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Table of Contents - Socorro Independent School District

VIEWS: 28 PAGES: 62

  • pg 1
									Socorro Independent School
District



OPEN ACCESS PLUS MEDICAL
BENEFITS
High Plan


EFFECTIVE DATE: September 1, 2009




ASO9
3325396




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




Printed in U.S.A.
                                                            Table of Contents
Important Information..................................................................................................................5
Special Plan Provisions..................................................................................................................7
     Case Management ..................................................................................................................................................7
How To File Your Claim ...............................................................................................................9
Accident and Health Provisions....................................................................................................9
Eligibility — Effective Date.........................................................................................................10
     Waiting Period......................................................................................................................................................10
     Dependent Insurance ............................................................................................................................................10
Open Access Plus Medical Benefits ............................................................................................11
     The Schedule ........................................................................................................................................................11
     Certification Requirements - Out-of-Network......................................................................................................25
     Prior Authorization/Pre-Authorized .....................................................................................................................25
     Covered Expenses ................................................................................................................................................25
Exclusions, Expenses Not Covered and General Limitations..................................................35
Coordination of Benefits..............................................................................................................38
Medicare Eligibles........................................................................................................................40
Expenses For Which A Third Party May Be Responsible .......................................................41
Payment of Benefits .....................................................................................................................42
Termination of Insurance............................................................................................................43
     Employees ............................................................................................................................................................43
     Dependents ...........................................................................................................................................................43
Medical Benefits Extension .........................................................................................................44
Federal Requirements .................................................................................................................44
     Notice of Provider Directory/Networks................................................................................................................44
     Qualified Medical Child Support Order (QMCSO) .............................................................................................45
     Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) ..................45
     Effect of Section 125 Tax Regulations on This Plan............................................................................................47
     Eligibility for Coverage for Adopted Children.....................................................................................................47
     Federal Tax Implications for Dependent Coverage ..............................................................................................47
     Coverage for Maternity Hospital Stay..................................................................................................................48
     Women’s Health and Cancer Rights Act (WHCRA) ...........................................................................................48
     Group Plan Coverage Instead of Medicaid...........................................................................................................48
     Pre-Existing Conditions Under the Health Insurance Portability & Accountability Act (HIPAA) ......................48
     Requirements of Medical Leave Act of 1993 (as amended) (FMLA) ..................................................................49
     Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) ....................................49
When You Have a Complaint or an Adverse Determination Appeal .....................................50
     COBRA Continuation Rights Under Federal Law ...............................................................................................52
Definitions.....................................................................................................................................56
                                       Important Information
THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR
ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY SOCORRO INDEPENDENT SCHOOL
DISTRICT WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CONNECTICUT GENERAL PROVIDES
CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CONNECTICUT GENERAL DOES NOT
INSURE THE BENEFITS DESCRIBED.
THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CONNECTICUT
GENERAL. BECAUSE THE PLAN IS NOT INSURED BY CONNECTICUT GENERAL, ALL
REFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED.
FOR EXAMPLE, REFERENCES TO "CG," "INSURANCE COMPANY," AND "POLICYHOLDER" SHALL
BE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO
MEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."

ASO1




For Employees who reside in Canada, this plan is available to the extent that services are not covered
under a Provincial government health insurance plan.
                                                           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.
                                                                         in the most effective setting possible whether at home, as an
                                                                         outpatient, or an inpatient in a Hospital or specialized facility.
Special Plan Provisions                                                  Should the need for Case Management arise, a Case
When you select a Participating Provider, this Plan pays a               Management professional will work closely with the patient,
greater share of the costs than if you select a non-Participating        his or her family and the attending Physician to determine
Provider. Participating Providers include Physicians, Hospitals          appropriate treatment options which will best meet the
and Other Health Care Professionals and Other Health Care                patient's needs and keep costs manageable. The Case Manager
Facilities. Consult your Physician Guide for a list of                   will help coordinate the treatment program and arrange for
Participating Providers in your area. Participating Providers            necessary resources. Case Managers are also available to
are committed to providing you and your Dependents                       answer questions and provide ongoing support for the family
appropriate care while lowering medical costs.                           in times of medical crisis.
Services Available in Conjunction With Your Medical                      Case Managers are Registered Nurses (RNs) and other
Plan                                                                     credentialed health care professionals, each trained in a
The following pages describe helpful services available in               clinical specialty area such as trauma, high risk pregnancy and
conjunction with your medical plan. You can access these                 neonates, oncology, mental health, rehabilitation or general
services by calling the toll-free number shown on the back of            medicine and surgery. A Case Manager trained in the
your ID card.                                                            appropriate clinical specialty area will be assigned to you or
                                                                         your Dependent. In addition, Case Managers are supported by
                                                                         a panel of Physician advisors who offer guidance on up-to-
                                                        FPINTRO4V1
                                                                         date treatment programs and medical technology. While the
                                                                         Case Manager recommends alternate treatment programs and
CIGNA'S Toll-Free Care Line                                              helps coordinate needed resources, the patient's attending
                                                                         Physician remains responsible for the actual medical care.
CIGNA's toll-free care line allows you to talk to a health care
professional during normal business hours, Monday through                1.   You, your dependent or an attending Physician can
Friday, simply by calling the toll-free number shown on your                  request Case Management services by calling the toll-free
ID card.                                                                      number shown on your ID card during normal business
                                                                              hours, Monday through Friday. In addition, your
CIGNA's toll-free care line personnel can provide you with the
                                                                              employer, a claim office or a utilization review program
names of Participating Providers. If you or your Dependents
                                                                              (see the PAC/CSR section of your certificate) may refer
need medical care, you may consult your Physician Guide
                                                                              an individual for Case Management.
which lists the Participating Providers in your area or call
CIGNA's toll-free number for assistance. If you or your                  2.   The Review Organization assesses each case to determine
Dependents need medical care while away from home, you                        whether Case Management is appropriate.
may have access to a national network of Participating                   3.   You or your Dependent is contacted by an assigned Case
Providers through CIGNA's Away-From-Home Care feature.                        Manager who explains in detail how the program works.
Call CIGNA's toll-free care line for the names of Participating               Participation in the program is voluntary - no penalty or
Providers in other network areas. Whether you obtain the                      benefit reduction is imposed if you do not wish to
name of a Participating Provider from your Physician Guide or                 participate in Case Management.
through the care line, it is recommended that prior to making
an appointment you call the provider to confirm that he or she
is a current participant in the Open Access Plus Program.                                                                             FPCM6




FPCCL10V1
                                                                         4.   Following an initial assessment, the Case Manager works
                                                                              with you, your family and Physician to determine the
                                                                              needs of the patient and to identify what alternate
                                                                              treatment programs are available (for example, in-home
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


                                                                     7                                                    myCIGNA.com
     services or a Hospital bed and other Durable Medical              Changing Primary Care Physicians:
     Equipment for the home).                                          You may request a transfer from one Primary Care Physician
6.   The Case Manager also acts as a liaison between the               to another by contacting us at the member services number on
     insurer, the patient, his or her family and Physician as          your ID card. Any such transfer will be effective on the first
     needed (for example, by helping you to understand a               day of the month following the month in which the processing
     complex medical diagnosis or treatment plan).                     of the change request is completed.
7.   Once the alternate treatment program is in place, the Case        In addition, if at any time a Primary Care Physician ceases to
     Manager continues to manage the case to ensure the                be a Participating Provider, you or your Dependent will be
     treatment program remains appropriate to the patient's            notified for the purpose of selecting a new Primary Care
     needs.                                                            Physician, if you choose.
While participation in Case Management is strictly voluntary,
Case Management professionals can offer quality, cost-                 NOT123                                                           V1
effective treatment alternatives, as well as provide assistance
in obtaining needed medical resources and ongoing family
support in a time of need.                                             Notice of Coverage for Acquired Brain Injury
                                                                       Your health benefit plan coverage for an acquired brain injury
                                                                       includes the following services:
FPCM2
                                                                          cognitive rehabilitation therapy;
                                                                          cognitive communication therapy;
Additional Programs
                                                                          neurocognitive therapy and rehabilitation;
We may, from time to time, offer or arrange for various
entities to offer discounts, benefits, or other consideration to          neurobehavioral, neurophysiological, neuropsychological
our members for the purpose of promoting the general health                and psychophysiological testing and treatment;
and well being of our members. We may also arrange for the                neurofeedback therapy and remediation;
reimbursement of all or a portion of the cost of services
                                                                          post-acute transition services and community reintegration
provided by other parties to the Policyholder. Contact us for
                                                                           services, including outpatient day treatment services or
details regarding any such arrangements.
                                                                           other post-acute care treatment services; and
                                                                          reasonable expenses related to periodic reevaluation of the
GM6000 NOT160                                                              care of an individual covered under the plan who has
                                                                           incurred an acquired brain injury, has been unresponsive to
                                                                           treatment, and becomes responsive to treatment at a later
Important Information About Your Medical
                                                                           date, at which time the cognitive rehabilitation services
Plan                                                                       would be a covered benefit.
Details of your medical benefits are described on the                  The fact that an acquired brain injury does not result in
following pages.                                                       hospitalization or acute care treatment does not affect the right
Opportunity to Select a Primary Care Physician                         of the insured or the enrollee to receive the preceding
Choice of Primary Care Physician:                                      treatments or services commensurate with their condition.
                                                                       Post-acute care treatment or services may be obtained in any
This medical plan does not require that you select a Primary           facility where such services may legally be provided,
Care Physician or obtain a referral from a Primary Care                including acute or post-acute rehabilitation hospitals and
Physician in order to receive all benefits available to you            assisted living facilities regulated under the Health and Safety
under this medical plan. Notwithstanding, a Primary Care               Code.
Physician may serve an important role in meeting your health
care needs by providing or arranging for medical care for you
and your Dependents. For this reason, we encourage the use of          GM6000 NOT207
Primary Care Physicians and provide you with the opportunity
to select a Primary Care Physician from a list provided by CG
                                                                       Notice of Certain Mandatory Benefits
for yourself and your Dependents. If you choose to select a
Primary Care Physician, the Primary Care Physician you                 This notice is to advise you of certain coverage and/or benefits
select for yourself may be different from the Primary Care             provided by your contract with Connecticut General Life
Physician you select for each of your Dependents.                      Insurance Company.



                                                                   8                                                    myCIGNA.com
Examinations for Detection of Cervical Cancer                            YOUR ACCOUNT NUMBER IS THE 7-DIGIT POLICY
Benefits are provided for each covered female age 18 and over            NUMBER SHOWN ON YOUR BENEFIT
for an annual medically recognized diagnostic examination for            IDENTIFICATION CARD.
the early detection of cervical cancer. Benefits include at a           PROMPT FILING OF ANY REQUIRED CLAIM FORMS
minimum:                                                                 RESULTS IN FASTER PAYMENT OF YOUR CLAIMS.
(a) a conventional Pap smear screening; or                           WARNING: Any person who knowingly presents a false or
(b) a screening using liquid-based cytology methods, as              fraudulent claim for payment of a loss or benefit is guilty of a
    approved by the United States Food and Drug                      crime and may be subject to fines and confinement in prison.
    Administration, alone or in combination with a test
    approved by the United States Food and Drug                      GM6000 CI 3                                                CLA9V41
    Administration for the detection of the human
    papillomavirus.
If any person covered by this plan has questions concerning
the above, please call Connecticut General Life Insurance            Accident and Health Provisions
Company at 1-800-244-6224, or write us at the address on the         Notice of Claim
back of your ID card.                                                Written notice of claim must be given to CG within 30 days
                                                                     after the occurrence or start of the loss on which claim is
GM6000 NOT208
                                                                     based. If notice is not given in that time, the claim will not be
                                                                     invalidated or reduced if it is shown that written notice was
                                                                     given as soon as was reasonably possible.
                                                                     Claim Forms
How To File Your Claim                                               When CG receives the notice of claim, it will give to the
The prompt filing of any required claim form will result in          claimant, or to the Employer for the claimant, the claim forms
faster payment of your claim.                                        which it uses for filing proof of loss. If the claimant does not
You may get the required claim forms from your Benefit Plan          receive these claim forms within 15 days after CG receives
Administrator. All fully completed claim forms and bills             notice of claim, he will be considered to meet the proof of loss
should be sent directly to your servicing CG Claim Office.           requirements if he submits written proof of loss within 90 days
                                                                     after the date of loss. This proof must describe the occurrence,
Depending on your Group Insurance Plan benefits, file your
                                                                     character and extent of the loss for which claim is made.
claim forms as described below.
                                                                     Proof of Loss
Hospital Confinement
                                                                     Written proof of loss must be given to CG within 90 days after
If possible, get your Group Medical Insurance claim form
                                                                     the date of the loss for which claim is made. If written proof of
before you are admitted to the Hospital. This form will make
                                                                     loss is not given in that time, the claim will not be invalidated
your admission easier and any cash deposit usually required
                                                                     or reduced if it is shown that written proof of loss was given as
will be waived.
                                                                     soon as was reasonably possible.
If you have a Benefit Identification Card, present it at the
                                                                     Physical Examination
admission office at the time of your admission. The card tells
the Hospital to send its bills directly to CG.                       The Employer, at its own expense, will have the right to
                                                                     examine any person for whom claim is pending as often as it
Doctor's Bills and Other Medical Expenses
                                                                     may reasonably require.
The first Medical Claim should be filed as soon as you have
incurred covered expenses. Itemized copies of your bills
should be sent with the claim form. If you have any additional       GM6000 P 1

bills after the first treatment, file them periodically.                                                                          CLA50

CLAIM REMINDERS
 BE SURE TO USE YOUR MEMBER ID AND
  ACCOUNT NUMBER WHEN YOU FILE CG'S CLAIM
  FORMS, OR WHEN YOU CALL YOUR CG CLAIM
  OFFICE.
  YOUR MEMBER ID IS THE ID SHOWN ON YOUR
  BENEFIT IDENTIFICATION CARD.


                                                                 9                                                    myCIGNA.com
Eligibility — Effective Date                                             Dependent Insurance. All of your Dependents as defined will
                                                                         be included.
Eligibility for Employee Insurance
                                                                         Your Dependent will not be denied enrollment for Medical
You will become eligible for insurance on the day you                    Insurance due to health status.
complete the waiting period if:
                                                                         Your Dependents will be insured only if you are insured.
 you are in a Class of Eligible Employees; and
                                                                         You will not be eligible to enroll your Dependents if you do
 you are an eligible, full-time Employee and you normally               not enroll them within 30 days of the date you become
  work at least 37.5 hours a week; or                                    eligible, unless you qualify under the section of this certificate
 you are an eligible food service Employee, bus driver or bus           entitled "Special Enrollment Rights Under the Health
  monitor and you normally work at least 20 hours a week.                Insurance Portability & Accountability Act (HIPAA)".
If you were previously insured and your insurance ceased, you
must satisfy the waiting period to become insured again. If              Exception for Newborns
your insurance ceased because you were no longer employed
in a Class of Eligible Employees, you are not required to                Any Dependent child born while you are insured for Medical
satisfy any waiting period if you again become a member of a             Insurance will become insured for Medical Insurance on the
Class of Eligible Employees within one year after your                   date of his birth if you elect Dependent Medical Insurance no
insurance ceased.                                                        later than 31 days after his birth. If you do not elect to insure
                                                                         your newborn child within such 31 days, coverage for that
Eligibility for Dependent Insurance                                      child will end on the 31st day. No benefits for expenses
You will become eligible for Dependent insurance on the later            incurred beyond the 31st day will be payable.
of:
   the day you become eligible for yourself; or                         GM6000 EF 2                                               ELI11V44 M
   the day you acquire your first Dependent.

Waiting Period
The first day of the month following 30 days from date of hire.
Classes of Eligible Employees
Each Employee as reported to the insurance company by your
Employer.
Employee Insurance
This plan is offered to you as an Employee.
You will not be enrolled for Medical Insurance if you do not
enroll within 30 days of the date you become eligible, unless
you qualify under the section of this certificate entitled
"Special Enrollment Rights Under the Health Insurance
Portability & Accountability Act (HIPAA)".


GM6000 EL 2                                                  V-32
                                                        ELI6V16 M




Dependent Insurance
For your Dependents to be insured, you will have to pay part
of the cost of Dependent Insurance.
Effective Date of Dependent Insurance
Insurance for your Dependents will become effective on the
date you elect it by signing an approved payroll deduction
form, but no earlier than the day you become eligible for


                                                                    10                                                    myCIGNA.com
                           OPEN ACCESS PLUS MEDICAL BENEFITS
                                                    The Schedule
For You and Your Dependents
Open Access Plus Medical Benefits provide coverage for care In-Network and Out-of-Network. To receive Open Access
Plus Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services
and supplies. That portion is the 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.
Coinsurance
The term Coinsurance means the percentage of charges for Covered Expenses that an insured person is required to pay
under the plan.
Copayments/Deductibles
Copayments are expenses to be paid by you or your Dependent for covered services. Deductibles are also expenses to be
paid by you or your Dependent. Deductible amounts are separate from and not reduced by Copayments. Copayments and
Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached, you
and your family need not satisfy any further medical deductible for the rest of that year.
Out-of-Pocket Expenses
Out-of-Pocket Expenses are Covered Expenses incurred for In-Network and Out-of-Network charges that are not paid by
the benefit plan because of any:
    Coinsurance.

Charges will not accumulate toward the Out-of-Pocket Maximum for Covered Expenses incurred for:
     Mental Health (other than Biologically Based Mental Illness) treatment
     non-compliance penalties.
     provider charges in excess of the Maximum Reimbursable Charge.
When the Out-of-Pocket Maximum shown in The Schedule is reached, Injury and Sickness benefits are payable at 100%
except for:
     Mental Health (other than Biologically Based Mental Illness) treatment
     non-compliance penalties.
     provider charges in excess of the Maximum Reimbursable Charge.

Accumulation of Plan Deductibles and Out-of-Pocket Maximums
Deductibles and Out-of-Pocket Maximums will not cross accumulate between In and Out-of-Network. All other plan
maximums and service-specific maximums (dollar and occurrence) cross-accumulate between In- and Out-of-Network
unless otherwise noted.
Contract Year
Contract Year means a twelve month period beginning on each 09/01.




                                                            11                                               myCIGNA.com
                          OPEN ACCESS PLUS MEDICAL BENEFITS
                                                   The Schedule
Multiple Surgical Reduction
Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser
charge. The most expensive procedure is paid as any other surgery.
Assistant Surgeon and Co-Surgeon Charges
Assistant Surgeon
The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed 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                           OUT-OF-NETWORK
Lifetime Maximum                                                             $1,000,000
Coinsurance Levels                         90%                                      50% of the Maximum Reimbursable
                                                                                    Charge
Maximum Reimbursable Charge
Maximum Reimbursable Charge is
determined based on the lesser of the
provider's normal charge for a similar
service or supply; or
A percentile of charges made by            Not Applicable                           90th Percentile
providers of such service or supply in
the geographic area where the service is
received. These charges are compiled
in a database we have selected.
Note:
The provider may bill you for the
difference between the provider's
normal charge and the Maximum
Reimbursable Charge, in addition to
applicable deductibles, copayments and
coinsurance.




                                                            12                                                 myCIGNA.com
      BENEFIT HIGHLIGHTS                             IN-NETWORK          OUT-OF-NETWORK
Contract Year Deductible
  Individual                               Not Applicable         $500 per person
  Family Maximum                           Not Applicable         $1,000 per family
  Family Maximum Calculation
  Individual Calculation:
  Family members meet only their
  individual deductible and then their
  claims will be covered under the plan
  coinsurance; if the family deductible
  has been met prior to their individual
  deductible being met, their claims
  will be paid at the plan coinsurance.
Out-of-Pocket Maximum
  Individual                               $1,000 per person      Not Applicable
  Family Maximum                           $2,000 per family      Not Applicable
  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%.




                                                            13                        myCIGNA.com
      BENEFIT HIGHLIGHTS                              IN-NETWORK                         OUT-OF-NETWORK
Physician's Services
  Primary Care Physician's Office visit   No charge after $15 per office visit    50% after plan deductible
                                          copay
  Specialty Care Physician's Office       No charge after $15 Specialist per      50% after plan deductible
  Visits                                  office visit copay
      Consultant and Referral
      Physician's Services
      Note:
      OB/GYN providers will be
      considered either as a PCP or
      Specialist, depending on how
      the provider contracts with CG.
  Surgery Performed In the Physician's    90%                                     50% after plan deductible
  Office
  Second Opinion Consultations            No charge after the $15 PCP or $15      50% after plan deductible
  (provided on a voluntary basis)         Specialist per office visit copay
  Allergy Treatment/Injections            90%                                     50% after plan deductible
  Allergy Serum (dispensed by the         No charge                               50% after plan deductible
  Physician in the office)
Preventive Care
  Routine Preventive Care
  Contract Year Maximum through age 6 (including immunizations): Unlimited
  Contract Year Maximum for ages 7 and above (excluding immunizations): 1 visit
  Note:
  Well-woman OB/GYN visits will be considered either a PCP or Specialist depending on how the provider contracts
  with CG.
  Routine Preventive Care for Children    No charge                               50% after plan deductible
  through age 6 (including
  immunizations)
  Immunizations                           No charge                               No charge
  Routine Preventive Care for age 7       No charge                               50% after plan deductible
  years and over (including
  immunizations)
  Immunizations                           No charge                               50% after plan deductible
Early Cancer Detection Colon/Rectal       100%                                    50% after plan deductible
  Contract Year Maximum:
  1 visit




                                                          14                                                  myCIGNA.com
      BENEFIT HIGHLIGHTS                             IN-NETWORK                           OUT-OF-NETWORK
Colorectal Exam                          100%                                      50% after plan deductible
  Contract Year Maximum:
  1 colonoscopy

Mammograms, PSA, PAP Smear
  Preventive Care Related Services       No charge                                 50% after plan deductible
  (i.e. "routine" services)
  Diagnostic Related Services (i.e.      90%                                       50% after plan deductible
  "non-routine" services)
Inpatient Hospital - Facility Services   $200 per contract year copay, then        $750 per contract year deductible,
                                         90%                                       then 50% after plan deductible
                                         Note:                                     Note:
                                         The $200 copay per contract year is       The $750 deductible per contract
                                         combined with Outpatient Hospital         year is combined with Mental
                                         and Mental Health/Chemical                Health/Chemical Dependency
                                         Dependency Inpatient Hospital.            Inpatient Hospital.

