Benefits will be paid by CG when it receives due proof of loss.
to the Injury or Sickness. If you incur a Covered Expense for                Recovery of Overpayment
which, in the opinion of CG, another party may be liable:
                                                                             When an overpayment has been made by CG, CG will have
1. CG shall, to the extent permitted by law, be subrogated to                the right at any time to: (a) recover that overpayment from the
   all rights, claims or interests which you may have against                person to whom or on whose behalf it was made; or (b) offset
   such party. You or your representative shall execute such                 the amount of that overpayment from a future claim payment.
   documents as may be required to secure CG's subrogation
                                                                             Calculation of Covered Expenses
   rights.
                                                                             CG, in its discretion, will calculate Covered Expenses
2. Alternatively, CG may, at its sole discretion, pay the
                                                                             following evaluation and validation of all provider billings in
   benefits otherwise payable under the Policy. However, you
                                                                             accordance with:
   must first agree in writing to refund to CG the lesser of:
                                                                             •   the methodologies in the most recent edition of the Current
  a. the amount actually paid for such Covered Expenses by
                                                                                 Procedural terminology.
     CG; or
                                                                             •   the methodologies as reported by generally recognized
  b. the amount you actually receive from the third party for
                                                                                 professionals or publications.
     such Covered Expenses;
  at the time that the third party's liability is determined and
  satisfied, whether by settlement, judgment, arbitration or                 GM6000 TRM366

  award or otherwise.

GM6000 CCP7                                                                  Termination of Insurance
                                                            CCL7V5

                                                                             Employees
                                                                             Your insurance will cease on the earliest date below:
Payment of Benefits                                                          •   the date you cease to be in a Class of Eligible Employees or
To Whom Payable                                                                  cease to qualify for the insurance.
All Medical Benefits are payable to you. However, at the                     •   the last day for which you have made any required
option of CG, all or any part of them may be paid directly to                    contribution for the insurance.
the person or institution on whose charge claim is based.                    •   the date the policy is canceled.



                                                                        40                                                   myCIGNA.com
•   the last day of the calendar month in which your Active           •   the last day for which you have paid the required premium;
    Service ends except as described below.                           •   the date you become eligible for other group coverage or for
Any continuation of insurance must be based on a plan which               Medicare;
precludes individual selection.                                       •   the date the policy is canceled.
Temporary Layoff or Leave of Absence                                  This state-required Special Continuation of Medical Insurance
If your Active Service ends due to temporary layoff or leave          can be elected in place of, but not in addition to, the COBRA
of absence, your insurance will be continued as determined by         continuation provisions set forth in the section entitled
your Employer.                                                        Continuation Required by Federal Law.
Injury or Sickness                                                    Provision Regarding Notification of Special Continuation
If your Active Service ends due to an Injury or Sickness, your        The Policyholder will give you written notice of your right to
insurance will be continued while you remain totally and              elect such continuation. You may elect such continuation by
continuously disabled as a result of the Injury or Sickness.          applying in writing and remitting the required premium to the
However, your insurance will not continue past the date your          Policyholder within 20 days of the date your insurance would
Employer stops paying premium for you or otherwise cancels            otherwise terminate.
the insurance.                                                        If the Policyholder fails to notify you of the continuation
                                                                      option, you may retain coverage by remitting the appropriate
GM6000 TRM23V3                                      M
                                                                      premium to the Policyholder within 30 days of the date of
                                                                      termination of coverage.
                                                                      If your insurance is being continued under this section, the
                                                                      insurance for any of your Dependents insured on the date your
Dependents                                                            insurance would otherwise cease may be continued, subject to
Your insurance for all of your Dependents will cease on the           the above provisions. The insurance for your Dependents will
earliest date below:                                                  continue until the earlier of:
•   the date your insurance ceases.                                   •   the date your insurance for yourself ceases; or
•   the date you cease to be eligible for Dependent Insurance.        • with respect to any one Dependent, the date that Dependent
•   the last day for which you have made any required                   no longer qualifies as a Dependent or becomes eligible for
    contribution for the insurance.                                     Medicare whichever comes first.
•   the date Dependent Insurance is canceled.                         Conversion Available After Continuation
The insurance for any one of your Dependents will cease on            The provisions of the "Conversion Privilege" section will
the date that Dependent no longer qualifies as a Dependent.           apply when the insurance ceases.


GM6000 TRM62                                                          GM6000 TER 6                                                 V-46
                                                                      GM6000 TER7                                                  V-12
                                                                                                                              TRM109V1


Special Continuation of Medical Insurance
If your insurance ceases for any reason other than
discontinuance of the policy or cancellation of coverage for
                                                                      Medical Benefits Extension
the class in which you belong, and if you: (a) have been              During Hospital Confinement
insured for at least 6 months, prior to the date coverage was         If the Medical Benefits under this plan cease for you or your
terminated; (b) did not lose coverage due to failure to pay           Dependent and you or your Dependent is Confined in a
required contribution; and (c) are not eligible for Medicare,         Hospital on that date, Medical Benefits will be paid for
you may continue the insurance by paying the required                 Covered Expenses incurred in connection with that Hospital
premiums to the Policyholder. In no event will the insurance          Confinement. However, no benefits will be paid after the
be continued beyond the earliest of the following dates:              earliest of:
•   18 months from the date the insurance would otherwise             •   the date you exceed the Maximum Benefit, if any, shown in
    terminate;                                                            the Schedule;
•   the date coverage for the employee's class of employees is        •   the date you are covered for medical benefits under another
    canceled;                                                             group plan;


                                                                 41                                                   myCIGNA.com
•   the date you or your Dependent is no longer Hospital                   required by the order and you will not be considered a Late
    Confined or is discharged to a step-down inpatient facility;           Entrant for Dependent Insurance.
    or                                                                     You must notify your Employer and elect coverage for that
•   the date the policy is canceled due to reasons of fraud,               child and yourself, if you are not already enrolled, within 31
    nonpayment of premium or abuse.                                        days of the QMCSO being issued.
The terms of this Medical Benefits Extension will not apply to             B. Qualified Medical Child Support Order Defined
a child born as a result of a pregnancy which exists when your             A Qualified Medical Child Support Order is a judgment,
Medical Benefits cease or your Dependent's Medical Benefits                decree or order (including approval of a settlement agreement)
cease.                                                                     or administrative notice, which is issued pursuant to a state
                                                                           domestic relations law (including a community property law),
GM6000 BEX182                                                  V10
                                                                           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:
Federal Requirements                                                       1. the order recognizes or creates a child’s right to receive
The following pages explain your rights and responsibilities                  group health benefits for which a participant or beneficiary
under federal laws and regulations. Some states may have                      is eligible;
similar requirements. If a similar provision appears elsewhere             2. the order specifies your name and last known address, and
in this booklet, the provision which provides the better benefit              the child’s name and last known address, except that the
will apply.                                                                   name and address of an official of a state or political
                                                                              subdivision may be substituted for the child’s mailing
FDRL1                                                            V2
                                                                              address;
                                                                           3. the order provides a description of the coverage to be
                                                                              provided, or the manner in which the type of coverage is to
Notice of Provider Directory/Networks                                         be determined;
                                                                           4. the order states the period to which it applies; and
Notice Regarding Provider/Pharmacy Directories and
Provider/Pharmacy Networks                                                 5. if the order is a National Medical Support Notice
                                                                              completed in accordance with the Child Support
If your Plan utilizes a network of Providers/Pharmacies, you
                                                                              Performance and Incentive Act of 1998, such Notice meets
will automatically and without charge, receive a separate
                                                                              the requirements above.
listing of Participating Providers/Pharmacies.
                                                                           The QMCSO may not require the health insurance policy to
You may also have access to a list of Providers who
                                                                           provide coverage for any type or form of benefit or option not
participate in the network by visiting www.cigna.com;
                                                                           otherwise provided under the policy, except that an order may
mycigna.com or by calling the toll-free telephone number on
                                                                           require a plan to comply with State laws regarding health care
your ID card.
                                                                           coverage.
Your Participating Provider/Pharmacy networks consist of a
                                                                           C. Payment of Benefits
group of local medical practitioners, and Hospitals, of varied
specialties as well as general practice or a group of local                Any payment of benefits in reimbursement for Covered
Pharmacies who are employed by or contracted with CIGNA                    Expenses paid by the child, or the child’s custodial parent or
HealthCare.                                                                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
FDRL32                                                                     child.


