Loudoun County School Board - Loudoun County Public Schools All... · PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna,

Loudoun County School Board

ANNUAL COMPLIANCE RIDER

EFFECTIVE DATE: January 1, 2017

ACASOM17

3320020

This document printed in December, 2016 takes the place of any documents previously issued to you which

described your benefits.

Printed in U.S.A.

Home Office: Bloomfield, Connecticut

Mailing Address: Hartford, Connecticut 06152

CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter

called Cigna)

ANNUAL COMPLIANCE RIDER

No. ACASOM17

Policyholder: Loudoun County School Board

Rider Eligibility: Each Employee

Policy No. or Nos. 3320020-OAP2, NETPS


You will become insured on the date you become eligible, if you are in Active Service on that date, or if

you are not in Active Service on that date due to your health status. If you are not insured for the benefits

described in your certificate on that date, the effective date of this annual compliance rider will be the date

you become insured.

This Annual Compliance Rider forms a part of the certificate issued to you by Cigna describing the

benefits provided under the policy(ies) specified above.

This Annual Compliance Rider replaces any other Annual Compliance Rider issued to you on a prior date.

The provisions set forth in this Annual Compliance Rider comply with legislative requirements regarding

group insurance plans covering insureds. These provisions supersede any provisions in your certificate to

the contrary unless the provisions in your certificate result in greater benefits.

READ THE FOLLOWING

NOTE: The provisions identified in this rider are specifically applicable ONLY for:

Benefit plans which have been made available by your Employer to you and/or your Dependents;

Benefit plans for which you and/or your Dependents are eligible;

Benefit plans which you have elected for you and/or your Dependents;

Benefit plans which are currently effective for you and/or your Dependents.

HC-RDR1 04-10

V1 AC

myCigna.com 4

Important Notices

Important Information

Mental Health Parity and Addiction Equity Act

The page regarding “Mental Health Parity and Addiction

Equity Act” found on the Important Information section in

your medical certificate is hereby NULL and VOID.

HC-NOT69 12-14

AC

The following Notice page concerning Discrimination is

Against the Law is added to your medical certificate

Discrimination is Against the Law

Cigna, in its role as benefits administrator, complies with

applicable Federal civil rights laws and does not discriminate

on the basis of race, color, national origin, age, disability or

sex. Cigna does not exclude people or treat them differently

because of race, color, national origin, age, disability or sex.

Cigna:

Provides free aids and services to people with disabilities to

communicate effectively with Cigna, such as qualified sign

language interpreters and written information in other

formats (large print, audio, accessible electronic formats,

other formats).

Provides free language services to people whose primary

language is not English, such as qualified interpreters and

information written in other languages.

If you need these services, contact Customer Service/Member

Services at the toll-free phone number shown on your ID card,

and ask an associate for assistance.

If you believe that Cigna has failed to provide these services

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

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

by sending an email to [email protected] or by

writing to the following address: Cigna, Nondiscrimination

Complaint Coordinator, P.O. Box 188016, Chattanooga, TN

37422.

If you need assistance filing a written grievance, please call

the toll-free phone shown on your ID card or send an email to

[email protected].

You can also file a civil rights complaint with the U.S.

Department of Health and Human Services, Office for Civil

Rights electronically through the Office for Civil Rights

Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at:

U.S. Department of Health and Human Services, 200

Independence Avenue, SW, Room 509F, HHH Building,

Washington, D.C. 20201; or by phone at 1-800-368-1019,

800-537-7697 (TDD).

Complaint forms are available at

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

HC-NOT76 10-16

AC

The following Notice page concerning Proficiency of

Language Assistance Services is added to your medical

certificate:

Proficiency of Language Assistance Services

ATTENTION: Language assistance services, free of charge,

are available to you. For current Cigna customers, call the

number on the back of your ID card. Otherwise, call 1-800-

244-6224 (TTY: Dial 711).

Spanish

ATENCIÓN: tiene a su disposición servicios gratuitos de

asistencia lingüística. Si es un cliente actual de Cigna, llame al

número que figura en el reverso de su tarjeta de identificación.

Si no lo es, llame al 1-800-244-6224 (los usuarios de TTY

deben llamar al 711).

Chinese

注意：我們可為您免費提供語言協助服務。對於 Cigna

的現有客戶，請致電您的 ID

卡背面的號碼。其他客戶請致電 1-800-244-6224

（聽障專線：請撥 711）。

Vietnamese

CHÚ Ý: Có dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Dành cho khách hàng hiện tại của Cigna, gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1-800-244-6224 (TTY: Quay số 711).

Korean

주의: 언어 지원 서비스를 비용없이 이용하실 수

있습니다. 기존 Cigna 가입자의 경우, 가입자 ID 카드

뒷면에 있는 전화번호로 연락해 주십시오. 아니면 1-800-

244-6224번으로 연락해 주십시오(TTY: 711번으로 전화).

Tagalog

PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa

wika nang libre. Para sa mga kasalukuyang customer ng

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

kaya, tumawag sa 1-800-244-6224 (TTY: I-dial ang 711).

myCigna.com 5

Russian

ВНИМАНИЕ: вам могут предоставить бесплатные

услуги перевода. Если вы уже участвуете в плане Cigna,

позвоните по номеру, указанному на обратной стороне

вашей идентификационной карточки участника плана.

Если вы не являетесь участником одного из наших

планов, позвоните по номеру 1-800-244-6224 (TTY: 711).

Arabic

Cignaلعمالء م.خدمات الترجمة المجانية متاحة لك برجاء االنتباة

برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الحاليين

(.177: اتصل ب TTY) 6224-244-800-1او اتصل بالشخصية.

French Creole

ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou

ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou.

Sinon, rele nimewo 1-800-244-6224 (TTY: Rele 711).

French

ATTENTION: des services d’aide linguistique vous sont

proposés gratuitement. Si vous êtes un client actuel de Cigna,

veuillez appeler le numéro indiqué au verso de votre carte

d’identité. Sinon, veuillez appeler le numéro 1-800-244-6224

(ATS: composez le numéro 711).

Portuguese

ATENÇÃO: Tem ao seu dispor serviços de assistência

linguística, totalmente gratuitos. Para clientes Cigna atuais,

ligue para o número que se encontra no verso do seu cartão de

identificação. Caso contrário, ligue para 1-800-244-6224

(Dispositivos TTY: marque 711).

Polish

UWAGA: W celu skorzystania z dostępnej, bezpłatnej

pomocy językowej, obecni klienci firmy Cigna mogą dzwonić

pod numer podany na odwrocie karty identyfikacyjnej.

Wszystkie inne osoby prosimy o skorzystanie z numeru 1-

800-244-6224 (TTY: wybierz 711).

Japanese

お知らせ：無料の日本語サポートサービスをご利用いた

だけます。現在のCignaのお客様は、IDカード裏面の電

話番号におかけ下さい。その他の方は、1-800-244-

6224におかけください。（文字電話: 番号711）。

Italian

ATTENZIONE: sono disponibili servizi di assistenza

linguistica gratuiti. Per i clientI Cigna attuali, chiamare il

numero sul retro della tessera ID. In caso contrario, chiamare

il numero 1-800-244-6224 (utenti TTY: chiamare il numero

711).

German

Achtung: Die Leistungen der Sprachunterstützung stehen

Ihnen kostenlos zur Verfügung. Für gegenwärtige Cigna-

Kunden, Bitte rufen Sie die Nummer auf der Rückseite Ihres

Personalausweises. Sonst, rufen Sie 1-800-244-6224 (TTY:

Wählen Sie 711).

Persian (Farsi)

برای : خدمات کمکی زبان، رایگان در دسترس شما است. توجه

، لطفا با شماره ای که در پشت کارت Cignaمشتریان فعلی

1- در غیر اینصورت، با شمارهشناسایی شما است تماس بگيرید.

را شماره گيری کنيد(. TTY :177) تماس بگیرید 6224-244-800

HC-NOT77 10-16 AC

myCigna.com 6

Important Information About Your

Medical Plan

The paragraph regarding “Direct Access for Mental Health

and Substance Abuse Services” shown under the Important

Information About Your Medical Plan section of your

medical certificate has been revised to show the following:

Direct Access for Mental Health and Substance Use

Disorder Services

Insureds covered by this plan are allowed direct access to a

licensed/certified Participating Provider for covered Mental

Health and Substance Use Disorder Services. There is no

requirement to obtain an authorization of care from your

Primary Care Physician for individual or group therapy visits

to the Participating Provider of your choice for Mental Health

and Substance Use Disorder Services.

HC-IMP166 12-15

AC

The Schedule

If you are enrolled in a medical plan with In- and Out-of-

Network features and subject to Out-of-Pocket maximums, the

following provision is added to The Schedule shown in your

medical certificate:

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

Out-of-Pocket Expenses are Covered Expenses incurred for

charges that are not paid by the benefit plan because of any

Deductibles, Copayments or Coinsurance. When the Out-of-

Pocket Maximum shown in The Schedule is reached, all

Covered Expenses, except charges for non-compliance

penalties, are payable by the benefit plan at 100%.

In addition, any existing “Out-of-Pocket Expenses” heading in

The Schedule of your In- and Out-of-Network medical

certificate is revised to read as follows:

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

Only

SCHED AC4

The Schedule

If The Schedule in your medical certificate contains an entry

for “Rx cap contribution to the combined Medical/Pharmacy

Out-of-Pocket Maximum” the text for “Option 2” found in

that section is replaced as follows:

Option 2: Pharmacy paid at Pharmacy Program levels until the

total Out-of-Pocket Maximum has been met, then paid at

100% for In-Network charges.

SCHED AC8

The Schedule

The following note is added to the “Maximum Reimbursable

Charge” section of The Schedule in your medical certificate:

Note:

Some providers forgive or waive the cost share obligation (e.g.

your copayment, deductible and/or coinsurance) that this plan

requires you to pay. Waiver of your required cost share

obligation can jeopardize your coverage under this plan. For

more details, see the Exclusions Section.

SCHED AC10

The Schedule

The Schedule shown in your medical certificate is amended to

accommodate the following provisions:

Any references to “Substance Abuse” are hereby replaced

with the term “Substance Use Disorder”.

The Nutritional Evaluation maximum will not apply to the

treatment of mental health and substance use disorder

conditions.

The Mental Health Inpatient heading is revised as follows:

Inpatient

Includes Acute Inpatient and Residential Treatment

The Mental Health Outpatient Physician’s Office Visit

heading is revised as follows:

Outpatient - Office Visits

Includes individual, family and group psychotherapy;

medication management, etc.

myCigna.com 7

The Mental Health Outpatient Facility heading is revised as

follows:

Outpatient - All Other Services

Includes Partial Hospitalization, Intensive Outpatient Services,

etc.

The Substance Use Disorder Inpatient heading is revised as

follows:

Inpatient

Includes Acute Inpatient Detoxification, Acute Inpatient

Rehabilitation and Residential Treatment

The Substance Use Disorder Outpatient Physician’s Office

Visit heading is revised as follows:

Outpatient - Office Visits

Includes individual, family and group psychotherapy;

medication management, etc.

The Substance Use Disorder Outpatient Facility heading is

revised as follows:

Outpatient - All Other Services

Includes Partial Hospitalization, Intensive Outpatient Services,

etc.