  Semi-Private Room and Board            Limited to the semi-private room          Limited to the semi-private room rate
                                         negotiated rate
  Private Room                           Limited to the semi-private room          Limited to the semi-private room rate
                                         negotiated rate
  Special Care Units (ICU/CCU)           Limited to the negotiated rate            Limited to the ICU/CCU daily room
                                                                                   rate
Outpatient Facility Services
 Operating Room, Recovery Room,          $200 per contract year copay, then        50% after plan deductible
 Procedures Room, Treatment Room         90%
 and Observation Room
                                         Note:
                                         The $200 copay per contract year is
                                         combined with Inpatient Hospital and
                                         Mental Health/Chemical Dependency
                                         Inpatient Hospital. Outpatient
                                         freestanding facilities are not subject
                                         to the copay.

Inpatient Hospital Physician's           90%                                       50% after plan deductible
Visits/Consultations
Inpatient Hospital Professional          90%                                       50% after plan deductible
Services
  Surgeon
  Radiologist
  Pathologist
  Anesthesiologist



                                                         15                                                    myCIGNA.com
      BENEFIT HIGHLIGHTS                            IN-NETWORK                        OUT-OF-NETWORK
Outpatient Professional Services        90%                                    50% after plan deductible
  Surgeon
  Radiologist
  Pathologist
  Anesthesiologist
Emergency and Urgent Care
Services
  Physician’s Office Visit              No charge after the $15 PCP or $15     No charge after the $15 PCP or $15
                                        Specialist per office visit copay      Specialist per office visit copay
                                                                               (except if not a true emergency, then
                                                                               50% after plan deductible)
  Hospital Emergency Room               90% after $100 per visit copay*        90% after $100 per visit copay*
                                                                               (except if not a true emergency, then
                                                                               50% after plan deductible)
                                        *waived if admitted                    *waived if admitted
  Outpatient Professional services      90%                                    90% (except if not a true emergency,
  (radiology, pathology and ER                                                 then 50% after plan deductible)
  Physician)
  Urgent Care Facility or Outpatient    No charge after $15 per visit copay*   No charge after $15 per visit copay*
  Facility                                                                     (except if not a true emergency, then
                                                                               50% after plan deductible)
                                        *waived if admitted                    *waived if admitted
  X-ray and/or Lab performed at the     90%                                    90% (except if not a true emergency,
  Emergency Room (billed by the                                                then 50% after plan deductible)
  facility as part of the ER visit)
  X-ray and/or Lab performed at the     No charge                              No charge (except if not a true
  Urgent Care Facility (billed by the                                          emergency, then 50% after plan
  facility as part of the UC visit)                                            deductible)
  Independent x-ray and/or Lab          90%                                    90% (except if not a true emergency,
  Facility in conjunction with an ER                                           then 50% after plan deductible)
  visit
  Advanced Radiological Imaging (i.e.   No charge                              No charge (except if not a true
  MRIs, MRAs, CAT Scans, PET                                                   emergency, then 50% after plan
  Scans etc.)                                                                  deductible)
  Ambulance                             90%                                    90% (except if not a true emergency,
                                                                               then 50% after plan deductible)




                                                        16                                                 myCIGNA.com
      BENEFIT HIGHLIGHTS                          IN-NETWORK                       OUT-OF-NETWORK
Inpatient Services at Other Health     90%                                  50% after plan deductible
Care Facilities
  Includes Skilled Nursing Facility,
  Rehabilitation Hospital and Sub-
  Acute Facilities
  Contract Year Maximum:
  $10,000
Laboratory and Radiology Services
(includes pre-admission testing)
  Physician’s Office Visit             90% after the $15 PCP or $15         50% after plan deductible
                                       Specialist per office visit copay
  Outpatient Hospital Facility         90%                                  50% after plan deductible
  Independent X-ray and/or Lab         90%                                  50% after plan deductible
  Facility
Advanced Radiological Imaging (i.e.
MRIs, MRAs, CAT Scans and PET
Scans)
  Physician’s Office Visit             90%                                  50% after plan deductible
  Inpatient Facility                   $200 per contract year copay, then   $750 per contract year deductible,
                                       90%                                  then 50% after plan deductible
  Outpatient Facility                  90%                                  50% after plan deductible
Outpatient Short-Term                  90%                                  50% after plan deductible
Rehabilitative Therapy
  Contract Year Maximum:
  Unlimited
  Includes:
  Cardiac Rehab
  Physical Therapy
  Speech Therapy
  Occupational Therapy
  Pulmonary Rehab
  Cognitive Therapy




                                                        17                                              myCIGNA.com
      BENEFIT HIGHLIGHTS                           IN-NETWORK                         OUT-OF-NETWORK
Chiropractic Services
  Contract Year Maximum:
  $1,500
  Physician's Office Visit              90% after the $15 PCP or $15           50% after plan deductible
                                        Specialist per office visit copay

                                        Note:
                                        Copay applies to office visit charge
                                        only, all other services provided in
                                        the chiropractor’s office (including
                                        lab/x-ray, manipulation and
                                        modalities) are 90% coinsurance.
Home Health Care                        90%                                    50% after plan deductible
 Contract Year Maximum:
 $10,000 (includes outpatient private
 nursing when approved as medically
 necessary)
Hospice
  Inpatient Services                    90%                                    50% after plan deductible

  Lifetime Maximum:
  $20,000
  Outpatient Services                   90%                                    50% after plan deductible
  (same coinsurance level as Home
  Health Care)
Bereavement Counseling
Services provided as part of Hospice
Care
  Inpatient                             90%                                    50% after plan deductible
  Outpatient                            90%                                    50% after plan deductible
Services provided by Mental Health      Covered under Mental Health Benefit    Covered under Mental Health Benefit
Professional




                                                         18                                                myCIGNA.com
      BENEFIT HIGHLIGHTS                            IN-NETWORK                        OUT-OF-NETWORK
Maternity Care Services
 Initial Visit to Confirm Pregnancy       No charge after the $15 PCP or $15   50% after plan deductible
                                          Specialist per office visit copay
  Note:
  OB/GYN providers will be
  considered either a PCP or Specialist
  depending on how the provider
  contracts with CG.
  All subsequent Prenatal Visits,         90%                                  50% after plan deductible
  Postnatal Visits and Physician's
  Delivery Charges (i.e. global
  maternity fee)
  Physician's Office Visits in addition   No charge after the $15 PCP or $15   50% after plan deductible
  to the global maternity fee when        Specialist per office visit copay
  performed by an OB/GYN or
  Specialist
  Delivery - Facility                     $200 per contract year copay, then   $750 per contract year deductible,
  (Inpatient Hospital, Birthing Center)   90%                                  then 50% after plan deductible
Family Planning Services
  Office Visits, Lab and Radiology        No charge after the $15 PCP or $15   50% after plan deductible
  Tests and Counseling                    Specialist per office visit copay
  Note:
  The standard benefit will include
  coverage for contraceptive devices
  (e.g. Depo-Provera and Intrauterine
  Devices (IUDs). Diaphragms will
  also be covered when services are
  provided in the physician's office.
  Surgical Sterilization Procedures for
  Vasectomy/Tubal Ligation (excludes
  reversals)
      Physician’s Office Visit            No charge after the $15 PCP or $15   50% after plan deductible
                                          Specialist per office visit copay
      Inpatient Facility                  $200 per contract year copay, then   $750 per contract year deductible,
                                          90%                                  then 50% after plan deductible
      Outpatient Facility                 $200 per contract year copay, then   50% after plan deductible
                                          90%
      Physician's Services                90%                                  50% after plan deductible




                                                          19                                               myCIGNA.com
        BENEFIT HIGHLIGHTS                              IN-NETWORK                          OUT-OF-NETWORK
Infertility Treatment                         Not Covered                            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 $15 PCP or $15     50% after plan deductible
                                              Specialist per office visit copay
  Inpatient Facility                          100% at Lifesource center after $200   $750 per contract year deductible,
                                              per admission copay, otherwise 90%     then 50% after plan deductible
                                              after $200 per admission copay
  Physician’s Services                        100% at Lifesource center, otherwise   50% after plan deductible
                                              90%
  Lifetime Travel Maximum:                    No charge (only available when         In-Network coverage only
  $10,000 per transplant                      using Lifesource facility)




                                                             20                                                  myCIGNA.com
       BENEFIT HIGHLIGHTS                             IN-NETWORK                        OUT-OF-NETWORK
Durable Medical Equipment                   90%                                  50% after plan deductible
  Contract Year Maximum:
  Unlimited
Diabetes Equipment                          90%                                  50% after plan deductible
  Contract Year Maximum:
  Unlimited
External Prosthetic Appliances              90%                                  50% after plan deductible
  Contract Year Maximum:
  Unlimited
Diabetes Equipment & Custom Foot            90%                                  50% after plan deductible
Orthotics
  Contract Year Maximum:
  Unlimited
Dental Care
(no dental benefiits unless related to
injury)
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 $15 PCP or $15   50% after plan deductible
                                            Specialist per office visit copay
  Inpatient Facility                        $200 per contract year copay, then   $750 per contract year deductible,
                                            90%                                  then 50% after plan deductible
  Outpatient Facility                       $200 per contract year copay, then   50% after plan deductible
                                            90%
  Physician's Services                      90%                                  50% after plan deductible




                                                            21                                               myCIGNA.com
       BENEFIT HIGHLIGHTS                             IN-NETWORK                           OUT-OF-NETWORK
Bariatric Surgery
Note:
Subject to any limitations shown in the
“Exclusions, Expenses Not Covered
and General Limitations” section of this
certificate.
  Physician’s Office Visit                 No charge after the $15 PCP or $15       50% after plan deductible
                                           Specialist per office visit copay
  Inpatient Facility                       $200 per contract year copay, then       $750 per contract year deductible,
                                           90%                                      then 50% after plan deductible

  Outpatient Facility                      $200 per contract year copay, then       50% after plan deductible
                                           90%
  Physician's Services                     90%                                      50% after plan deductible

Oral Surgery
(Impacted Wisdom Teeth)
Note:
Any service related to extraction of
Impacted Wisdom Teeth is covered.

  Physician’s Office Visit                 No charge after the $15 PCP or $15       No charge after the $15 PCP or $15
                                           Specialist per office visit copay        Specialist per office visit copay

  Inpatient Facility                       $200 per contract year copay, then       $200 per contract year copay, then
                                           90%                                      90%

  Outpatient Facility                      $200 per contract year copay, then       $200 per contract year copay, then
                                           90%                                      90%

  Physician's Services                     90%                                      90%

Biologically Based Mental Illness
  Inpatient                                $200 per contract year copay, then       $750 per contract year deductible,
  Contract Year Maximum:                   90%                                      then 50% after plan deductible
  Unlimited
  Outpatient                               First 5 visits: No charge                50% after plan deductible
  Contract Year Maximum:
  Unlimited                                6 visits and over: No charge after $25
                                           per office visit copay
  Outpatient Group Therapy (One            No charge after $15 per visit copay      50% after plan deductible
  group therapy session equals one
  individual therapy session)




                                                            22                                                  myCIGNA.com
      BENEFIT HIGHLIGHTS                              IN-NETWORK                            OUT-OF-NETWORK
  Intensive Outpatient                     50% after $75 per program copay          50% after $50 per program
  Lifetime Maximum:                                                                 deductible
  Up to 3 per program
  Based on a ratio of 1:1
Eye Care Services                          Not covered                              100%
Note:
Allow 1 Routine Eye Exam (including
refraction) and 1 Routine Contact Lens
fitting exam every contract year.
Hearing Services                           100%                                     50% after plan deductible
Includes Routine Hearing screening,
testing and exam.

  Contract Year Maximum:
  1 visit
Routine Foot Disorders                     Not covered except for services          Not covered except for services
                                           associated with foot care for diabetes   associated with foot care for diabetes
                                           and peripheral vascular disease.         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 and will not count toward any plan limits that are shown in the Schedule for
mental health and substance abuse services including in-hospital services. Once the medical condition is stabilized,
whether the treatment will be characterized as either a medical expense or a mental health/substance abuse expense will be
determined by the utilization review Physician in accordance with the applicable mixed services claim guidelines.
Mental Health (other than
Biologically Based Mental Illness)
  Inpatient                                $200 per contract year copay, then       $750 per contract year deductible,
  Contract Year Maximum: 30 days           90%                                      then 50% after plan deductible
  Acute: based on a ratio of 1:1
  Partial: based on a ratio of 2:1
  Residential: based on a ratio of 2:1
  Outpatient                               First 5 visits: No charge                50% after plan deductible
  Contract Year Maximum:
  30 visits                                6 visits and over: No charge after $15
                                           per office visit copay
  Outpatient Group Therapy (One            No charge after $15 per visit copay      50% after plan deductible
  group therapy session equals one
  individual therapy session)
  Intensive Outpatient                     90% after $50 per program copay          50% after $50 per program
  Lifetime Maximum:                                                                 deductible
  Up to 3 per program
  Based on a ratio of 1:1




                                                            23                                                  myCIGNA.com
      BENEFIT HIGHLIGHTS                             IN-NETWORK                           OUT-OF-NETWORK
Chemical Dependency
Note: Lifetime maximum of 3 series of
treatments is covered. A series of
treatment can be a combination of
inpatient and outpatient treatments.
  Inpatient                               $200 per admission copay, then 90%       50% after plan deductible
  Contract Year Maximum:
  Unlimited

  Acute detox: requires 24 hour
  nursing; based on a ratio of 1:1
  Acute Inpatient Rehab: requires 24
  hour nursing; based on a ratio of 1:1
  Partial: based on a ratio of 2:1
  Residential: based on a ratio of 2:1
  Outpatient                              First 5 visits: No charge                50% after plan deductible
  Contract Year Maximum:
  Unlimited                               6 visits and over: No charge after $15
                                          per office visit copay

  Intensive Outpatient                    90%                                      50% after plan deductible
  (Chemical Dependency)
  Lifetime Maximum:
  Up to 3 per program
  Based on a ratio of 1:1




                                                           24                                                  myCIGNA.com
Open Access Plus Medical Benefits                                          In any case, those expenses incurred for which payment is
                                                                           excluded by the terms set forth above will not be considered as
                                                                           expenses incurred for the purpose of any other part of this
Certification Requirements - Out-of-Network                                plan, except for the "Coordination of Benefits" section.
For You and Your Dependents
Pre-Admission Certification/Continued Stay Review for                      GM6000 PAC2                                                      V9
Hospital Confinement
Pre-Admission Certification (PAC) and Continued Stay
Review (CSR) refer to the process used to certify the Medical              Prior Authorization/Pre-Authorized
Necessity and length of a Hospital Confinement when you or                 The term Prior Authorization means the approval that a
your Dependent require treatment in a Hospital:                            Participating Provider must receive from the Review
   as a registered bed patient;                                           Organization, prior to services being rendered, in order for
                                                                           certain services and benefits to be covered under this policy.
   for a Partial Hospitalization for the treatment of Mental
    Health or Substance Abuse;                                             Services that require Prior Authorization include, but are not
                                                                           limited to:
   for Mental Health or Substance Abuse Residential
    Treatment Services.                                                       inpatient Hospital services;
You or your Dependent should request PAC prior to any non-                    inpatient services at any participating Other Health Care
emergency treatment in a Hospital described above. In the                      Facility;
case of an emergency admission, you should contact the                        residential treatment;
Review Organization within 48 hours after the admission. For                  intensive outpatient programs;
an admission due to pregnancy, you should call the Review
Organization by the end of the third month of pregnancy. CSR                  nonemergency ambulance; or
should be requested, prior to the end of the certified length of              transplant services.
stay, for continued Hospital Confinement.
Covered Expenses incurred will not include the first $250 of               GM6000 05BPT16                                                   V6
Hospital charges made for each separate admission to the
Hospital:
   unless PAC is received: (a) prior to the date of admission; or         Covered Expenses
    (b) in the case of an emergency admission, within 48 hours
    after the date of admission.                                           The term Covered Expenses means the expenses incurred by
                                                                           or on behalf of a person for the charges listed below if they are
Covered Expenses incurred for which benefits would
                                                                           incurred after he becomes insured for these benefits. Expenses
otherwise be payable under this plan for the charges listed
                                                                           incurred for such charges are considered Covered Expenses to
below will not include:
                                                                           the extent that the services or supplies provided are
   Hospital charges for Bed and Board, for treatment listed               recommended by a Physician, and are Medically Necessary
    above for which PAC was performed, which are made for                  for the care and treatment of an Injury or a Sickness, as
    any day in excess of the number of days certified through              determined by CG. Any applicable Copayments,
    PAC or CSR; and                                                        Deductibles or limits are shown in The Schedule.
   any Hospital charges for treatment listed above for which              Covered Expenses
    PAC was requested, but which was not certified as
                                                                            charges made by a Hospital, on its own behalf, for Bed and
    Medically Necessary.
                                                                             Board and other Necessary Services and Supplies; except
                                                                             that for any day of Hospital Confinement, Covered
GM6000 PAC1                                                     V33          Expenses will not include that portion of charges for Bed
                                                                             and Board which is more than the Bed and Board Limit
                                                                             shown in The Schedule.
PAC and CSR are performed through a utilization review
                                                                              charges for licensed ambulance service to or from the
program by a Review Organization with which CG has
contracted.                                                                    nearest Hospital where the needed medical care and
                                                                               treatment can be provided.