                                                                           FDRL2                                                            V1
Qualified Medical Child Support Order
(QMCSO)
A. 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


                                                                      42                                                   myCIGNA.com
Special Enrollment Rights Under the Health                                   •   termination of employment;
Insurance Portability & Accountability Act                                   •   reduction in work hours to below the minimum required
(HIPAA)                                                                          for eligibility;
If you or your eligible Dependent(s) experience a special                    •   you or your Dependent(s) no longer reside, live or work
enrollment event as described below, you or your eligible                        in the other plan’s network service area and no other
Dependent(s) may be entitled to enroll in the Plan outside of a                  coverage is available under the other plan;
designated enrollment period upon the occurrence of one of                   •   you or your Dependent(s) incur a claim which meets or
the special enrollment events listed below. If you are already                   exceeds the lifetime maximum limit that is applicable to
enrolled in the Plan, you may request enrollment for you and                     all benefits offered under the other plan; or
your eligible Dependent(s) under a different option offered by               •   the other plan no longer offers any benefits to a class of
the Employer for which you are currently eligible. If you are                    similarly situated individuals.
not already enrolled in the Plan, you must request special
enrollment for yourself in addition to your eligible                     •   Termination of employer contributions (excluding
Dependent(s). You and all of your eligible Dependent(s) must                 continuation coverage). If a current or former employer
be covered under the same option. The special enrollment                     ceases all contributions toward the Employee’s or
events include:                                                              Dependent’s other coverage, special enrollment may be
                                                                             requested in this Plan for you and all of your eligible
•   Acquiring a new Dependent. If you acquire a new                          Dependent(s).
    Dependent(s) through marriage, birth, adoption or
    placement for adoption, you may request special enrollment           •   Exhaustion of COBRA or other continuation coverage.
    for any of the following combinations of individuals if not              Special enrollment may be requested in this Plan for you
    already enrolled in the Plan: Employee only; spouse only;                and all of your eligible Dependent(s) upon exhaustion of
    Employee and spouse; Dependent child(ren) only;                          COBRA or other continuation coverage. If you or your
    Employee and Dependent child(ren); Employee, spouse and                  Dependent(s) elect COBRA or other continuation coverage
    Dependent child(ren). Enrollment of Dependent children is                following loss of coverage under another plan, the COBRA
    limited to the newborn or adopted children or children who               or other continuation coverage must be exhausted before
    became Dependent children of the Employee due to                         any special enrollment rights exist under this Plan. An
    marriage. Dependent children who were already Dependents                 individual is considered to have exhausted COBRA or other
    of the Employee but not currently enrolled in the Plan are               continuation coverage only if such coverage ceases: (a) due
    not entitled to special enrollment.                                      to failure of the employer or other responsible entity to
                                                                             remit premiums on a timely basis; (b) when the person no
•   Loss of eligibility for State Medicaid or Children’s                     longer resides or works in the other plan’s service area and
    Health Insurance Program (CHIP). If you and/or your                      there is no other COBRA or continuation coverage available
    Dependent(s) were covered under a state Medicaid or CHIP                 under the plan; or (c) when the individual incurs a claim that
    plan and the coverage is terminated due to a loss of                     would meet or exceed a lifetime maximum limit on all
    eligibility, you may request special enrollment for yourself             benefits and there is no other COBRA or other continuation
    and any affected Dependent(s) who are not already enrolled               coverage available to the individual. This does not include
    in the Plan. You must request enrollment within 60 days                  termination of an employer’s limited period of contributions
    after termination of Medicaid or CHIP coverage.                          toward COBRA or other continuation coverage as provided
•   Loss of eligibility for other coverage (excluding                        under any severance or other agreement.
    continuation coverage). If coverage was declined under
    this Plan due to coverage under another plan, and eligibility
                                                                         FDRL3                                                                V4
    for the other coverage is lost, you and all of your eligible
    Dependent(s) may request special enrollment in this Plan. If
    required by the Plan, when enrollment in this Plan was               •   Eligibility for employment assistance under State
    previously declined, it must have been declined in writing               Medicaid or Children’s Health Insurance Program
    with a statement that the reason for declining enrollment                (CHIP). If you and/or your Dependent(s) become eligible
    was due to other health coverage. This provision applies to              for assistance with group health plan premium payments
    loss of eligibility as a result of any of the following:                 under a state Medicaid or CHIP plan, you may request
    •   divorce or legal separation;                                         special enrollment for yourself and any affected
    •   cessation of Dependent status (such as reaching the                  Dependent(s) who are not already enrolled in the Plan. You
                                                                             must request enrollment within 60 days after the date you
        limiting age);
                                                                             are determined to be eligible for assistance.
    •   death of the Employee;


                                                                    43                                                      myCIGNA.com
Except as stated above, special enrollment must be requested
within 30 days after the occurrence of the special enrollment
event. If the special enrollment event is the birth or adoption             Effect of Section 125 Tax Regulations on This
of a Dependent child, coverage will be effective immediately                Plan
on the date of birth, adoption or placement for adoption.
Coverage with regard to any other special enrollment event                  Your Employer has chosen to administer this Plan in
will be effective on the first day of the calendar month                    accordance with Section 125 regulations of the Internal
following receipt of the request for special enrollment.                    Revenue Code. Per this regulation, you may agree to a pretax
                                                                            salary reduction put toward the cost of your benefits.
Individuals who enroll in the Plan due to a special enrollment
                                                                            Otherwise, you will receive your taxable earnings as cash
event will not be considered Late Entrants. Any Pre-existing
                                                                            (salary).
Condition limitation will be applied upon enrollment, reduced
by prior Creditable Coverage, but will not be extended as for a             A. Coverage Elections
Late Entrant.                                                               Per Section 125 regulations, you are generally allowed to
Domestic Partners and their children (if not legal children of              enroll for or change coverage only before each annual benefit
the Employee) are not eligible for special enrollment.                      period. However, exceptions are allowed if your Employer
                                                                            agrees and you enroll for or change coverage within 30 days
                                                                            of the following:
FDRL4                                                             V3
                                                                            •    the date you meet the Special Enrollment criteria described
                                                                                 above; or
                                                                            •    the date you meet the criteria shown in the following
Coverage of Students on Medically Necessary                                      Sections B through F.
Leave of Absence                                                            B. Change of Status
If your Dependent child is covered by this plan as a student, as            A change in status is defined as:
defined in the Definition of Dependent, coverage will remain
active for that child if the child is on a medically necessary              1.     change in legal marital status due to marriage, death of a
leave of absence from a postsecondary educational institution                      spouse, divorce, annulment or legal separation;
(such as a college, university or trade school.)                            2.     change in number of Dependents due to birth, adoption,
Coverage will terminate on the earlier of:                                         placement for adoption, or death of a Dependent;
a)   The date that is one year after the first day of the                   3.     change in employment status of Employee, spouse or
     medically necessary leave of absence; or                                      Dependent due to termination or start of employment,
                                                                                   strike, lockout, beginning or end of unpaid leave of
b) The date on which coverage would otherwise terminate                            absence, including under the Family and Medical Leave
   under the terms of the plan.                                                    Act (FMLA), or change in worksite;
The child must be a Dependent under the terms of the plan and               4.     changes in employment status of Employee, spouse or
must have been enrolled in the plan on the basis of being a                        Dependent resulting in eligibility or ineligibility for
student at a postsecondary educational institution immediately                     coverage;
before the first day of the medically necessary leave of
absence.                                                                    5.     change in residence of Employee, spouse or Dependent to
                                                                                   a location outside of the Employer’s network service
The plan must receive written certification from the treating                      area; and
physician that the child is suffering from a serious illness or
injury and that the leave of absence (or other change in                    6.     changes which cause a Dependent to become eligible or
enrollment) is medically necessary.                                                ineligible for coverage.
A “medically necessary leave of absence” is a leave of                      C. Court Order
absence from a postsecondary educational institution, or any                A change in coverage due to and consistent with a court order
other change in enrollment of the child at the institution that:            of the Employee or other person to cover a Dependent.
(1) starts while the child is suffering from a serious illness or           D. Medicare or Medicaid Eligibility/Entitlement
condition; (2) is medically necessary; and (3) causes the child
to lose student status under the terms of the plan.                         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
FDRL76                                                                      Medicaid eligibility.



                                                                       44                                                    myCIGNA.com
E. Change in Cost of Coverage                                          health insurance who does not meet the federal definition of a
If the cost of benefits increases or decreases during a benefit        Dependent, the premium may be taxable to you as income. If
period, your Employer may, in accordance with plan terms,              you have questions concerning your specific situation, you
automatically change your elective contribution.                       should consult your own tax consultant or attorney.
When the change in cost is significant, you may either
increase your contribution or elect less-costly coverage. When         FDRL7
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
                                                                       Coverage for Maternity Hospital Stay
your election to the new benefit option.
                                                                       Group health plans and health insurance issuers offering group
F. Changes in Coverage of Spouse or Dependent Under
                                                                       health insurance coverage generally may not, under a federal
    Another Employer’s Plan
                                                                       law known as the “Newborns’ and Mothers’ Health Protection
You may make a coverage election change if the plan of your            Act”: restrict benefits for any Hospital length of stay in
spouse or Dependent: (a) incurs a change such as adding or             connection with childbirth for the mother or newborn child to
deleting a benefit option; (b) allows election changes due to          less than 48 hours following a vaginal delivery, or less than 96
Special Enrollment, Change in Status, Court Order or                   hours following a cesarean section; or require that a provider
Medicare or Medicaid Eligibility/Entitlement; or (c) this Plan         obtain authorization from the plan or insurance issuer for
and the other plan have different periods of coverage or open          prescribing a length of stay not in excess of the above periods.
enrollment 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,
FDRL70
                                                                       as applicable.
                                                                       Please review this Plan for further details on the specific
                                                                       coverage available to you and your Dependents.
Eligibility for Coverage for Adopted Children
Any child under the age of 18 who is adopted by you,
                                                                       FDRL8
including a child who is placed with you for adoption, will be
eligible for Dependent Insurance upon the date of placement
with you. A child will be considered placed for adoption when
you become legally obligated to support that child, totally or         Women’s Health and Cancer Rights Act
partially, prior to that child’s adoption.                             (WHCRA)
If a child placed for adoption is not adopted, all health              Do you know that your plan, as required by the Women’s
coverage ceases when the placement ends, and will not be               Health and Cancer Rights Act of 1998, provides benefits for
continued.                                                             mastectomy-related services including all stages of
The provisions in the “Exception for Newborns” section of              reconstruction and surgery to achieve symmetry between the
this document that describe requirements for enrollment and            breasts, prostheses, and complications resulting from a
effective date of insurance will also apply to an adopted child        mastectomy, including lymphedema? Call Member Services at
or a child placed with you for adoption.                               the toll free number listed on your ID card for more
                                                                       information.
FDRL6