SCHED AC15

Certification Requirements - Out-of-Network

The following replaces any existing bullet regarding a

registered bed patient in the Pre-Admission

Certification/Continued Stay Review for Hospital

Confinement section of your medical certificate when you or

your Dependent require treatment in a Hospital:

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

stays;

HC-PAC1 11-14

V11 AC1

Certification Requirements – Out-of-Network

Any reference to “Substance Abuse” is hereby replaced with

the term “Substance Use Disorder”.

If you are enrolled in a Network Point of Service medical

benefit plan, the following replaces any existing bullet

regarding Residential Treatment Services (if not already

included) in the Pre-Admission Certification/Continued Stay

Review for Hospital Confinement section when you or your

Dependent require treatment in a Hospital:

for Mental Health or Substance Use Disorder Residential

Treatment Services.

HC-PAC44 12-15

AC

Prior Authorization/Pre-Authorized

The following replaces any existing bullet regarding inpatient

Hospital services in the Prior Authorization/Pre-Authorized

section of your medical certificate for services that require

Prior Authorization:

inpatient Hospital services, except for 48/96 hour maternity

stays;

HC-PRA1 11-14

V5 AC

Prior Authorization/Pre-Authorized

The following bullet has been added to the Services that

require Prior Authorization in the Prior Authorization/Pre-

Authorized section of your medical certificate:

Services that require Prior Authorization include, but are not

limited to:

Partial Hospitalization;

HC-PRA19 12-15

AC

Covered Expenses

The following replaces the existing “Clinical Trials”

paragraphs shown in the Covered Expenses section of your


Clinical Trials

This benefit plan covers routine patient care costs related to a

qualified clinical trial for an individual who meets the

following requirements:

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

according to the trial protocol with respect to treatment of

cancer or other life-threatening disease or condition; and

(b) either

the referring health care professional is a participating

health care provider and has concluded that the

individual’s participation in such trial would be

myCigna.com 8

appropriate based upon the individual meeting the

conditions described in paragraph (a); or

the individual provides medical and scientific

information establishing that the individual’s

participation in such trial would be appropriate based

upon the individual meeting the conditions described in

paragraph (a).

For purposes of clinical trials, the term “life-threatening

disease or condition” means any disease or condition from

which the likelihood of death is probable unless the course of

the disease or condition is interrupted.

The clinical trial must meet the following requirements:

The study or investigation must:

be approved or funded by any of the agencies or entities

authorized by federal law to conduct clinical trials;

be conducted under an investigational new drug application

reviewed by the Food and Drug Administration; or

involve a drug trial that is exempt from having such an

investigational new drug application.

Routine patient care costs are costs associated with the

provision of health care items and services including drugs,

items, devices and services otherwise covered by this benefit

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

and, in addition:

services required solely for the provision of the

investigational drug, item, device or service;

services required for the clinically appropriate monitoring of

the investigational drug, device, item or service;

services provided for the prevention of complications

arising from the provision of the investigational drug,

device, item or service; and

reasonable and necessary care arising from the provision of

the investigational drug, device, item or service, including

the diagnosis or treatment of complications.

Routine patient care costs do not include:

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

items and services that are provided solely to satisfy data

collection and analysis needs and that are not used in the

direct clinical management of the patient.

If your plan includes In-Network providers, Clinical trials

conducted by non-participating providers will be covered at

the In-Network benefit level if:

there are not In-Network providers participating in the

clinical trial that are willing to accept the individual as a

patient, or

the clinical trial is conducted outside the individual's state of

residence.

HC-COV1 10-13

V12 AC

Covered Expenses

The following replaces the “Mental Health and Substance

Abuse Services” section shown under the Covered Expenses

in your medical certificate:

Mental Health and Substance Use Disorder Services

Mental Health Services are services that are required to treat

a disorder that impairs the behavior, emotional reaction or

thought processes. In determining benefits payable, charges

made for the treatment of any physiological conditions related

to Mental Health will not be considered to be charges made

for treatment of Mental Health.

Substance Use Disorder is defined as the psychological or

physical dependence on alcohol or other mind-altering drugs

that requires diagnosis, care, and treatment. In determining

benefits payable, charges made for the treatment of any

physiological conditions related to rehabilitation services for

alcohol or drug abuse or addiction will not be considered to be

charges made for treatment of Substance Use Disorder.

Inpatient Mental Health Services

Services that are provided by a Hospital while you or your

Dependent is Confined in a Hospital for the treatment and

evaluation of Mental Health. Inpatient Mental Health Services

include Mental Health Residential Treatment Services.

Mental Health Residential Treatment Services are services

provided by a Hospital for the evaluation and treatment of the

psychological and social functional disturbances that are a

result of subacute Mental Health conditions.

Mental Health Residential Treatment Center means an

institution which specializes in the treatment of psychological

and social disturbances that are the result of Mental Health

conditions; provides a subacute, structured, psychotherapeutic

treatment program, under the supervision of Physicians;

provides 24-hour care, in which a person lives in an open

setting; and is licensed in accordance with the laws of the

appropriate legally authorized agency as a residential

treatment center.

A person is considered confined in a Mental Health

Residential Treatment Center when she/he is a registered bed

patient in a Mental Health Residential Treatment Center upon

the recommendation of a Physician.

Outpatient Mental Health Services

Services of Providers who are qualified to treat Mental Health

when treatment is provided on an outpatient basis, while you

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

provided in an individual, group or Mental Health Partial

myCigna.com 9

Hospitalization or Intensive Outpatient Therapy Program.

Covered services include, but are not limited to, outpatient

treatment of conditions such as: anxiety or depression which

interfere with daily functioning; emotional adjustment or

concerns related to chronic conditions, such as psychosis or

depression; emotional reactions associated with marital

problems or divorce; child/adolescent problems of conduct or

poor impulse control; affective disorders; suicidal or

homicidal threats or acts; eating disorders; or acute

exacerbation of chronic Mental Health conditions (crisis

intervention and relapse prevention) and outpatient testing and

assessment.

Mental Health Partial Hospitalization Services are rendered

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

hour period by a certified/licensed Mental Health program in

accordance with the laws of the appropriate legally authorized

agency.

A Mental Health Intensive Outpatient Therapy Program

consists of distinct levels or phases of treatment that are

provided by a certified/licensed Mental Health program in

accordance with the laws of the appropriate, legally authorized

agency. Intensive Outpatient Therapy Programs provide a

combination of individual, family and/or group therapy in a

day, totaling nine or more hours in a week.

Inpatient Substance Use Disorder Rehabilitation Services

Services provided for rehabilitation, while you or your

Dependent is Confined in a Hospital, when required for the

diagnosis and treatment of abuse or addiction to alcohol and/or

drugs. Inpatient Substance Use Disorder Services include

Residential Treatment services.

Substance Use Disorder Residential Treatment Services are services provided by a Hospital for the evaluation and

treatment of the psychological and social functional

disturbances that are a result of subacute Substance Use

Disorder conditions.

Substance Use Disorder Residential Treatment Center

means an institution which specializes in the treatment of

psychological and social disturbances that are the result of

Substance Use Disorder; provides a subacute, structured,

psychotherapeutic treatment program, under the supervision of

Physicians; provides 24-hour care, in which a person lives in

an open setting; and is licensed in accordance with the laws of

the appropriate legally authorized agency as a residential

treatment center.

A person is considered confined in a Substance Use Disorder


patient in a Substance Use Disorder Residential Treatment

Center upon the recommendation of a Physician.

Outpatient Substance Use Disorder Rehabilitation Services

Services provided for the diagnosis and treatment of

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

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

including outpatient rehabilitation in an individual, or a

Substance Use Disorder Partial Hospitalization or Intensive

Outpatient Therapy Program.

Substance Use Disorder Partial Hospitalization Services are

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

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

Disorder program in accordance with the laws of the

appropriate legally authorized agency.

A Substance Use Disorder Intensive Outpatient Therapy

Program consists of distinct levels or phases of treatment that

are provided by a certified/licensed Substance Use Disorder

program in accordance with the laws of the appropriate legally

authorized agency. Intensive Outpatient Therapy Programs

provide a combination of individual, family and/or group

therapy in a day, totaling nine, or more hours in a week.

Substance Use Disorder Detoxification Services

Detoxification and related medical ancillary services are

provided when required for the diagnosis and treatment of

addiction to alcohol and/or drugs. Cigna will decide, based on

the Medical Necessity of each situation, whether such services

will be provided in an inpatient or outpatient setting.

Exclusions

The following are specifically excluded from Mental Health

and Substance Use Disorder Services:

treatment of disorders which have been diagnosed as

organic mental disorders associated with permanent

dysfunction of the brain.

developmental disorders, including but not limited to,

developmental reading disorders, developmental arithmetic

disorders, developmental language disorders or

developmental articulation disorders.

counseling for activities of an educational nature.

counseling for borderline intellectual functioning.

counseling for occupational problems.

counseling related to consciousness raising.

vocational or religious counseling.

I.Q. testing.

custodial care, including but not limited to geriatric day

care.

psychological testing on children requested by or for a

school system.

occupational/recreational therapy programs even if

combined with supportive therapy for age-related cognitive

decline.

HC-COV481 12-15

AC

myCigna.com 10

Covered Expenses

The following page replaces the "Transplant Services" section

shown under the Covered Expenses section in your medical

certificate:

Transplant Services

charges made for human organ and tissue Transplant

services which include solid organ and bone marrow/stem

cell procedures at designated facilities throughout the

United States. procedures at designated facilities throughout

the United States or its territories. This coverage is subject

to the following conditions and limitations.

Transplant services include the recipient’s medical, surgical

and Hospital services; inpatient immunosuppressive

medications; and costs for organ or bone marrow/stem cell

procurement. Transplant services are covered only if they are

required to perform any of the following human to human

organ or tissue transplants: allogeneic bone marrow/stem cell,

autologous bone marrow/stem cell, cornea, heart, heart/lung,

kidney, kidney/pancreas, liver, lung, pancreas or intestine

which includes small bowel-liver or multi-visceral.

All Transplant services, other than cornea, are covered at

100% when received at Cigna LIFESOURCE Transplant

Network® facilities. Cornea transplants are not covered at

Cigna LIFESOURCE Transplant Network® facilities.

Transplant services, including cornea, received at participating

facilities specifically contracted with Cigna for those

Transplant services, other than Cigna LIFESOURCE

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

level. Transplant services received at any other facilities,

including Non-Participating Providers and Participating

Providers not specifically contracted with Cigna for

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

All Transplant services, other than cornea, must be received at

a Cigna LIFESOURCE Transplant Network® facility. Cornea

transplants are payable when received from Participating

Provider facilities other than Cigna LIFESOURCE Transplant

Network® facilities. Transplant services received at any other

facilities are not covered.

Coverage for organ procurement costs are limited to costs

directly related to the procurement of an organ, from a cadaver

or a live donor. Organ procurement costs shall consist of

surgery necessary for organ removal, organ transportation and

the transportation (refer to Transplant Travel Services),

hospitalization and surgery of a live donor. Compatibility

testing undertaken prior to procurement is covered if

Medically Necessary. Costs related to the search for, and

identification of a bone marrow or stem cell donor for an

allogeneic transplant are also covered.