                                                                      25                                                   myCIGNA.com
   charges made by a Hospital, on its own behalf, for medical               charges made for Routine Preventive Care from age 3
    care and treatment received as an outpatient.                             including immunizations, not to exceed the maximum
   charges made by a Free-Standing Surgical Facility, on its                 shown in the Schedule. Routine Preventive Care means
    own behalf for medical care and treatment.                                health care assessments, wellness visits and any related
                                                                              services.
   charges made on its own behalf, by an Other Health Care
    Facility, including a Skilled Nursing Facility, a                        charges made for visits for routine preventive care of a
    Rehabilitation Hospital or a subacute facility for medical                Dependent child during the first two years of that
    care and treatment; except that for any day of Other Health               Dependent child’s life, excluding immunizations.
    Care Facility confinement, Covered Expenses will not
    include that portion of charges which are in excess of the            GM6000 CM6                                                FLX108V799 M
    Other Health Care Facility Daily Limit shown in The
    Schedule.
                                                                             charges made for or in connection with annual diagnostic
   charges made for Emergency Services and Urgent Care.
                                                                              examinations for the detection of prostate cancer, regardless
   charges made by a Physician or a Psychologist for                         of medical necessity; and a prostate-specific antigen (PSA)
    professional services.                                                    test for a man who is: (a) at least 50 years of age and
   charges made by a Nurse, other than a member of your                      asymptomatic; or (b) at least 40 years of age with a family
    family or your Dependent's family, for professional nursing               history of prostate cancer, or another prostate risk factor.
    service.                                                                 charges for a minimum of 48 hours of inpatient care
                                                                              following a mastectomy and a minimum 24 hours following
GM6000 CM5                                              FLX107V126
                                                                              a lymph node dissection for the treatment of breast cancer.
                                                                              A shorter period of inpatient care may be deemed
                                                                              acceptable if the insured consults with the Physician and
   charges made for anesthetics and their administration;                    both agree it is appropriate.
    diagnostic x-ray and laboratory examinations; x-ray,                     charges for immunizations for Dependent children from
    radium, and radioactive isotope treatment; chemotherapy;                  birth through age 6. These immunizations will include: (a)
    blood transfusions; oxygen and other gases and their                      diphtheria; (b) Haemophilus influenzae type b; (c) hepatitis
    administration.                                                           B; (d) measles; (e) mumps; (f) pertussis; (g) polio; (h)
                                                                              rubella; (i) tetanus; (j) varicella (chicken pox); (k) rotavirus;
GM6000 CM6                                              FLX108V745            and (l) any other children's immunizations required by the
                                                                              State Board of Health. A deductible, copayment, or
                                                                              coinsurance is not required for immunizations.
   charges made for a mammogram for women ages 35 to 69,
    every one to two years, or at any age for women at risk,
    when recommended by a Physician.                                      GM6000 CM65                                                INDEM160V3

   charges made for an annual Papanicolaou laboratory
    screening test.                                                          charges for a service provided through Telemedicine for
   charges for appropriate counseling, medical services                      diagnosis, consultation, treatment, transfer of medical data,
    connected with surgical therapies, including vasectomy and                and medical education.
    tubal ligation.                                                           These benefits may not be subject to a greater deductible,
   charges made for laboratory services, radiation therapy and               copayment, or coinsurance than for the same service under
    other diagnostic and therapeutic radiological procedures.                 this plan provided through a face-to-face consultation.
   charges made for Family Planning, including medical                       The term Telemedicine means the practice of health care
    history, physical exam, related laboratory tests, medical                 delivery, diagnosis, consultation, treatment, transfer of
    supervision in accordance with generally accepted medical                 medical data, and medical education through the use of
    practices, other medical services, information and                        interactive audio, video, or other electronic media. It does
    counseling on contraception, implanted/injected                           not include the use of telephone or fax.
    contraceptives.                                                          charges for Hospital Confinement of a mother and her
   office visits, tests and counseling for Family Planning                   newborn child for 48 hours following a vaginal delivery, or
    services are subject to the Preventive Care Maximum shown                 for 96 hours following a cesarean delivery. After consulting
    in the Schedule.                                                          with her attending Physician the mother may request an



                                                                     26                                                      myCIGNA.com
    earlier discharge if it is determined that less time is needed                post-acute transition services and community reintegration
    for recovery. If medical necessity requires the mother and/or                 services, including outpatient day treatment services or
    newborn to remain confined for longer than 48 hours, the                      other post-acute care treatment services; and g) reasonable
    additional confinement will be covered. If the mother is                      expenses related to periodic reevaluation of the care of an
    discharged prior to the 48 or 96 hours, the additional                        individual covered under the plan who has incurred an
    confinement will be covered. If the mother is discharged                      acquired brain injury, has been unresponsive to treatment,
    prior to the 48 or 96 hours described above, a postpartum                     and becomes responsive to treatment at a later date, at
    home care visit will be covered. Postpartum home care                         which time the cognitive rehabilitation services would be a
    services include parent education; assistance and training in                 covered benefit
    breast feeding and bottle feeding; and the performance of                    charges made for an annual medically recognized diagnostic
    any necessary and appropriate clinical tests.                                 examination for the early detection of cervical cancer for
   charges for diagnostic and surgical treatment for conditions                  each covered female age 18 and over. Such coverage shall
    effecting temporomandibular joint and craniomandibular                        include at a minimum: (a) a conventional Pap smear
    disorders which are a result of: (a) an accident; (b) trauma;                 screening; or (b) a screening using liquid-based cytology
    (c) a congenital defect; (d) a developmental defect; or (e) a                 methods, as approved by the United States Food and Drug
    pathology.                                                                    Administration, alone or in combination with a test
                                                                                  approved by the United States Food and Drug
                                                                                  Administration for the detection of the human
GM6000 CM5                                                  INDEM160V7
                                                                                  papillomavirus.
                                                                                 charges for treatment of Biologically-Based Mental Illness
The following benefits will apply to insulin and non-insulin                      at the same rate as for other illnesses. A Biologically-Based
dependent diabetics as well as covered individuals who have                       Mental Illness is defined as: schizophrenia, paranoid and
elevated blood sugar levels due to pregnancy or other medical                     other psychotic disorders, bipolar disorders (hypomanic,
conditions:                                                                       manic, depressive, and mixed), major depressive disorder,
   charges for Durable Medical Equipment, including podiatric                    schizoaffective disorders (bipolar or depressive), obsessive-
    appliances, related to diabetes. A special maximum will not                   compulsive disorders, and depression in childhood or
    apply.                                                                        adolescence.
   charges for insulin; syringes; prefilled insulin cartridges for
    the blind; oral blood sugar control agents; glucose test                  GM6000 INDEM262
    strips; visual reading ketone strips; urine test strips; lancets;
    and alcohol swabs.
                                                                                 charges made for special formula treatment for
   charges for training by a Physician, including a podiatrist                   phenylketonuria and other inherited diseases.
    with recent education in diabetes management, but limited
    to the following:                                                            charges made for reconstructive surgery of craniofacial
                                                                                  abnormalities for covered Dependents age 18 or younger to
       medically necessary visits when diabetes is diagnosed;                    improve the function of, or to attempt to create a normal
       visits following a diagnosis of a significant change in the               appearance for an abnormal structure caused by congenital
        symptoms or conditions that warrant change in self-                       defects, developmental deformities, trauma, tumors,
        management;                                                               infection or disease.
       visits when reeducation or refresher training is prescribed
        by the Physician; and                                                 GM6000 CM65
       medical nutrition therapy related to diabetes management.             GM6000 INDEM62
                                                                              GM6000 CM5                                                05BPT90V3


GM6000 CM65                                                 INDEM160V6
                                                                                 charges made for medical and surgical services for the
                                                                                  treatment or control of clinically severe (morbid) obesity as
   charges made for an acquired brain injury including: a)                       defined below and if the services are demonstrated, through
    cognitive rehabilitation therapy; b) cognitive                                existing peer reviewed, evidence based, scientific literature
    communication therapy; c) neurocognitive therapy and                          and scientifically based guidelines, to be safe and effective
    rehabilitation; d) neurobehavioral, neurophysiological,                       for the treatment or control of the condition. Clinically
    neuropsychological and psychophysiological testing and                        severe (morbid) obesity is defined by the National Heart,
    treatment; e) neurofeedback therapy and remediation; f)


                                                                         27                                                   myCIGNA.com
    Lung and Blood Institute (NHLBI) as a Body Mass Index                             the trial is approved by the Institutional Review Board of
    (BMI) of 40 or greater without comorbidities, or a BMI of                          the institution administering the treatment; and
    35-39 with comorbidities. The following items are                                 coverage will not be extended to clinical trials conducted
    specifically excluded:                                                             at nonparticipating facilities if a person is eligible to
       medical and surgical services to alter appearances or                          participate in a covered clinical trial from a Participating
        physical changes that are the result of any medical or                         Provider.
        surgical services performed for the treatment or control of            Routine patient services do not include, and reimbursement
        obesity or clinically severe (morbid) obesity; and                     will not be provided for:
       weight loss programs or treatments, whether or not they                   the investigational service or supply itself;
        are prescribed or recommended by a Physician or under
                                                                                  services or supplies listed herein as Exclusions;
        medical supervision.
                                                                                  services or supplies related to data collection for the clinical
                                                                                   trial (i.e., protocol-induced costs);
GM6000 06BNR1                                                        V1
                                                                                  services or supplies which, in the absence of private health
                                                                                   care coverage, are provided by a clinical trial sponsor or
   orthognathic surgery to repair or correct a severe facial                      other party (e.g., device, drug, item or service supplied by
    deformity or disfigurement that orthodontics alone can not                     manufacturer and not yet FDA approved) without charge to
    correct, provided:                                                             the trial participant.
       the deformity or disfigurement is accompanied by a                     Genetic Testing
        documented clinically significant functional impairment,                charges made for genetic testing that uses a proven testing
        and there is a reasonable expectation that the procedure                 method for the identification of genetically-linked
        will result in meaningful functional improvement; or                     inheritable disease. Genetic testing is covered only if:
       the orthognathic surgery is Medically Necessary as a                          a person has symptoms or signs of a genetically-linked
        result of tumor, trauma, disease or;                                           inheritable disease;
       the orthognathic surgery is performed prior to age 19 and                     it has been determined that a person is at risk for carrier
        is required as a result of severe congenital facial                            status as supported by existing peer-reviewed, evidence-
        deformity or congenital condition.                                             based, scientific literature for the development of a
Repeat or subsequent orthognathic surgeries for the same                               genetically-linked inheritable disease when the results
condition are covered only when the previous orthognathic                              will impact clinical outcome; or
surgery met the above requirements, and there is a high
probability of significant additional improvement as
                                                                               GM6000 05BPT1
determined by the utilization review Physician.

                                                                                      the therapeutic purpose is to identify specific genetic
GM6000 06BNR10
                                                                                       mutation that has been demonstrated in the existing peer-
                                                                                       reviewed, evidence-based, scientific literature to directly
Clinical Trials                                                                        impact treatment options.
 charges made for routine patient services associated with                    Pre-implantation genetic testing, genetic diagnosis prior to
  cancer clinical trials approved and sponsored by the federal                 embryo transfer, is covered when either parent has an
  government. In addition the following criteria must be met:                  inherited disease or is a documented carrier of a genetically-
       the cancer clinical trial is listed on the NIH web site                linked inheritable disease.
        www.clinicaltrials.gov as being sponsored by the federal               Genetic counseling is covered if a person is undergoing
        government;                                                            approved genetic testing, or if a person has an inherited
       the trial investigates a treatment for terminal cancer and:            disease and is a potential candidate for genetic testing. Genetic
        (1) the person has failed standard therapies for the                   counseling is limited to 3 visits per contract year for both pre-
        disease; (2) cannot tolerate standard therapies for the                and postgenetic testing.
        disease; or (3) no effective nonexperimental treatment for             Nutritional Evaluation
        the disease exists;
                                                                                charges made for nutritional evaluation and counseling
       the person meets all inclusion criteria for the clinical trial           when diet is a part of the medical management of a
        and is not treated “off-protocol”;                                       documented organic disease.


                                                                          28                                                       myCIGNA.com
Internal Prosthetic/Medical Appliances                                            by a Physician for professional services;
 charges made for internal prosthetic/medical appliances that                    by a Psychologist, social worker, family counselor or
  provide permanent or temporary internal functional supports                      ordained minister for individual and family counseling;
  for nonfunctional body parts are covered. Medically                             for pain relief treatment, including drugs, medicines and
  Necessary repair, maintenance or replacement of a covered                        medical supplies;
  appliance is also covered.
                                                                                  by an Other Health Care Facility for:
                                                                                      part-time or intermittent nursing care by or under the
GM6000 05BPT2                                                   V1
                                                                                       supervision of a Nurse;
                                                                                      part-time or intermittent services of an Other Health
Home Health Care Services                                                              Care Professional;
 charges made for Home Health Care Services when you:
     require skilled care;                                                GM6000 CM34                                                  FLX124V38

     are unable to obtain the required care as an ambulatory
      outpatient; and                                                                 physical, occupational and speech therapy;
     do not require confinement in a Hospital or Other Health                        medical supplies; drugs and medicines lawfully
      Care Facility.                                                                   dispensed only on the written prescription of a
Home Health Care Services are provided under the terms of a                            Physician; and laboratory services; but only to the
Home Health Care plan for the person named in that plan.                               extent such charges would have been payable under the
If you are a minor or an adult who is dependent upon others                            policy if the person had remained or been Confined in a
for nonskilled care (e.g. bathing, eating, toileting), Home                            Hospital or Hospice Facility.
Health Care Services will only be provided for you during                  The following charges for Hospice Care Services are not
times when there is a family member or care giver present in               included as Covered Expenses:
the home to meet your nonskilled care needs.                                  for the services of a person who is a member of your family
Home Health Care Services are those skilled health care                        or your Dependent's family or who normally resides in your
services that can be provided during intermittent visits of two                house or your Dependent's house;
hours or less by Other Health Care Professionals. Necessary                   for any period when you or your Dependent is not under the
consumable medical supplies, home infusion therapy, and                        care of a Physician;
Durable Medical Equipment administered or used by Other
                                                                              for services or supplies not listed in the Hospice Care
Health Care Professionals in providing Home Health Care
Services are covered. Home Health Care Services do not                         Program;
include services of a person who is a member of your family                   for any curative or life-prolonging procedures;
or your Dependent's family or who normally resides in your                    to the extent that any other benefits are payable for those
house or your Dependent's house. Physical, occupational, and                   expenses under the policy;
speech therapy provided in the home are subject to the benefit
                                                                              for services or supplies that are primarily to aid you or your
limitations described under "Short-Term Rehabilitative
                                                                               Dependent in daily living;
Therapy."

                                                                           GM6000 CM35                                                  FLX124V27
GM6000 INDEM2                                                   V16



Hospice Care Services                                                      Mental Health and Chemical Dependency Services
 charges made for a person who has been diagnosed as
                                                                           Mental Health Services are services that are required to treat
  having six months or fewer to live, due to Terminal Illness,             a disorder that impairs the behavior, emotional reaction or
  for the following Hospice Care Services provided under a                 thought processes. In determining benefits payable, charges
  Hospice Care Program:                                                    made for the treatment of any physiological conditions related
                                                                           to Mental Health will not be considered to be charges made
     by a Hospice Facility for Bed and Board and Services and             for treatment of Mental Health.
      Supplies;
                                                                           Chemical Dependency is defined as the abuse of or
     by a Hospice Facility for services provided on an                    psychological or physical dependence on or addiction to
      outpatient basis;


                                                                      29                                                       myCIGNA.com
alcohol or a controlled substance that requires diagnosis, care,           Residential Treatment Center for Children and
and treatment. In determining benefits payable, charges made               Adolescents means a child care institution that provides
for the treatment of any physiological conditions related to               residential care and treatment for emotionally disturbed
rehabilitation services for Chemical Dependency will not be                children and adolescents, and that is accredited as a
considered to be charges made for treatment of Chemical                    Residential Treatment Center by the Council on Accreditation,
Dependency.                                                                the Joint Commission on Accreditation of Hospitals, or the
A Controlled Substance means a Toxic Inhalant or a                         American Association of Psychiatric Services for Children.
substance designated as a controlled substance in Chapter 481,
Health and Safety code.                                                    GM6000 INDEM10                                                 V53
A Toxic Inhalant means a volatile chemical under Chapter
484, Health and Safety code, or usable glue or aerosol paint
                                                                           A Crisis Stabilization Unit means a 24-hour residential
under Section 485.001, Health and Safety code.
                                                                           program that is usually short term in nature and that provides
Inpatient Mental Health Services                                           intensive supervision and highly structured activities to
Services that are provided by an In-Network Hospital while                 individuals who are demonstrating an acute demonstrable
you or your Dependents are Confined in a Hospital for the                  psychiatric crisis of moderate to severe proportions.
treatment and evaluation of Mental Health. Inpatient Mental                Mental Health Residential Treatment services in a Mental
Health Services include Mental Health treatment in a                       Health Residential Treatment Center for Children and
Residential Treatment Center for Children and Adolescents,                 Adolescents, or a Crisis Stabilization Unit are exchanged with
Crisis Stabilization Unit, Partial Hospitalization and Mental              Inpatient Mental Health Benefits at a rate of:
Health Residential Treatment Services.
                                                                              2 days of Mental Health Residential Treatment at a Center
Inpatient Mental Health benefits are exchangeable with                         for Children and Adolescents being equal to 1 day of
Partial Hospitalization sessions when benefits are provided                    Inpatient Mental Health Treatment.
for not less than 4 hours and not more than 12 hours in any 24-
                                                                              2 days of Mental Health Services provided through Crisis
hour period. The benefit exchange will be two partial
                                                                               Stabilization Units being equal to 1 day of Inpatient Mental
hospitalization sessions are equal to one day of inpatient care.
                                                                               Health Treatment.
                                                                           Outpatient Mental Health Services
GM6000 INDEM9                                                   V59
                                                                           Services of Providers who are qualified to treat Mental Health
                                                                           when treatment is provided on an outpatient basis, while you
Mental Health Residential Treatment Services are services                  or your Dependent is not Confined in a Hospital, and is
provided by a Hospital for the evaluation and treatment of the             provided in an individual, group or Mental Health Intensive
psychological and social functional disturbances that are a                Outpatient Therapy Program. Covered services include, but
result of subacute Mental Health conditions.                               are not limited to, outpatient treatment of conditions such as:
Mental Health Residential Treatment benefits are exchanged                 anxiety or depression which interfere with daily functioning;
with Inpatient Mental Health benefits at a rate of two days of             emotional adjustment or concerns related to chronic
Mental Health Residential Treatment being equal to one day                 conditions, such as psychosis or depression; emotional
of Inpatient Mental Health Treatment.                                      reactions associated with marital problems or divorce;
                                                                           child/adolescent problems of conduct or poor impulse control;
Mental Health Residential Treatment Center means an                        affective disorders; suicidal or homicidal threats or acts; eating
institution which (a) specializes in the treatment of                      disorders; or acute exacerbation of chronic Mental Health
psychological and social disturbances that are the result of               conditions (crisis intervention and relapse prevention) and
Mental Health conditions; (b) provides a subacute, structured,             outpatient testing and assessment.
psychotherapeutic treatment program, under the supervision of
Physicians; (c) provides 24-hour care, in which a person lives             A Mental Health Intensive Outpatient Therapy Program
in an open setting; and (d) is licensed in accordance with the             consists of distinct levels or phases of treatment that are
laws of the appropriate legally authorized agency as a                     provided by a certified/licensed Mental Health program.
residential treatment center.                                              Intensive Outpatient Therapy Programs provide a combination
                                                                           of individual, family and/or group therapy in a day, totaling 9
A person is considered Confined in a Mental Health                         or more hours in a week. Mental Health Intensive Outpatient
Residential Treatment Center when she/he is a registered bed               Therapy Program services are exchanged with Outpatient
patient in a Mental Health Residential Treatment Center upon               Mental Health services at a rate of 1 visit of Mental Health
the recommendation of a Physician.



                                                                      30                                                   myCIGNA.com
Intensive Outpatient Therapy being equal to 1 visit of                   A person is considered Confined in a Chemical Dependency
Outpatient Mental Health Services.                                       Residential Treatment Center when she/he is a registered bed
                                                                         patient in a Chemical Dependency Residential Treatment
                                                                         Center upon the recommendation of a Physician.
GM6000 INDEM17                                                 V4


                                                                         GM6000 INDEM11                                                V65

Inpatient Chemical Dependency Rehabilitation Services
Services provided for rehabilitation, while you or your                  Outpatient Chemical Dependency Rehabilitation Services
Dependent is Confined in a Hospital, when required for the               Services provided for the diagnosis and treatment of Chemical
diagnosis and treatment of Chemical Dependency.                          Dependency, while you or your Dependent is not Confined in
Inpatient Chemical Dependency services are exchangeable                  a Hospital, including outpatient rehabilitation in an individual,
with Partial Hospitalization sessions when services are                  group or Chemical Dependency intensive Outpatient
provided for not less than 4 hours and not more than 12 hours            Structured Therapy Program.
in any 24-hour period. The exchange for services will be 2               A Chemical Dependency Outpatient Structured Therapy
partial hospitalization sessions are equal to 1 day of inpatient         Program consists of distinct levels or phases of treatment that
care.                                                                    are provided by a certified/licensed Chemical Dependency
Chemical Dependency Outpatient Therapy Program                           program. Intensive Outpatient Therapy Programs provide a
consists of distinct levels or phases of treatment that are              combination of individual, family and/or group therapy in a
provided by a certified/licensed Chemical Dependency                     day, totaling 9 or more hours in a week. Chemical
program. Intensive outpatient structured therapy programs                Dependency Intensive Outpatient Therapy Program services
provide a combination of individual, family and/or group                 are exchanged with Outpatient Chemical Dependency services
therapy in a day, totaling 9 or more hours in a week.                    at a rate of 1 visit of Chemical Dependency Intensive
                                                                         Outpatient Therapy being equal to 1 visit of Outpatient
Chemical Dependency Outpatient Therapy Program benefits                  Chemical Dependency Rehabilitation Services.
are exchanged with Inpatient Chemical Dependency benefits
at a rate of 3 days of Chemical Dependency Outpatient                    Lifetime Maximum
Structured Therapy being equal to 1 day of Inpatient Chemical            Chemical Dependency Benefits will be limited to a lifetime
Dependency Rehabilitation Services.                                      maximum of three separate Series of Treatments per person.
Chemical Dependency Residential Treatment Services are                   A Series of Treatments is a planned, structured and
services provided by a Hospital for the evaluation and                   organized program to promote chemical free status which may
treatment of the psychological and social functional                     or may not include different facilities or modalities, and is
disturbances that are a result of subacute Substance Abuse               complete when you are discharged on medical advice from
conditions.                                                              inpatient detoxification, inpatient rehabilitation, partial
Chemical Dependency Residential Treatment benefits are                   hospitalization or intensive outpatient, or a series of these
exchanged with Inpatient Chemical Dependency benefits at a               levels of treatment without a lapse in treatment, or when you
rate of 2 days of Chemical Dependency Residential Treatment              fail to materially comply with the treatment program for a
being equal to 1 day of Inpatient Chemical Dependency                    period of 30 days.
Treatment.
Chemical Dependency Residential Treatment Center                         GM6000 INDEM11                                                V66
means an institution which (a) specializes in the treatment of
psychological and social disturbances that are the result of
Chemical Dependency conditions; (b) provides a subacute,
                                                                         Chemical Dependency Detoxification Services
structured, psychotherapeutic treatment program, under the
supervision of Physicians; (c) provided 24-hour care, in which           Detoxification and related medical ancillary services provided
a person lives in an open setting; and (d) is licensed in                when required for the diagnosis and treatment of addiction to
accordance with the laws of the appropriate legally authorized           alcohol and/or drugs. CG will decide, based on the Medical
agency as a residential treatment center.                                Necessity of each situation, whether such services will be
                                                                         provided in an inpatient or outpatient setting.