                                                                       FDRL51



Federal Tax Implications for Dependent
Coverage
Premium payments for Dependent health insurance are usually
exempt from federal income tax. Generally, if you can claim
an individual as a Dependent for purposes of federal income
tax, then the premium for that Dependent’s health insurance
coverage will not be taxable to you as income. However, in
the rare instance that you cover an individual under your


                                                                  45                                                   myCIGNA.com
Group Plan Coverage Instead of Medicaid                                B. Reinstatement of Canceled Insurance Following Leave
If your income and liquid resources do not exceed certain              Upon your return to Active Service following a leave of
limits established by law, the state may decide to pay                 absence that qualifies under the Family and Medical Leave
premiums for this coverage instead of for Medicaid, if it is           Act of 1993, as amended, any canceled insurance (health, life
cost effective. This includes premiums for continuation                or disability) will be reinstated as of the date of your return.
coverage required by federal law.                                      You will not be required to satisfy any eligibility or benefit
                                                                       waiting period or the requirements of any Pre-existing
                                                                       Condition limitation to the extent that they had been satisfied
FDRL75
                                                                       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.
Obtaining a Certificate of Creditable Coverage
Under This Plan
                                                                       FDRL74
Upon loss of coverage under this Plan, a Certificate of
Creditable Coverage will be mailed to each terminating
individual at the last address on file. You or your dependent
may also request a Certificate of Creditable Coverage, without         Uniformed Services Employment and Re-
charge, at any time while enrolled in the Plan and for 24              Employment Rights Act of 1994 (USERRA)
months following termination of coverage. You may need this            The Uniformed Services Employment and Re-employment
document as evidence of your prior coverage to reduce any              Rights Act of 1994 (USERRA) sets requirements for
pre-existing condition limitation period under another plan, to        continuation of health coverage and re-employment in regard
help you get special enrollment in another plan, or to obtain          to an Employee’s military leave of absence. These
certain types of individual health coverage even if you have           requirements apply to medical and dental coverage for you
health problems. To obtain a Certificate of Creditable                 and your Dependents. They do not apply to any Life, Short-
Coverage, contact the Plan Administrator or call the toll-free         term or Long-term Disability or Accidental Death &
customer service number on the back of your ID card.                   Dismemberment coverage you may have.
                                                                       A. Continuation of Coverage
FDRL50
                                                                       For leaves of less than 31 days, coverage will continue as
                                                                       described in the Termination section regarding Leave of
                                                                       Absence.
Requirements of Medical Leave Act of 1993 (as                          For leaves of 31 days or more, you may continue coverage for
amended) (FMLA)                                                        yourself and your Dependents as follows:
Any provisions of the policy that provide for: (a) continuation        You may continue benefits by paying the required premium to
of insurance during a leave of absence; and (b) reinstatement          your Employer, until the earliest of the following:
of insurance following a return to Active Service; are modified        •   24 months from the last day of employment with the
by the following provisions of the federal Family and Medical              Employer;
Leave Act of 1993, as amended, where applicable:
                                                                       •   the day after you fail to return to work; and
A. Continuation of Health Insurance During Leave
                                                                       •   the date the policy cancels.
Your health insurance will be continued during a leave of
absence if:                                                            Your Employer may charge you and your Dependents up to
                                                                       102% of the total premium.
•   that leave qualifies as a leave of absence under the Family
    and Medical Leave Act of 1993, as amended; and                     Following continuation of health coverage per USERRA
                                                                       requirements, you may convert to a plan of individual
•   you are an eligible Employee under the terms of that Act.          coverage according to any “Conversion Privilege” shown in
The cost of your health insurance during such leave must be            your certificate.
paid, whether entirely by your Employer or in part by you and          B. Reinstatement of Benefits (applicable to all coverages)
your Employer.
                                                                       If your coverage ends during the leave of absence because you
                                                                       do not elect USERRA or an available conversion plan at the
                                                                       expiration of USERRA and you are reemployed by your



                                                                  46                                                       myCIGNA.com
current Employer, coverage for you and your Dependents may              •   for a Dependent child, failure to continue to qualify as a
be reinstated if (a) you gave your Employer advance written or              Dependent under the Plan.
verbal notice of your military service leave, and (b) the               Who is Entitled to COBRA Continuation?
duration of all military leaves while you are employed with
your current Employer does not exceed 5 years.                          Only a “qualified beneficiary” (as defined by federal law) may
                                                                        elect to continue health insurance coverage. A qualified
You and your Dependents will be subject to only the balance             beneficiary may include the following individuals who were
of a Pre-Existing Condition Limitation (PCL) or waiting                 covered by the Plan on the day the qualifying event occurred:
period that was not yet satisfied before the leave began.               you, your spouse, and your Dependent children. Each
However, if an Injury or Sickness occurs or is aggravated               qualified beneficiary has their own right to elect or decline
during the military leave, full Plan limitations will apply.            COBRA continuation coverage even if you decline or are not
Any 63-day break in coverage rule regarding credit for time             eligible for COBRA continuation.
accrued toward a PCL waiting period will be waived.                     The following individuals are not qualified beneficiaries for
If your coverage under this plan terminates as a result of your         purposes of COBRA continuation: domestic partners, same
eligibility for military medical and dental coverage and your           sex spouses, grandchildren (unless adopted by you),
order to active duty is canceled before your active duty service        stepchildren (unless adopted by you). Although these
commences, these reinstatement rights will continue to apply.           individuals do not have an independent right to elect COBRA
                                                                        continuation coverage, if you elect COBRA continuation
                                                                        coverage for yourself, you may also cover your Dependents
FDRL58
                                                                        even if they are not considered qualified beneficiaries under
                                                                        COBRA. However, such individuals’ coverage will terminate
                                                                        when your COBRA continuation coverage terminates. The
COBRA Continuation Rights Under Federal                                 sections titled “Secondary Qualifying Events” and “Medicare
Law                                                                     Extension For Your Dependents” are not applicable to these
                                                                        individuals.
For You and Your Dependents
What is COBRA Continuation Coverage?
                                                                        FDRL67
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          Secondary Qualifying Events
the Plan. You and/or your Dependents will be permitted to               If, as a result of your termination of employment or reduction
continue the same coverage under which you or your                      in work hours, your Dependent(s) have elected COBRA
Dependents were covered on the day before the qualifying                continuation coverage and one or more Dependents experience
event occurred, unless you move out of that plan’s coverage             another COBRA qualifying event, the affected Dependent(s)
area or the plan is no longer available. You and/or your                may elect to extend their COBRA continuation coverage for
Dependents cannot change coverage options until the next                an additional 18 months (7 months if the secondary event
open enrollment period.                                                 occurs within the disability extension period) for a maximum
When is COBRA Continuation Available?                                   of 36 months from the initial qualifying event. The second
For you and your Dependents, COBRA continuation is                      qualifying event must occur before the end of the initial 18
available for up to 18 months from the date of the following            months of COBRA continuation coverage or within the
qualifying events if the event would result in a loss of                disability extension period discussed below. Under no
coverage under the Plan:                                                circumstances will COBRA continuation coverage be
                                                                        available for more than 36 months from the initial qualifying
•   your termination of employment for any reason, other than           event. Secondary qualifying events are: your death; your
    gross misconduct, or                                                divorce or legal separation; or, for a Dependent child, failure
•   your reduction in work hours.                                       to continue to qualify as a Dependent under the Plan.
For your Dependents, COBRA continuation coverage is                     Disability Extension
available for up to 36 months from the date of the following            If, after electing COBRA continuation coverage due to your
qualifying events if the event would result in a loss of                termination of employment or reduction in work hours, you or
coverage under the Plan:                                                one of your Dependents is determined by the Social Security
•   your death;                                                         Administration (SSA) to be totally disabled under title II or
•   your divorce or legal separation; or                                XVI of the SSA, you and all of your Dependents who have



