Cigna HealthCare of Illinois, Inc. Individual Services – Illinois P.O. Box 30365 Tampa, FL 33630-3365 1-877-484-5967 Cigna HealthCare of Illinois, Inc. (“Cigna”) Cigna Connect 2500 Health Maintenance Organization (HMO) OUTLINE OF COVERAGE READ YOUR EVIDENCE OF COVERAGE (EOC) CAREFULLY. This outline of coverage provides a very brief description of the important features of your EOC. This is not the insurance contract and only the actual EOC provisions will control. The EOC itself sets forth, in detail, the rights and obligations of both You and Cigna HealthCare of Illinois, Inc. It is, therefore, important that you READ YOUR EOC CAREFULLY! A. Coverage is provided by Cigna HealthCare of Illinois, Inc. (referred to herein as “Cigna”), a health maintenance organization (HMO) which is organized under the laws of the State of IL. B. To obtain additional information, including Provider information write to the following address or call the toll-free number: Cigna HealthCare of Illinois, Inc. Individual Services – Illinois P.O. Box 30365 Tampa FL 33630-3365 1-877-484-5967 C. An HMO Plan requires that the Member use providers in the Cigna network. A Participating Provider is a Participating Hospitals, Participating Physicians, Other Participating Health Professionals, and Other Participating Health Care Facilities which are: (i) licensed in accordance with any applicable Federal and state laws, (ii) accredited by the Joint Commission on the Accreditation of Healthcare Organizations or by another organization, if approved by Cigna, and (iii) acting within the scope of the practitioner’s license and accreditation, and have contracted with Cigna to provide services to Members. A Non-Participating Provider (Out-of-Network Provider) is a Provider who does not have a Participating Provider agreement in effect with Cigna at the time services are rendered. Services from Non-Participating Providers are not covered, except for Emergency Medical Treatment. You will be responsible for the full cost of non-emergency services from a Non-Participating Provider. D. Covered Services and Benefits See page 4 for complete benefit schedule. ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 1 MIHM0149, MIHM0150 Deductibles Individual Deductible means the amount of Covered Expenses incurred from Participating Providers, for medical services, that You must pay each Year before any benefits are available. The amount of the Individual In-Network Deductible is described in the Schedule of Benefits. Family Deductible applies if You have a family plan and You and one or more of your Family Member(s) are insured under the EOC. Each Member can contribute up to the Individual Deductible amount toward the Family Deductible. The Individual Deductible paid by each Family Member counts towards satisfying the Family Deductible. Once the Family Deductible amount is satisfied, the remaining Individual Deductibles will be waived for the remainder of the Year. The amount of the Family Deductible is described in the Schedule of Benefits. Out-of-Pocket Maximum(s) Individual Out-of-Pocket Maximum means the annual limit on Out-of-Pocket expense for each Member covered under the EOC. Once the Individual In-Network Out- of -Pocket Maximum has been met for the Year, for Covered Services received from Participating Providers, You will no longer have to pay any Coinsurance for medical services for Covered Expenses incurred during the remainder of that Year from Participating Providers. Non-compliance penalty Charges do not apply to the Individual In-Network Out -of -Pocket Maximum and will always be paid by You. The Individual Out -of -Pocket Maximum is an accumulation of Covered Expenses incurred from Participating Providers. It includes Deductible, Coinsurance and Copayments for medical services incurred from Participating Providers. It also includes Pediatric Dental and Vision expenses. The amount of the Individual Out-of-Pocket Maximum is shown in the Schedule of Benefits. Family Out-of-Pocket Maximum applies if You cover other Family Member(s), and means the maximum amount of Deductible, Coinsurance and Copayments You and your Family Member(s) will be responsible to pay for Covered Services in a Year. Each Member can contribute up to the Individual Out-of-Pocket amount toward the Family Out-of-Pocket maximum. When the Family Out-of-Pocket is met, You and Your Dependent(s) will no longer be responsible to pay Coinsurance or Copayments for medical or pharmacy services for Covered Expenses incurred during the remainder of that Year. The amount of the Family Out-of-Pocket Maximum is described in the Schedule of Benefits for the EOC. Maximum Reimbursable Charge The Maximum Reimbursable Charge for Emergency Services delivered in the Emergency department of a Hospital is determined based on:  Usual, reasonable and customary charges made by providers of such service or supply in the geographic area where it is received as compiled in a nationally-recognized database that uses generally accepted industry standards and practices for determining the customary and reasonable billed charge for a service, and that fairly and accurately reflects the market rate; or  An agreed-upon rate