Transplant Travel Services

Charges made for non-taxable travel expenses incurred by you

in connection with a preapproved organ/tissue transplant are

covered subject to the following conditions and limitations.

Transplant travel benefits are not available for cornea

transplants. Benefits for transportation and lodging are

available to you only if you are the recipient of a preapproved

organ/tissue transplant from a designated Cigna

LIFESOURCE Transplant Network® facility. The term

recipient is defined to include a person receiving authorized

transplant related services during any of the following:

evaluation, candidacy, transplant event, or post-transplant

care. Travel expenses for the person receiving the transplant

will include charges for: transportation to and from the

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

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

or traveling to and from the transplant site.

In addition to your coverage for the charges associated with

the items above, such charges will also be considered covered

travel expenses for one companion to accompany you. The

term companion includes your spouse, a member of your

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

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

of age. The following are specifically excluded travel

expenses: any expenses that if reimbursed would be taxable

income, travel costs incurred due to travel within 60 miles of

your home; food and meals; laundry bills; telephone bills;

alcohol or tobacco products; and charges for transportation

that exceed coach class rates.

These benefits are only available when the covered person is

the recipient of an organ/tissue transplant. Travel expenses for

the designated live donor for a covered recipient are covered

subject to the same conditions and limitations noted above.

Charges for the expenses of a donor companion are not

covered. No benefits are available when the covered person is

a donor.

HC-COV482 12-15

AC

myCigna.com 11

Exclusions, Expenses Not Covered and

General Limitations

The following exclusion regarding “cosmetic surgery and

therapies” under the Exclusions, Expenses Not Covered and

General Limitations section of your medical certificate is

revised as follows:

cosmetic surgery and therapies. Cosmetic surgery or therapy

is defined as surgery or therapy performed to improve or

alter appearance or self-esteem.

HC-EXC228 10-16

V1 AC


General Limitations

The following exclusion regarding “transsexual surgery”

under the Exclusions, Expenses Not Covered and General

Limitations section of your medical certificate is hereby

NULL and VOID:

transsexual surgery including medical or psychological

counseling and hormonal therapy in preparation for, or

subsequent to, any such surgery.

HC-EXC228 10-16

AC


General Limitations

The bullet regarding charges which you are not obligated to

pay found in the Exclusions, Expenses Not Covered and


revised as follows:

charges which you are not obligated to pay or for which you

are not billed or for which you would not have been billed

except that they were covered under this plan. For example,

if Cigna determines that a provider is or has waived,

reduced, or forgiven any portion of its charges and/or any

portion of copayment, deductible, and/or coinsurance

amount(s) you are required to pay for a Covered Service (as

shown on the Schedule) without Cigna’s express consent,

then Cigna in its sole discretion shall have the right to deny

the payment of benefits in connection with the Covered

Service, or reduce the benefits in proportion to the amount

of the copayment, deductible, and/or coinsurance amounts

waived, forgiven or reduced, regardless of whether the

provider represents that you remain responsible for any

amounts that your plan does not cover. In the exercise of

that discretion, Cigna shall have the right to require you to

provide proof sufficient to Cigna that you have made your

required cost share payment(s) prior to the payment of any

benefits by Cigna. This exclusion includes, but is not

limited to, charges of a Non-Participating Provider who has

agreed to charge you or charged you at an in-network

benefits level or some other benefits level not otherwise

applicable to the services received.

The following bullet is added to the Exclusions, Expenses

Not Covered and General Limitations section of your


charges arising out of or relating to any violation of a

healthcare-related state or federal law or which themselves

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

HC-EXC56 10-14

V6 AC


General Limitations

The paragraph regarding “Experimental, investigational and

unproven services” found in the Exclusions, Expenses Not

Covered and General Limitations section of your medical

certificate is revised as follows:

Experimental, investigational and unproven services are

medical, surgical, diagnostic, psychiatric, Substance Use

Disorder or other health care technologies, supplies,

treatments, procedures, drug therapies or devices that are

determined by the utilization review Physician to be:

The following bullet regarding “cosmetic surgery and

therapies” found in the Exclusions, Expenses Not Covered

and General Limitations section of your medical certificate

has been revised as follows:

cosmetic surgery and therapies. Cosmetic surgery or therapy

is defined as surgery or therapy performed to improve or

alter appearance.

The term “mental retardation” shown in the bullet regarding

“nonmedical counseling or ancillary services” found in the

Exclusions, Expenses Not Covered and General

Limitations section of your medical certificate is hereby

changed to “intellectual disabilities”.

HC-EXC190 12-15

AC

myCigna.com 12


General Limitations

The bullet regarding phase I, II or III clinical trials under the

experimental, investigational or unproven services exclusion

found in the Exclusions, Expenses Not Covered and


revised as follows:

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

except for routine patient care costs related to qualified

clinical trials as provided in the “Clinical Trials” section(s)

of this plan.

HC-EXC56 10-13

V5 AC

Expenses For Which A Third Party May

Be Responsible

The following bullets are added under the “Additional Terms”

section of your medical certificate entitled Expenses For

Which A Third Party May Be Responsible:

Additional Terms

The plan hereby disavows all equitable defenses in the

pursuit of its right of recovery. The plan’s recovery rights

are neither affected nor diminished by equitable defenses.

Participants must assist the plan in pursuing any recovery

rights by providing requested information.

HC-SUB1 04-10

V9 AC

Payment of Benefits

The following paragraph replaces the existing paragraph in the

subsection entitled “Recovery of Overpayment” found in the

Payment of Benefits section of your certificate:

Recovery of Overpayment

When an overpayment has been made by Cigna, Cigna will

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

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

the amount of that overpayment from a future claim payment.

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

assignment of Medical Benefits separately creates an equitable

lien by agreement pursuant to which Cigna may seek recovery

of any overpayment. You agree that Cigna, in seeking

recovery of any overpayment as a contractual right or as an

equitable lien by agreement, may pursue the general assets of

the person or entity to whom or on whose behalf the

overpayment was made.

HC-POB1 09-13

V7 AC

Definitions

Dependent

If Dependents are covered under the plan, the following

paragraph regarding anyone who is eligible as an Employee in

the "Dependent" definition in the Definitions section in your

medical certificate is hereby changed to read as follows:

Anyone who is eligible as an Employee will not be considered

as a Dependent spouse. A child under age 26 may be covered

as either an Employee or as a Dependent child. You cannot be

covered as an Employee while also covered as a Dependent of

an Employee.

HC-DFS734 05-14

V1 AC

Definitions

Hospital



If you are enrolled in a Network/Network Point of Service

medical benefit plan, the following replaces any existing bullet

regarding “an institution which: specializes in” (if not already

included) under the definition of “Hospital” in the Definitions

section of your medical certificate:

The term Hospital means:

an institution which: specializes in treatment of Mental

Health and Substance Use Disorder or other related illness;

provides residential treatment programs; and is licensed in

accordance with the laws of the appropriate legally

authorized agency.

HC-DFS806 12-15

AC

myCigna.com 13

Definitions

Hospital Confinement or Confined in a Hospital



If you are enrolled in a Network/Network Point of Service

medical benefit plan, the following replaces any existing page

regarding “Hospital Confinement or Confined in a Hospital”

in the Definitions section of your medical certificate:

A person will be considered Confined in a Hospital if he is:

a registered bed patient in a Hospital upon the

recommendation of a Physician;

receiving treatment for Mental Health and Substance Use

Disorder Services in a Mental Health or Substance Use

Disorder Residential Treatment Center.

HC-DFS807 12-15

AC

Definitions

Maximum Reimbursable Charge

For the definition Maximum Reimbursable Charge shown

in your medical certificate, any reference to “Substance

Abuse” is hereby replaced with the term “Substance Use

Disorder”.

HC-DFS792 05-15

V1 AC

Definitions

The following replaces any definition of “Review

Organization” that is found in your medical certificate in the

section entitled Definitions:

Review Organization

The term Review Organization refers to an affiliate of Cigna

or another entity to which Cigna has delegated responsibility

for performing utilization review services. The Review

Organization is an organization with a staff of clinicians which

may include Physicians, Registered Graduate Nurses, licensed

mental health and substance use disorder professionals, and

other trained staff members who perform utilization review

services.

HC-DFS808 12-15

AC

The following Federal Requirements replace any such

provisions shown in your Certificate.

Federal Requirements

The following pages explain your rights and responsibilities

under federal laws and regulations. Some states may have

similar requirements. If a similar provision appears elsewhere

in this booklet, the provision which provides the better benefit

will apply.

HC-FED1 10-10 AC

Notice of Provider Directory/Networks

Notice Regarding Provider Directories and Provider

Networks

A list of network providers is available to you without charge

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

ID card. The network consists of providers, including

hospitals, of varied specialties as well as general practice,

affiliated or contracted with Cigna or an organization

contracting on its behalf.

HC-FED78 10-10

AC

Special Enrollment Rights Under the Health

Insurance Portability & Accountability Act

(HIPAA)

If you or your eligible Dependent(s) experience a special

enrollment event as described below, you or your eligible

Dependent(s) may be entitled to enroll in the Plan outside of a

designated enrollment period upon the occurrence of one of

the special enrollment events listed below. If you are already

enrolled in the Plan, you may request enrollment for you and

your eligible Dependent(s) under a different option offered by

the Employer for which you are currently eligible. If you are

not already enrolled in the Plan, you must request special

enrollment for yourself in addition to your eligible

Dependent(s). You and all of your eligible Dependent(s) must

be covered under the same option. The special enrollment

events include:

Acquiring a new Dependent. If you acquire a new

Dependent(s) through marriage, birth, adoption or

placement for adoption, you may request special enrollment

for any of the following combinations of individuals if not

already enrolled in the Plan: Employee only; spouse only;

Employee and spouse; Dependent child(ren) only;

Employee and Dependent child(ren); Employee, spouse and

Dependent child(ren). Enrollment of Dependent children is

myCigna.com 14

limited to the newborn or adopted children or children who

became Dependent children of the Employee due to

marriage.

HC-FED71 12-14

AC

Special Enrollment Rights Under the Health


(HIPAA)

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 no later than the

first day of the first calendar month following receipt of

the request for special enrollment.

HC-FED71 12-14

V1 AC

Effect of Section 125 Tax Regulations on This

Plan

Your Employer has chosen to administer this Plan in

accordance with Section 125 regulations of the Internal

Revenue Code. Per this regulation, you may agree to a pretax

salary reduction put toward the cost of your benefits.

Otherwise, you will receive your taxable earnings as cash

(salary).

A. Coverage Elections

Per Section 125 regulations, you are generally allowed to

enroll for or change coverage only before each annual benefit

period. However, exceptions are allowed if your Employer

agrees and you enroll for or change coverage within 30 days

of the following:

the date you meet the Special Enrollment criteria described

above; or

the date you meet the criteria shown in the following

Sections B through H.

B. Change of Status

A change in status is defined as:

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

spouse, divorce, annulment or legal separation;

change in number of Dependents due to birth, adoption,

placement for adoption, or death of a Dependent;

change in employment status of Employee, spouse or

Dependent due to termination or start of employment,

strike, lockout, beginning or end of unpaid leave of absence,

including under the Family and Medical Leave Act

(FMLA), or change in worksite;

changes in employment status of Employee, spouse or

Dependent resulting in eligibility or ineligibility for

coverage;

change in residence of Employee, spouse or Dependent to a

location outside of the Employer’s network service area;

and

changes which cause a Dependent to become eligible or

ineligible for coverage.