                                                                   47                                                    myCIGNA.com
elected COBRA continuation coverage may extend such                        continue until the earliest of: (a) the end of the applicable
continuation for an additional 11 months, for a maximum of                 maximum period; (b) the date the pre-existing condition
29 months from the initial qualifying event.                               provision is no longer applicable; or (c) the occurrence of an
To qualify for the disability extension, all of the following              event described in one of the first three bullets above; or
requirements must be satisfied:                                        •   any reason the Plan would terminate coverage of a
1. SSA must determine that the disability occurred prior to or             participant or beneficiary who is not receiving continuation
   within 60 days after the disabled individual elected COBRA              coverage (e.g., fraud).
   continuation coverage; and                                          Moving Out of Employer’s Service Area or Elimination of
2. A copy of the written SSA determination must be provided            a Service Area
   to the Plan Administrator within 60 calendar days after the         If you and/or your Dependents move out of the Employer’s
   date the SSA determination is made AND before the end of            service area or the Employer eliminates a service area in your
   the initial 18-month continuation period.                           location, your COBRA continuation coverage under the plan
If the SSA later determines that the individual is no longer           will be limited to emergency services only. Because the Plan
disabled, you must notify the Plan Administrator within 30             does not provide out-of-network coverage, nonemergency
days after the date the final determination is made by SSA.            services will not be covered under the plan outside of the
The 11-month disability extension will terminate for all               Employer’s service area. If the Employer offers another
covered persons on the first day of the month that is more than        benefit option through CIGNA or another carrier which can
30 days after the date the SSA makes a final determination             provide coverage in your location, you may elect COBRA
that the disabled individual is no longer disabled.                    continuation coverage under that option.
All causes for “Termination of COBRA Continuation” listed
below will also apply to the period of disability extension.           FDRL22                                                           V1

Medicare Extension for Your Dependents
When the qualifying event is your termination of employment            Employer’s Notification Requirements
or reduction in work hours and you became enrolled in                  Your Employer is required to provide you and/or your
Medicare (Part A, Part B or both) within the 18 months before          Dependents with the following notices:
the qualifying event, COBRA continuation coverage for your
                                                                       •   An initial notification of COBRA continuation rights must
Dependents will last for up to 36 months after the date you
                                                                           be provided within 90 days after your (or your spouse’s)
became enrolled in Medicare. Your COBRA continuation
                                                                           coverage under the Plan begins (or the Plan first becomes
coverage will last for up to 18 months from the date of your
                                                                           subject to COBRA continuation requirements, if later). If
termination of employment or reduction in work hours.
                                                                           you and/or your Dependents experience a qualifying event
                                                                           before the end of that 90-day period, the initial notice must
FDRL21                                                                     be provided within the time frame required for the COBRA
                                                                           continuation coverage election notice as explained below.
Termination of COBRA Continuation                                      •   A COBRA continuation coverage election notice must be
                                                                           provided to you and/or your Dependents within the
COBRA continuation coverage will be terminated upon the                    following timeframes:
occurrence of any of the following:
                                                                           (a) if the Plan provides that COBRA continuation coverage
•   the end of the COBRA continuation period of 18, 29 or 36                   and the period within which an Employer must notify
    months, as applicable;                                                     the Plan Administrator of a qualifying event starts upon
•   failure to pay the required premium within 30 calendar days                the loss of coverage, 44 days after loss of coverage
    after the due date;                                                        under the Plan;
•   cancellation of the Employer’s policy with CIGNA;                      (b) if the Plan provides that COBRA continuation coverage
•   after electing COBRA continuation coverage, a qualified                    and the period within which an Employer must notify
    beneficiary enrolls in Medicare (Part A, Part B, or both);                 the Plan Administrator of a qualifying event starts upon
                                                                               the occurrence of a qualifying event, 44 days after the
•   after electing COBRA continuation coverage, a qualified                    qualifying event occurs; or
    beneficiary becomes covered under another group health
    plan, unless the qualified beneficiary has a condition for             (c) in the case of a multi-employer plan, no later than 14
    which the new plan limits or excludes coverage under a pre-                days after the end of the period in which Employers
    existing condition provision. In such case coverage will



                                                                  48                                                    myCIGNA.com
         must provide notice of a qualifying event to the Plan            When and How to Pay COBRA Premiums
         Administrator.                                                   First payment for COBRA continuation
How to Elect COBRA Continuation Coverage                                  If you elect COBRA continuation coverage, you do not have
The COBRA coverage election notice will list the individuals              to send any payment with the election form. However, you
who are eligible for COBRA continuation coverage and                      must make your first payment no later than 45 calendar days
inform you of the applicable premium. The notice will also                after the date of your election. (This is the date the Election
include instructions for electing COBRA continuation                      Notice is postmarked, if mailed.) If you do not make your first
coverage. You must notify the Plan Administrator of your                  payment within that 45 days, you will lose all COBRA
election no later than the due date stated on the COBRA                   continuation rights under the Plan.
election notice. If a written election notice is required, it must        Subsequent payments
be post-marked no later than the due date stated on the
                                                                          After you make your first payment for COBRA continuation
COBRA election notice. If you do not make proper
                                                                          coverage, you will be required to make subsequent payments
notification by the due date shown on the notice, you and your
                                                                          of the required premium for each additional month of
Dependents will lose the right to elect COBRA continuation
                                                                          coverage. Payment is due on the first day of each month. If
coverage. If you reject COBRA continuation coverage before
                                                                          you make a payment on or before its due date, your coverage
the due date, you may change your mind as long as you
                                                                          under the Plan will continue for that coverage period without
furnish a completed election form before the due date.
                                                                          any break.
Each qualified beneficiary has an independent right to elect
                                                                          Grace periods for subsequent payments
COBRA continuation coverage. Continuation coverage may
be elected for only one, several, or for all Dependents who are           Although subsequent payments are due by the first day of the
qualified beneficiaries. Parents may elect to continue coverage           month, you will be given a grace period of 30 days after the
on behalf of their Dependent children. You or your spouse                 first day of the coverage period to make each monthly
may elect continuation coverage on behalf of all the qualified            payment. Your COBRA continuation coverage will be
beneficiaries. You are not required to elect COBRA                        provided for each coverage period as long as payment for that
continuation coverage in order for your Dependents to elect               coverage period is made before the end of the grace period for
COBRA continuation.                                                       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
FDRL23                                                                    confirm coverage during this time may be informed that
                                                                          coverage has been suspended. If payment is received before
How Much Does COBRA Continuation Coverage Cost?                           the end of the grace period, your coverage will be reinstated
                                                                          back to the beginning of the coverage period. This means that
Each qualified beneficiary may be required to pay the entire
                                                                          any claim you submit for benefits while your coverage is
cost of continuation coverage. The amount may not exceed
                                                                          suspended may be denied and may have to be resubmitted
102% of the cost to the group health plan (including both
                                                                          once your coverage is reinstated. If you fail to make a
Employer and Employee contributions) for coverage of a
                                                                          payment before the end of the grace period for that coverage
similarly situated active Employee or family member. The
                                                                          period, you will lose all rights to COBRA continuation
premium during the 11-month disability extension may not
                                                                          coverage under the Plan.
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                  FDRL24                                                          V2
example:
If the Employee alone elects COBRA continuation coverage,                 You Must Give Notice of Certain Qualifying Events
the Employee will be charged 102% (or 150%) of the active
Employee premium. If the spouse or one Dependent child                    If you or your Dependent(s) experience one of the following
alone elects COBRA continuation coverage, they will be                    qualifying events, you must notify the Plan Administrator
charged 102% (or 150%) of the active Employee premium. If                 within 60 calendar days after the later of the date the
more than one qualified beneficiary elects COBRA                          qualifying event occurs or the date coverage would cease as a
continuation coverage, they will be charged 102% (or 150%)                result of the qualifying event:
of the applicable family premium.                                         •   Your divorce or legal separation;
                                                                          •   Your child ceases to qualify as a Dependent under the Plan;
                                                                              or