                                                                    31                                                   myCIGNA.com
Exclusions                                                                  equipment includes, but is not limited to, crutches, hospital
The following are specifically excluded from Mental Health                  beds, respirators, wheel chairs, and dialysis machines.
and Chemical Dependency Services:                                           Durable Medical Equipment items that are not covered include
   any court ordered treatment or therapy, or any treatment or             but are not limited to those that are listed below:
    therapy ordered as a condition of parole, probation or                     Bed Related Items: bed trays, over the bed tables, bed
    custody or visitation evaluations unless Medically                          wedges, pillows, custom bedroom equipment, mattresses,
    Necessary and otherwise covered under this policy or                        including nonpower mattresses, custom mattresses and
    agreement;                                                                  posturepedic mattresses.
   treatment of medical disorders which have been diagnosed                   Bath Related Items: bath lifts, nonportable whirlpools,
    as organic mental disorders associated with permanent                       bathtub rails, toilet rails, raised toilet seats, bath benches,
    dysfunction of the brain;                                                   bath stools, hand held showers, paraffin baths, bath mats,
   developmental disorders, including but not limited to,                      and spas.
    developmental reading disorders, developmental arithmetic                  Chairs, Lifts and Standing Devices: computerized or
    disorders, developmental language disorders or                              gyroscopic mobility systems, roll about chairs, geriatric
    developmental articulation disorders;                                       chairs, hip chairs, seat lifts (mechanical or motorized),
   counseling for activities of an educational nature;                         patient lifts (mechanical or motorized – manual hydraulic
                                                                                lifts are covered if patient is two-person transfer), and auto
   counseling for borderline intellectual functioning;                         tilt chairs.
   counseling for occupational problems;                                      Fixtures to Real Property: ceiling lifts and wheelchair
   counseling related to consciousness raising;                                ramps.
   vocational or religious counseling;                                        Car/Van Modifications.
   I.Q. testing;                                                              Air Quality Items: room humidifiers, vaporizers, air
   custodial care, including but not limited to geriatric day                  purifiers and electrostatic machines.
    care;                                                                      Blood/Injection Related Items: blood pressure cuffs,
   psychological testing on children requested by or for a                     centrifuges, nova pens and needleless injectors.
    school system;                                                             Other Equipment: heat lamps, heating pads, cryounits,
   occupational/recreational therapy programs even if                          cryotherapy machines, electronic-controlled therapy units,
    combined with supportive therapy for age-related cognitive                  ultraviolet cabinets, sheepskin pads and boots, postural
    decline;                                                                    drainage board, AC/DC adaptors, enuresis alarms, magnetic
                                                                                equipment, scales (baby and adult), stair gliders, elevators,
                                                                                saunas, any exercise equipment and diathermy machines.
GM6000 INDEM12                                                   V56


                                                                            GM6000 05BPT3
Durable Medical Equipment
 charges made for purchase or rental of Durable Medical
                                                                            External Prosthetic Appliances and Devices
  Equipment that is ordered or prescribed by a Physician and
  provided by a vendor approved by CG for use outside a                      charges made or ordered by a Physician for: the initial
  Hospital or Other Health Care Facility. Coverage for repair,                purchase and fitting of external prosthetic appliances and
  replacement or duplicate equipment is provided only when                    devices available only by prescription which are necessary
  required due to anatomical change and/or reasonable wear                    for the alleviation or correction of Injury, Sickness or
  and tear. All maintenance and repairs that result from a                    congenital defect. Coverage for External Prosthetic
  person’s misuse are the person’s responsibility. Coverage                   Appliances is limited to the most appropriate and cost
  for Durable Medical Equipment is limited to the lowest-cost                 effective alternative as determined by the utilization review
  alternative as determined by the utilization review                         Physician.
  Physician.                                                                External prosthetic appliances and devices shall include
Durable Medical Equipment is defined as items which are                     prostheses/prosthetic appliances and devices, orthoses and
designed for and able to withstand repeated use by more than                orthotic devices; braces; and splints.
one person; customarily serve a medical purpose; generally
are not useful in the absence of Injury or Sickness; are
appropriate for use in the home; and are not disposable. Such


                                                                       32                                                       myCIGNA.com
Prostheses/Prosthetic Appliances and Devices                                  orthosis shoes, shoe additions, procedures for foot
Prostheses/prosthetic appliances and devices are defined as                    orthopedic shoes, shoe modifications and transfers;
fabricated replacements for missing body parts.                               orthoses primarily used for cosmetic rather than functional
Prostheses/prosthetic appliances and devices include, but are                  reasons; and
not limited to:
                                                                              orthoses primarily for improved athletic performance or
   basic limb prostheses;                                                     sports participation.
   terminal devices such as hands or hooks; and                           Braces
 speech prostheses.                                                       A Brace is defined as an orthosis or orthopedic appliance that
Orthoses and Orthotic Devices                                              supports or holds in correct position any movable part of the
Orthoses and orthotic devices are defined as orthopedic                    body and that allows for motion of that part.
appliances or apparatuses used to support, align, prevent or               The following braces are specifically excluded: Copes
correct deformities. Coverage is provided for custom foot                  scoliosis braces.
orthoses and other orthoses as follows:                                    Splints
   Nonfoot orthoses – only the following nonfoot orthoses are             A Splint is defined as an appliance for preventing movement
    covered:                                                               of a joint or for the fixation of displaced or movable parts.
       rigid and semirigid custom fabricated orthoses,                    Coverage for replacement of external prosthetic appliances
       semirigid prefabricated and flexible orthoses; and                 and devices is limited to the following:
       rigid prefabricated orthoses including preparation, fitting           Replacement due to regular wear. Replacement for damage
        and basic additions, such as bars and joints.                          due to abuse or misuse by the person will not be covered.
   Custom foot orthoses – custom foot orthoses are only                      Replacement will be provided when anatomic change has
    covered as follows:                                                        rendered the external prosthetic appliance or device
       for persons with impaired peripheral sensation and/or                  ineffective. Anatomic change includes significant weight
        altered peripheral circulation (e.g. diabetic neuropathy               gain or loss, atrophy and/or growth.
        and peripheral vascular disease);                                     Coverage for replacement is limited as follows:
       when the foot orthosis is an integral part of a leg brace                 No more than once every 24 months for persons 19 years
        and is necessary for the proper functioning of the brace;                  of age and older and
       when the foot orthosis is for use as a replacement or                     No more than once every 12 months for persons 18 years
        substitute for missing parts of the foot (e.g. amputated                   of age and under.
        toes) and is necessary for the alleviation or correction of               Replacement due to a surgical alteration or revision of the
        Injury, Sickness or congenital defect; and                                 site.
       for persons with neurologic or neuromuscular condition             The following are specifically excluded external prosthetic
        (e.g. cerebral palsy, hemiplegia, spina bifida) producing          appliances and devices:
        spasticity, malalignment, or pathological positioning of
                                                                              External and internal power enhancements or power
        the foot and there is reasonable expectation of
                                                                               controls for prosthetic limbs and terminal devices; and
        improvement.
                                                                              Myoelectric prostheses peripheral nerve stimulators.

GM6000 06BNR5
                                                                           GM6000 05BPT5


The following are specifically excluded orthoses and orthotic
devices:                                                                   Short-Term Rehabilitative Therapy
   prefabricated foot orthoses;                                           Short-term Rehabilitative Therapy that is part of a
                                                                           rehabilitation program, including physical, speech,
   cranial banding and/or cranial orthoses. Other similar                 occupational, cognitive, osteopathic manipulative, cardiac
    devices are excluded except when used postoperatively for              rehabilitation and pulmonary rehabilitation therapy, when
    synostotic plagiocephaly. When used for this indication, the           provided in the most medically appropriate setting.
    cranial orthosis will be subject to the limitations and
    maximums of the External Prosthetic Appliances and
    Devices benefit;



                                                                      33                                                     myCIGNA.com
The following limitation applies to Short-term Rehabilitative           Chiropractic Care services that are not covered include but are
Therapy:                                                                not limited to:
   Occupational therapy is provided only for purposes of                  services of a chiropractor which are not within his scope of
    enabling persons to perform the activities of daily living              practice, as defined by state law;
    after an Illness or Injury or Sickness.                                charges for care not provided in an office setting;
Short-term Rehabilitative Therapy services that are not                    maintenance or preventive treatment consisting of routine,
covered include but are not limited to:                                     longterm or non-Medically Necessary care provided to
   Sensory integration therapy, group therapy; treatment of                prevent recurrence or to maintain the patient’s current
    dyslexia; behavior modification or myofunctional therapy                status; and
    for dysfluency, such as stuttering or other involuntarily              vitamin therapy.
    acted conditions without evidence of an underlying medical
    condition or neurological disorder;
                                                                        GM6000 07BNR4
   Treatment for functional articulation disorder such as
    correction of tongue thrust, lisp, verbal apraxia or
    swallowing dysfunction that is not based on an underlying           Transplant Services
    diagnosed medical condition or Injury; and
                                                                         charges made for human organ and tissue Transplant
   Maintenance or preventive treatment consisting of routine,            services which include solid organ and bone marrow/stem
    long-term or non-Medically Necessary care provided to                 cell procedures at designated facilities throughout the
    prevent recurrence or to maintain the patient’s current               United States or its territories. This coverage is subject to
    status;                                                               the following conditions and limitations.
A separate Copayment will apply to the services provided by             Transplant services include the recipient’s medical, surgical
each provider.                                                          and Hospital services; inpatient immunosuppressive
Services that are provided by a chiropractic Physician are not          medications; and costs for organ or bone marrow/stem cell
covered.                                                                procurement. Transplant services are covered only if they are
                                                                        required to perform any of the following human to human
These services include the conservative management of acute
                                                                        organ or tissue transplants: allogeneic bone marrow/stem cell,
neuromusculoskeletal conditions through manipulation and
                                                                        autologous bone marrow/stem cell, cornea, heart, heart/lung,
ancillary physiological treatment rendered to restore motion,
                                                                        kidney, kidney/pancreas, liver, lung, pancreas or intestine
reduce pain and improve function.
                                                                        which includes small bowel-liver or multi-visceral.
                                                                        All Transplant services, other than cornea, are covered at
GM6000 07BNR3                                                           100% when received at CIGNA LIFESOURCE Transplant
                                                                        Network® facilities. Cornea transplants are not covered at
Chiropractic Care Services                                              CIGNA LIFESOURCE Transplant Network® facilities.
                                                                        Transplant services, including cornea, received at participating
Charges made for diagnostic and treatment services utilized in          facilities specifically contracted with CIGNA for those
an office setting by chiropractic Physicians. Chiropractic              Transplant services, other than CIGNA LIFESOURCE
treatment includes the conservative management of acute                 Transplant Network® facilities, are payable at the In-Network
neuromusculoskeletal conditions through manipulation and                level. Transplant services received at any other facilities,
ancillary physiological treatment rendered to specific joints to        including Non-Participating Providers and Participating
restore motion, reduce pain, and improve function. For these            Providers not specifically contracted with CIGNA for
services you have direct access to qualified chiropractic               Transplant services, are covered at the Out-of-Network level.
Physicians.
                                                                        Coverage for organ procurement costs are limited to costs
The following limitation applies to Chiropractic Care                   directly related to the procurement of an organ, from a cadaver
Services:                                                               or a live donor. Organ procurement costs shall consist of
   Occupational therapy is provided only for purposes of               surgery necessary for organ removal, organ transportation and
    enabling persons to perform the activities of daily living          the transportation, hospitalization and surgery of a live donor.
    after an Injury or Sickness;                                        Compatibility testing undertaken prior to procurement is
                                                                        covered if Medically Necessary. Costs related to the search
                                                                        for, and identification of a bone marrow or stem cell donor for
                                                                        an allogeneic transplant are also covered.



                                                                   34                                                    myCIGNA.com
Transplant Travel Services                                                   which is accompanied by functional deficit; (other than
Charges made for reasonable travel expenses incurred by you                  abnormalities of the jaw or conditions related to TMJ
in connection with a preapproved organ/tissue transplant are                 disorder) provided that: (a) the surgery or therapy restores
covered subject to the following conditions and limitations.                 or improves function; (b) reconstruction is required as a
Transplant travel benefits are not available for cornea                      result of Medically Necessary, noncosmetic surgery; or (c)
transplants. Benefits for transportation, lodging and food are               the surgery or therapy is performed prior to age 19 and is
available to you only if you are the recipient of a preapproved              required as a result of the congenital absence or agenesis
organ/tissue transplant from a designated CIGNA                              (lack of formation or development) of a body part. Repeat
LIFESOURCE Transplant Network® facility. The term                            or subsequent surgeries for the same condition are covered
recipient is defined to include a person receiving authorized                only when there is the probability of significant additional
transplant related services during any of the following: (a)                 improvement as determined by the utilization review
evaluation, (b) candidacy, (c) transplant event, or (d) post-                Physician.
transplant care. Travel expenses for the person receiving the
transplant will include charges for: transportation to and from          GM6000 05BPT2                                                      V2
the transplant site (including charges for a rental car used
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.                  Exclusions, Expenses Not Covered and
In addition to your coverage for the charges associated with             General Limitations
the items above, such charges will also be considered covered            Additional coverage limitations determined by plan or
travel expenses for one companion to accompany you. The                  provider type are shown in the Schedule. Payment for the
term companion includes your spouse, a member of your                    following is specifically excluded from this plan:
family, your legal guardian, or any person not related to you,
but actively involved as your caregiver. The following are                  expenses for supplies, care, treatment, or surgery that are
specifically excluded travel expenses:                                       not Medically Necessary.
  travel costs incurred due to travel within 60 miles of your               to the extent that you or any one of your Dependents is in
  home; laundry bills; telephone bills; alcohol or tobacco                   any way paid or entitled to payment for those expenses by
  products; and charges for transportation that exceed coach                 or through a public program, other than Medicaid.
  class rates.                                                              to the extent that payment is unlawful where the person
These benefits are only available when the covered person is                 resides when the expenses are incurred.
the recipient of an organ transplant. No benefits are available             charges made by a Hospital owned or operated by or which
when the covered person is a donor.                                          provides care or performs services for, the United States
                                                                             Government, if such charges are directly related to a
                                                                             military-service-connected Injury or Sickness.
GM6000 05BPT7                                                 V11
                                                                            for or in connection with an Injury or Sickness which is due
                                                                             to war, declared or undeclared.
Breast Reconstruction and Breast Prostheses
                                                                            charges which you are not obligated to pay or for which you
 charges made for reconstructive surgery following a                        are not billed or for which you would not have been billed
  mastectomy; benefits include: (a) surgical services for                    except that they were covered under this plan.
  reconstruction of the breast on which surgery was
                                                                            assistance in the activities of daily living, including but not
  performed; (b) surgical services for reconstruction of the
                                                                             limited to eating, bathing, dressing or other Custodial
  nondiseased breast to produce symmetrical appearance; (c)
                                                                             Services or self-care activities, homemaker services and
  postoperative breast prostheses; and (d) mastectomy bras
                                                                             services primarily for rest, domiciliary or convalescent care.
  and external prosthetics, limited to the lowest cost
  alternative available that meets external prosthetic
  placement needs. During all stages of mastectomy,
  treatment of physical complications, including lymphedema
  therapy, are covered.
Reconstructive Surgery
 charges made for reconstructive surgery or therapy to repair
  or correct a severe physical deformity or disfigurement



                                                                    35                                                     myCIGNA.com
   for or in connection with experimental, investigational or                  (BMI) classifications of the National Heart, Lung, and
    unproven services.                                                          Blood Institute (NHLBI) guideline is covered only at
    Experimental, investigational and unproven services are                     approved centers if the services are demonstrated, through
    medical, surgical, diagnostic, psychiatric, substance abuse                 existing peer-reviewed, evidence-based, scientific literature
    or other health care technologies, supplies, treatments,                    and scientifically based guidelines, to be safe and effective
    procedures, drug therapies or devices that are determined by                for treatment of the condition. Clinically severe obesity is
    the utilization review Physician to be:                                     defined by the NHLBI as a BMI of 40 or greater without
                                                                                comorbidities, or 35-39 with comorbidities. The following
       not demonstrated, through existing peer-reviewed,                       are specifically excluded:
        evidence-based, scientific literature to be safe and
        effective for treating or diagnosing the condition or                      medical and surgical services to alter appearances or
        sickness for which its use is proposed;                                     physical changes that are the result of any surgery
                                                                                    performed for the management of obesity or clinically
       not approved by the U.S. Food and Drug Administration                       severe (morbid) obesity; and
        (FDA) or other appropriate regulatory agency to be
        lawfully marketed for the proposed use;                                    weight loss programs or treatments, whether prescribed or
                                                                                    recommended by a Physician or under medical
       the subject of review or approval by an Institutional                       supervision.
        Review Board for the proposed use except as provided in
        the “Clinical Trials” section of this plan; or                         unless otherwise covered in this plan, for reports,
                                                                                evaluations, physical examinations, or hospitalization not
       the subject of an ongoing phase I, II or III clinical trial,            required for health reasons including, but not limited to,
        except as provided in the “Clinical Trials” section of this             employment, insurance or government licenses, and court-
        plan.                                                                   ordered, forensic or custodial evaluations.
   cosmetic surgery and therapies. Cosmetic surgery or therapy                court-ordered treatment or hospitalization, unless such
    is defined as surgery or therapy performed to improve or                    treatment is prescribed by a Physician and listed as covered
    alter appearance or self-esteem or to treat psychological                   in this plan.
    symptomatology or psychosocial complaints related to
    one’s appearance.                                                          infertility services including infertility drugs, surgical or
                                                                                medical treatment programs for infertility, including in vitro
   regardless of clinical indication for macromastia or                        fertilization, gamete intrafallopian transfer (GIFT), zygote
    gynecomastia surgeries; blepharoplasty; redundant skin                      intrafallopian transfer (ZIFT), variations of these
    surgery; removal of skin tags; acupressure;                                 procedures, and any costs associated with the collection,
    craniosacral/cranial therapy; dance therapy; movement                       washing, preparation or storage of sperm for artificial
    therapy; applied kinesiology; rolfing; prolotherapy; and                    insemination (including donor fees). Cryopreservation of
    extracorporeal shock wave lithotripsy (ESWL) for                            donor sperm and eggs are also excluded from coverage.
    musculoskeletal and orthopedic conditions.
                                                                               reversal of male and female voluntary sterilization
   for or in connection with treatment of the teeth or                         procedures.
    periodontium unless such expenses are incurred for: (a)
    charges made for a continuous course of dental treatment                   transsexual surgery including medical or psychological
    started within six months of an Injury to sound natural teeth;              counseling and hormonal therapy in preparation for, or
    (b) charges made by a Hospital for Bed and Board or                         subsequent to, any such surgery.
    Necessary Services and Supplies; (c) charges made by a                     any services or supplies for the treatment of male or female
    Free-Standing Surgical Facility or the outpatient department                sexual dysfunction such as, but not limited to, treatment of
    of a Hospital in connection with surgery; or (d) charges                    erectile dysfunction (including penile implants), anorgasmy,
    made by a Physician for any of the following Surgical                       and premature ejaculation.
    Procedures: excision of epulis; excision of unerupted                      medical and Hospital care and costs for the infant child of a
    impacted tooth, including removal of alveolar bone and                      Dependent, unless this infant child is otherwise eligible
    sectioning of tooth; removal of residual root (when                         under this plan.
    performed by a Dentist other than the one who extracted the
                                                                               nonmedical counseling or ancillary services, including but
    tooth); intraoral drainage of acute alveolar abscess with
    cellulitis; alveolectomy; gingivectomy, for gingivitis or                   not limited to Custodial Services, education, training,
    periodontitis.                                                              vocational rehabilitation, behavioral training, biofeedback,
                                                                                neurofeedback, hypnosis, sleep therapy, employment
   for medical and surgical services intended primarily for the                counseling, back school, return to work services, work
    treatment or control of obesity. However, treatment of                      hardening programs, driving safety, and services, training,
    clinically severe obesity, as defined by the body mass index