C. Court Order

A change in coverage due to and consistent with a court order

of the Employee or other person to cover a Dependent.

D. Medicare or Medicaid Eligibility/Entitlement

The Employee, spouse or Dependent cancels or reduces

coverage due to entitlement to Medicare or Medicaid, or

enrolls or increases coverage due to loss of Medicare or

Medicaid eligibility.

E. Change in Cost of Coverage

If the cost of benefits increases or decreases during a benefit

period, your Employer may, in accordance with plan terms,

automatically change your elective contribution.

When the change in cost is significant, you may either

increase your contribution or elect less-costly coverage. When

a significant overall reduction is made to the benefit option

you have elected, you may elect another available benefit

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

your election to the new benefit option.

F. Changes in Coverage of Spouse or Dependent Under

Another Employer’s Plan

You may make a coverage election change if the plan of your

spouse or Dependent: incurs a change such as adding or

deleting a benefit option; allows election changes due to

Special Enrollment, Change in Status, Court Order or

Medicare or Medicaid Eligibility/Entitlement; or this Plan and

the other plan have different periods of coverage or open

enrollment periods.

G. Reduction in work hours

If an Employee’s work hours are reduced below 30

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

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

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

Minimum Essential Coverage (MEC). The new coverage must

be effective no later than the 1st day of the 2

nd month following

the month that includes the date the original coverage is

revoked.

myCigna.com 15

H. Enrollment in Qualified Health Plan (QHP)

The Employee must be eligible for a Special Enrollment

Period to enroll in a QHP through a Marketplace or the

Employee wants to enroll in a QHP through a Marketplace

during the Marketplace’s annual open enrollment period; and

the disenrollment from the group plan corresponds to the

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

through a Marketplace for new coverage effective beginning

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

original coverage.

HC-FED70 12-14

AC1

Eligibility for Coverage for Adopted Children

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

placed with you for adoption, will be eligible for Dependent

Insurance, if otherwise eligible as a Dependent, upon the date

of placement with you. A child will be considered placed for

adoption when you become legally obligated to support that

child, totally or partially, prior to that child’s adoption.

If a child placed for adoption is not adopted, all health

coverage ceases when the placement ends, and will not be

continued.

The provisions in the “Exception for Newborns” section of

this document that describe requirements for enrollment and

effective date of insurance will also apply to an adopted child

or a child placed with you for adoption.

HC-FED67 09-14

AC

Women’s Health and Cancer Rights Act

(WHCRA)

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

Health and Cancer Rights Act of 1998, provides benefits for

mastectomy-related services including all stages of

reconstruction and surgery to achieve symmetry between the

breasts, prostheses, and complications resulting from a

mastectomy, including lymphedema? Call Member Services at

the toll free number listed on your ID card for more

information.

HC-FED12 10-10

AC

Pre-Existing Conditions Under the Health


(HIPAA)

Any Pre-existing Condition Limitation under this plan will no

longer be imposed.

HC-FED32 04-11

AC1

Obtaining a Certificate of Creditable Coverage

Under This Plan

The section entitled “Obtaining a Certificate of Creditable

Coverage Under This Plan” shown under the Federal

Requirements provision of your medical certificate is hereby

removed.

Upon loss of coverage under this Plan, a Certificate of

Creditable Coverage will be mailed to each terminating

individual at the last address on file. You or your Dependent

may also request a Certificate of Creditable Coverage, without

charge, at any time while enrolled in the Plan and for 24

months following termination of coverage. You may need this

document as evidence of your prior coverage to reduce any

pre-existing condition limitation period under another plan, to

help you get special enrollment in another plan, or to obtain

certain types of individual health coverage even if you have

health problems. To obtain a Certificate of Creditable

Coverage, contact the Plan Administrator or call the toll-free

customer service number on the back of your ID card.

HC-FED15 10-10

AC

Claim Determination Procedures

The following complies with federal law. Provisions of

applicable laws of your state may supersede.

Procedures Regarding Medical Necessity Determinations

In general, health services and benefits must be Medically

Necessary to be covered under the plan. The procedures for

determining Medical Necessity vary, according to the type of

service or benefit requested, and the type of health plan.

Medical Necessity determinations are made on a preservice,

concurrent, or postservice basis, as described below:

Certain services require prior authorization in order to be

covered. The booklet describes who is responsible for

obtaining this review. You or your authorized representative

(typically, your health care professional) must request prior

authorization according to the procedures described below, in

myCigna.com 16

the booklet, and in your provider’s network participation

documents as applicable.

When services or benefits are determined to be not covered,

you or your representative will receive a written description of

the adverse determination, and may appeal the determination.

Appeal procedures are described in the booklet, in your

provider’s network participation documents as applicable, and

in the determination notices.

Preservice Determinations

When you or your representative requests a required prior

authorization, Cigna will notify you or your representative of

the determination within 15 days after receiving the request.

However, if more time is needed due to matters beyond

Cigna’s control, Cigna will notify you or your representative

within 15 days after receiving your request. This notice will

include the date a determination can be expected, which will

be no more than 30 days after receipt of the request. If more

time is needed because necessary information is missing from

the request, the notice will also specify what information is

needed, and you or your representative must provide the

specified information to Cigna within 45 days after receiving

the notice. The determination period will be suspended on the

date Cigna sends such a notice of missing information, and the

determination period will resume on the date you or your

representative responds to the notice.

If the determination periods above would seriously jeopardize

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

or in the opinion of a health care professional with knowledge

of your health condition, cause you severe pain which cannot

be managed without the requested services, Cigna will make

the preservice determination on an expedited basis. Cigna will

defer to the determination of the treating health care

professional regarding whether an expedited determination is

necessary. Cigna will notify you or your representative of an

expedited determination within 72 hours after receiving the

request.

However, if necessary information is missing from the

request, Cigna will notify you or your representative within 24

hours after receiving the request to specify what information is

needed. You or your representative must provide the specified

information to Cigna within 48 hours after receiving the

notice. Cigna will notify you or your representative of the

expedited benefit determination within 48 hours after you or

your representative responds to the notice. Expedited

determinations may be provided orally, followed within 3 days

by written or electronic notification.

If you or your representative fails to follow Cigna’s

procedures for requesting a required preservice determination,

Cigna will notify you or your representative of the failure and

describe the proper procedures for filing within 5 days (or 24

hours, if an expedited determination is required, as described

above) after receiving the request. This notice may be

provided orally, unless you or your representative requests

written notification.

Concurrent Determinations

When an ongoing course of treatment has been approved for

you and you wish to extend the approval, you or your

representative must request a required concurrent coverage

determination at least 24 hours prior to the expiration of the

approved period of time or number of treatments. When you

or your representative requests such a determination, Cigna

will notify you or your representative of the determination

within 24 hours after receiving the request.

Postservice Determinations

When you or your representative requests a coverage

determination or a claim payment determination after services

have been rendered, Cigna will notify you or your

representative of the determination within 30 days after

receiving the request. However, if more time is needed to

make a determination due to matters beyond Cigna’s control,

Cigna will notify you or your representative within 30 days

after receiving the request. This notice will include the date a

determination can be expected, which will be no more than 45

days after receipt of the request.

If more time is needed because necessary information is

missing from the request, the notice will also specify what

information is needed, and you or your representative must

provide the specified information to Cigna within 45 days

after receiving the notice. The determination period will be

suspended on the date Cigna sends such a notice of missing

information, and the determination period will resume on the

date you or your representative responds to the notice.

Notice of Adverse Determination

Every notice of an adverse benefit determination will be

provided in writing or electronically, and will include all of

the following that pertain to the determination: information

sufficient to identify the claim including, if applicable, the

date of service, provider and claim amount; diagnosis and

treatment codes, and their meanings; the specific reason or

reasons for the adverse determination including, if applicable,

the denial code and its meaning and a description of any

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

plan provisions on which the determination is based; a

description of any additional material or information necessary

to perfect the claim and an explanation of why such material

or information is necessary; a description of the plan’s review

procedures and the time limits applicable, including a

statement of a claimant’s rights to bring a civil action under

section 502(a) of ERISA following an adverse benefit

determination on appeal, (if applicable); upon request and free

of charge, a copy of any internal rule, guideline, protocol or

other similar criterion that was relied upon in making the

adverse determination regarding your claim; and an

myCigna.com 17

explanation of the scientific or clinical judgment for a

determination that is based on a Medical Necessity,

experimental treatment or other similar exclusion or limit; a

description of any available internal appeal and/or external

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

insurance consumer assistance or ombudsman available to

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

involving urgent care, a description of the expedited review

process applicable to such claim.

HC-FED79 03-13

AC

Medical - When You Have a Complaint or an

Appeal

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

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

you to act on your behalf; unless otherwise noted.

We want you to be completely satisfied with the care you

receive. That is why we have established a process for

addressing your concerns and solving your problems.

Start With Customer Service

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

regarding a person, a service, the quality of care, contractual

benefits, or a rescission of coverage, you may call the toll-

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

claim form and explain your concern to one of our Customer

Service representatives. You may also express that concern

in writing.

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

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

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

any case within 30 days. If you are not satisfied with the

results of a coverage decision, you may start the appeals

procedure.

Internal Appeals Procedure

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

in writing to Cigna within 180 days of receipt of a denial

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

should be approved and include any information supporting

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

ask Cigna to register your appeal by telephone. Call or write

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

benefits, or claim form.

Your appeal will be reviewed and the decision made by

someone not involved in the initial decision. Appeals

involving Medical Necessity or clinical appropriateness will

be considered by a health care professional.

We will respond in writing with a decision within 30 calendar

days after we receive an appeal for a required preservice or

concurrent care coverage determination or a postservice

Medical Necessity determination. We will respond within 60

calendar days after we receive an appeal for any other

postservice coverage determination. If more time or

information is needed to make the determination, we will

notify you in writing to request an extension of up to 15

calendar days and to specify any additional information

needed to complete the review.

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

considered, relied upon or generated by Cigna in connection

with the appeal, this information will be provided

automatically to you as soon as possible and sufficiently in

advance of the decision, so that you will have an opportunity

to respond. Also, if any new or additional rationale is

considered by Cigna, Cigna will provide the rationale to you

as soon as possible and sufficiently in advance of the decision

so that you will have an opportunity to respond.

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

the time frames under this process would seriously jeopardize

your life, health or ability to regain maximum functionality or

in the opinion of your health care provider would cause you

severe pain which cannot be managed without the requested

services; or (b) your appeal involves nonauthorization of an

admission or continuing inpatient Hospital stay.

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

above, you may also ask for an expedited external review at

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

would be detrimental to your medical condition.

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

decision within 72 hours, followed up in writing.

External Review Procedure

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

internal appeal review and the appeal involves medical

judgment or a rescission of coverage, you may request that

your appeal be referred to an Independent Review

Organization (IRO). The IRO is composed of persons who are

not employed by Cigna, or any of its affiliates. A decision to

request an external review to an IRO will not affect the

claimant's rights to any other benefits under the plan.