                                                                     49                                                  myCIGNA.com
•   The occurrence of a secondary qualifying event as discussed            period begins on the first day of the month that you become
    under “Secondary Qualifying Events” above (this notice                 TAA-eligible. If you elect COBRA coverage during this
    must be received prior to the end of the initial 18- or 29-            special election period, COBRA coverage will be effective on
    month COBRA period).                                                   the first day of the special election period and will continue for
(Also refer to the section titled “Disability Extension” for               18 months, unless you experience one of the events discussed
additional notice requirements.)                                           under “Termination of COBRA Continuation” above.
                                                                           Coverage will not be retroactive to the initial loss of coverage.
Notice must be made in writing and must include: the name of               If you receive a determination that you are TAA-eligible, you
the Plan, name and address of the Employee covered under the               must notify the Plan Administrator immediately.
Plan, name and address(es) of the qualified beneficiaries
affected by the qualifying event; the qualifying event; the date           Conversion Available Following Continuation
the qualifying event occurred; and supporting documentation                If your or your Dependents’ COBRA continuation ends due to
(e.g., divorce decree, birth certificate, disability determination,        the expiration of the maximum 18-, 29- or 36-month period,
etc.).                                                                     whichever applies, you and/or your Dependents may be
Newly Acquired Dependents                                                  entitled to convert to the coverage in accordance with the
                                                                           Medical Conversion benefit then available to Employees and
If you acquire a new Dependent through marriage, birth,                    the Dependents. Please refer to the section titled “Conversion
adoption or placement for adoption while your coverage is                  Privilege” for more information.
being continued, you may cover such Dependent under your
COBRA continuation coverage. However, only your newborn                    Interaction With Other Continuation Benefits
or adopted Dependent child is a qualified beneficiary and may              You may be eligible for other continuation benefits under state
continue COBRA continuation coverage for the remainder of                  law. Refer to the Termination section for any other
the coverage period following your early termination of                    continuation benefits.
COBRA coverage or due to a secondary qualifying event.
COBRA coverage for your Dependent spouse and any
                                                                           FDRL26                                                          V2
Dependent children who are not your children (e.g.,
stepchildren or grandchildren) will cease on the date your
COBRA coverage ceases and they are not eligible for a
secondary qualifying event.                                                Notice of an Appeal or a Grievance
                                                                           The appeal or grievance provision in this certificate may be
FDRL25                                                           V1        superseded by the law of your state. Please see your
                                                                           explanation of benefits for the applicable appeal or grievance
                                                                           procedure.
Trade Act of 2002
The Trade Act of 2002 created a new tax credit for certain
                                                                           GM6000 NOT90
individuals who become eligible for trade adjustment
assistance and for certain retired Employees who are receiving
pension payments from the Pension Benefit Guaranty
Corporation (PBGC) (eligible individuals). Under the new tax
                                                                           The Following Will Apply To Residents of
provisions, eligible individuals can either take a tax credit or           Colorado
get advance payment of 65% of premiums paid for qualified
health insurance, including continuation coverage. If you have             When You Have A Complaint or An
questions about these new tax provisions, you may call the
Health Coverage Tax Credit Customer Contact Center toll-free               Appeal
at 1-866-628-4282. TDD/TYY callers may call toll-free at 1-                For the purposes of this section, any reference to "you," "your"
866-626-4282. More information about the Trade Act is also                 or "Member" also refers to a representative or provider
available at www.doleta.gov/tradeact/2002act_index.asp.                    designated by you to act on your behalf, unless otherwise
In addition, if you initially declined COBRA continuation                  noted.
coverage and, within 60 days after your loss of coverage under             We want you to be completely satisfied with the care you
the Plan, you are deemed eligible by the U.S. Department of                receive. That is why we have established a process for
Labor or a state labor agency for trade adjustment assistance              addressing your concerns and solving your problems.
(TAA) benefits and the tax credit, you may be eligible for a
special 60 day COBRA election period. The special election



                                                                      50                                                   myCIGNA.com
Start with Member Services                                                extension does not apply to postservice appeals involving
We are here to listen and help. If you have a concern regarding           Medical Necessity.
a person, a service, the quality of care, or contractual benefits,        You may request that the appeal process be expedited if, (a)
you can call our toll-free number and explain your concern to             the time frames under this process would seriously jeopardize
one of our Customer Service representatives. You can also                 your life, health or ability to regain maximum function or in
express that concern in writing. Please call or write to us at the        the opinion of your Physician would cause you severe pain
following:                                                                which cannot be managed without the requested services; or
  Customer Services Toll-Free Number or address that                      (b) your appeal involves nonauthorization of an admission or
  appears on your Benefit Identification card, explanation of             continuing inpatient Hospital stay. CG's Physician reviewer, in
  benefits or claim form.                                                 consultation with the treating Physician, will decide if an
                                                                          expedited appeal is necessary. When an appeal is expedited,
We will do our best to resolve the matter on your initial                 we will respond orally with a decision within 72 hours,
contact. If we need more time to review or investigate your               followed up in writing.
concern, we will get back to you as soon as possible, but in
any case within 30 days.
                                                                          GM6000 APL551
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure                                                         Level Two Appeal
CG has a two step appeals procedure for coverage decisions.               If you are dissatisfied with our level one appeal decision, you
To initiate an appeal, you must submit a request for an appeal            may request a second review. To start a level two appeal,
in writing within 365 days of receipt of a denial notice. You             follow the same process required for a level one appeal.
should state the reason why you feel your appeal should be                Most requests for a second review will be conducted by the
approved and include any information supporting your appeal.              Appeals Committee, which consists of at least three people.
If you are unable or choose not to write, you may ask to                  Anyone involved in the prior decision may not vote on the
register your appeal by telephone. Call or write to us at the             Committee. For appeals involving Medical Necessity or
toll-free number or address on your Benefit Identification                clinical appropriateness, the Committee will consult with at
card, explanation of benefits or claim form. You may also                 least one Physician reviewer in the same or similar specialty
register your appeal by an arranged appointment or walk-in                as the care under consideration, as determined by CG's
interview.                                                                Physician reviewer.
                                                                          You have the following rights: (1) to attend the Committee
GM6000 APL550                                                   V1        review; (2) to present your situation to the Committee in
                                                                          person or in writing; (3) to submit supporting material both
                                                                          before and at the Committee review; (4) to ask questions of
Level One Appeal                                                          any CG representative prior to the review; and (5) to question
Your appeal will be reviewed and the decision made by                     any reviewer at the review; and (6) to be assisted or
someone not involved in the initial decision. Appeals                     represented by a person of your choice.
involving Medical Necessity or clinical appropriateness will              For level two appeals we will acknowledge in writing that we
be considered by a health care professional who will consult              have received your request and schedule a Committee review.
with an appropriate clinical peer or peers in the same or                 For required preservice and concurrent care coverage
similar specialty as would typically manage the case being                determinations, the Committee review will be completed
reviewed.                                                                 within 15 calendar days. For postservice claims, the
For level one appeals, we will respond in writing with a                  Committee review will be completed within 30 calendar days.
decision within 15 calendar days after we receive an appeal               If more time or information is needed to make the
for a required preservice or concurrent care coverage                     determination, we will notify you in writing to request an
determination (decision). We will respond within 30 calendar              extension of up to 15 calendar days and to specify any
days after we receive an appeal for a postservice coverage                additional information needed by the Committee to complete
determination. However, for postservice appeals involving                 the review. You will be notified in writing of the Committee's
Medical Necessity, we will respond in writing within 20                   decision within five working days after the Committee
working days. If more time or information is needed to make               meeting, and within the Committee review time frames above
the determination, we will notify you in writing to request an            if the Committee does not approve the requested coverage.
extension of up to 15 calendar days and to specify any
additional information needed to complete the review. This


                                                                     51                                                  myCIGNA.com
You may request that the appeal process be expedited if, (a)            writing. If the Commissioner determines that the independent
the time frames under this process would seriously jeopardize           external review entity presents a conflict of interest, the
your life, health or ability to regain maximum function or in           Commissioner shall assign, within one working day, another
the opinion of your Physician would cause you severe pain               independent external review entity to conduct the external
which cannot be managed without the requested services; or              review. Upon this reassignment, the Commissioner will notify
(b) your appeal involves nonauthorization of an admission or            CG, electronically, by facsimile, or by telephone, followed up
continuing inpatient Hospital stay. CG's Physician reviewer, in         in writing, of the name and address of the new independent
consultation with the treating Physician will decide if an              external review entity to which the appeal should be sent. The
expedited appeal is necessary. CG's Physician reviewer will             Commissioner will also notify you in writing of the
consult with a Physician reviewer in the same or similar                Commissioner's determination regarding the potential conflict
specialty as the care under consideration to make a decision.           of interest and the name and address of the new independent
When an appeal is expedited, we will respond orally with a              external review entity.
decision within 72 hours, followed up in writing.
                                                                        GM6000 APL553
GM6000 APL552                                                 V1