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




                                                                    37                                                    myCIGNA.com
   to the extent of the exclusions imposed by any certification          Coordination of Benefits
    requirement shown in this plan.
                                                                          This section applies if you or any one of your Dependents is
   rhinoplasty when solely for the purpose of changing                   covered under more than one Plan and determines how
    appearance.                                                           benefits payable from all such Plans will be coordinated. You
   rhinoplasty when as a primary treatment for an obstructive            should file all claims with each Plan.
    sleep disorder when criteria for approval have not been met.          Definitions
                                                                          For the purposes of this section, the following terms have the
GM6000 05BPT14                                                V143        meanings set forth below:
GM6000 05BPT105
                                                                          Plan
GM6000 06BNR2V2
GM6000 06BNR2                                                V88 M        Any of the following that provides benefits or services for
                                                                          medical care or treatment:
                                                                          (1) Group insurance and/or group-type coverage, whether
Pre-existing Condition Limitations
                                                                              insured or self-insured which neither can be purchased by
No payment will be made for Covered Expenses for or in                        the general public, nor is individually underwritten,
connection with an Injury or a Sickness which is a Pre-                       including closed panel coverage.
existing Condition, unless those expenses are incurred after a
                                                                          (2) Coverage under Medicare and other governmental benefits
continuous one-year period during which a person is satisfying
                                                                              as permitted by law, excepting Medicaid and Medicare
a waiting period and/or is insured for these benefits.
                                                                              supplement policies.
Pre-existing Condition
                                                                          (3) Medical benefits coverage of group, group-type, and
A Pre-existing Condition is an Injury or a Sickness for which a               individual automobile contracts.
person receives treatment, incurs expenses or receives a
                                                                          Each Plan or part of a Plan which has the right to coordinate
diagnosis from a Physician during the 90 days before the
                                                                          benefits will be considered a separate Plan.
earlier of the date a person begins an eligibility waiting period,
or becomes insured for these benefits.                                    Closed Panel Plan
Exceptions to Pre-existing Condition Limitation                           A Plan that provides medical or dental benefits primarily in
                                                                          the form of services through a panel of employed or
Pregnancy, and genetic information with no related treatment,
                                                                          contracted providers, and that limits or excludes benefits
will not be considered Pre-existing Conditions.
                                                                          provided by providers outside of the panel, except in the case
A newborn child, an adopted child, or a child placed for                  of emergency or if referred by a provider within the panel.
adoption before age 18 will not be subject to any Pre-existing
Condition limitation if such child was covered within 31 days             Primary Plan
of birth, adoption or placement for adoption. Such waiver will            The Plan that determines and provides or pays benefits
not apply if 63 days elapse between coverage during a prior               without taking into consideration the existence of any other
period of Creditable Coverage and coverage under this plan.               Plan.
Credit for Coverage Under Prior Plan                                      Secondary Plan
If a person was previously covered under a plan which                     A Plan that determines, and may reduce its benefits after
qualifies as Creditable Coverage, the following will apply,               taking into consideration, the benefits provided or paid by the
provided he notifies the Employer of such prior coverage, and             Primary Plan. A Secondary Plan may also recover from the
fewer than 63 days elapse between coverage under the prior                Primary Plan the Reasonable Cash Value of any services it
plan and coverage under this plan, exclusive of any waiting               provided to you.
period.
CG will reduce any Pre-existing Condition limitation period               GM6000 COB11
under this policy by the number of days of prior Creditable
Coverage you had under a creditable health plan or policy.
                                                                          Allowable Expense
                                                                          A necessary, reasonable and customary service or expense,
GM6000 CM10                                             INDEM82 V3
                                                                          including deductibles, coinsurance or copayments, that is
                                                                          covered in full or in part by any Plan covering you. When a
                                                                          Plan provides benefits in the form of services, the Reasonable



                                                                     38                                                  myCIGNA.com
Cash Value of each service is the Allowable Expense and is a           Order of Benefit Determination Rules
paid benefit.                                                          A Plan that does not have a coordination of benefits rule
Examples of expenses or services that are not Allowable                consistent with this section shall always be the Primary Plan.
Expenses include, but are not limited to the following:                If the Plan does have a coordination of benefits rule consistent
(1) An expense or service or a portion of an expense or                with this section, the first of the following rules that applies to
    service that is not covered by any of the Plans is not an          the situation is the one to use:
    Allowable Expense.                                                 (1) The Plan that covers you as an enrollee or an employee
(2) If you are confined to a private Hospital room and no Plan             shall be the Primary Plan and the Plan that covers you as a
    provides coverage for more than a semiprivate room, the                Dependent shall be the Secondary Plan;
    difference in cost between a private and semiprivate room          (2) If you are a Dependent child whose parents are not
    is not an Allowable Expense.                                           divorced or legally separated, the Primary Plan shall be
(3) If you are covered by two or more Plans that provide                   the Plan which covers the parent whose birthday falls first
    services or supplies on the basis of reasonable and                    in the calendar year as an enrollee or employee;
    customary fees, any amount in excess of the highest                (3) If you are the Dependent of divorced or separated parents,
    reasonable and customary fee is not an Allowable                       benefits for the Dependent shall be determined in the
    Expense.                                                               following order:
(4) If you are covered by one Plan that provides services or                (a) first, if a court decree states that one parent is
    supplies on the basis of reasonable and customary fees                      responsible for the child's healthcare expenses or
    and one Plan that provides services and supplies on the                     health coverage and the Plan for that parent has actual
    basis of negotiated fees, the Primary Plan's fee                            knowledge of the terms of the order, but only from
    arrangement shall be the Allowable Expense.                                 the time of actual knowledge;
(5) If your benefits are reduced under the Primary Plan                     (b) then, the Plan of the parent with custody of the child;
    (through the imposition of a higher copayment amount,                   (c) then, the Plan of the spouse of the parent with custody
    higher coinsurance percentage, a deductible and/or a                        of the child;
    penalty) because you did not comply with Plan provisions
                                                                            (d) then, the Plan of the parent not having custody of the
    or because you did not use a preferred provider, the
                                                                                child, and
    amount of the reduction is not an Allowable Expense.
    Such Plan provisions include second surgical opinions                   (e) finally, the Plan of the spouse of the parent not having
    and precertification of admissions or services.                             custody of the child.
Claim Determination Period
A calendar year, but does not include any part of a year during        GM6000 COB13

which you are not covered under this policy or any date before
this section or any similar provision takes effect.                    (4) The Plan that covers you as an active employee (or as that
                                                                           employee's Dependent) shall be the Primary Plan and the
GM6000 COB12                                                               Plan that covers you as laid-off or retired employee (or as
                                                                           that employee's Dependent) shall be the secondary Plan.
                                                                           If the other Plan does not have a similar provision and, as
Reasonable Cash Value                                                      a result, the Plans cannot agree on the order of benefit
An amount which a duly licensed provider of health care                    determination, this paragraph shall not apply.
services usually charges patients and which is within the range        (5) The Plan that covers you under a right of continuation
of fees usually charged for the same service by other health               which is provided by federal or state law shall be the
care providers located within the immediate geographic area                Secondary Plan and the Plan that covers you as an active
where the health care service is rendered under similar or                 employee or retiree (or as that employee's Dependent)
comparable circumstances.                                                  shall be the Primary Plan. If the other Plan does not have
                                                                           a similar provision and, as a result, the Plans cannot agree
                                                                           on the order of benefit determination, this paragraph shall
                                                                           not apply.
                                                                       (6) If one of the Plans that covers you is issued out of the
                                                                           state whose laws govern this Policy, and determines the
                                                                           order of benefits based upon the gender of a parent, and as


                                                                  39                                                    myCIGNA.com
     a result, the Plans do not agree on the order of benefit           instruments and documents as we determine are necessary to
     determination, the Plan with the gender rules shall                secure the right of recovery.
     determine the order of benefits.                                   Right to Receive and Release Information
If none of the above rules determines the order of benefits, the        CG, without consent or notice to you, may obtain information
Plan that has covered you for the longer period of time shall           from and release information to any other Plan with respect to
be primary.                                                             you in order to coordinate your benefits pursuant to this
When coordinating benefits with Medicare, this Plan will be             section. You must provide us with any information we request
the Secondary Plan and determine benefits after Medicare,               in order to coordinate your benefits pursuant to this section.
where permitted by the Social Security Act of 1965, as                  This request may occur in connection with a submitted claim;
amended. However, when more than one Plan is secondary to               if so, you will be advised that the "other coverage"
Medicare, the benefit determination rules identified above,             information, (including an Explanation of Benefits paid under
will be used to determine how benefits will be coordinated.             the Primary Plan) is required before the claim will be
Effect on the Benefits of This Plan                                     processed for payment. If no response is received within 90
                                                                        days of the request, the claim will be denied. If the requested
If this Plan is the Secondary Plan, this Plan may reduce                information is subsequently received, the claim will be
benefits so that the total benefits paid by all Plans during a          processed.
Claim Determination Period are not more than 100% of the
total of all Allowable Expenses.
                                                                        GM6000 COB15
The difference between the amount that this Plan would have
paid if this Plan had been the Primary Plan, and the benefit
payments that this Plan had actually paid as the Secondary
Plan, will be recorded as a benefit reserve for you. CG will use        Medicare Eligibles
this benefit reserve to pay any Allowable Expense not
otherwise paid during the Claim Determination Period.                   CG will pay as the Secondary Plan as permitted
                                                                        by the Social Security Act of 1965 as amended
GM6000 COB14                                                            for the following:
                                                                        (a) a former Employee who is eligible for
As each claim is submitted, CG will determine the following:                Medicare and whose insurance is continued
(1) CG's obligation to provide services and supplies under                  for any reason as provided in this plan;
    this policy;
(2) whether a benefit reserve has been recorded for you; and
                                                                        (b) a former Employee's Dependent, or a former
(3) whether there are any unpaid Allowable Expenses during
                                                                            Dependent Spouse, who is eligible for
    the Claims Determination Period.                                        Medicare and whose insurance is continued
If there is a benefit reserve, CG will use the benefit reserve              for any reason as provided in this plan;
recorded for you to pay up to 100% of the total of all
                                                                        (c) an Employee whose Employer and each
Allowable Expenses. At the end of the Claim Determination
Period, your benefit reserve will return to zero and a new                  other Employer participating in the
benefit reserve will be calculated for each new Claim                       Employer's plan have fewer than 100
Determination Period.                                                       Employees and that Employee is eligible for
Recovery of Excess Benefits                                                 Medicare due to disability;
If CG pays charges for benefits that should have been paid by
the Primary Plan, or if CG pays charges in excess of those for          (d) the Dependent of an Employee whose
which we are obligated to provide under the Policy, CG will                 Employer and each other Employer
have the right to recover the actual payment made or the                    participating in the Employer's plan have
Reasonable Cash Value of any services.
                                                                            fewer than 100 Employees and that
CG will have sole discretion to seek such recovery from any
person to, or for whom, or with respect to whom, such                       Dependent is eligible for Medicare due to
services were provided or such payments made by any                         disability;
insurance company, healthcare plan or other organization. If
we request, you must execute and deliver to us such


                                                                   40                                                 myCIGNA.com
(e) an Employee or a Dependent of an                       Domestic Partners
    Employee of an Employer who has fewer                  Under federal law, the Medicare Secondary
    than 20 Employees, if that person is eligible          Payer Rules do not apply to Domestic Partners
    for Medicare due to age;                               covered under a group health plan. Therefore,
(f) an Employee, retired Employee, Employee's              Medicare is always the Primary Plan for a
    Dependent or retired Employee's Dependent              person covered as a Domestic Partner, and
    who is eligible for Medicare due to End                CIGNA is the Secondary Plan.
    Stage Renal Disease after that person has
    been eligible for Medicare for 30 months;              GM6000 MEL45                                                    V3



GM6000 MEL23                                     V4
                                                           Expenses For Which A Third Party May
CG will assume the amount payable under:                   Be Responsible
                                                           This plan does not cover:
 Part A of Medicare for a person who is
                                                           1. Expenses incurred by you or your Dependent (hereinafter
  eligible for that Part without premium                      individually and collectively referred to as a "Participant,")
  payment, but has not applied, to be the                     for which another party may be responsible as a result of
  amount he would receive if he had applied.                  having caused or contributed to an Injury or Sickness.
                                                           2. Expenses incurred by a Participant to the extent any
 Part B of Medicare for a person who is
                                                              payment is received for them either directly or indirectly
  entitled to be enrolled in that Part, but is not,           from a third party tortfeasor or as a result of a settlement,
  to be the amount he would receive if he were                judgment or arbitration award in connection with any
  enrolled.                                                   automobile medical, automobile no-fault, uninsured or
                                                              underinsured motorist, homeowners, workers'
 Part B of Medicare for a person who has                     compensation, government insurance (other than Medicaid),
  entered into a private contract with a provider,            or similar type of insurance or coverage.
  to be the amount he would receive in the                 Subrogation/Right of Reimbursement
  absence of such private contract.                        If a Participant incurs a Covered Expense for which, in the
                                                           opinion of the plan or its claim administrator, another party
A person is considered eligible for Medicare on            may be responsible or for which the Participant may receive
the earliest date any coverage under Medicare              payment as described above:
could become effective for him.                            1. Subrogation: The plan shall, to the extent permitted by law,
                                                              be subrogated to all rights, claims or interests that a
This reduction will not apply to any Employee                 Participant may have against such party and shall
and his Dependent or any former Employee and                  automatically have a lien upon the proceeds of any recovery
his Dependent unless he is listed under (a)                   by a Participant from such party to the extent of any benefits
                                                              paid under the plan. A Participant or his/her representative
through (f) above.                                            shall execute such documents as may be required to secure
                                                              the plan’s subrogation rights.
                                                           2. Right of Reimbursement: The plan is also granted a right of
                                                              reimbursement from the proceeds of any recovery whether
                                                              by settlement, judgment, or otherwise. This right of
                                                              reimbursement is cumulative with and not exclusive of the
                                                              subrogation right granted in paragraph 1, but only to the
                                                              extent of the benefits provided by the plan.




                                                      41                                                    myCIGNA.com
Lien of the Plan                                                                 including, but not limited to, attorney’s fees, litigation, court
By accepting benefits under this plan, a Participant:                            costs, and other expenses. The plan shall also be entitled to
                                                                                 offset the reimbursement obligation against any entitlement
   grants a lien and assigns to the plan an amount equal to the                 to future medical benefits hereunder until the Participant has
    benefits paid under the plan against any recovery made by                    fully complied with his reimbursement obligations
    or on behalf of the Participant which is binding on any                      hereunder, regardless of how those future medical benefits
    attorney or other party who represents the Participant                       are incurred.
    whether or not an agent of the Participant or of any
    insurance company or other financially responsible party                    Any reference to state law in any other provision of this
    against whom a Participant may have a claim provided said                    plan shall not be applicable to this provision, if the plan is
    attorney, insurance carrier or other party has been notified                 governed by ERISA. By acceptance of benefits under the
    by the plan or its agents;                                                   plan, the Participant agrees that a breach hereof would cause
                                                                                 irreparable and substantial harm and that no adequate
   agrees that this lien shall constitute a charge against the                  remedy at law would exist. Further, the Plan shall be
    proceeds of any recovery and the plan shall be entitled to                   entitled to invoke such equitable remedies as may be
    assert a security interest thereon;                                          necessary to enforce the terms of the plan, including, but not
   agrees to hold the proceeds of any recovery in trust for the                 limited to, specific performance, restitution, the imposition
    benefit of the plan to the extent of any payment made by the                 of an equitable lien and/or constructive trust, as well as
    plan.                                                                        injunctive relief.
Additional Terms
 No adult Participant hereunder may assign any rights that it               GM6000 CCP7                                                   CCL1V24
  may have to recover medical expenses from any third party
  or other person or entity to any minor Dependent of said
  adult Participant without the prior express written consent
  of the plan. The plan’s right to recover shall apply to                    Payment of Benefits
  decedents’, minors’, and incompetent or disabled persons’                  To Whom Payable
  settlements or recoveries.                                                 All Medical Benefits are payable to you. However, at the
   No Participant shall make any settlement, which specifically             option of CG, all or any part of them may be paid directly to
    reduces or excludes, or attempts to reduce or exclude, the               the person or institution on whose charge claim is based.
    benefits provided by the plan.                                           Medical Benefits are not assignable unless agreed to by CG.
   The plan’s right of recovery shall be a prior lien against any           CG may, at its option, make payment to you for the cost of
    proceeds recovered by the Participant. This right of                     any Covered Expenses received by you or your Dependent
    recovery shall not be defeated nor reduced by the                        from a Non-Participating Provider even if benefits have been
    application of any so-called “Made-Whole Doctrine”,                      assigned. When benefits are paid to you or your Dependent,
    “Rimes Doctrine”, or any other such doctrine purporting to               you or your Dependent is responsible for reimbursing the
    defeat the plan’s recovery rights by allocating the proceeds             Provider. If any person to whom benefits are payable is a
    exclusively to non-medical expense damages.                              minor or, in the opinion of CG, is not able to give a valid
   No Participant hereunder shall incur any expenses on behalf              receipt for any payment due him, such payment will be made
    of the plan in pursuit of the plan’s rights hereunder,                   to his legal guardian. If no request for payment has been made
    specifically; no court costs, attorneys' fees or other                   by his legal guardian, CG may, at its option, make payment to
    representatives' fees may be deducted from the plan’s                    the person or institution appearing to have assumed his
    recovery without the prior express written consent of the                custody and support.
    plan. This right shall not be defeated by any so-called                  If you die while any of these benefits remain unpaid, CG may
    “Fund Doctrine”, “Common Fund Doctrine”, or “Attorney’s                  choose to make direct payment to any of your following living
    Fund Doctrine”.                                                          relatives: spouse, mother, father, child or children, brothers or
   The plan shall recover the full amount of benefits provided              sisters; or to the executors or administrators of your estate.
    hereunder without regard to any claim of fault on the part of            Payment as described above will release CG from all liability
    any Participant, whether under comparative negligence or                 to the extent of any payment made.
    otherwise.                                                               Time of Payment
   In the event that a Participant shall fail or refuse to honor its        Benefits will be paid by CG when it receives due proof of loss.
    obligations hereunder, then the plan shall be entitled to
    recover any costs incurred in enforcing the terms hereof


                                                                        42                                                      myCIGNA.com
Recovery of Overpayment                                                 Retirement
When an overpayment has been made by CG, CG will have                   If your Active Service ends because you retire, your insurance
the right at any time to: (a) recover that overpayment from the         will be continued until the date on which your Employer stops
person to whom or on whose behalf it was made; or (b) offset            paying premium for you or otherwise cancels the insurance.
the amount of that overpayment from a future claim payment.
Calculation of Covered Expenses                                         GM6000 TRM15V44
CG, in its discretion, will calculate Covered Expenses
following evaluation and validation of all provider billings in
accordance with:
                                                                        Dependents
   the methodologies in the most recent edition of the Current
                                                                        Your insurance for all of your Dependents will cease on the
    Procedural terminology.
                                                                        earliest date below:
   the methodologies as reported by generally recognized
                                                                           the date your insurance ceases.
    professionals or publications.
                                                                           the date you cease to be eligible for Dependent Insurance.
                                                                           the last day for which you have made any required
GM6000 TRM366
                                                                            contribution for the insurance.
                                                                           the date Dependent Insurance is canceled.
                                                                        The insurance for any one of your Dependents will cease on
Termination of Insurance                                                the date that Dependent no longer qualifies as a Dependent.

Employees
                                                                        GM6000 TRM62
Your insurance will cease on the earliest date below:
   the date you cease to be in a Class of Eligible Employees or
    cease to qualify for the insurance.                                 Special Continuation of Medical Insurance
   the last day for which you have made any required                   If Medical Insurance for you or your Dependent would
    contribution for the insurance.                                     otherwise cease for any reason except due to involuntary
                                                                        termination for cause or due to discontinuance in entirety of
   the date the policy is canceled.                                    the policy or an insured class, coverage may be continued if:
   the last day of the calendar month in which your Active                the person was covered by this policy and/or a prior policy
    Service ends except as described below.                                 for the three months immediately prior to the date coverage
Any continuation of insurance must be based on a plan which                 would otherwise cease, and
precludes individual selection.                                            the person elects continuation coverage and pays the first
Temporary Layoff or Leave of Absence                                        monthly premium within 31 days of the later of either the
If your Active Service ends due to temporary layoff or leave                date coverage would otherwise cease or the date required
of absence, your insurance will be continued until the date                 notice is provided.
your Employer cancels your insurance. However, your                     Coverage will continue until the earliest of the following:
insurance will not be continued for more than 60 days past the             6 months after continuation coverage is elected;
date your Active Service ends.
                                                                           the end of the period for which premium is paid;
Injury or Sickness
                                                                           the date the policy is discontinued and not replaced;
If your Active Service ends due to an Injury or Sickness, your
insurance will be continued while you remain totally and                   the date the person becomes eligible for Medicare; and
continuously disabled as a result of the Injury or Sickness.               the date the person becomes insured under another similar
However, the insurance will not continue past the date your                 policy or becomes eligible for coverage under a group plan
Employer cancels the insurance.                                             or a state or federal plan.


                                                                        GM6000 TRM353




                                                                   43                                                   myCIGNA.com
Texas – Special Continuation of Dependent Medical                           the date you are covered for medical benefits under another
Insurance                                                                    group policy;
If your Dependent's Medical Insurance would otherwise cease                 the date you are no longer Totally Disabled;
because of your death or retirement, or because of divorce or               90 days from the date your Medical Benefits cease; or
annulment, his insurance will be continued upon payment of
                                                                            90 days from the date the policy is canceled.
required premium, if: (a) he has been insured under the policy,
or a previous policy sponsored by your Employer, for at least            Totally Disabled
one year prior to the date the insurance would cease; or (b) he          You will be considered Totally Disabled if, because of an
is a Dependent child less than one year old. The insurance will          Injury or a Sickness:
be continued until the earliest of:
                                                                            you are unable to perform the basic duties of your
   three years from the date the insurance would otherwise                  occupation; and
    have ceased;
                                                                            you are not performing any other work or engaging in any
   the last day for which the required premium has been paid;               other occupation for wage or profit.
   with respect to any one Dependent, the earlier of the dates          Your Dependent will be considered Totally Disabled if,
    that Dependent: (a) becomes eligible for similar group               because of an Injury or a Sickness:
    coverage; or (b) no longer qualifies as a Dependent for any
                                                                            he is unable to engage in the normal activities of a person of
    reason other than your death or retirement or divorce or
                                                                             the same age, sex and ability; or
    annulment; or
                                                                            in the case of a Dependent who normally works for wage or
   the date the policy cancels.
                                                                             profit, he is not performing such work.
If, on the day before the Effective Date of the policy, medical
                                                                         The terms of this Medical Benefits Extension will not apply to
insurance was being continued for a Dependent under a group
                                                                         a child born as a result of a pregnancy which exists when you
medical policy: (a) sponsored by your Employer; and (b)
                                                                         or your Dependent's Medical Benefits cease.
replaced by the policy, his insurance will be continued for the
remaining portion of his period of continuation under the
policy, as set forth above.                                              GM6000 BEX183                                                  V11

Your Dependent must provide your Employer with written
notice of retirement, death, divorce or annulment within 15
days of such event. Your Employer will, upon receiving notice            Federal Requirements
of the death, retirement, divorce or annulment, notify your
Dependent of his right to elect continuation as set forth above.         The following pages explain your rights and responsibilities
Your Dependent may elect in writing such continuation within             under federal laws and regulations. Some states may have
45 days after the date the insurance would otherwise cease, by           similar requirements. If a similar provision appears elsewhere
paying the required premium to your Employer.                            in this booklet, the provision which provides the better benefit
                                                                         will apply.