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

and your benefit plan will abide by the decision of the IRO.

To request a review, you must notify the Appeals Coordinator

within 4 months of your receipt of Cigna's appeal review

denial. Cigna will then forward the file to a randomly selected

IRO. The IRO will render an opinion within 45 days.

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

medical condition, as determined by Cigna's reviewer, or if

your appeal concerns an admission, availability of care,

continued stay, or health care item or service for which you

myCigna.com 18

received emergency services, but you have not yet been

discharged from a facility, the external review shall be

completed within 72 hours.

Notice of Benefit Determination on Appeal

Every notice of a determination on appeal will be provided in

writing or electronically and, if an adverse determination, will

include: information sufficient to identify the claim including,

if applicable, the date of service, provider and claim amount;

diagnosis and treatment codes, and their meanings; the

specific reason or reasons for the adverse determination

including, if applicable, the denial code and its meaning and a

description of any standard that was used in the denial;

reference to the specific plan provisions on which the

determination is based; a statement that the claimant is entitled

to receive, upon request and free of charge, reasonable access

to and copies of all documents, records, and other Relevant

Information as defined below; a statement describing any

voluntary appeal procedures offered by the plan and the

claimant’s right to bring an action under ERISA section

502(a), if applicable; upon request and free of charge, a copy

of any internal rule, guideline, protocol or other similar

criterion that was relied upon in making the adverse

determination regarding your appeal, and an explanation of the

scientific or clinical judgment for a determination that is based

on a Medical Necessity, experimental treatment or other

similar exclusion or limit; and information about any office of

health insurance consumer assistance or ombudsman available

to assist you in the appeal process. A final notice of an adverse

determination will include a discussion of the decision.

You also have the right to bring a civil action under section

502(a) of ERISA if you are not satisfied with the decision on

review. You or your plan may have other voluntary alternative

dispute resolution options such as Mediation. One way to find

out what may be available is to contact your local U.S.

Department of Labor office and your State insurance

regulatory agency. You may also contact the Plan

Administrator.

Relevant Information

Relevant Information is any document, record or other

information which: was relied upon in making the benefit

determination; was submitted, considered or generated in the

course of making the benefit determination, without regard to

whether such document, record, or other information was

relied upon in making the benefit determination; demonstrates

compliance with the administrative processes and safeguards

required by federal law in making the benefit determination;

or constitutes a statement of policy or guidance with respect to

the plan concerning the denied treatment option or benefit for

the claimant's diagnosis, without regard to whether such

advice or statement was relied upon in making the benefit

determination.

Legal Action

If your plan is governed by ERISA, you have the right to bring

a civil action under section 502(a) of ERISA if you are not

satisfied with the outcome of the Appeals Procedure. In most

instances, you may not initiate a legal action against Cigna

until you have completed the appeal processes. However, no

action will be brought at all unless brought within 3 years after

a claim is submitted for In-Network Services or within three

years after proof of claim is required under the Plan for Out-

of-Network services.

HC-FED82 03-14

AC

COBRA Continuation Rights Under Federal

Law

For You and Your Dependents

Who is Entitled to COBRA Continuation?

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

elect to continue health insurance coverage. A qualified

beneficiary may include the following individuals who were

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

you, your spouse, and your Dependent children. Each

qualified beneficiary has their own right to elect or decline

COBRA continuation coverage even if you decline or are not

eligible for COBRA continuation.

The following individuals are not qualified beneficiaries for

purposes of COBRA continuation: domestic partners,

grandchildren (unless adopted by you), stepchildren (unless

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

independent right to elect COBRA continuation coverage, if

you elect COBRA continuation coverage for yourself, you

may also cover your Dependents even if they are not

considered qualified beneficiaries under COBRA. However,

such individuals’ coverage will terminate when your COBRA

continuation coverage terminates. The sections titled

“Secondary Qualifying Events” and “Medicare Extension For

Your Dependents” are not applicable to these individuals.

HC-FED54 12-13

AC1

myCigna.com 19

COBRA Continuation Rights Under Federal

Law


The following paragraphs regarding the “Trade Act of 2002”

are hereby rendered NULL and VOID:

Trade Act of 2002

The Trade Act of 2002 created a new tax credit for certain

individuals who become eligible for trade adjustment

assistance and for certain retired Employees who are receiving

pension payments from the Pension Benefit Guaranty

Corporation (PBGC) (eligible individuals). Under the new tax

provisions, eligible individuals can either take a tax credit or

get advance payment of 72.5% of premiums paid for qualified

health insurance, including continuation coverage. If you have

questions about these new tax provisions, you may call the

Health Coverage Tax Credit Customer Contact Center toll-free

at 1-866-628-4282. TDD/TYY callers may call toll-free at 1-

866-626-4282. More information about the Trade Act is also

available at www.doleta.gov/tradeact.

In addition, if you initially declined COBRA continuation

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

(TAA) benefits and the tax credit, you may be eligible for a

special 60 day COBRA election period. The special election

period begins on the first day of the month that you become

TAA-eligible. If you elect COBRA coverage during this

special election period, COBRA coverage will be effective on

the first day of the special election period and will continue for

18 months, unless you experience one of the events discussed

under “Termination of COBRA Continuation” above.

Coverage will not be retroactive to the initial loss of coverage.

If you receive a determination that you are TAA-eligible, you

must notify the Plan Administrator immediately.

HC-FED66 07-14

AC

Medical Conversion Privilege/Conversion

Available Following Continuation

Any provisions regarding “Medical Conversion Privilege” or

“Conversion Available Following Continuation” under this

plan are hereby NULL and VOID.

HC-FED66 07-14

AC1

myCigna.com 1




called Cigna)

CERTIFICATE RIDER

No. CR7BIASO35-4


Rider Eligibility: Each Employee as reported to the insurance company by your Employer

Policy No. or Nos. 3320020-OAP2


You will become insured on the date you become eligible if you are in Active Service on that date or if you are

not in Active Service on that date due to your health status. If you are not insured for the benefits described in

your certificate on that date, the effective date of this certificate rider will be the date you become insured.

This certificate rider forms a part of the certificate issued to you by Cigna describing the benefits provided under

the policy(ies) specified above.

HC-RDR1 04-10

V1

myCigna.com 2

The sections entitled Calendar Year Deductible and Out-of-Pocket Maximum in THE SCHEDULE — Open Access Plus

Medical Benefits — in your certificate are changed to read as attached.

The page in your certificate coded HC-DFS673 V1 is replaced by the page coded HC-DFS673 V1 M attached to this certificate

rider.

myCigna.com 3

Open Access Plus Medical Benefits

The Schedule

BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK .

Calendar Year Deductible

Individual

$500 per person $1,000 per person

Family Maximum

$1,000 per family $2,000 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 $2,000 per person $4,000 per person

Family Maximum

$4,000 per family $8,000 per family

Family Maximum Calculation

Individual Calculation:

Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%.

myCigna.com 4

Definitions

Dependent

Dependents are:

your lawful spouse; and

any child of yours who is:

less than 26 years old.

26 or more years old, unmarried, and primarily supported

by you and incapable of self-sustaining employment by

reason of mental or physical disability which arose while

the child was covered as a Dependent under this Plan, or

while covered as a dependent under a prior plan with no

break in coverage.

Proof of the child's condition and dependence must be

submitted to Cigna within 31 days after the date the child

ceases to qualify above. From time to time, but not more

frequently than once a year, Cigna may require proof of

the continuation of such condition and dependence.

The term child means a child born to you or a child legally

adopted by you. It also includes a stepchild or a child for

whom you are the legal guardian.

Anyone who is eligible as an Employee will not be considered

as a Dependent spouse. A child under age 26 may be covered

as either an Employee or as a Dependent child. You cannot be

covered as an Employee while also covered as a Dependent of

an Employee.

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

Employee.

HC-DFS673 07-14

V1 M

myCigna.com 1




called Cigna)

CERTIFICATE RIDER

No. CR7MNASO35-3


Rider Eligibility: Each Employee who resides in Massachusetts

Policy No. or Nos. 3320020-OAP2


You will become insured on the date you become eligible if you are in Active Service on that date or if you are

not in Active Service on that date due to your health status. If you are not insured for the benefits described in

your certificate on that date, the effective date of this certificate rider will be the date you become insured.

This certificate rider forms a part of the certificate issued to you by Cigna describing the benefits provided under

the policy(ies) specified above.

HC-RDR1 04-10

V1

myCigna.com 2

The pages in your certificate coded HC-MANCR1 and HC-MANCR2V3 are replaced by the pages coded HC-MANCR1 and

HC-MANCR2V4 attached to this certificate rider.

myCigna.com 3

Notice To Massachusetts Residents

This Open Access Plus Medical

Benefits health plan, alone, does not

meet Minimum Creditable

Coverage standards and will not

satisfy the individual mandate that

you have health insurance. For

additional information, please see the

section “Massachusetts Requirement

to Purchase Health Insurance,”

immediately preceding the Schedule.

HC-MANCR1

myCigna.com 4

Massachusetts Requirement To Purchase Health Insurance:

This Open Access Plus Medical Benefits health plan, alone, does not meet Minimum Creditable Coverage standards

that are effective January 1, 2016, as part of the Massachusetts Health Care Reform Law because:

Prescription drugs are not covered.

The out-of-pocket maximum does not include one or more of the following for in-network services: all copayments of

any size, coinsurance, deductibles, or similar charges for Essential Health Benefits.

If you purchase this health plan only, you will not satisfy the statutory requirement that you have health insurance meeting

these standards.

If this health plan is offered to you through your place of employment, contact your employer or other plan sponsor to

determine if it offers other health plan options that meet Minimum Creditable Coverage standards. Your employer or other

plan-sponsor also may offer supplemental plans you can add to this insured health plan in order to meet Minimum

Creditable Coverage.

If this health plan is not offered to you through your place of employment and you want to learn about other health plan

options available to individuals, you may contact the Division of Insurance by calling (617) 521-7794 or visiting its

website at www.mass.gov/doi, or the Connector by calling 1-877-MA-ENROLL or visiting its website at

www.mahealthconnector.org.

THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS THAT ARE EFFECTIVE

JANUARY 1, 2016. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN

MATERIAL EACH YEAR TO DETERMINE WHETHER YOUR PLAN MEETS THE LATEST STANDARDS.

If you have questions about this notice, you may contact the Division of Insurance by calling (617) 521-7794 or

visiting its website at www.mass.gov/doi.

HC-MANCR2V4

Loudoun County School Board

EXTRATERRITORIAL LEGISLATION


ETALLM17A

3320020

This document printed in December, 2016 takes the place of any documents previously issued to you which

described your benefits.

Printed in U.S.A.