                                                                        Within six working days from the date CG receives notice
Standard External Review Process for Medical Necessity                  from the Commissioner regarding the selection of the
Adverse Decisions                                                       independent external review entity, we will deliver the
If you remain dissatisfied with the decision of CG, you may             following to the assigned independent external review entity:
submit a written request for External Independent Review                (1) all relevant medical records; (2) a copy of any and all
(EIR). You have 60 calendar days after the date of receipt of           denial letters; (3) a copy of the signed consent form; (4) all
CG's final adverse determination to submit a written request            documentation provided to CG by you and/or a health care
for EIR. All requests for external review must be in writing to         professional in support of your request for coverage; (5)
CG and must include a completed external review request                 criteria used and clinical reasons for the adverse decision; and
form. All requests must also include a signed consent,                  (6) an index of all submitted documents. Within two working
authorizing CG to disclose protected health information,                days of receipt of the material from CG, the independent
including medical records, pertinent to the external review.            external review entity will deliver to you the index of all
                                                                        materials that CG has submitted to the independent external
Within two working days of receipt of your request for EIR,
                                                                        review entity. We will provide you, upon request, all relevant
CG will deliver a copy of your request to the Commissioner. If
                                                                        information supplied to the independent external review entity
we decide to reverse our final adverse determination before
                                                                        that is not confidential or privileged under state or federal law.
sending your request to the Commissioner, we will inform you
within one working day of our decision by facsimile,                    The independent external review entity will notify, you or
telephone or other electronic means, followed up in writing.            your health care professional and CG of any additional
                                                                        medical information required to conduct the review. Within
Within two working days of receiving your request for EIR
                                                                        five working days of such a request, you or your health care
from CG, the Commissioner will assign an independent
                                                                        professional will submit the additional information, or an
external review entity to conduct the external review. Upon
                                                                        explanation of why the additional information is not being
assignment, the Commissioner will notify CG, electronically,
                                                                        submitted to the independent external review entity and CG.
by facsimile, or by telephone, followed up in writing, of the
                                                                        If you or your health care professional fails to provide the
name and address of the independent external review entity to
                                                                        additional information or the explanation of why additional
which your appeal should be sent. Within two working days of
                                                                        information is not being submitted within five working
receiving the notice from the Commissioner, we will provide
                                                                        days, the independent external review entity will make a
you either electronically, by facsimile, or by telephone,
                                                                        decision based on the information submitted by CG. If CG
followed up in writing, with a description of the independent
                                                                        fails to provide the required documents and information
external review entity and how to provide the Commissioner
                                                                        within six working days, the independent external review
with documentation regarding any potential conflict of interest
                                                                        entity may terminate the external review and make a
with the independent external review entity. Within two
                                                                        decision to reverse CG's final adverse determination.
working days of receipt of notice from CG concerning the
                                                                        Immediately upon the reversal, the independent external
independent external review entity, you may provide the
                                                                        review entity will notify you, CG and the Commissioner.
Commissioner with documentation regarding a potential
conflict of interest of the independent external review entity,         Upon receipt of any new information from you, CG may
electronically, by facsimile, or by telephone, followed up in           reconsider its final adverse determination that is the subject
                                                                        of the external review. The external review may only be


                                                                   52                                                   myCIGNA.com
terminated if CG decides to reverse its final adverse                  Commissioner will inform us of the name and address of the
determination and provide coverage or payment for the                  independent external review entity. Within one working day of
health care service that was denied. Within one working day            receiving the notice from the Commissioner, we will notify
of CG making the decision to reverse its final adverse                 you, electronically, by facsimile, or by telephone, followed up
determination, CG will notify you, the independent external            in writing. The notice will include a written description of the
review, and the Commissioner of its decision, electronically,          independent external review entity that the Commissioner has
by facsimile, or by telephone, followed up in writing. The             selected.
independent external review entity will terminate the
external review upon receipt of the notice from CG.
                                                                       GM6000 APL555                                                 V1


GM6000 APL554
                                                                       Within three working days of receiving the request for an
                                                                       expedited external review, we will provide all necessary
Within 30 working days after the date of receipt of the request        documents and information considered in making the final
of the external review by CG, the independent external review          adverse determination to the independent external review
entity will provide written notice of its decision to uphold or        entity either electronically, by telephone, by facsimile or by
reverse CG's final adverse determination to you, if applicable,        any other available expeditious method. Within one working
to your designated representative, to CG, to your Physician            day of receiving the documents and information, the
and to the Commissioner. The independent external review               independent external review entity will deliver to you an index
entity may request that the Commissioner extend the deadline           of all materials that we have submitted. We will provide to
for the written notice of the decision for up to 10 working            you, upon request, all information submitted to the
days.                                                                  independent external review entity that is not confidential or
Upon our receipt of the independent external review entity's           privileged under state or federal law.
notice of the decision reversing our final adverse                     The independent external review entity will notify you,
determination, we will approve the coverage that was the               your health care professional and CG, either electronically,
subject of the final adverse determination. For preservice and         by facsimile, or by telephone followed up in writing, of any
concurrent care reviews, we will approve the coverage within           additional information that is required to conduct the
one working day. For postservice review, we will approve the           review. You or your health care professional will submit
coverage, within five working days. We will provide written            the additional information, or an explanation of why the
notice of the approval to you within one working day of our            additional information is not being submitted to the
approval of coverage. The coverage will be provided subject            independent external review entity and CG within two
to the terms and conditions applicable to benefits under the           working days of such a request.
plan.                                                                  Within seven working days after the date of receipt of the
Expedited External Review Process for Medical Necessity                request for external review by CG, the independent external
Adverse Decisions                                                      review entity will make a decision to uphold or reverse CG's
You or your designated representative may make a request               final adverse determination and notify you, your Physician,
with CG for an expedited external review if you have a                 CG, and the Commissioner of the decision. The independent
medical condition if the time frame for completion of a                review entity may request the Commissioner extend the
standard external review would seriously jeopardize your life          deadline for the written notice up to five working days for the
or health, would jeopardize your ability to regain maximum             consideration of additional information.
function or, if you have a disability, would create an imminent        Upon our receipt of the independent external review entity's
and substantial limitation of your existing ability to live            decision, we will approve the coverage that was subject to the
independently. Your request for an expedited review must               review within one working day. We will provide written
include a Physician certification that your medical condition          notice of the approval to you within one working day of
meets the expedited review criteria.                                   receipt of the independent external review entity's notice. The
Upon receipt of your request for an expedited external review,         coverage will be provided subject to the terms and conditions
we will notify and send a copy of the request to the                   applicable to benefits under the plan. An expedited external
Commissioner within one working day either electronically,             review may not be provided for postservice adverse
by telephone, by facsimile or any other available expeditious          determinations.
method. Within one working day of receiving the request from           An external review decision is binding on CG and you, except
CG, the Commissioner will assign an independent external               to the extent CG and you have other remedies available under
review entity to conduct the review. Upon assignment, the              federal or state law. You may not file a subsequent request for


                                                                  53                                                  myCIGNA.com
external review involving the same plan's final adverse                  the course of making the benefit determination, without regard
determination for which you have already received an external            to whether such document, record, or other information was
review decision.                                                         relied upon in making the benefit determination; (c)
                                                                         demonstrates compliance with the administrative processes
                                                                         and safeguards required by federal law in making the benefit
GM6000 APL556
                                                                         determination; or (d) constitutes a statement of policy or
                                                                         guidance with respect to the plan concerning the denied
Appeal to the State of Colorado                                          treatment option or benefit or the claimant's diagnosis, without
You have the right to contact the Colorado Division of                   regard to whether such advice or statement was relied upon in
Insurance for assistance at any time. The Colorado Division of           making the benefit determination.
Insurance may be contacted at the following address and                  Legal Action
telephone number:                                                        If your plan is governed by ERISA, you have the right to bring
        Colorado Division of Insurance                                   a civil action under Section 502(a) of ERISA if you are not
        Department of Regulatory Affairs                                 satisfied with the outcome of the Appeals Procedure. In most
        1560 Broadway, Suite 850                                         instances, you may not initiate a legal action against CG until
        Denver, CO 80202                                                 you have completed the Level One and Level Two Appeal
        1-800-930-3745                                                   processes. If your Appeal is expedited, there is no need to
                                                                         complete the Level Two process prior to bringing legal action.

GM6000 APL557
                                                                         GM6000 APL558


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         Definitions
include: (1) the specific reason or reasons for the adverse              Active Service
determination; (2) reference to the specific plan provisions on          You will be considered in Active Service:
which the determination is based; (3) a statement that the
claimant is entitled to receive, upon request and free of charge,        •   on any of your Employer's scheduled work days if you are
reasonable access to and copies of all documents, records, and               performing the regular duties of your work on that day
other Relevant Information as defined; (4) a statement                       either at your Employer's place of business or at some
describing any voluntary appeal procedures offered by the                    location to which you are required to travel for your
plan and the claimant's right to bring an action under ERISA                 Employer's business.
section 502(a); (5) upon request and free of charge, a copy of           •   on a day which is not one of your Employer's scheduled
any internal rule, guideline, protocol or other similar criterion            work days if you were in Active Service on the preceding
that was relied upon in making the adverse determination                     scheduled work day.
regarding your appeal, and an explanation of the scientific or
clinical judgment for a determination that is based on a
                                                                         DFS1                                                           M
Medical Necessity, experimental treatment or other similar
exclusion or limit.
You also have the right to bring a civil action under Section            Bed and Board
502(a) of ERISA if you are not satisfied with the decision on            The term Bed and Board includes all charges made by a
review. You or your plan may have other voluntary alternative            Hospital on its own behalf for room and meals and for all
dispute resolution options such as Mediation. One way to find            general services and activities needed for the care of registered
out what may be available is to contact your local U.S.                  bed patients.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.                                                           DFS14

Relevant Information
Relevant Information is any document, record, or other                   Biologically-Based Mental Illness
information which (a) was relied upon in making the benefit              A serious mental illness is defined as: schizophrenia;
determination; (b) was submitted, considered, or generated in            schizoaffective disorder; bipolar affective disorder; panic