GM6000 TER34
                                                         TRM136V3        FDRL1                                                           V2




Medical Benefits Extension                                               Notice of Provider Directory/Networks
Upon Policy Cancellation                                                 Notice Regarding Provider Directories and Provider
                                                                         Networks
If the Medical Benefits under this plan cease for you or your
Dependent due to cancellation of the policy, and you or your             If your Plan utilizes a network of Providers, you will
Dependent is Totally Disabled on that date due to an Injury or           automatically and without charge, receive a separate listing of
Sickness, Medical Benefits will be paid for Covered Expenses             Participating Providers.
incurred in connection with that Injury or Sickness. However,            You may also have access to a list of Providers who
no benefits will be paid after the earliest of:                          participate in the network by visiting www.cigna.com;
   the date you exceed the Maximum Benefit, if any, shown in            mycigna.com or by calling the toll-free telephone number on
    the Schedule;                                                        your ID card.




                                                                    44                                                    myCIGNA.com
Your Participating Provider network consists of a group of                C. Payment of Benefits
local medical practitioners, including Hospitals, of varied               Any payment of benefits in reimbursement for Covered
specialties as well as general practice, who are employed by or           Expenses paid by the child, or the child’s custodial parent or
contracted with CIGNA HealthCare.                                         legal guardian, shall be made to the child, the child’s custodial
                                                                          parent or legal guardian, or a state official whose name and
FDRL32
                                                                          address have been substituted for the name and address of the
                                                                          child.


Qualified Medical Child Support Order                                     FDRL2                                                          V1

(QMCSO)
A. Eligibility for Coverage Under a QMCSO
                                                                          Special Enrollment Rights Under the Health
If a Qualified Medical Child Support Order (QMCSO) is
issued for your child, that child will be eligible for coverage as        Insurance Portability & Accountability Act
required by the order and you will not be considered a Late               (HIPAA)
Entrant for Dependent Insurance.                                          If you or your eligible Dependent(s) experience a special
You must notify your Employer and elect coverage for that                 enrollment event as described below, you or your eligible
child and yourself, if you are not already enrolled, within 31            Dependent(s) may be entitled to enroll in the Plan outside of a
days of the QMCSO being issued.                                           designated enrollment period upon the occurrence of one of
                                                                          the special enrollment events listed below. If you are already
B. Qualified Medical Child Support Order Defined
                                                                          enrolled in the Plan, you may request enrollment for you and
A Qualified Medical Child Support Order is a judgment,                    your eligible Dependent(s) under a different option offered by
decree or order (including approval of a settlement agreement)            the Employer for which you are currently eligible. If you are
or administrative notice, which is issued pursuant to a state             not already enrolled in the Plan, you must request special
domestic relations law (including a community property law),              enrollment for yourself in addition to your eligible
or to an administrative process, which provides for child                 Dependent(s). You and all of your eligible Dependent(s) must
support or provides for health benefit coverage to such child             be covered under the same option. The special enrollment
and relates to benefits under the group health plan, and                  events include:
satisfies all of the following:
                                                                             Acquiring a new Dependent. If you acquire a new
1. the order recognizes or creates a child’s right to receive                 Dependent(s) through marriage, birth, adoption or
   group health benefits for which a participant or beneficiary               placement for adoption, you may request special enrollment
   is eligible;                                                               for any of the following combinations of individuals if not
2. the order specifies your name and last known address, and                  already enrolled in the Plan: Employee only; spouse only;
   the child’s name and last known address, except that the                   Employee and spouse; Dependent child(ren) only;
   name and address of an official of a state or political                    Employee and Dependent child(ren); Employee, spouse and
   subdivision may be substituted for the child’s mailing                     Dependent child(ren). Enrollment of Dependent children is
   address;                                                                   limited to the newborn or adopted children or children who
3. the order provides a description of the coverage to be                     became Dependent children of the Employee due to
   provided, or the manner in which the type of coverage is to                marriage. Dependent children who were already Dependents
   be determined;                                                             of the Employee but not currently enrolled in the Plan are
                                                                              not entitled to special enrollment.
4. the order states the period to which it applies; and
                                                                             Loss of eligibility for State Medicaid or Children’s
5. if the order is a National Medical Support Notice                          Health Insurance Program (CHIP). If you and/or your
   completed in accordance with the Child Support                             Dependent(s) were covered under a state Medicaid or CHIP
   Performance and Incentive Act of 1998, such Notice meets                   plan and the coverage is terminated due to a loss of
   the requirements above.                                                    eligibility, you may request special enrollment for yourself
The QMCSO may not require the health insurance policy to                      and any affected Dependent(s) who are not already enrolled
provide coverage for any type or form of benefit or option not                in the Plan. You must request enrollment within 60 days
otherwise provided under the policy, except that an order may                 after termination of Medicaid or CHIP coverage.
require a plan to comply with State laws regarding health care               Loss of eligibility for other coverage (excluding
coverage.                                                                     continuation coverage). If coverage was declined under



                                                                     45                                                   myCIGNA.com
    this Plan due to coverage under another plan, and eligibility            Exhaustion of COBRA or other continuation coverage.
    for the other coverage is lost, you and all of your eligible              Special enrollment may be requested in this Plan for you
    Dependent(s) may request special enrollment in this Plan. If              and all of your eligible Dependent(s) upon exhaustion of
    required by the Plan, when enrollment in this Plan was                    COBRA or other continuation coverage. If you or your
    previously declined, it must have been declined in writing                Dependent(s) elect COBRA or other continuation coverage
    with a statement that the reason for declining enrollment                 following loss of coverage under another plan, the COBRA
    was due to other health coverage. This provision applies to               or other continuation coverage must be exhausted before
    loss of eligibility as a result of any of the following:                  any special enrollment rights exist under this Plan. An
       divorce or legal separation;                                          individual is considered to have exhausted COBRA or other
                                                                              continuation coverage only if such coverage ceases: (a) due
       cessation of Dependent status (such as reaching the                   to failure of the employer or other responsible entity to
        limiting age);                                                        remit premiums on a timely basis; (b) when the person no
       death of the Employee;                                                longer resides or works in the other plan’s service area and
       termination of employment;                                            there is no other COBRA or continuation coverage available
                                                                              under the plan; or (c) when the individual incurs a claim that
       reduction in work hours to below the minimum required
                                                                              would meet or exceed a lifetime maximum limit on all
        for eligibility;
                                                                              benefits and there is no other COBRA or other continuation
       you or your Dependent(s) no longer reside, live or work               coverage available to the individual. This does not include
        in the other plan’s network service area and no other                 termination of an employer’s limited period of contributions
        coverage is available under the other plan;                           toward COBRA or other continuation coverage as provided
       you or your Dependent(s) incur a claim which meets or                 under any severance or other agreement.
        exceeds the lifetime maximum limit that is applicable to
        all benefits offered under the other plan; or                     FDRL3                                                             V4
       the other plan no longer offers any benefits to a class of
        similarly situated individuals.
                                                                             Eligibility for employment assistance under State
   Termination of employer contributions (excluding                          Medicaid or Children’s Health Insurance Program
    continuation coverage). If a current or former employer                   (CHIP). If you and/or your Dependent(s) become eligible
    ceases all contributions toward the Employee’s or                         for assistance with group health plan premium payments
    Dependent’s other coverage, special enrollment may be                     under a state Medicaid or CHIP plan, you may request
    requested in this Plan for you and all of your eligible                   special enrollment for yourself and any affected
    Dependent(s).                                                             Dependent(s) who are not already enrolled in the Plan. You
                                                                              must request enrollment within 60 days after the date you
                                                                              are determined to be eligible for assistance.
                                                                          Except as stated above, special enrollment must be requested
                                                                          within 30 days after the occurrence of the special enrollment
                                                                          event. If the special enrollment event is the birth or adoption
                                                                          of a Dependent child, coverage will be effective immediately
                                                                          on the date of birth, adoption or placement for adoption.
                                                                          Coverage with regard to any other special enrollment event
                                                                          will be effective on the first day of the calendar month
                                                                          following receipt of the request for special enrollment.
                                                                          Individuals who enroll in the Plan due to a special enrollment
                                                                          event will not be denied enrollment. You will not be enrolled
                                                                          in this Plan if you do not enroll within 30 days of the date you
                                                                          become eligible, unless you are eligible for special enrollment.
                                                                          Domestic Partners and their children (if not legal children of
                                                                          the Employee) are not eligible for special enrollment.


                                                                          FDRL4                                                         V3 M




                                                                     46                                                    myCIGNA.com
Effect of Section 125 Tax Regulations on This                            E. Change in Cost of Coverage
Plan                                                                     If the cost of benefits increases or decreases during a benefit
Your Employer has chosen to administer this Plan in                      period, your Employer may, in accordance with plan terms,
accordance with Section 125 regulations of the Internal                  automatically change your elective contribution.
Revenue Code. Per this regulation, you may agree to a pretax             When the change in cost is significant, you may either
salary reduction put toward the cost of your benefits.                   increase your contribution or elect less-costly coverage. When
Otherwise, you will receive your taxable earnings as cash                a significant overall reduction is made to the benefit option
(salary).                                                                you have elected, you may elect another available benefit
A. Coverage Elections                                                    option. When a new benefit option is added, you may change
                                                                         your election to the new benefit option.
Per Section 125 regulations, you are generally allowed to
enroll for or change coverage only before each annual benefit            F. Changes in Coverage of Spouse or Dependent Under
period. However, exceptions are allowed if your Employer                     Another Employer’s Plan
agrees and you enroll for or change coverage within 30 days              You may make a coverage election change if the plan of your
of the following:                                                        spouse or Dependent: (a) incurs a change such as adding or
    the date you meet the Special Enrollment criteria described         deleting a benefit option; (b) allows election changes due to
     above; or                                                           Special Enrollment, Change in Status, Court Order or
                                                                         Medicare or Medicaid Eligibility/Entitlement; or (c) this Plan
    the date you meet the criteria shown in the following               and the other plan have different periods of coverage or open
     Sections B through F.                                               enrollment periods.
B. Change of Status
A change in status is defined as:                                        FDRL70
1.     change in legal marital status due to marriage, death of a
       spouse, divorce, annulment or legal separation;
2.     change in number of Dependents due to birth, adoption,            Eligibility for Coverage for Adopted Children
       placement for adoption, or death of a Dependent;
                                                                         Any child under the age of 18 who is adopted by you,
3.     change in employment status of Employee, spouse or                including a child who is placed with you for adoption, will be
       Dependent due to termination or start of employment,              eligible for Dependent Insurance upon the date of placement
       strike, lockout, beginning or end of unpaid leave of              with you. A child will be considered placed for adoption when
       absence, including under the Family and Medical Leave             you become legally obligated to support that child, totally or
       Act (FMLA), or change in worksite;                                partially, prior to that child’s adoption.
4.     changes in employment status of Employee, spouse or               If a child placed for adoption is not adopted, all health
       Dependent resulting in eligibility or ineligibility for           coverage ceases when the placement ends, and will not be
       coverage;                                                         continued.
5.     change in residence of Employee, spouse or Dependent to           The provisions in the “Exception for Newborns” section of
       a location outside of the Employer’s network service              this document that describe requirements for enrollment and
       area; and                                                         effective date of insurance will also apply to an adopted child
6.     changes which cause a Dependent to become eligible or             or a child placed with you for adoption.
       ineligible for coverage.
C. Court Order                                                           FDRL6

A change in coverage due to and consistent with a court order
of the Employee or other person to cover a Dependent.
D. Medicare or Medicaid Eligibility/Entitlement                          Federal Tax Implications for Dependent
The Employee, spouse or Dependent cancels or reduces                     Coverage
coverage due to entitlement to Medicare or Medicaid, or                  Premium payments for Dependent health insurance are usually
enrolls or increases coverage due to loss of Medicare or                 exempt from federal income tax. Generally, if you can claim
Medicaid eligibility.                                                    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


                                                                    47                                                   myCIGNA.com
health insurance who does not meet the federal definition of a          Group Plan Coverage Instead of Medicaid
Dependent, the premium may be taxable to you as income. If
                                                                        If your income and liquid resources do not exceed certain
you have questions concerning your specific situation, you
                                                                        limits established by law, the state may decide to pay
should consult your own tax consultant or attorney.
                                                                        premiums for this coverage instead of for Medicaid, if it is
                                                                        cost effective. This includes premiums for continuation
FDRL7                                                                   coverage required by federal law.


                                                                        FDRL75
Coverage for Maternity Hospital Stay
Group health plans and health insurance issuers offering group
health insurance coverage generally may not, under a federal            Pre-Existing Conditions Under the Health
law known as the “Newborns’ and Mothers’ Health Protection              Insurance Portability & Accountability Act
Act”: restrict benefits for any Hospital length of stay in
connection with childbirth for the mother or newborn child to           (HIPAA)
less than 48 hours following a vaginal delivery, or less than 96        A federal law known as the Health Insurance Portability &
hours following a cesarean section; or require that a provider          Accountability Act (HIPAA) establishes requirements for Pre-
obtain authorization from the plan or insurance issuer for              existing Condition limitation provisions in health plans.
prescribing a length of stay not in excess of the above periods.        Following is an explanation of the requirements and
The law generally does not prohibit an attending provider of            limitations under this law.
the mother or newborn, in consultation with the mother, from            A. Pre-Existing Condition Limitation
discharging the mother or newborn earlier than 48 or 96 hours,
                                                                        Under HIPAA, a Pre-existing Condition limitation is a
as applicable.
                                                                        limitation or exclusion of benefits relating to a condition based
Please review this Plan for further details on the specific             on the fact that the condition was present before the effective
coverage available to you and your Dependents.                          date of coverage under the plan, whether or not any medical
                                                                        advice, diagnosis, care, or treatment was recommended or
FDRL8
                                                                        received before that date. A Pre-existing Condition limitation
                                                                        is permitted under group health plans, provided it is applied
                                                                        only to a physical or mental condition for which medical
                                                                        advice, diagnosis, care, or treatment was recommended or
Women’s Health and Cancer Rights Act                                    received within the 6-month period (or a shorter period as
(WHCRA)                                                                 applies under the plan) ending on the enrollment date. Plan
Do you know that your plan, as required by the Women’s                  provisions may vary. Please refer to the section entitled
Health and Cancer Rights Act of 1998, provides benefits for             “Exclusions, Expenses Not Covered and General Limitations”
mastectomy-related services including all stages of                     for the specific Pre-existing Condition limitation provision
reconstruction and surgery to achieve symmetry between the              which applies under this Plan, if any.
breasts, prostheses, and complications resulting from a                 B. Exceptions to Pre-existing Condition Limitation
mastectomy, including lymphedema? Call Member Services at               Pregnancy, and genetic information with no related treatment,
the toll free number listed on your ID card for more                    will not be considered Pre-existing Conditions.
information.
                                                                        A newborn child, an adopted child, or a child placed for
                                                                        adoption before age 18 will not be subject to any Pre-existing
FDRL51                                                                  Condition limitation if such child was covered under any
                                                                        creditable coverage within 30 days of birth, adoption or
                                                                        placement for adoption. Such waiver will not apply if 63 days
                                                                        or more elapse between coverage under the prior creditable
                                                                        coverage and coverage under this Plan.
                                                                        C. Credit for Coverage Under Prior Plan
                                                                        If you and/or your Dependent(s) were previously covered
                                                                        under a plan which qualifies as Creditable Coverage, CG will
                                                                        reduce any Pre-existing Condition limitation period under this
                                                                        policy by the number of days of prior Creditable Coverage


                                                                   48                                                  myCIGNA.com
you had under the prior plan(s). However, credit is available         document as evidence of your prior coverage to reduce any
only if you notify the Employer of such prior coverage, and           pre-existing condition limitation period under another plan, to
fewer than 63 days elapse between coverage under the prior            help you get special enrollment in another plan, or to obtain
plan and coverage under this Plan, exclusive of any waiting           certain types of individual health coverage even if you have
period. Credit will be given for coverage under all prior             health problems. To obtain a Certificate of Creditable
Creditable Coverage, provided fewer than 63 days elapsed              Coverage, contact the Plan Administrator or call the toll-free
between coverage under any two plans.                                 customer service number on the back of your ID card.
If you and/or your Dependent enrolled or re-enrolled in
COBRA continuation coverage or state continuation coverage            FDRL73
under the extended election period allowed in the American
Recovery and Reinvestment Act of 2009 (“ARRA”), this lapse
in coverage will be disregarded for the purposes of
determining Creditable Coverage.                                      Requirements of Medical Leave Act of 1993 (as
D. Certificate of Prior Creditable Coverage                           amended) (FMLA)
You must provide proof of your prior Creditable Coverage in           Any provisions of the policy that provide for: (a) continuation
order to reduce a Pre-Existing Condition limitation period.           of insurance during a leave of absence; and (b) reinstatement
You should submit proof of prior coverage with your                   of insurance following a return to Active Service; are modified
enrollment material. A certificate of prior Creditable                by the following provisions of the federal Family and Medical
Coverage, or other proofs of coverage which need to be                Leave Act of 1993, as amended, where applicable:
submitted outside the standard enrollment form process for            A. Continuation of Health Insurance During Leave
any reason, may be sent directly to: Eligibility Production           Your health insurance will be continued during a leave of
Services, 900 Cottage Grove Road, Routing C2ECC, Hartford,            absence if:
CT 06152. You should contact the Plan Administrator or a
                                                                         that leave qualifies as a leave of absence under the Family
CIGNA Customer Service Representative if assistance is
needed to obtain proof of prior Creditable Coverage. Once                 and Medical Leave Act of 1993, as amended; and
your prior coverage records are reviewed and credit is                   you are an eligible Employee under the terms of that Act.
calculated, you will receive a notice of any remaining Pre-           The cost of your health insurance during such leave must be
existing Condition limitation period.                                 paid, whether entirely by your Employer or in part by you and
E. Creditable Coverage                                                your Employer.
Creditable Coverage will include coverage under any of the            B. Reinstatement of Canceled Insurance Following Leave
following: A self-insured employer group health plan;                 Upon your return to Active Service following a leave of
Individual or group health insurance indemnity or HMO plans;          absence that qualifies under the Family and Medical Leave
Part A or Part B of Medicare; Medicaid, except coverage               Act of 1993, as amended, any canceled insurance (health, life
solely for pediatric vaccines; A health plan for certain              or disability) will be reinstated as of the date of your return.
members of the uniformed armed services and their
                                                                      You will not be required to satisfy any eligibility or benefit
dependents, including the Commissioned Corps of the
                                                                      waiting period or the requirements of any Pre-existing
National Oceanic and Atmospheric Administration and of the
                                                                      Condition limitation to the extent that they had been satisfied
Public Health Service; A medical care program of the Indian
                                                                      prior to the start of such leave of absence.
Health Service or of a tribal organization; A state health
benefits risk pool; The Federal Employees Health Benefits             Your Employer will give you detailed information about the
Program; A public health plan established by a State, the U.S.        Family and Medical Leave Act of 1993, as amended.
government, or a foreign country; the Peace Corps Act; Or a
State Children’s Health Insurance Program.
                                                                      FDRL74
F. Obtaining a Certificate of Creditable Coverage Under
     This Plan
Upon loss of coverage under this Plan, a Certificate of               Uniformed Services Employment and Re-
Creditable Coverage will be mailed to each terminating
individual at the last address on file. You or your dependent
                                                                      Employment Rights Act of 1994 (USERRA)
may also request a Certificate of Creditable Coverage, without        The Uniformed Services Employment and Re-employment
charge, at any time while enrolled in the Plan and for 24             Rights Act of 1994 (USERRA) sets requirements for
months following termination of coverage. You may need this           continuation of health coverage and re-employment in regard