between Cigna and the Provider. The Maximum Reimbursable Charge for all other Covered Services is determined based on the lesser of:  The provider's normal charge for a similar service or supply; or ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 2 MIHM0149, MIHM0150  Usual, reasonable and customary charges made by providers of such service or supply in the geographic area where it is received as compiled in a nationally-recognized database that uses generally accepted industry standards and practices for determining the customary and reasonable billed charge for a service, and that fairly and accurately reflects the market rate; or  The median amount negotiated with Participating Providers for the same services; or  A percentage of a fee schedule developed by Cigna that is based upon a methodology similar to a methodology utilized by Medicare to determine the allowable fee for the same or similar service within the geographic market. ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 3 MIHM0149, MIHM0150 E. BENEFIT SCHEDULE The following is the Schedule of Benefits, including medical, prescription drugs and pediatric vision benefits. The Plan sets forth, in more detail, the rights and obligations of both You and Your Family Member(s) and the Plan. It is, therefore, important that all Members READ THE ENTIRE PLAN CAREFULLY! Services for Out-of-Network providers are not covered except for initial care to treat and stabilize an Emergency Medical Condition. SERVICES FROM NON-PARTICIPATING PROVIDERS ARE NOT AVAILABLE EXCEPT AS DESCRIBED IN THE “EMERGENCY SERVICES” PROVISION OF THE “SERVICES AND BENEFITS” SECTION OR WITH THE PRIOR APPROVAL OF THE CIGNA MEDICAL DIRECTOR. Members are entitled to receive the services and benefits set forth in this Schedule, subject to payment of Copayments, Percentage Copayment and any applicable Deductible as specified in the Schedule, and subject to the conditions, limitations and exclusions of this Plan. Services that require Prior Authorization include, but are not limited to, inpatient Hospital services, inpatient services at any Other Participating Healthcare Facility, outpatient facility services, advanced radiological imaging, non-emergency ambulance, and Transplant Services. Prior authorization for non- emergency ambulance services may be obtained from a Participating Provider that is treating the Member. Prior Authorization requirements for Prescription Drugs are detailed in the “Prescription Drugs” section of the Plan. BENEFIT INFORMATION IN-NETWORK PROVIDER Note: (Based on Cigna Contract Allowance) Covered Services are subject to YOU PAY: applicable Annual Deductible unless specifically waived. Medical Benefits Annual Deductible $2,500 Individual $5,000 Family Service-specific Deductible amounts are displayed with the service (e.g. Inpatient Hospital Admission) in the Benefit Schedule. Out-of-Pocket Maximum Individual $7,150 Family $14,300 The following do not accumulate to the In-Network Out of Pocket Maximum: Penalties ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 4 MIHM0149, MIHM0150 BENEFIT INFORMATION IN-NETWORK PROVIDER Note: (Based on Cigna Contract Allowance) Covered Services are subject to YOU PAY: applicable Annual Deductible unless specifically waived. Coinsurance You and Your Family Members pay 30% of Charges after the Annual Deductible Prior Authorization Program Prior Authorization – Inpatient Services Your Participating Provider must obtain approval for inpatient admissions; or Your Provider may be assessed a penalty for non-compliance. Prior Authorization – Outpatient Services Your Participating Provider must obtain approval for certain outpatient procedures and services; or Your NOTE: Please refer to the section on Prior Authorization Provider may be assessed a penalty for non- of inpatient and outpatient services above for more compliance. information in Your Plan. You can obtain a complete list of admissions, services and procedures that require Prior Authorization by calling Cigna at the number on the back of Your ID card or at www.mycigna.com under “View Medical Benefits Details”. Preventive Care Services Please refer to “Preventive Care-Periodic Health 0% Deductible waived Examinations” section of the Plan for additional details. ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 5 MIHM0149, MIHM0150 BENEFIT INFORMATION IN-NETWORK PROVIDER Note: (Based on Cigna Contract Allowance) Covered Services are subject to YOU PAY: applicable Annual Deductible unless specifically waived. Pediatric Vision Care Performed by an Ophthalmologist or Optometrist for a Member who is under age 19. Please be aware that not all contracted vision care providers provide all vision care services as part of their practice. Please check with the provider to verify that he or she offers the services you wish to receive under his/her Cigna participating provider agreement. Comprehensive Eye Exam 0% per exam Deductible waived Limited to one exam per year Pediatric Frames for Children 0%per pair Deductible waived Limited to one pair per year Eyeglass Lenses for Children 0% per pair Deductible waived Limited to one pair per year Single Vision, Lined Bifocal, Lined Trifocal, Lenticular