                                                                    54                                                   myCIGNA.com
disorder; specific obsessive-compulsive disorder; or major                         mental or physical handicap. Proof of the child's condition
depressive disorder.                                                               and dependence must be submitted to CG within 31 days
                                                                                   after the date the child ceases to qualify above. During the
                                                                                   next two years CG may, from time to time, require proof
DFS1398
                                                                                   of the continuation of such condition and dependence.
                                                                                   After that, CG may require proof no more than once a
Charges                                                                            year.
The term "charges" means the actual billed charges; except                   The term child means a child born to you or a child legally
when the provider has contracted directly or indirectly with                 adopted by you, including that child from the first day of
CG for a different amount.                                                   placement in your home regardless of whether the adoption
                                                                             has become final. It also includes a stepchild who lives with
                                                                             you. If your Domestic Partner has a child who lives with you,
DFS940                                                                       that child will also be included as a Dependent.
                                                                             Benefits for a Dependent child or student will continue until
Custodial Services                                                           the last day of the calendar month in which the limiting age is
Any services that are of a sheltering, protective, or                        reached.
safeguarding nature. Such services may include a stay in an                  Anyone who is eligible as an Employee will not be considered
institutional setting, at-home care, or nursing services to care             as a Dependent.
for someone because of age or mental or physical condition.                  No one may be considered as a Dependent of more than one
This service primarily helps the person in daily living.                     Employee.
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;                                                                             DFS1964 M

they are intended to provide care while the patient cannot care
for himself or herself. Custodial Services include but are not
                                                                             Domestic Partner
limited to:
                                                                             A Domestic Partner is defined as a person of the same sex
•   Services related to watching or protecting a person;
                                                                             who:
•   Services related to performing or assisting a person in
                                                                             •   shares your permanent residence;
    performing any activities of daily living, such as: (a)
    walking, (b) grooming, (c) bathing, (d) dressing, (e) getting            •   has resided with you for no less than one year;
    in or out of bed, (f) toileting, (g) eating, (h) preparing foods,        •   is no less than 18 years of age;
    or (i) taking medications that can be self administered, and             •   is financially interdependent with you and has proven such
•   Services not required to be performed by trained or skilled                  interdependence by providing documentation of at least two
    medical or paramedical personnel.                                            of the following arrangements: common ownership of real
                                                                                 property or a common leasehold interest in such property;
                                                                                 community ownership of a motor vehicle; a joint bank
DFS1812
                                                                                 account or a joint credit account; designation as a
                                                                                 beneficiary for life insurance or retirement benefits or under
Dependent                                                                        your partner's will; assignment of a durable power of
Dependents are:                                                                  attorney or health care power of attorney; or such other
                                                                                 proof as is considered by CG to be sufficient to establish
•   your lawful spouse;                                                          financial interdependency under the circumstances of your
•   your same sex Domestic Partner; and                                          particular case;
•   any unmarried child of yours who:                                        •   is not a blood relative any closer than would prohibit legal
    •   is less than 19 years old; or                                            marriage; and
    •   is 19 years but less than 25 years old and primarily                 •   has signed jointly with you, a notarized affidavit which can
        supported by you or has the same legal residence as you;                 be made available to CG upon request.
        or
    •   is 25 or more years old and primarily supported by you
        and incapable of self-sustaining employment by reason of



                                                                        55                                                    myCIGNA.com
In addition, you and your Domestic Partner will be considered             Emergency Services
to have met the terms of this definition as long as neither you           Emergency services are medical, psychiatric, surgical,
nor your Domestic Partner:                                                Hospital and related health care services and testing, including
•   has signed a Domestic Partner affidavit or declaration with           ambulance service, which are required to treat a sudden,
    any other person within twelve months prior to designating            unexpected onset of a bodily Injury or serious Sickness which
    each other as Domestic Partners hereunder;                            could reasonably be expected by a prudent layperson to result
•   is currently legally married to another person; or                    in serious medical complications, loss of life or permanent
                                                                          impairment to bodily functions in the absence of immediate
•   has any other Domestic Partner, spouse or spouse equivalent           medical attention. Examples of emergency situations include
    of the same or opposite sex.                                          uncontrolled bleeding, seizures or loss of consciousness,
You and your Domestic Partner must have registered as                     shortness of breath, chest pains or severe squeezing sensations
Domestic Partners, if you reside in a state that provides for             in the chest, suspected overdose of medication or poisoning,
such registration.                                                        sudden paralysis or slurred speech, burns, cuts and broken
The section of this certificate entitled "COBRA Continuation              bones. The symptoms that led you to believe you needed
Rights Under Federal Law" will not apply to your Domestic                 emergency care, as coded by the provider and recorded by the
Partner and his or her Dependents.                                        Hospital on the UB92 claim form, or its successor, or the final
                                                                          diagnosis, whichever reasonably indicated an emergency
                                                                          medical condition, will be the basis for the determination of
DFS1222                                                  DFS2051 M        coverage, provided such symptoms reasonably indicate an
                                                                          emergency.
Emergency Service Provider
The term Emergency Service Provider means a local                         DFS1533

government, or an authority formed by two or more local
governments, that provide fire-fighting and fire prevention               Employee
services, emergency medical services, ambulance services, or
search and rescue services, or a not-for-profit non-                      The term Employee means a full-time employee of the
governmental entity organized for the purpose of providing                Employer who is currently in Active Service. The term does
any such services, through the use of bona fide volunteers.               not include employees who are temporary or who normally
                                                                          work less than 20 hours a week for the Employer. The term
                                                                          Employee may include officers, managers and Employees of
DEF                                                        DFS2121        the Employer, the bona fide volunteers if the Employer is an
                                                                          Emergency Service Provider, the partners if the Employer is
                                                                          a partnership, the officers, managers, and Employees of
                                                                          subsidiary or affiliated corporations of a corporation
                                                                          Employer, and the individual proprietors, partners, and
                                                                          Employees of individuals and firms, the business of which
                                                                          is controlled by the insured Employer through stock
                                                                          ownership, contract, or otherwise.


                                                                          DEF                                                       DFS2119



                                                                          Employer
                                                                          The term Employer means the Policyholder and all Affiliated
                                                                          Employers. The term Employer may include an Emergency
                                                                          Service Provider, any municipal or governmental corporation,
                                                                          unit, agency or department thereof, and the proper officers, as
                                                                          such, of an Emergency Service Provider or an unincorporated
                                                                          municipality or department thereof, as well as private
                                                                          individuals, partnerships, and corporations.


                                                                          DEF                                                       DFS2120




                                                                     56                                                  myCIGNA.com
                                                                        Hospice Care Services
Expense Incurred                                                        The term Hospice Care Services means any services provided
An expense is incurred when the service or the supply for               by: (a) a Hospital, (b) a Skilled Nursing Facility or a similar
which it is incurred is provided.                                       institution, (c) a Home Health Care Agency, (d) a Hospice
                                                                        Facility, or (e) any other licensed facility or agency under a
                                                                        Hospice Care Program.
DFS60


                                                                        DFS599
Free-Standing Surgical Facility
The term Free-standing Surgical Facility means an institution           Hospice Facility
which meets all of the following requirements:
                                                                        The term Hospice Facility means an institution or part of it
•   it has a medical staff of Physicians, Nurses and licensed           which:
    anesthesiologists;
                                                                        •   primarily provides care for Terminally Ill patients;
•   it maintains at least two operating rooms and one
    recovery room;                                                      •   is accredited by the National Hospice Organization;
•   it maintains diagnostic laboratory and x-ray facilities;            •   meets standards established by CG; and
•   it has equipment for emergency care;                                •   fulfills any licensing requirements of the state or locality
                                                                            in which it operates.
•   it has a blood supply;
•   it maintains medical records;
                                                                        DFS72
•   it has agreements with Hospitals for immediate
    acceptance of patients who need Hospital Confinement
    on an inpatient basis; and                                          Hospital
•   it is licensed in accordance with the laws of the                   The term Hospital means:
    appropriate legally authorized agency.                              •   an institution licensed as a hospital, which: (a) maintains, on
                                                                            the premises, all facilities necessary for medical and
                                                                            surgical treatment or has a written agreement with another
DFS682
                                                                            institution licensed to provide surgical treatment; (b)
                                                                            provides such treatment on an inpatient basis, for
Hospice Care Program                                                        compensation, under the supervision of Physicians; and (c)
The term Hospice Care Program means:                                        provides 24-hour service by Registered Graduate Nurses;
•   a coordinated, interdisciplinary program to meet the                •   an institution which qualifies as a hospital, a psychiatric
    physical, psychological, spiritual and social needs of dying            hospital or a tuberculosis hospital, and a provider of
    persons and their families;                                             services under Medicare, if such institution is accredited as
                                                                            a hospital by the Joint Commission on the Accreditation of
•   a program that provides palliative and supportive                       Healthcare Organizations; or
    medical, nursing and other health services through home
    or inpatient care during the illness;                               •   an institution which: (a) specializes in treatment of Mental
                                                                            Health and Substance Abuse or other related illness; (b)
•   a program for persons who have a Terminal Illness and                   provides residential treatment programs; and (c) is licensed
    for the families of those persons.                                      in accordance with the laws of the appropriate legally
                                                                            authorized agency.
DFS70                                                                   The term Hospital will not include an institution which is
                                                                        primarily a place for rest, a place for the aged, or a nursing
                                                                        home.