                                                                 49                                                   myCIGNA.com
to an Employee’s military leave of absence. These                       The Following Will Apply to Residents of
requirements apply to medical and dental coverage for you
and your Dependents. They do not apply to any Life, Short-              Texas
term or Long-term Disability or Accidental Death &
Dismemberment coverage you may have.                                    When You Have a Complaint or an
A. Continuation of Coverage                                             Adverse Determination Appeal
For leaves of less than 31 days, coverage will continue as              For the purposes of this section, any reference to "you," "your"
described in the Termination section regarding Leave of                 or "Member" also refers to a representative or provider
Absence.                                                                designated by you to act on your behalf, unless otherwise
For leaves of 31 days or more, you may continue coverage for            noted.
yourself and your Dependents as follows:                                We want you to be completely satisfied with the care you
You may continue benefits by paying the required premium to             receive. That is why we have established a process for
your Employer, until the earliest of the following:                     addressing your concerns and solving your problems.
   24 months from the last day of employment with the                  When You Have a Complaint
    Employer;                                                           We are here to listen and help. If you have a complaint
   the day after you fail to return to work; and                       regarding a person, a service, the quality of care, or
   the date the policy cancels.                                        contractual benefits not related to Medical Necessity, you can
                                                                        call our toll-free number and explain your concern to one of
Your Employer may charge you and your Dependents up to                  our Customer Service representatives. A complaint does not
102% of the total premium.                                              include: (a) a misunderstanding or problem of misinformation
Following continuation of health coverage per USERRA                    that can be promptly resolved by CG by clearing up the
requirements, you may convert to a plan of individual                   misunderstanding or supplying the correct information to your
coverage according to any “Conversion Privilege” shown in               satisfaction; or (b) you or your provider's dissatisfaction or
your certificate.                                                       disagreement with an adverse determination. You can also
B. Reinstatement of Benefits (applicable to all coverages)              express that complaint in writing. Please call or write to us at
                                                                        the following:
If your coverage ends during the leave of absence because you
do not elect USERRA or an available conversion plan at the                Customer Services Toll-Free Number or address that
expiration of USERRA and you are reemployed by your                       appears on your Benefit Identification card, explanation of
current Employer, coverage for you and your Dependents may                benefits or claim form.
be reinstated if (a) you gave your Employer advance written or          We will do our best to resolve the matter on your initial
verbal notice of your military service leave, and (b) the               contact. If we need more time to review or investigate your
duration of all military leaves while you are employed with             complaint, we will send you a letter acknowledging the date
your current Employer does not exceed 5 years.                          on which we received your complaint no later than the fifth
You and your Dependents will be subject to only the balance             working day after we receive your complaint. We will respond
of a Pre-Existing Condition Limitation (PCL) or waiting                 in writing with a decision 30 calendar days after we receive a
period that was not yet satisfied before the leave began.               complaint for a postservice coverage determination. If more
However, if an Injury or Sickness occurs or is aggravated               time or information is needed to make the determination, we
during the military leave, full Plan limitations will apply.            will notify you in writing to request an extension of up to 15
                                                                        calendar days and to specify any additional information
Any 63-day break in coverage rule regarding credit for time             needed to complete the review.
accrued toward a PCL waiting period will be waived.
If your coverage under this plan terminates as a result of your
                                                                        GM6000 APL484                                                   V1
eligibility for military medical and dental coverage and your
order to active duty is canceled before your active duty service
commences, these reinstatement rights will continue to apply.           You may request that the appeal process be expedited if, (a)
                                                                        the time frames under this process would seriously jeopardize
                                                                        your life, health or ability to regain maximum function or in
FDRL58
                                                                        the opinion of your Physician would cause you severe pain
                                                                        which cannot be managed without the requested services; or
                                                                        (b) your appeal involves nonauthorization of an admission or
                                                                        continuing inpatient Hospital stay. CG's Physician reviewer, in


                                                                   50                                                  myCIGNA.com
consultation with the treating Physician, will decide if an              You may request that the appeal process be expedited if, (a)
expedited appeal is necessary. When a complaint is expedited,            the time frames under this process would seriously jeopardize
we will respond orally with a decision within the earlier of: (a)        your life, health or ability to regain maximum function or in
72 hours; or (b) one working day, followed up in writing                 the opinion of your Physician would cause you severe pain
within 3 calendar days.                                                  which cannot be managed without the requested services; or
If you are not satisfied with the results of a coverage decision,        (b) your appeal involves nonauthorization of an admission or
you can start the complaint appeals procedure.                           continuing inpatient Hospital stay. CG's Physician reviewer, in
                                                                         consultation with the treating Physician will decide if an
Complaint Appeals Procedure                                              expedited appeal is necessary. When an appeal is expedited,
To initiate an appeal of a complaint resolution decision, you            we will respond orally with a decision within the earlier of: (1)
must submit a request for an appeal in writing. You should               72 hours; or (2) one working day, followed up in writing
state the reason why you feel your appeal should be approved             within three calendar days.
and include any information supporting your appeal. If you are
unable or choose not to write, you may ask to register your
appeal by telephone. Call or write to us at the toll-free number         GM6000 APL486

or address on your Benefit Identification card, explanation of
benefits or claim form.                                                  When You have an Adverse Determination Appeal
                                                                         An Adverse Determination is a decision made by CG that the
GM6000 APL485                                                            health care service(s) furnished or proposed to be furnished to
                                                                         you is (are) not Medically Necessary or clinically appropriate.
                                                                         An Adverse Determination also includes a denial by CG of a
Your complaint appeal request will be conducted by the                   request to cover a specific prescription drug prescribed by
Complaint Appeals Committee, which consists of at least three            your Physician. If you are not satisfied with the Adverse
people. Anyone involved in the prior decision may not vote on            Determination, you may appeal the Adverse Determination
the Committee. You may present your situation to the                     orally or in writing. You should state the reason why you feel
Committee in person or by conference call.                               your appeal should be approved and include any information
We will acknowledge in writing that we have received your                supporting your appeal. We will acknowledge the appeal in
request within five working days after the date we receive               writing within five working days after we receive the Adverse
your request for a Committee review and schedule a                       Determination Appeal request.
Committee review. The Committee review will be completed                 Your appeal of an Adverse Determination will be reviewed
within 30 calendar days. If more time or information is needed           and the decision made by a health care professional not
to make the determination, we will notify you in writing to              involved in the initial decision. We will respond in writing
request an extension of up to 15 calendar days and to specify            with a decision within 30 calendar days after receiving the
any additional information needed by the Committee to                    Adverse Determination appeal request.
complete the review. You will be notified in writing of the
Committee's decision within five working days after the                  You may request that the appeal process be expedited if, (a)
Committee meeting, and within the Committee review time                  the time frames under this process would seriously jeopardize
frames above if the Committee does not approve the requested             your life, health or ability to regain maximum function or in
coverage.                                                                the opinion of your Physician would cause you severe pain
                                                                         which cannot be managed without the requested services; or
                                                                         (b) your appeal involves nonauthorization of an admission or
                                                                         continuing inpatient Hospital stay. CG's Physician reviewer, in
                                                                         consultation with the treating Physician will decide if an
                                                                         expedited appeal is necessary. When an appeal is expedited,
                                                                         we will respond orally with a decision within the earlier of: (a)
                                                                         72 hours; or (b) one working day, followed up in writing
                                                                         within three calendar days.
                                                                         In addition, your treating Physician may request in writing a
                                                                         specialty review within 10 working days of our written
                                                                         decision. The specialty review will be conducted by a
                                                                         Physician in the same or similar specialty as the care under
                                                                         consideration. The specialty review will be completed and a
                                                                         response sent within 15 working days of the request. Specialty



                                                                    51                                                  myCIGNA.com
review is voluntary. If the specialty reviewer upholds the                 appeal process be expedited if (a) the time frames under this
initial adverse determination and you remain dissatisfied, you             process would seriously jeopardize your life, health or ability
are still eligible to request a review by an Independent Review            to regain maximum functionality or in the opinion of your
Organization.                                                              physician, would cause you severe pain which cannot be
                                                                           managed without the requested services; or (b) your appeal
                                                                           involves nonauthorization of an admission or continuing
GM6000 APL487                                                    V1
                                                                           inpatient hospital stay. The Claim Adminstrator’s Physician
                                                                           reviewer, in consultation with the treating physician, will
Independent Review Procedure                                               decide if an expedited appeal is necessary. When an appeal is
If you are not fully satisfied with the decision of CG's Adverse           expedited, CG will respond orally with a decision within 72
Determination appeal process or if you feel your condition is              hours, followed up in writing.
life-threatening, you may request that your appeal be referred
to an Independent Review Organization. In addition, your                   GM6000 APL488                                                  V1
treating Physician may request in writing that CG conduct a
specialty review. The specialty review request must be made
within 10 days of receipt of the Adverse Determination appeal              Notice of Benefit Determination on Appeal
decision letter. CG must complete the specialist review and                Every notice of an appeal decision will be provided in writing
send a written response within 15 days of its receipt of the               or electronically and, if an adverse determination, will include:
request for specialty review. If the specialist upholds the initial        (1) the specific reason or reasons for the denial decision; (2)
Adverse Determination, you are still eligible to request a                 reference to the specific plan provisions on which the decision
review by an Independent Review Organization. The                          is based
Independent Review Organization is composed of persons                     Relevant Information
who are not employed by CG or any of its affiliates. A
                                                                           Relevant Information is any document, record, or other
decision to use the voluntary level of appeal will not affect the
                                                                           information which (a) was relied upon in making the benefit
claimant's rights to any other benefits under the plan.
                                                                           determination; (b) was submitted, considered, or generated in
There is no charge for you to initiate this independent review             the course of making the benefit determination, without regard
process and the decision to use the process is voluntary. CG               to whether such document, record, or other information was
will abide by the decision of the Independent Review                       relied upon in making the benefit determination; (c)
Organization. In order to request a referral to an Independent             demonstrates compliance with the administrative processes
Review Organization, certain conditions apply. The reason for              and safeguards required by federal law in making the benefit
the denial must be based on a Medical Necessity or clinical                determination; or (d) constitutes a statement of policy or
appropriateness determination by CG. Administrative,                       guidance with respect to the plan concerning the denied
eligibility or benefit coverage limits or exclusions are not               treatment option or benefit or the claimant's diagnosis, without
eligible for appeal under this process. To initiate a level two            regard to whether such advice or statement was relied upon in
appeal, follow the same process required for a level one appeal            making the benefit determination.
except send this appeal to Socorro Independent School District
who will administer the Level Two Appeal Process.
                                                                           GM6000 APL489
          Socorro Independent School District
          Attn: Health Insurance Representative
          12440 Rojas Drive                                                COBRA Continuation Rights Under Federal
          El Paso, Tx. 79928                                               Law
          915.937.0214                                                     For You and Your Dependents
You will be notified in writing of the Committee’s decision                What is COBRA Continuation Coverage?
after the Appeal Committee meeting. The Appeal Committee
                                                                           Under federal law, you and/or your Dependents must be given
refers to the Socorro Independent School District Medical
                                                                           the opportunity to continue health insurance when there is a
Appeals Committee doing the second level nonurgent care
                                                                           “qualifying event” that would result in loss of coverage under
review.
                                                                           the Plan. You and/or your Dependents will be permitted to
                                                                           continue the same coverage under which you or your
For submitting urgent care appeals at this level, follow the               Dependents were covered on the day before the qualifying
process in Level One Appeal. You may request that the                      event occurred, unless you move out of that plan’s coverage



                                                                      52                                                  myCIGNA.com
area or the plan is no longer available. You and/or your              another COBRA qualifying event, the affected Dependent(s)
Dependents cannot change coverage options until the next              may elect to extend their COBRA continuation coverage for
open enrollment period.                                               an additional 18 months (7 months if the secondary event
When is COBRA Continuation Available?                                 occurs within the disability extension period) for a maximum
                                                                      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
   your termination of employment for any reason, other than         available for more than 36 months from the initial qualifying
    gross misconduct, or                                              event. Secondary qualifying events are: your death; your
   your reduction in work hours.                                     divorce or legal separation; or, for a Dependent child, failure
                                                                      to continue to qualify as a Dependent under the Plan.
For your Dependents, COBRA continuation coverage is
available for up to 36 months from the date of the following          Disability Extension
qualifying events if the event would result in a loss of              If, after electing COBRA continuation coverage due to your
coverage under the Plan:                                              termination of employment or reduction in work hours, you or
   your death;                                                       one of your Dependents is determined by the Social Security
                                                                      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
   for a Dependent child, failure to continue to qualify as a        elected COBRA continuation coverage may extend such
    Dependent under the Plan.                                         continuation for an additional 11 months, for a maximum of
Who is Entitled to COBRA Continuation?                                29 months from the initial qualifying event.
Only a “qualified beneficiary” (as defined by federal law) may        To qualify for the disability extension, all of the following
elect to continue health insurance coverage. A qualified              requirements must be satisfied:
beneficiary may include the following individuals who were            1. SSA must determine that the disability occurred prior to or
covered by the Plan on the day the qualifying event occurred:            within 60 days after the disabled individual elected COBRA
you, your spouse, and your Dependent children. Each                      continuation coverage; and
qualified beneficiary has their own right to elect or decline
                                                                      2. A copy of the written SSA determination must be provided
COBRA continuation coverage even if you decline or are not               to the Plan Administrator within 60 calendar days after the
eligible for COBRA continuation.                                         date the SSA determination is made AND before the end of
The following individuals are not qualified beneficiaries for            the initial 18-month continuation period.
purposes of COBRA continuation: domestic partners, same
                                                                      If the SSA later determines that the individual is no longer
sex spouses, grandchildren (unless adopted by you),
                                                                      disabled, you must notify the Plan Administrator within 30
stepchildren (unless adopted by you). Although these
                                                                      days after the date the final determination is made by SSA.
individuals do not have an independent right to elect COBRA           The 11-month disability extension will terminate for all
continuation coverage, if you elect COBRA continuation                covered persons on the first day of the month that is more than
coverage for yourself, you may also cover your Dependents
                                                                      30 days after the date the SSA makes a final determination
even if they are not considered qualified beneficiaries under
                                                                      that the disabled individual is no longer disabled.
COBRA. However, such individuals’ coverage will terminate
when your COBRA continuation coverage terminates. The                 All causes for “Termination of COBRA Continuation” listed
sections titled “Secondary Qualifying Events” and “Medicare           below will also apply to the period of disability extension.
Extension For Your Dependents” are not applicable to these
individuals.


FDRL67



Secondary Qualifying Events
If, as a result of your termination of employment or reduction
in work hours, your Dependent(s) have elected COBRA
continuation coverage and one or more Dependents experience



                                                                 53                                                   myCIGNA.com
Medicare Extension for Your Dependents                                     Employer’s Notification Requirements
When the qualifying event is your termination of employment                Your Employer is required to provide you and/or your
or reduction in work hours and you became enrolled in                      Dependents with the following notices:
Medicare (Part A, Part B or both) within the 18 months before                 An initial notification of COBRA continuation rights must
the qualifying event, COBRA continuation coverage for your                     be provided within 90 days after your (or your spouse’s)
Dependents will last for up to 36 months after the date you                    coverage under the Plan begins (or the Plan first becomes
became enrolled in Medicare. Your COBRA continuation                           subject to COBRA continuation requirements, if later). If
coverage will last for up to 18 months from the date of your                   you and/or your Dependents experience a qualifying event
termination of employment or reduction in work hours.                          before the end of that 90-day period, the initial notice must
                                                                               be provided within the time frame required for the COBRA
FDRL21
                                                                               continuation coverage election notice as explained below.
                                                                              A COBRA continuation coverage election notice must be
                                                                               provided to you and/or your Dependents within the
Termination of COBRA Continuation
                                                                               following timeframes:
COBRA continuation coverage will be terminated upon the
                                                                               (a) if the Plan provides that COBRA continuation coverage
occurrence of any of the following:
                                                                                   and the period within which an Employer must notify
   the end of the COBRA continuation period of 18, 29 or 36                       the Plan Administrator of a qualifying event starts upon
    months, as applicable;                                                         the loss of coverage, 44 days after loss of coverage
   failure to pay the required premium within 30 calendar days                    under the Plan;
    after the due date;                                                        (b) if the Plan provides that COBRA continuation coverage
   cancellation of the Employer’s policy with CIGNA;                              and the period within which an Employer must notify
                                                                                   the Plan Administrator of a qualifying event starts upon
   after electing COBRA continuation coverage, a qualified
                                                                                   the occurrence of a qualifying event, 44 days after the
    beneficiary enrolls in Medicare (Part A, Part B, or both);
                                                                                   qualifying event occurs; or
   after electing COBRA continuation coverage, a qualified
                                                                               (c) in the case of a multi-employer plan, no later than 14
    beneficiary becomes covered under another group health
                                                                                   days after the end of the period in which Employers
    plan, unless the qualified beneficiary has a condition for
                                                                                   must provide notice of a qualifying event to the Plan
    which the new plan limits or excludes coverage under a pre-
                                                                                   Administrator.
    existing condition provision. In such case coverage will
    continue until the earliest of: (a) the end of the applicable          How to Elect COBRA Continuation Coverage
    maximum period; (b) the date the pre-existing condition                The COBRA coverage election notice will list the individuals
    provision is no longer applicable; or (c) the occurrence of an         who are eligible for COBRA continuation coverage and
    event described in one of the first three bullets above; or            inform you of the applicable premium. The notice will also
   any reason the Plan would terminate coverage of a                      include instructions for electing COBRA continuation
    participant or beneficiary who is not receiving continuation           coverage. You must notify the Plan Administrator of your
    coverage (e.g., fraud).                                                election no later than the due date stated on the COBRA
                                                                           election notice. If a written election notice is required, it must
Moving Out of Employer’s Service Area or Elimination of
                                                                           be post-marked no later than the due date stated on the
a Service Area
                                                                           COBRA election notice. If you do not make proper
If you and/or your Dependents move out of the Employer’s                   notification by the due date shown on the notice, you and your
service area or the Employer eliminates a service area in your             Dependents will lose the right to elect COBRA continuation
location, your COBRA continuation coverage under the plan                  coverage. If you reject COBRA continuation coverage before
will be limited to out-of-network coverage only. In-network                the due date, you may change your mind as long as you
coverage is not available outside of the Employer’s service                furnish a completed election form before the due date.
area. If the Employer offers another benefit option through
                                                                           Each qualified beneficiary has an independent right to elect
CIGNA or another carrier which can provide coverage in your
                                                                           COBRA continuation coverage. Continuation coverage may
location, you may elect COBRA continuation coverage under
                                                                           be elected for only one, several, or for all Dependents who are
that option.
                                                                           qualified beneficiaries. Parents may elect to continue coverage
                                                                           on behalf of their Dependent children. You or your spouse
FDRL22                                                           V1        may elect continuation coverage on behalf of all the qualified
                                                                           beneficiaries. You are not required to elect COBRA



                                                                      54                                                    myCIGNA.com
continuation coverage in order for your Dependents to elect            during this time. Any providers who contact the Plan to
COBRA continuation.                                                    confirm coverage during this time may be informed that
                                                                       coverage has been suspended. If payment is received before
                                                                       the end of the grace period, your coverage will be reinstated
FDRL23
                                                                       back to the beginning of the coverage period. This means that
                                                                       any claim you submit for benefits while your coverage is
How Much Does COBRA Continuation Coverage Cost?                        suspended may be denied and may have to be resubmitted
Each qualified beneficiary may be required to pay the entire           once your coverage is reinstated. If you fail to make a
cost of continuation coverage. The amount may not exceed               payment before the end of the grace period for that coverage
102% of the cost to the group health plan (including both              period, you will lose all rights to COBRA continuation
Employer and Employee contributions) for coverage of a                 coverage under the Plan.
similarly situated active Employee or family member. The
premium during the 11-month disability extension may not               FDRL24                                                           V2
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               You Must Give Notice of Certain Qualifying Events
example:                                                               If you or your Dependent(s) experience one of the following
If the Employee alone elects COBRA continuation coverage,              qualifying events, you must notify the Plan Administrator
the Employee will be charged 102% (or 150%) of the active              within 60 calendar days after the later of the date the
Employee premium. If the spouse or one Dependent child                 qualifying event occurs or the date coverage would cease as a
alone elects COBRA continuation coverage, they will be                 result of the qualifying event:
charged 102% (or 150%) of the active Employee premium. If                 Your divorce or legal separation;
more than one qualified beneficiary elects COBRA                          Your child ceases to qualify as a Dependent under the Plan;
continuation coverage, they will be charged 102% (or 150%)                 or
of the applicable family premium.
                                                                          The occurrence of a secondary qualifying event as discussed
When and How to Pay COBRA Premiums                                         under “Secondary Qualifying Events” above (this notice
First payment for COBRA continuation                                       must be received prior to the end of the initial 18- or 29-
If you elect COBRA continuation coverage, you do not have                  month COBRA period).
to send any payment with the election form. However, you               (Also refer to the section titled “Disability Extension” for
must make your first payment no later than 45 calendar days            additional notice requirements.)
after the date of your election. (This is the date the Election
                                                                       Notice must be made in writing and must include: the name of
Notice is postmarked, if mailed.) If you do not make your first
                                                                       the Plan, name and address of the Employee covered under the
payment within that 45 days, you will lose all COBRA
                                                                       Plan, name and address(es) of the qualified beneficiaries
continuation rights under the Plan.
                                                                       affected by the qualifying event; the qualifying event; the date
Subsequent payments                                                    the qualifying event occurred; and supporting documentation
After you make your first payment for COBRA continuation               (e.g., divorce decree, birth certificate, disability determination,
coverage, you will be required to make subsequent payments             etc.).
of the required premium for each additional month of
coverage. Payment is due on the first day of each month. If
you make a payment on or before its due date, your coverage
under the Plan will continue for that coverage period without
any break.
Grace periods for subsequent payments
Although subsequent payments are due by the first day of the
month, you will be given a grace period of 30 days after the
first day of the coverage period to make each monthly
payment. Your COBRA continuation coverage will be
provided for each coverage period as long as payment for that
coverage period is made before the end of the grace period for
that payment. However, if your payment is received after the
due date, your coverage under the Plan may be suspended


                                                                  55                                                    myCIGNA.com
Newly Acquired Dependents                                               (TAA) benefits and the tax credit, you may be eligible for a
If you acquire a new Dependent through marriage, birth,                 special 60 day COBRA election period. The special election
adoption or placement for adoption while your coverage is               period begins on the first day of the month that you become
being continued, you may cover such Dependent under your                TAA-eligible. If you elect COBRA coverage during this
COBRA continuation coverage. However, only your newborn                 special election period, COBRA coverage will be effective on
or adopted Dependent child is a qualified beneficiary and may           the first day of the special election period and will continue for
continue COBRA continuation coverage for the remainder of               18 months, unless you experience one of the events discussed
the coverage period following your early termination of                 under “Termination of COBRA Continuation” above.
COBRA coverage or due to a secondary qualifying event.                  Coverage will not be retroactive to the initial loss of coverage.
COBRA coverage for your Dependent spouse and any                        If you receive a determination that you are TAA-eligible, you
Dependent children who are not your children (e.g.,                     must notify the Plan Administrator immediately.
stepchildren or grandchildren) will cease on the date your              Interaction With Other Continuation Benefits
COBRA coverage ceases and they are not eligible for a                   You may be eligible for other continuation benefits under state
secondary qualifying event.                                             law. Refer to the Termination section for any other
COBRA Continuation for Retirees Following Employer’s                    continuation benefits.
Bankruptcy
If you are covered as a retiree, and a proceeding in bankruptcy         FDRL26
is filed with respect to the Employer under Title 11 of the
United States Code, you may be entitled to COBRA
continuation coverage. If the bankruptcy results in a loss of
coverage for you, your Dependents or your surviving spouse              Definitions
within one year before or after such proceeding, you and your           Active Service
covered Dependents will become COBRA qualified
beneficiaries with respect to the bankruptcy. You will be               You will be considered in Active Service:
entitled to COBRA continuation coverage until your death.                  on any of your Employer's scheduled work days if you are
Your surviving spouse and covered Dependent children will                   performing the regular duties of your work on a full-time
be entitled to COBRA continuation coverage for up to 36                     basis on that day either at your Employer's place of business
months following your death. However, COBRA continuation                    or at some location to which you are required to travel for
coverage will cease upon the occurrence of any of the events                your Employer's business.
listed under “Termination of COBRA Continuation” above.                    on a day which is not one of your Employer's scheduled
                                                                            work days if you were in Active Service on the preceding
FDRL25                                                        V1
                                                                            scheduled work day.