Contact Lenses and Professional Services for Children (Limited to one pair per year) Elective 0% per pair Deductible waived Therapeutic 0% per pair Deductible waived Note: Routine vision screening performed by a PCP or pediatrician is covered under the Preventive Services benefit Physician Services Office Visit Visits 1-3 per Year: $0 Copayment, Primary Care Physician (PCP) all visits after the first 3 per Year: 30% 30% Specialist Physician (including consultant and referral services) NOTE: if a Copayment applies for OB/GYN visits, the level of Copayment You pay will depend on how Your doctor is listed in the provider directory ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 6 MIHM0149, MIHM0150 BENEFIT INFORMATION IN-NETWORK PROVIDER Note: (Based on Cigna Contract Allowance) Covered Services are subject to YOU PAY: applicable Annual Deductible unless specifically waived. Electronic visit with an Expanded Access Telehealth 0% Deductible Waived Physician Note: if an Expanded Access Telehealth Physician issues a Prescription, that Prescription is subject to all Plan Prescription Drug benefits, limitations and exclusions. Physician Services, continued Surgery in Physician’s office 30% Outpatient Professional Fees for Surgery (including 30% surgery, anesthesia, diagnostic procedures, dialysis, radiation therapy) Inpatient Surgery, Anesthesia, Radiation Therapy, 30% Chemotherapy In-hospital visits 30% Allergy testing and treatment/injections 30% Second Surgical Opinion 0% Deductible waived Hospital Services Inpatient Hospital Services 30% Facility Charges Professional Charges 30% Emergency Admissions Benefits are shown in the Emergency Services Schedule Outpatient Facility Services Including Diagnostic and Free-Standing Outpatient Surgical and Outpatient 30% Hospital facilities ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 7 MIHM0149, MIHM0150 BENEFIT INFORMATION IN-NETWORK PROVIDER Note: (Based on Cigna Contract Allowance) Covered Services are subject to YOU PAY: applicable Annual Deductible unless specifically waived. Laboratory, Diagnostic Therapeutic Radiology and Advanced Imaging Services Facility and interpretation charges Physician’s Office 30% Free-standing/Independent lab or x-ray facility 30% Outpatient hospital lab or x-ray 30% 30% MRIs, MRAs, CAT Scans, PET Scans Short-Term Rehabilitative Services Physical, Occupational and Speech 30% Therapy Naprapathic Services 30% Maximum of 15 visits per Member, per Calendar Year Cardiac & Pulmonary Rehabilitation Maximum of 36 visits per Member, within a six month 30% period Chiropractic Services 30% Maximum of 25 visits per Member, per Calendar Year Treatment of Temporomandibular Joint Dysfunction (TMJ/TMD) 30% Habilitative Services 30% ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 8 MIHM0149, MIHM0150 BENEFIT INFORMATION IN-NETWORK PROVIDER Note: (Based on Cigna Contract Allowance) Covered Services are subject to YOU PAY: applicable Annual Deductible unless specifically waived. Family Planning Womens’ Contraceptive Services and Sterilization 0% Deductible waived Male Sterilization 30% Maternity (Pregnancy and Delivery)/Complications of Pregnancy Initial Office Visit to confirm pregnancy PCP or Specialist Office visit benefit applies and subsequent prenatal visits billed separately from the “global” fee Prenatal services, Postnatal and Delivery (billed as 30% “global” fee) Inpatient Hospital Services benefit applies Hospital Delivery charges Prenatal testing or treatment billed separately from 30% “global” fee Postnatal visit or treatment billed separately from PCP or Specialist Office visit benefit applies “global” fee Dialysis Inpatient Inpatient Hospital Services benefit applies Outpatient 30% Autism Spectrum Disorders Diagnosis of Autism Spectrum Disorder Office Visit PCP or Specialist Office Visit benefit applies Diagnostic testing 30% Treatment of Autism Spectrum Disorder Copay or Coinsurance applies for specific benefit provided Please refer to “Autism Spectrum Disorder” section of the Plan for specific details and limitations. ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 9 MIHM0149, MIHM0150 BENEFIT INFORMATION IN-NETWORK PROVIDER Note: (Based on Cigna Contract Allowance) Covered Services are subject to YOU PAY: applicable Annual Deductible unless specifically waived. Inpatient Services at Other Health Care Facilities Including Skilled Nursing, Rehabilitation Hospital and 30% Sub-Acute Facilities Home Health Services 30% External Prosthetic Appliances 30% Durable Medical Equipment 30% Hospice Inpatient Hospital Services benefit applies Inpatient 30% Outpatient Newborn/Infant Hearing Screening 0% Deductible waived Hearing Aids (limited to hearing aids for children and bone anchored 30% hearing aids) Maximum of 2 hearing aids for children every 3 years Mental, Emotional, Functional Nervous Disorders and Serious Mental Illness Inpatient (Includes Acute and Residential Treatment) Inpatient Hospital Services benefit applies Outpatient (Includes individual, group, intensive outpatient and partial hospitalization) Office Visit 30% All other outpatient services 30% ILINDHMOOOC042016 894946 IL 1/17 Cigna Connect 2500 10 MIHM0149, MIHM0150