                                                                        DFS1732




                                                                   57                                                    myCIGNA.com
Hospital Confinement or Confined in a Hospital                           The percentile used to determine the Maximum Reimbursable
A person will be considered Confined in a Hospital if he is:             Charge can be obtained by contacting Member
                                                                         Services/Customer Service.
•   a registered bed patient in a Hospital upon the
    recommendation of a Physician;                                       The Maximum Reimbursable Charge is subject to all other
                                                                         benefit limitations and applicable coding and payment
•   receiving treatment for Mental Health and Substance Abuse            methodologies determined by CG. Additional information
    Services in a Partial Hospitalization program;                       about how CG determines the Maximum Reimbursable
•   receiving treatment for Mental Health and Substance Abuse            Charge is available upon request.
    Services in a Mental Health or Substance Abuse Residential
    Treatment Center.
                                                                         GM6000 DFS1997                                                    V14


DFS1836
                                                                         Medicaid
                                                                         The term Medicaid means a state program of medical aid for
In-Network/Out-of-Network                                                needy persons established under Title XIX of the Social
The term In-Network refers to healthcare services or items               Security Act of 1965 as amended.
provided by your Primary Care Physician or services/items
provided by another Participating Provider and authorized by
                                                                         DFS192
your Primary Care Physician or the Review Organization.
Authorization by your Primary Care Physician or the Review
Organization is not required in the case of Mental Health and            Medically Necessary/Medical Necessity
Substance Abuse treatment, other than Hospital Confinement
                                                                         Medically Necessary Covered Services and Supplies are those
solely for detoxification.
                                                                         determined by the Medical Director to be:
The term Out-of-Network refers to care which does not
                                                                         •   required to diagnose or treat an illness, injury, disease or its
qualify as In-Network.
                                                                             symptoms;
Emergency Care which meets the definition of Emergency
                                                                         •   in accordance with generally accepted standards of medical
Services and is authorized as such by either the Primary Care
                                                                             practice;
Physician or the Review Organization is considered In-
Network. (For details, refer to the Emergency Services and               •   clinically appropriate in terms of type, frequency, extent,
Urgent Care coverage section.)                                               site and duration;
                                                                         •   not primarily for the convenience of the patient, Physician
                                                                             or other health care provider; and
DFS1694
                                                                         •   rendered in the least intensive setting that is appropriate for
                                                                             the delivery of the services and supplies. Where applicable,
Injury                                                                       the Medical Director may compare the cost-effectiveness of
The term Injury means an accidental bodily injury.                           alternative services, settings or supplies when determining
                                                                             least intensive setting.
DFS147
                                                                         DFS1813

Maximum Reimbursable Charge - Medical
The Maximum Reimbursable Charge for covered services is                  Medicare
determined based on the lesser of:                                       The term Medicare means the program of medical care
•   the provider’s normal charge for a similar service or supply;        benefits provided under Title XVIII of the Social Security Act
    or                                                                   of 1965 as amended.
•   a policyholder-selected percentile of charges made by
    providers of such service or supply in the geographic area           DFS149
    where it is received as compiled in a database selected by
    CG.




                                                                    58                                                      myCIGNA.com
Necessary Services and Supplies                                          Participating Pharmacy
The term Necessary Services and Supplies includes any                    The term Participating Pharmacy means a retail pharmacy
charges, except charges for Bed and Board, made by a                     with which Connecticut General Life Insurance Company has
Hospital on its own behalf for medical services and supplies             contracted to provide prescription services to insureds; or a
actually used during Hospital Confinement.                               designated mail-order pharmacy with which CG has
The term Necessary Services and Supplies will not include                contracted to provide mail-order prescription services to
any charges for special nursing fees, dental fees or medical             insureds.
fees.
                                                                         DFS1937

DFS285

                                                                         Participating Provider
Nurse                                                                    The term Participating Provider means a hospital, a
The term Nurse means a Registered Graduate Nurse, a                      Physician or any other health care practitioner or entity that
Licensed Practical Nurse or a Licensed Vocational Nurse who              has a direct or indirect contractual arrangement with CIGNA
has the right to use the abbreviation "R.N.," "L.P.N." or                to provide covered services with regard to a particular plan
"L.V.N."                                                                 under which the participant is covered.


DFS155                                                                   DFS1910




Other Health Care Facility                                               Pharmacy
The term Other Health Care Facility means a facility other               The term Pharmacy means a retail pharmacy, or a mail-order
than a Hospital or hospice facility. Examples of Other Health            pharmacy.
Care Facilities include, but are not limited to, licensed skilled
nursing facilities, rehabilitation Hospitals and subacute                DFS1934
facilities.

                                                                         Pharmacy & Therapeutics (P & T) Committee
DFS1686
                                                                         A committee of CG Participating Providers, Medical Directors
                                                                         and Pharmacy Directors which regularly reviews Prescription
Other Health Professional                                                Drugs and Related Supplies for safety and efficacy. The P&T
The term Other Health Professional means an individual other             Committee evaluates Prescription Drugs and Related Supplies
than a Physician who is licensed or otherwise authorized under           for potential addition to or deletion from the Prescription Drug
the applicable state law to deliver medical services and                 List and may also set dosage and/or dispensing limits on
supplies. Other Health Professionals include, but are not                Prescription Drugs and Related Supplies.
limited to physical therapists, registered nurses and licensed
practical nurses.                                                        DFS1919



DFS1685
                                                                         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




                                                                    59                                                   myCIGNA.com
•   performing a service for which benefits are provided under          Psychologist
    this plan when performed by a Physician.                            The term Psychologist means a person who is licensed or
                                                                        certified as a clinical psychologist. Where no licensure or
DFS164
                                                                        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: (1)
Prescription Drug                                                       any other licensed counseling practitioner whose services are
Prescription Drug means; (a) a drug which has been approved             required to be covered by law in the locality where the policy
by the Food and Drug Administration for safety and efficacy;            is issued if he is: (a) operating within the scope of his license;
(b) certain drugs approved under the Drug Efficacy Study                and (b) performing a service for which benefits are provided
Implementation review; or (c) drugs marketed prior to 1938              under this plan when performed by a Psychologist; and (2) any
and not subject to review, and which can, under federal or              psychotherapist while he is providing care authorized by the
state law, be dispensed only pursuant to a Prescription Order.          Provider Organization if he is: (a) state licensed or nationally
                                                                        certified by his professional discipline; and (b) performing a
                                                                        service for which benefits are provided under this plan when
DFS1708                                                                 performed by a Psychologist.

Prescription Drug List                                                  DFS585

Prescription Drug List means a listing of approved
Prescription Drugs and Related Supplies. The Prescription
                                                                        Related Supplies
Drugs and Related Supplies included in the Prescription Drug
List have been approved in accordance with parameters                   Related Supplies means diabetic supplies (insulin needles and
established by the P&T Committee. The Prescription Drug                 syringes, lancets and glucose test strips), needles and syringes
List is regularly reviewed and updated.                                 for injectables covered under the pharmacy plan, and spacers
                                                                        for use with oral inhalers.

DFS1924
                                                                        DFS1710


Prescription Order
                                                                        Review Organization
Prescription Order means the lawful authorization for a
Prescription Drug or Related Supply by a Physician who is               The term Review Organization refers to an affiliate of CG or
duly licensed to make such authorization within the course of           another entity to which CG has delegated responsibility for
such Physician's professional practice or each authorized refill        performing utilization review services. The Review
thereof.                                                                Organization is an organization with a staff of clinicians which
                                                                        may include Physicians, Registered Graduate Nurses, licensed
                                                                        mental health and substance abuse professionals, and other
DFS1711                                                                 trained staff members who perform utilization review services.

Primary Care Physician                                                  DFS1688

The term Primary Care Physician means a Physician: (a) who
qualifies as a Participating Provider in general practice,
                                                                        Sickness - For Medical Insurance
internal medicine, family practice or pediatrics; and (b) who
has been selected by you, as authorized by the Provider                 The term Sickness means a physical or mental illness. It also
Organization, to provide or arrange for medical care for you or         means: (1) pregnancy; and (2) cleft lip and cleft palate for
any of your insured Dependents.                                         newborn children including inpatient or outpatient expenses
                                                                        arising from oral and facial surgery, prosthetic treatment,
                                                                        orthodontics, prosthodontic treatment, habilitative speech
DFS622                                                                  therapy, otolaryngology treatment and audiological
                                                                        assessments and treatment in connection with that condition.
                                                                        Any dental exclusions will not apply to cleft lip and cleft
                                                                        palate for newborn children. Further, expenses incurred for
                                                                        routine Hospital and pediatric care of a newborn child prior to


                                                                   60                                                   myCIGNA.com
discharge from the Hospital nursery will be considered to be
incurred as a result of Sickness.


DFS601



Skilled Nursing Facility
The term Skilled Nursing Facility means a licensed institution
(other than a Hospital, as defined) which specializes in:
•   physical rehabilitation on an inpatient basis; or
•   skilled nursing and medical care on an inpatient basis;
but only if that institution: (a) maintains on the premises all
facilities necessary for medical treatment; (b) provides such
treatment, for compensation, under the supervision of
Physicians; and (c) provides Nurses' services.


DFS193



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.

DFS197



Urgent Care
Urgent Care is medical, surgical, Hospital or related health
care services and testing which are not Emergency Services,
but which are determined by CG, 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.


DFS1534




                                                                  61   myCIGNA.com

				
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