                                                                        DFS1
Trade Act of 2002
The Trade Act of 2002 created a new tax credit for certain
individuals who become eligible for trade adjustment                    Bed and Board
assistance and for certain retired Employees who are receiving          The term Bed and Board includes all charges made by a
pension payments from the Pension Benefit Guaranty                      Hospital on its own behalf for room and meals and for all
Corporation (PBGC) (eligible individuals). Under the new tax            general services and activities needed for the care of registered
provisions, eligible individuals can either take a tax credit or        bed patients.
get advance payment of 65% of premiums paid for qualified
health insurance, including continuation coverage. If you have
questions about these new tax provisions, you may call the              DFS14

Health Coverage Tax Credit Customer Contact Center toll-free
at 1-866-628-4282. TDD/TYY callers may call toll-free at 1-             Charges
866-626-4282. More information about the Trade Act is also
available at www.doleta.gov/tradeact/2002act_index.asp.                 The term "charges" means the actual billed charges; except
                                                                        when the provider has contracted directly or indirectly with
In addition, if you initially declined COBRA continuation               CG for a different amount.
coverage and, within 60 days after your loss of coverage under
the Plan, you are deemed eligible by the U.S. Department of
Labor or a state labor agency for trade adjustment assistance           DFS940




                                                                   56                                                   myCIGNA.com
                                                                             A child includes your natural child, stepchild, or legally
Chiropractic Care                                                            adopted child, or the child for whom you are the legal
                                                                             guardian, or the child who is the subject of a lawsuit for
The term Chiropractic Care means the conservative                            adoption by you, or the child who is supported pursuant to a
management of neuromusculoskeletal conditions through                        court order imposed on you (including a qualified medical
manipulation and ancillary physiological treatment rendered to               child support order) or your grandchild who is your Dependent
specific joints to restore motion, reduce pain and improve                   for federal income tax purposes at the time of application.
function.
                                                                             Benefits for a Dependent child will continue until the last day
                                                                             of the calendar month in which the limiting age is reached.
DFS1689
                                                                             Anyone who is eligible as an Employee will not be considered
                                                                             as a Dependent.
Custodial Services                                                           No one may be considered as a Dependent of more than one
Any services that are of a sheltering, protective, or                        Employee.
safeguarding nature. Such services may include a stay in an
institutional setting, at-home care, or nursing services to care
                                                                             DFS1877
for someone because of age or mental or physical condition.
This service primarily helps the person in daily living.
Custodial care also can provide medical services, given mainly               Emergency Services/Emergency Medical Condition
to maintain the person’s current state of health. These services             Emergency Services are a health care item or service furnished
cannot be intended to greatly improve a medical condition;                   or required to evaluate and treat an Emergency Medical
they are intended to provide care while the patient cannot care              Condition, which may include, but shall not be limited to
for himself or herself. Custodial Services include but are not               health care services that are provided in a licensed Hospital's
limited to:                                                                  emergency facility by an appropriate provider. An Emergency
   Services related to watching or protecting a person;                     Medical Condition is the sudden and, at the time, unexpected
   Services related to performing or assisting a person in                  onset of a health condition that manifests itself by symptoms
    performing any activities of daily living, such as: (a)                  of sufficient severity that would lead a prudent layperson,
    walking, (b) grooming, (c) bathing, (d) dressing, (e) getting            possessing an average knowledge of medicine and health, to
    in or out of bed, (f) toileting, (g) eating, (h) preparing foods,        believe that immediate medical care is required, which may
    or (i) taking medications that can be self administered, and             include, but shall not be limited to:
   Services not required to be performed by trained or skilled              (1) Placing the person's health in significant jeopardy;
    medical or paramedical personnel.                                        (2) Serious impairment to a bodily function;
                                                                             (3) Serious dysfunction of any bodily organ or part;
DFS1812                                                                      (4) Inadequately controlled pain; or
                                                                             (5) With respect to a pregnant woman who is having
Dependent                                                                        contractions:
Dependents are:                                                                    (a) That there is inadequate time to effect a safe transfer
                                                                                       to another hospital before delivery; or
   your lawful spouse; and
                                                                                   (b) That transfer to another hospital may pose a threat to
   any unmarried child of yours who is
                                                                                       the health or safety of the woman or unborn child.
       less than 25 years old;
       25 or more years old and primarily supported by you and
                                                                             DFS1540
        incapable of self-sustaining employment by reason of
        mental or physical handicap. Proof of the child's condition
        and dependence must be submitted to CG within 31 days
        after the date the child ceases to qualify above. During the
        next two years CG may, from time to time, require proof
        of the continuation of such condition and dependence.
        After that, CG may require proof no more than once a
        year.



                                                                        57                                                    myCIGNA.com
Employee                                                             Hospice Care Program
The term Employee means a full-time employee of the                  The term Hospice Care Program means:
Employer who is currently in Active Service. The term does              a coordinated, interdisciplinary program to meet the
not include employees who are part-time or temporary or who              physical, psychological, spiritual and social needs of dying
normally work less than 20 hours a week for the Employer.                persons and their families;
                                                                        a program that provides palliative and supportive
DFS1427 M                                                                medical, nursing and other health services through home
                                                                         or inpatient care during the illness;
Employer                                                                a program for persons who have a Terminal Illness and
                                                                         for the families of those persons.
The term Employer means the plan sponsor self-insuring the
benefits described in this booklet, on whose behalf CG is
providing claim administration services.                             DFS70



DFS1595                                                              Hospice Care Services
                                                                     The term Hospice Care Services means any services provided
Expense Incurred                                                     by: (a) a Hospital, (b) a Skilled Nursing Facility or a similar
                                                                     institution, (c) a Home Health Care Agency, (d) a Hospice
An expense is incurred when the service or the supply for
                                                                     Facility, or (e) any other licensed facility or agency under a
which it is incurred is provided.
                                                                     Hospice Care Program.

DFS60
                                                                     DFS599


Free-Standing Surgical Facility
                                                                     Hospice Facility
The term Free-standing Surgical Facility means an institution
                                                                     The term Hospice Facility means an institution or part of it
which meets all of the following requirements:
                                                                     which:
   it has a medical staff of Physicians, Nurses and licensed
                                                                        primarily provides care for Terminally Ill patients;
    anesthesiologists;
                                                                        is accredited by the National Hospice Organization;
   it maintains at least two operating rooms and one
    recovery room;                                                      meets standards established by CG; and
   it maintains diagnostic laboratory and x-ray facilities;            fulfills any licensing requirements of the state or locality
                                                                         in which it operates.
   it has equipment for emergency care;
   it has a blood supply;
                                                                     DFS72
   it maintains medical records;
   it has agreements with Hospitals for immediate
    acceptance of patients who need Hospital Confinement             Hospital
    on an inpatient basis; and                                       The term Hospital means:
   it is licensed in accordance with the laws of the                   an institution licensed as a hospital, which: (a) maintains, on
    appropriate legally authorized agency.                               the premises, all facilities necessary for medical and
                                                                         surgical treatment; (b) provides such treatment on an
                                                                         inpatient basis, for compensation, under the supervision of
DFS682
                                                                         Physicians; and (c) provides 24-hour service by Registered
                                                                         Graduate Nurses;
                                                                        an institution which qualifies as a hospital, a psychiatric
                                                                         hospital or a tuberculosis hospital, and a provider of
                                                                         services under Medicare, if such institution is accredited as
                                                                         a hospital by the Joint Commission on the Accreditation of
                                                                         Healthcare Organizations;


                                                                58                                                    myCIGNA.com
   an institution which: (a) specializes in treatment of Mental
    Health and Substance Abuse or other related illness; (b)            Maintenance Treatment
    provides residential treatment programs; and (c) is licensed
    or certified in accordance with the laws of the appropriate         The term Maintenance Treatment means:
    legally authorized agency;                                             treatment rendered to keep or maintain the patient's current
   a Free-standing Surgical Facility; or                                   status.

   a Psychiatric Day Treatment Facility.
                                                                        DFS1650
The term Hospital will not include an institution which is
primarily a place for rest, a place for the aged, or a nursing
home.                                                                   Maximum Reimbursable Charge - Medical
                                                                        The Maximum Reimbursable Charge for covered services is
DFS1746                                                                 determined based on the lesser of:
                                                                           the provider’s normal charge for a similar service or supply;
                                                                            or
Hospital Confinement or Confined in a Hospital
                                                                           a policyholder-selected percentile of charges made by
A person will be considered Confined in a Hospital if he is:
                                                                            providers of such service or supply in the geographic area
   a registered bed patient in a Hospital upon the                         where it is received as compiled in a database selected by
    recommendation of a Physician;                                          CG.
   receiving treatment for Mental Health and Substance Abuse           The percentile used to determine the Maximum Reimbursable
    Services in a Partial Hospitalization program;                      Charge is listed in The Schedule.
   receiving treatment for Mental Health and Substance Abuse           The Maximum Reimbursable Charge is subject to all other
    Services in a Mental Health or Substance Abuse Residential          benefit limitations and applicable coding and payment
    Treatment Center.                                                   methodologies determined by CG. Additional information
                                                                        about how CG determines the Maximum Reimbursable
DFS1815
                                                                        Charge is available upon request.


                                                                        GM6000 DFS1997                                                    V14
Injury
The term Injury means an accidental bodily injury.
                                                                        Medicaid
DFS147
                                                                        The term Medicaid means a state program of medical aid for
                                                                        needy persons established under Title XIX of the Social
                                                                        Security Act of 1965 as amended.
Inpatient Mental Illness Benefits
Benefits that are provided while you or your Dependents are             DFS192
Confined in a Hospital for the treatment and evaluation of
Mental Illness. Inpatient Mental Illness Services include
Mental Illness treatment in a Residential Treatment Center for          Medically Necessary/Medical Necessity
Children and Adolescents, and from a Crisis Stabilization               Medically Necessary Covered Services and Supplies are those
Unit, Partial Hospitalization, and Mental Illness Residential           determined by the Medical Director to be:
Treatment Services.
                                                                           required to diagnose or treat an illness, injury, disease or its
Inpatient mental illness benefits are exchangeable with Partial             symptoms;
Hospitalization sessions when benefits are provided for not
                                                                           in accordance with generally accepted standards of medical
less than four (4) hours and not more than twelve (12) hours in
any twenty-four (24) hour period. The benefit exchange will                 practice;
be two (2) partial hospitalization sessions are equal to one (1)           clinically appropriate in terms of type, frequency, extent,
day of inpatient care.                                                      site and duration;
                                                                           not primarily for the convenience of the patient, Physician
DFS1593
                                                                            or other health care provider; and



                                                                   59                                                      myCIGNA.com
   rendered in the least intensive setting that is appropriate for           any charges, by whomever made, for licensed ambulance
    the delivery of the services and supplies. Where applicable,               service to or from the nearest Hospital where the needed
    the Medical Director may compare the cost-effectiveness of                 medical care and treatment can be provided; and
    alternative services, settings or supplies when determining               any charges, by whomever made, for the administration of
    least intensive setting.                                                   anesthetics during Hospital Confinement.
                                                                           The term Necessary Services and Supplies will not include
DFS1813                                                                    any charges for special nursing fees, dental fees or medical
                                                                           fees.
Medicare
The term Medicare means the program of medical care                        DFS151

benefits provided under Title XVIII of the Social Security Act
of 1965 as amended.                                                        Nurse
                                                                           The term Nurse means a Registered Graduate Nurse, a
DFS149                                                                     Licensed Practical Nurse or a Licensed Vocational Nurse who
                                                                           has the right to use the abbreviation "R.N.," "L.P.N." or
                                                                           "L.V.N."
Mental Illness Residential Treatment Services
The Mental Illness Residential Treatment Services are services
provided by a Hospital that is designated by CG for the                    DFS155

evaluation and treatment of the psychological and social
functional disturbances that are a result of subacute mental               Other Health Care Facility
illness conditions.
                                                                           The term Other Health Care Facility means a facility other
Mental Illness Residential Treatment benefits are exchanged                than a Hospital or hospice facility. Examples of Other Health
with Inpatient Mental Illness benefits at a rate of two (2) days           Care Facilities include, but are not limited to, licensed skilled
of Mental Illness Residential Treatment being equal to one (1)             nursing facilities, rehabilitation Hospitals and subacute
day of Inpatient Mental Illness Treatment.                                 facilities.
Mental Illness Residential Treatment Center means an
institution which (a) specializes in the treatment of
                                                                           DFS1686
psychological and social disturbances that are the result of
mental illness conditions; (b) provides a subacute, structured,
psychotherapeutic treatment program, under the supervision of              Other Health Professional
Physicians; (c) provides 24-hour care, in which a person lives
                                                                           The term Other Health Professional means an individual other
in an open setting; and (d) is licensed in accordance with the
                                                                           than a Physician who is licensed or otherwise authorized under
laws of the appropriate legally authorized agency as a
                                                                           the applicable state law to deliver medical services and
Residential Treatment Center.
                                                                           supplies. Other Health Professionals include, but are not
A person is considered Confined in a Residential Treatment                 limited to physical therapists, registered nurses and licensed
Center when she/he is a registered bed patient in a Residential            practical nurses.
Treatment Center upon the recommendation of a Physician.

                                                                           DFS1685
DFS1584



Necessary Services and Supplies
The term Necessary Services and Supplies includes:
   any charges, except charges for Bed and Board, made by a
    Hospital on its own behalf for medical services and supplies
    actually used during Hospital Confinement;




                                                                      60                                                    myCIGNA.com
Outpatient Chemical Dependency Rehabilitation Services                       performing a service for which benefits are provided under
Outpatient Chemical Dependency Rehabilitation Services are                    this plan when performed by a Physician.
services provided for the diagnosis and treatment of Chemical
Dependency, while you or your Dependent are not Confined                  DFS164
in a Hospital, including outpatient rehabilitation in an
individual, group, structured group or in a Chemical
Dependency Outpatient Structured Therapy Program.                         Preventive Treatment
                                                                          The term Preventive Treatment means:
DFS1587 M                                                                    treatment rendered to prevent disease or its recurrence.


Outpatient Mental Illness Services                                        DFS1652

Outpatient Mental Illness Services are services of providers
who are qualified to treat mental illness when treatment is               Primary Care Physician
provided on an outpatient basis, while you or your Dependent
                                                                          The term Primary Care Physician means a Physician: (a) who
is not Confined in a Hospital, in an individual, group or
                                                                          qualifies as a Participating Provider in general practice,
structured group therapy program. Covered services include,
                                                                          internal medicine, family practice or pediatrics; and (b) who
but are not limited to, outpatient treatment of conditions such
                                                                          has been selected by you, as authorized by the Provider
as: anxiety or depression which interferes with daily
                                                                          Organization, to provide or arrange for medical care for you or
functioning; emotional adjustment or concerns related to
                                                                          any of your insured Dependents.
chronic conditions, such as psychosis or depression; emotional
reactions associated with marital problems or divorce;
child/adolescent problems of conduct or poor impulse control;             DFS622
affective disorders; suicidal or homicidal threats or acts; eating
disorders; or acute exacerbation of chronic mental illness
conditions (crisis intervention and relapse prevention) and               Psychologist
outpatient testing and assessment.                                        The term Psychologist means a person who is licensed or
                                                                          certified as a clinical psychologist. Where no licensure or
                                                                          certification exists, the term Psychologist means a person who
DFS1594
                                                                          is considered qualified as a clinical psychologist by a
                                                                          recognized psychological association. It will also include any
Participating Provider                                                    other licensed counseling practitioner whose services are
                                                                          required to be covered by law in the locality where the policy
The term Participating Provider means a hospital, a
                                                                          is issued if he is:
Physician or any other health care practitioner or entity that
has a direct or indirect contractual arrangement with CIGNA                  operating within the scope of his license; and
to provide covered services with regard to a particular plan                 performing a service for which benefits are provided under
under which the participant is covered.                                       this plan when performed by a Psychologist.

DFS1910                                                                   DFS170



Physician                                                                 Residential Treatment for Children and Adolescents
The term Physician means a licensed medical practitioner who              The Residential Treatment for Children and Adolescents
is practicing within the scope of his license and who is                  means a child care institution that provides residential care and
licensed to prescribe and administer drugs or to perform                  treatment for emotionally disturbed children and adolescents,
surgery. It will also include any other licensed medical                  and that is accredited as a Residential Treatment Center by the
practitioner whose services are required to be covered by law             Council on Accreditation, the Joint Commission on
in the locality where the policy is issued if he is:                      Accreditation of Hospitals, or the American Association of
   operating within the scope of his license; and                        Psychiatric Services for Children.


                                                                          DFS1583




                                                                     61                                                    myCIGNA.com
                                                                         Terminal Illness
Review Organization                                                      A Terminal Illness will be considered to exist if a person
The term Review Organization refers to an affiliate of CG or             becomes terminally ill with a prognosis of six months or less
another entity to which CG has delegated responsibility for              to live, as diagnosed by a Physician.
performing utilization review services. The Review
Organization is an organization with a staff of clinicians which         DFS197
may include Physicians, Registered Graduate Nurses, licensed
mental health and substance abuse professionals, and other
trained staff members who perform utilization review services.           Toxic Inhalant
                                                                         A Toxic Inhalant means a volatile chemical under Chapter
                                                                         484, Health and Safety Code, or usable glue or aerosol paint
DFS1688
                                                                         under Section 485.001, Health and Safety Code.
Series of Treatments
A Series of Treatments is a planned, structured and organized
                                                                         DFS1592
program to promote chemical free status which may or may
not include different facilities or modalities, and is complete
when you are discharged on medical advice from inpatient                 Urgent Care
detoxification, inpatient rehabilitation, partial hospitalization
                                                                         Urgent Care is medical, surgical, Hospital and related health
or intensive outpatient care, or a series of these levels of
                                                                         care service and testing which is provided to treat a condition
treatment without a lapse in treatment, or when you fail to
                                                                         that is: (1) less severe than an Emergency Medical Condition;
materially comply with the treatment program for a period of
                                                                         (2) requires immediate medical attention; and (3) is
thirty (30) days.
                                                                         unforeseen. Care which could have been foreseen as needed
                                                                         before leaving the provider network area where the insured
DFS1589                                                                  ordinarily receives and/or was scheduled to receive services
                                                                         does not meet the definition of Urgent Care. Such foreseeable
                                                                         care includes, but is not limited to, delivery beyond the 35th
Sickness – For Medical Insurance                                         week of pregnancy, dialysis, scheduled medical treatments or
The term Sickness means a physical or mental illness. It also            therapy, or care received after a Physician's recommendation
includes pregnancy. Expenses incurred for routine Hospital               that the insured should not travel due to any medical
and pediatric care of a newborn child prior to discharge from            condition.
the Hospital nursery will be considered to be incurred as a
result of Sickness.
                                                                         DFS1541


DFS531



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




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