Table of Contents

IMPORTANT INFORMATION ............................................................................................................................ 4

CERTIFICATE RIDER – Arkansas Residents ...................................................................................................... 5

CERTIFICATE RIDER – Colorado Residents ...................................................................................................... 7

CERTIFICATE RIDER – Connecticut Residents .................................................................................................. 8

CERTIFICATE RIDER – Delaware Residents ...................................................................................................... 8

CERTIFICATE RIDER – Florida Residents ........................................................................................................ 11

CERTIFICATE RIDER – Georgia Residents ...................................................................................................... 14

CERTIFICATE RIDER – Idaho Residents .......................................................................................................... 16

CERTIFICATE RIDER – Illinois Residents ........................................................................................................ 20

CERTIFICATE RIDER – Kansas Residents ........................................................................................................ 21

CERTIFICATE RIDER – Kentucky Residents .................................................................................................... 21

CERTIFICATE RIDER – Louisiana Residents.................................................................................................... 26

CERTIFICATE RIDER – Maine Residents ......................................................................................................... 28

CERTIFICATE RIDER – Maryland Residents .................................................................................................... 31

CERTIFICATE RIDER – Massachusetts Residents ............................................................................................ 33

CERTIFICATE RIDER – Minnesota Residents .................................................................................................. 35

CERTIFICATE RIDER – Missouri Residents ..................................................................................................... 37

CERTIFICATE RIDER – Nebraska Residents .................................................................................................... 39

CERTIFICATE RIDER – New Hampshire Residents ......................................................................................... 39

CERTIFICATE RIDER – New Jersey Residents ................................................................................................. 40

CERTIFICATE RIDER – New Mexico Residents............................................................................................... 40

CERTIFICATE RIDER – North Carolina Residents ........................................................................................... 53

CERTIFICATE RIDER – Ohio Residents ........................................................................................................... 54

CERTIFICATE RIDER – Oregon Residents ....................................................................................................... 61

CERTIFICATE RIDER – Pennsylvania Residents .............................................................................................. 64

CERTIFICATE RIDER – South Carolina Residents ........................................................................................... 67

CERTIFICATE RIDER – Texas Residents .......................................................................................................... 67

CERTIFICATE RIDER – Utah Residents ........................................................................................................... 77

CERTIFICATE RIDER – Vermont Residents ..................................................................................................... 79

CERTIFICATE RIDER – Wyoming Residents ................................................................................................... 87

myCigna.com 4


called Cigna)

CERTIFICATE RIDER


Rider Eligibility: Each Employee as noted within this certificate rider

Policy No. or Nos.: 3320020

Effective Date: January 1, 2017

This rider forms a part of the certificate issued to you by Cigna describing the benefits provided under the

policy(ies) specified above. This rider replaces any other issued to you previously.

IMPORTANT INFORMATION

For Residents of States other than the State of Virginia:

State-specific riders contain provisions that may add to or change your certificate provisions.

The provisions identified in your state-specific rider, attached, are ONLY applicable to Employees residing in

that state. The state for which the rider is applicable is identified at the beginning of each state specific rider in the

"Rider Eligibility" section.

Additionally, the provisions identified in each state-specific rider only apply to:

(a) Benefit plans made available to you and/or your Dependents by your Employer;

(b) Benefit plans for which you and/or your Dependents are eligible;

(c) Benefit plans which you have elected for you and/or your Dependents;

(d) Benefit plans which are currently effective for you and/or your Dependents.

Please refer to the Table of Contents for the state-specific rider that is applicable for your residence state.

HC-ETRDR

myCigna.com 5

CIGNA HEALTH AND LIFE INSURANCE

COMPANY, a Cigna company (hereinafter called

Cigna)

CERTIFICATE RIDER – Arkansas Residents

Rider Eligibility: Each Employee who is located in Arkansas

You will become insured on the date you become eligible,

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

your health status.

This rider forms a part of the certificate issued to you by

Cigna.

The provisions set forth in this rider comply with the legal

requirements of Arkansas for group insurance plans covering

insureds located in Arkansas. These provisions supersede any

provisions in your certificate to the contrary unless the

provisions in your certificate result in greater benefits.

HC-ETARRDR

Eligibility – Effective Date

Dependent Insurance

Exception for Adopted Children

Any Dependent child adopted by you while you are insured

will become insured from the date the adopted child is placed

with you, or from the date you file the petition for adoption, if

you elect Dependent Insurance no later than 90 days from the

date of the petition for adoption, or from the date of

placement, whichever is later. A newborn adopted child will

become insured from the moment of birth, if the petition is

filed and if you elect Dependent Insurance no later than 90

days from the child’s birth.

If you do not elect to insure your adopted child within such 90

days, or if your petition for adoption is dismissed or denied, no

benefits for expenses incurred beyond the 90th day following

placement or filing of the petition to adopt, whichever is later,

will be payable.

HC-ELG1 04-10

V23-ET2

Covered Expenses

charges made for anesthesia, hospitalization services and/or

ambulatory surgical facility charges performed in

connection with dental procedures when such services are

required to effectively perform the procedures and the

patient is:

under seven years of age and it is determined by two

dentists that treatment in a hospital or ambulatory surgical

center is required without delay due to a significantly

complex dental condition;

a person with a serious diagnosed mental or physical

condition; or

a person with a significant behavioral problem as

determined by their Physician.

charges for colorectal cancer examinations and laboratory

tests for covered persons who are fifty years of age or older;

less than fifty years of age and at high risk for colorectal

cancer according to American Cancer Society colorectal

cancer screening guidelines as they existed on January 1,

2005; or are experiencing the following symptoms of

colorectal cancer as determined by a Physician: bleeding

from the rectum or blood in the stool; or a change in bowel

habits, such as diarrhea, constipation, or narrowing of the

stool, that lasts more than five days.

The colorectal screening shall involve an examination of the

entire colon, including the following examinations and

laboratory tests:

an annual fecal occult blood test utilizing the take-home

multiple sample method, or an annual fecal

immunochemical test in conjunction with a flexible

sigmoidoscopy every five years;

a double-contrast barium enema every five years; or

a colonoscopy every ten years; and any additional

medically recognized screening tests for colorectal cancer

required by the Director of the Department of Health, as

determined in consultation with appropriate health care

organizations.

charges for prostate cancer examinations and laboratory

tests once a year for non-symptomatic covered persons who

are forty years of age or older in accordance with the

National Comprehensive Cancer Guidelines.

The following applies only to state employees and public

school employees:

charges for diagnosis and treatment of autism spectrum

disorder, as defined in the most recent edition of the

“Diagnostic and Statistical Manual of Mental Disorders”.

The following treatment is covered when Medically

Necessary and evidence-based:

applied behavior analysis;

myCigna.com 6

pharmacy care;

psychiatric care;

psychological care;

therapeutic care;

equipment determined necessary to provide evidence-

based treatment;

any care determined to be Medically Necessary and

evidence-based.

In addition, Covered Expenses will include expenses incurred

at any of the Approximate Age Intervals shown below for a

Dependent child who is age 18 or less, for charges made for

Child Preventive Care Services consisting of the following

services delivered or supervised by a Physician, in keeping

with prevailing medical standards:

a history;

physical examination;

development assessment;

anticipatory guidance;

appropriate immunizations, which are not subject to any

copay, coinsurance, deductible, or dollar limit; and

laboratory tests;

excluding any charges for:

more than one visit to one provider for Child Preventive

Care Services at each of the Approximate Age Intervals up

to a total of 20 visits for each Dependent child;

services for which benefits are otherwise provided under

this Comprehensive Medical Benefits section;

services for which benefits are not payable according to the

Expenses Not Covered section.

Approximate Age Intervals are: Birth, 2 weeks, 2 months, 4

months, 6 months, 9 months, 12 months, 15 months, 18

months, 2 years, 3 years, 4 years, 5 years, 6 years, 8 years, 10

years, 12 years, 14 years, 16 years, and 18 years.

charges made for family planning, including medical

history, physical exam, related laboratory tests, medical

supervision in accordance with generally accepted medical

practices, other medical services, information and

counseling on contraception, implanted/injected

contraceptives, after appropriate counseling, medical

services connected with surgical therapies (tubal ligations,

vasectomies).

charges made for corrective surgery and related medical

care for Covered Persons of any age diagnosed as having a

craniofacial anomaly if the surgery and treatment are

Medically Necessary to improve a functional impairment, as

determined by a nationally accredited cleft-craniofacial

team. Medical care coverage includes dental care, vision

care, and the use of at least one hearing aid. Craniofacial

anomaly means a congenital or acquired musculoskeletal

disorder that primarily affects the cranial facial tissue.

charges for gastric pacemakers to treat gastroparesis, a

neuromuscular stomach disorder in which food empties into

the stomach more slowly than normal.

Telemedicine

Charges for covered services performed through telemedicine

on the same basis and to the same extent as the same service

would be covered if provided in-person.

Telemedicine means the medium of delivering clinical

healthcare services by means of real-time two-way

electronic audio-visual communications, including

without limitation the application of secure video

conferencing, to provide or support the healthcare

delivery that facilitates the assessment, diagnosis,

consultation, or treatment of a patient’s health care while

the patient is at an Originating Site and the healthcare

professional is at a Distant Site.

Distant Site means the location of the healthcare

professional delivering healthcare services through

telemedicine at the time the services are provided.

Originating Site means the offices of a healthcare

professional or a licensed healthcare entity where the

patient is located at the time services are provided by a

healthcare professional through telemedicine; and the

home of a patient in connection with treatment for end-

stage renal disease.

HC-COV145 04-10

V4-ET2

Covered Expenses

External Prosthetic Appliances and Devices

charges for orthotic and prosthetic devices and services will

be no less than eighty percent (80%) of Medicare allowable

charges as defined by the Center of Medicare Medicaid

Services, Health care Common Procedure Coding System as

of January 1, 2009. Devices must be prescribed and

provided by a licensed doctor of medicine, doctor of

osteopathy, or doctor of podiatric medicine, an orthotist, or

prosthetist, and are subject to prior authorization.

Deductibles, co-payments and co-insurance provisions will

not be more restrictive than those that apply to other

medical conditions.

HC-COV9 04-10

V9 ET

myCigna.com 7

Definitions

Dependent


adopted by you from the date you file a petition for adoption.

HC-DFS705 10-15

V1-ET



Cigna)

CERTIFICATE RIDER – Colorado Residents

Rider Eligibility: Each Employee who is located in Colorado



your health status.


Cigna.


requirements of Colorado group insurance plans covering

insureds located in Colorado. These provisions supersede any



HC-ETCORDR

Definitions

Dependent

Dependents include:

your lawful spouse or your partner in a Civil Union;

HC-DFS675 01-15

V2-ET

Emergency Service Provider

The term Emergency Service Provider means a local

government, or an authority formed by two or more local

governments, that provide fire-fighting and fire prevention

services, emergency medical services, ambulance services, or

search and rescue services, or a not-for-profit non-

governmental entity organized for the purpose of providing

any such services, through the use of bona fide volunteers.

HC-DFS236 04-10

V1-ET

Employee

The term Employee means a full-time employee of the

Employer who is currently in Active Service. The term does

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

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

The term Employee may include officers, managers and

Employees of the Employer, the bona fide volunteers if the

Employer is an Emergency Service Provider, the partners if

the Employer is a partnership, the officers, managers, and

Employees of subsidiary or affiliated corporations of a

corporation Employer, and the individual proprietors,

partners, and Employees of individuals and firms, the

business of which is controlled by the insured Employer

through stock ownership, contract, or otherwise.

HC-DFS239 04-10

V1-ET

Employer

The term Employer means the Policyholder and all Affiliated

Employers. The term Employer may include an Emergency

Service Provider, any municipal or governmental corporation,

unit, agency or department thereof, and the proper officers, as

such, of an Emergency Service Provider or an unincorporated

municipality or department thereof, as well as private

individuals, partnerships, and corporations.

HC-DFS240 04-10

V1-ET

myCigna.com 8



Cigna)

CERTIFICATE RIDER – Connecticut Residents

Rider Eligibility: Each Employee who is located in

Connecticut



your health status.


Cigna.


requirements of Connecticut group insurance plans covering

insureds located in Connecticut. These provisions supersede

any provisions in your certificate to the contrary unless the


HC-ETCTRDR

Certification Requirements - Out-of-Network


Pre-Admission Certification/Continued Stay Review for

Hospital Confinement

Covered Expenses incurred will be reduced by the lesser of

50% or the amount of the penalty under the plan or $500

(whichever is less) for Hospital charges made for each

separate admission to the Hospital unless PAC is received:

prior to the date of admission; or in the case of an

emergency admission, within 48 hours after the date of

admission.

Covered Expenses incurred for which benefits would

otherwise be payable under this plan for the charges listed

below will be reduced by the lesser of 50% or the amount of

the penalty under the plan or $500 (whichever is less):

Hospital charges for Bed and Board, for treatment listed

above for which PAC was performed, which are made for

any day in excess of the number of days certified through

PAC or CSR.

The following only applies if the plan includes Outpatient

Certification Requirements:

Covered Expenses incurred will be reduced by the lesser of

the amount of the penalty under the plan, $500 or 50% for

charges made for any outpatient diagnostic testing or

procedure performed unless Outpatient Certification is

received prior to the date the testing or procedure is

performed.

HC-PAC2 10-14

V2-ET

Definitions

Dependent

Federal rights may not be available to same-sex spouses, or

Civil Union partners or Dependents.

Connecticut law allows same-sex marriages, and grants parties

to a civil union the same benefits, protections and

responsibilities that flow from marriage under state law.

However, some or all of the benefits, protections and

responsibilities related to health insurance that are available to

married persons of the opposite sex under federal law may not

be available to same-sex spouses, or parties to a civil union.

HC-DFS673 01-15

V5-ET2



Cigna)

CERTIFICATE RIDER – Delaware Residents

Rider Eligibility: Each Employee who is located in Delaware



your health status.


Cigna.


requirements of Delaware group insurance plans covering

insureds located in Delaware. These provisions supersede any



HC-ETDERDR

myCigna.com 9

Covered Expenses

charges made for treatment of Serious Mental Illness. Such

Covered Expenses will be payable the same as for other

illnesses. Any Mental Illness Maximums in the Schedule

and any Full Payment Area exceptions for mental illness

will not apply to Serious Mental Illness.

HC-COV446 01-15

V2-ET1

When You Have A Complaint Or An

Appeal

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

or "Member" also refers to a representative or provider

designated by you to act on your behalf, unless otherwise

noted.




Start with Member Services

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

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

you can call our toll-free number and explain your concern to

one of our Customer Service representatives. You can also

express that concern in writing. Please call or write to us at the

following:

Customer Services Toll-Free Number or address that

appears on your Benefit Identification card, explanation

of benefits or claim form.




any case within 30 days.

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

you can start the appeals procedure.

Appeals Procedure

Cigna has a two step appeals procedure for coverage

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

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




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

the toll-free number or address on your Benefit Identification

card, explanation of benefits or claim form.

Level One Appeal





For level one appeals, we will respond in writing with a

decision within fifteen calendar days after we receive an

appeal for a required preservice or concurrent care coverage

determination (decision). We will respond within 30 calendar

days after we receive an appeal for a postservice coverage

determination. If more time or information is needed to make

the determination, we will notify you in writing to request an

extension of up to 15 calendar days and to specify an

additional information needed to complete the review.

You may request that the appeal process be expedited if, the

time frames under this process would seriously jeopardize

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

the opinion of your Physician would cause you severe pain

which cannot be managed without the requested services; or

your appeal involves nonauthorization of an admission or

continuing inpatient Hospital stay. Cigna's Physician reviewer,

in consultation with the treating Physician, will decide if an

expedited appeal is necessary. When an appeal is expedited,

we will respond orally with a decision within 72 hours,

followed up in writing.

Level Two Appeal

If you are dissatisfied with our level one appeal decision, you

may request a second review. To start a level two appeal,

follow the same process required for a level one appeal.

Most requests for a second review will be conducted by the

Appeals Committee, which consists of at least three people.

Anyone involved in the prior decision may not vote on the

Committee. For appeals involving Medical Necessity or

clinical appropriateness, the Committee will consult with at

least one Physician reviewer in the same or similar specialty

as the care under consideration, as determined by Cigna's

Physician reviewer. You may present your situation to the

Committee in person or by conference call.

For level two appeals we will acknowledge in writing that we

have received your request and schedule a Committee review.

For required preservice and concurrent care coverage

determinations, the Committee review will be completed

within 15 calendar days. For postservice claims, the

Committee review will be completed within 30 calendar days.

If more time or information is needed to make the

determination, we will notify you in writing to request an

extension of up to 15 calendar days and to specify any

additional information needed by the Committee to complete

the review. You will be notified in writing of the Committee's

decision within five working days after the Committee

meeting, and within the Committee review time frames above

if the Committee does not approve the requested coverage.



myCigna.com 10






in consultation with the treating Physician will decide if an




Independent Review Procedure

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

two appeal review regarding your Medical Necessity or

clinical appropriateness issue, you may request that your

appeal be referred to an Independent Review Organization.

The Independent Review Organization is composed of persons

who are not employed by Cigna HealthCare or any of its

affiliates. A decision to use the voluntary level of appeal will

not affect the claimant's rights to any other benefits under the

plan.

There is no charge for you to initiate this independent review

process. Cigna will abide by the decision of the Independent

Review Organization.

In order to request a referral to an Independent Review

Organization, certain conditions apply. The reason for the

denial must be based on a Medical Necessity or clinical

appropriateness determination by Cigna. Administrative,

eligibility or benefit coverage limits or exclusions are not

eligible for appeal under this process.


within 180 days of your receipt of Cigna's level-two appeal

review denial. Cigna will then forward the file to the

Independent Review Organization.

The Independent Review Organization will render an opinion

within 30 days. When requested and when a delay would be

detrimental to your condition, as determined by Cigna's

Physician reviewer, the review shall be completed within 3

days.

The Independent Review Program is a voluntary program

arranged by Cigna.

Appeal to the State of Delaware

You have the right to appeal a claim denial for medical

reasons or to appeal a claim denial for non-medical reasons to

the Delaware Insurance Department. The Delaware Insurance

Department also provides free informal mediation services

which are in addition to, but do not replace, your right to

appeal this decision. You can contact the Delaware Insurance

Department for information about an appeal or mediation by

calling the Consumer Services Division at (302) 674-7310.

You may go to the Delaware Insurance Department at The

Rodney Building, 841 Silver Lake Blvd., Dover, DE 19904

between the hours of 8:30 a.m. and 4:00 p.m. to personally

discuss the appeal or mediation process. You may also wish to

submit a complaint by sending an email to the Delaware

Insurance Department at [email protected], or by

using the complaint form, found at

http://www.delawareinsurance.gov/complaint/complaintform.

pdf and faxing the complaint to (302) 739-6278.

All appeals must be filed within 60 days from the date you

receive this notice otherwise this decision will be final.




include: the specific reason or reasons for the adverse

determination; reference to the specific plan provisions on

which the determination is based; a statement that the claimant

is entitled to receive, upon request and free of charge,

reasonable access to and copies of all documents, records, and

other Relevant Information as defined; a statement describing

any voluntary appeal procedures offered by the plan and the

claimant's right to bring an action under ERISA section

502(a); upon request and free of charge, a copy of any internal

rule, guideline, protocol or other similar criterion that was

relied upon in making the adverse determination regarding

your appeal, and an explanation of the scientific or clinical

judgment for a determination that is based on a Medical

Necessity, experimental treatment or other similar exclusion

or limit.

You also have the right to bring a civil action under Section







Administrator.


Relevant Information is any document, record, or other

information which was relied upon in making the benefit

determination; was submitted, considered, or generated in the







the plan concerning the denied treatment option or benefit or



determination.

Legal Action


a civil action under Section 502(a) of ERISA if you are not

myCigna.com 11



until you have completed the Level One and Level Two

Appeal processes. If your Appeal is expedited, there is no

need to complete the Level Two process prior to bringing

legal action.

HC-APL63 04-10

V1-ET



Cigna)

CERTIFICATE RIDER – Florida Residents

Rider Eligibility: Each Employee who is located in Florida

The benefits of the policy providing your coverage are

primarily governed by the law of a state other than

Florida.



your health status.


Cigna.


requirements of Florida group insurance plans covering

insureds located in Florida. These provisions supersede any



HC-ETFLRDR


Dependent Insurance

Effective Date of Dependent Insurance

Insurance for your Dependents will become effective on the

date you elect it by signing an approved payroll deduction

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

Dependent Insurance. All of your Dependents as defined will

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

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

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

coverage will be offered at an additional premium. Coverage

for an adopted child will become effective from the date of

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

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

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

placement in your home, coverage will be offered at an

additional premium.

HC-ELG9 04-10

V1-ET


Medical plan

Direct Access For A Dermatologist

Individuals covered by this plan may have direct access to any

participating dermatologist for a maximum of 5 visits per

contract year without an authorization of care. The 5 visits do

not have to be with the same provider. Any additional visits

will require authorization. Included in this benefit are

management of the dermatologic condition as well as minor

procedures. All other procedures that are not minor will

require prior authorization.

HC-IMP174 12-15

ET1

Covered Expenses

charges made for or in connection with mammograms for

breast cancer screening or diagnostic purposes, including,

but not limited to: a baseline mammogram for women ages

35 through 39; a mammogram for women ages 40 through

49, every two years or more frequently based on the

attending Physician's recommendations; a mammogram

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

mammograms upon the recommendation of a Physician for

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

family history; has biopsy proven benign breast disease; or

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

covered with or without a Physician’s recommendation,

provided the mammogram is performed at an approved

facility for breast cancer screening.

charges made for diagnosis and Medically Necessary

surgical procedures to treat dysfunction of the

temporomandibular joint. Appliances and non-surgical

treatment including for orthodontia are not covered.

charges for the treatment of cleft lip and cleft palate

including medical, dental, speech therapy, audiology and

nutrition services, when prescribed by a Physician.

myCigna.com 12

charges for general anesthesia and hospitalization services

for dental procedures for an individual who is under age 8

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

child's Physician that treatment in a Hospital or ambulatory

surgical center is necessary due to a significantly complex

dental condition or developmental disability in which

patient management in the dental office has proven to be

ineffective; or has one or more medical conditions that

would create significant or undue medical risk if the

procedure were not rendered in a Hospital or ambulatory

surgical center.

charges for the services of certified nurse-midwives,

licensed midwives, and licensed birth centers regardless of

whether or not such services are received in a home birth

setting.

charges for or in connection with Medically Necessary

diagnosis and treatment of osteoporosis for high risk

individuals. This includes, but is not limited to individuals

who: have vertebral abnormalities; are receiving long-term

glucocorticoid (steroid) therapy; have primary

hyperparathyroidism; have a family history of osteoporosis;

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

risk for osteoporosis.

charges for an inpatient Hospital stay following a

mastectomy will be covered for a period determined to be

Medically Necessary by the Physician and in consultation

with the patient. Postsurgical follow-up care may be

provided at the Hospital, Physician's office, outpatient

center, or at the home of the patient.

charges for newborn and infant hearing screening and

Medically Necessary follow-up evaluations. When ordered

by the treating Physician, a newborn’s hearing screening

must include auditory brainstem responses or evoked

otacoustic emissions or other appropriate technology

approved by the FDA. All screenings shall be conducted by

a licensed audiologist, Physician, or supervised individual

who has training specific to newborn hearing screening.

Newborn means an age range from birth through 29 days.

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

In addition, Covered Expenses will include expenses incurred

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

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

Child Preventive Care Services consisting of the following

services delivered or supervised by a Physician, in keeping

with prevailing medical standards:

a history;

physical examination;

development assessment;

anticipatory guidance; and

appropriate immunizations and laboratory tests;



Care Services at each of the Approximate Age Intervals, up

to a total of 18 visits for each Dependent child;


this Covered Expenses section;

services for which benefits are not payable, according to the


It is provided that any Deductible that would otherwise apply

will be waived for those Covered Expenses incurred for Child

Preventive Care Services. Approximate Age Intervals are:

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

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

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

HC-COV25 04-10

V1-ET1

Medical Conversion Privilege


When a person's Medical Expense Insurance ceases, he may

be eligible to be insured under an individual policy of medical

care benefits (called the Converted Policy).

A Converted Policy will be issued by Cigna only to a person

who:

resides in a state that requires offering a conversion

policy,

is Entitled to Convert, and

applies in writing and pays the first premium for the

Converted Policy to Cigna within 31 days after the date

his insurance ceases. Evidence of good health is not

needed.

Employees Entitled to Convert

You are Entitled to Convert Medical Expense Insurance for

yourself and all of your Dependents who were insured when

your insurance ceased but only if:

you are not eligible for other individual insurance coverage

on a guaranteed issue basis.

you have been insured for at least three consecutive months

under the policy or under it and a prior policy issued to the

Policyholder.

your insurance ceased because you were no longer in Active

Service or no longer eligible for Medical Expense

Insurance.

you are not eligible for Medicare.

you would not be Overinsured.

myCigna.com 13

you have paid all required premium or contribution.

you have not performed an act or practice that constitutes

fraud in connection with the coverage.

you have not made an intentional misrepresentation of a

material fact under the terms of the coverage.

your insurance did not cease because the policy in its

entirety canceled.

If you retire, you may apply for a Converted Policy within 31

days after your retirement date in place of any continuation of

your insurance that may be available under this plan when you

retire, if you are otherwise Entitled to Convert.

Dependents Entitled to Convert

The following Dependents are also Entitled to Convert:

a child who is not eligible for other individual insurance

coverage on a guaranteed issue basis, and whose insurance

under this plan ceases because he no longer qualifies as a

Dependent or because of your death;

a spouse who is not eligible for other individual insurance

coverage on a guaranteed issue basis, and whose insurance

under this plan ceases due to divorce, annulment of

marriage or your death;

your Dependents whose insurance under this plan ceases

because your insurance ceased solely because you are

eligible for Medicare;

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

insurance coverage on a guaranteed issue basis, is not eligible

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

premium or contribution, has not performed an act or practice

that constitutes fraud in connection with the coverage, and has

not made an intentional misrepresentation of a material fact

under the terms of the coverage.

Overinsured

A person will be considered Overinsured if either of the

following occurs:

his insurance under this plan is replaced by similar group

coverage within 31 days.

the benefits under the Converted Policy, combined with

Similar Benefits, result in an excess of insurance based on

Cigna's underwriting standards for individual policies.

Similar Benefits are: those for which the person is covered by

another hospital, surgical or medical expense insurance policy,

or a hospital, or medical service subscriber contract, or a

medical practice or other prepayment plan or by any other

plan or program; those for which the person is eligible,

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

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

by or through any state, provincial or federal law.

Converted Policy

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

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

current conversion policy offerings available in the state

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

The Converted Policy will be issued to you if you are Entitled

to Convert, insuring you and those Dependents for whom you

may convert. If you are not Entitled to Convert and your

spouse and children are Entitled to Convert, it will be issued to

the spouse, covering all such Dependents. Otherwise, a

Converted Policy will be issued to each Dependent who is

Entitled to Convert. The Converted Policy will take effect on

the day after the person's insurance under this plan ceases. The

premium on its effective date will be based on: class of risk

and age; and benefits.

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

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

amount payable under the Converted Policy and the Medical

Benefits Extension of this plan (if any) will not be more than

the amount that would have been payable under this plan if the

person's insurance had not ceased. After that, the amount

payable under the Converted Policy will be reduced by any

amount still payable under the Medical Benefits Extension of

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

request, further details of the Converted Policy.

HC-CNV28 04-14

V1-ET

Medical Benefits Extension Upon Policy

Cancellation

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

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

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

Sickness or pregnancy, Medical Benefits will be paid for

Covered Expenses incurred in connection with that Injury,

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

the earliest of:

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

the Schedule;

the date a succeeding carrier agrees to provide coverage

without limitation for the disabling condition;

the date you are no longer Totally Disabled;

12 months from the date the policy is canceled; or

for pregnancy, until delivery.

myCigna.com 14

Totally Disabled

You will be considered Totally Disabled if, because of an

Injury or a Sickness:

you are unable to perform the basic duties of your

occupation; and

you are not performing any other work or engaging in any

other occupation for wage or profit.

Your Dependent will be considered Totally Disabled if,

because of an Injury or a Sickness:

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

the same age, sex and ability; or

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

profit, he is not performing such work.

HC-BEX42 04-11

ET

Definitions

Dependent

A child includes a legally adopted child, including that child

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

that a written agreement to adopt such child has been entered

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

adopted child will include the necessary care and treatment of

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

or adoption. Coverage is not required if the adopted child is

ultimately not placed in your home.

A child includes a child born to an insured Dependent child of

yours until such child is 18 months old.

HC-DFS162 07-14

V2-ET



Cigna)

CERTIFICATE RIDER – Georgia Residents

Rider Eligibility: Each Employee who is located in Georgia



your health status.


Cigna.


requirements of Georgia group insurance plans covering

insureds located in Georgia. These provisions supersede any



HC-ETGARDR


Appeal

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



noted.






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

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

explain your concern to one of our Customer Service

representatives. Please call us at the Customer Service Toll-

Free Number that appears on your Benefit Identification card,

explanation of benefits or claim form.







Appeals Procedure



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

notice, to the following address:

Cigna

National Appeals Organization (NAO)

PO Box 188011

Chattanooga, TN 37422

You should state the reason why you feel your appeal should

be approved and include any information supporting your

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

to register your appeal by telephone. Call us at the toll-free

number on your Benefit Identification card, explanation of

benefits or claim form.

myCigna.com 15

Level-One Appeal





For level-one appeals, we will respond in writing with a

decision within 15 calendar days after we receive an appeal

for a required preservice or concurrent care coverage












(b) your appeal involves nonauthorization of an admission or

continuing inpatient Hospital stay.


above, you may also ask for an expedited external

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

an expedited level-one appeal would be detrimental to your

medical condition.

Cigna's Physician Reviewer, in consultation with the treating

Physician, will decide if an expedited appeal is necessary.

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


Level Two Appeal




Requests for a level-two appeal regarding the Medical

Necessity or clinical appropriateness of your issue will be

conducted by a Committee, which consists of at least three

people not previously involved in the prior decision. The

Committee will consult with at least one Physician in the same

or similar specialty as the care under consideration, as

determined by Cigna's Physician Reviewer. You may present

your situation to the Committee in person or by conference

call.




Committee review will be completed within 30 calendar days.





the review. In the event any new or additional information

(evidence) is considered, relied upon or generated by Cigna in

connection with the level-two appeal, Cigna will provide this

information to you as soon as possible and sufficiently in






You will be notified in writing of the Committee's decision

within five working days after the Committee meeting, and

within the Committee review time frames above if the

Committee does not approve the requested coverage.







continuing inpatient Hospital stay. Cigna's Physician

Reviewer, in consultation with the treating Physician will

decide if an expedited appeal is necessary. When an appeal is

expedited, we will respond orally with a decision within 72

hours, followed up in writing.


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

level two appeal review and the appeal involves medical

judgment or a rescission of coverage, you may request that

your appeal be referred to an Independent Review

Organization. The Independent Review Organization is

composed of persons who are not employed by Cigna

HealthCare or any of its affiliates. A decision to request an

appeal to an Independent Review Organization will not

affect the claimant's rights to any other benefits under the

plan.

There is no charge for you to initiate this independent

review process. Cigna will abide by the decision of the


To request a review, you must notify the Appeals

Coordinator within 180 days of your receipt of Cigna's level

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

the Independent Review Organization.

The Independent Review Organization will render an

opinion within 45 days. When requested and if a delay

would be detrimental to your condition, as determined by

Cigna's Physician Reviewer, or if your appeal concerns an

admission, availability of care, continued stay, or health

care item or service for which you received emergency

services, but you have no yet been discharged from the

facility, the review shall be completed within 72 hours.

myCigna.com 16




include: information sufficient to identify the claim; the

specific reason or reasons for the adverse determination;





Information as defined; a statement describing any voluntary

appeal procedures offered by the plan and the claimant's right

to bring an action under ERISA section 502(a); upon request

and free of charge, a copy of any internal rule, guideline,

protocol or other similar criterion that was relied upon in

making the adverse determination regarding your appeal, and

an explanation of the scientific or clinical judgment for a


experimental treatment or other similar exclusion or limit; and

information about any office of health insurance consumer

assistance or ombudsman available to assist you in the appeal

process. A final notice of adverse determination will include a

discussion of the decision.








Administrator.














determination.

Legal Action




instances, you may not initiate a legal action against Cigna in

federal court until you have completed the level one and level

two Appeal processes. If your Appeal is expedited, there is no

need to complete the level two process prior to bringing legal

action. However, no action will be brought at all unless

brought within 3 years after a claim is submitted for In-

Network Services or within three years after proof of claim is

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

Appeal to the State of Georgia

You have the right to contact the Department of Insurance or

the Department of Human Resources for assistance at any

time. The Department of Insurance or the Department of

Human Resources may be contacted at the following

respective addresses and telephone numbers:

Georgia Department of Insurance

2 Martin Luther King, Jr. Drive

Floyd Memorial Bldg, 704 West Tower

Atlanta, GA 30334

404-656-2056

Georgia Dept. of Human Resources

Two Peachtree Street, NW

Suite 33.250

Atlanta, GA 30303-3167

404-657-5550

HC-APL46 05-14

V2-ET



Cigna)

CERTIFICATE RIDER – Idaho Residents

Rider Eligibility: Each Employee who is located in Idaho



your health status.


Cigna.


requirements of Idaho group insurance plans covering insureds

located in Idaho. These provisions supersede any provisions in

your certificate to the contrary unless the provisions in your

certificate result in greater benefits.

HC-ETIDRDR

myCigna.com 17


Appeal




noted.




Start with Customer Service





representatives. Please call us at the Customer Service toll-free

number that appears on your Benefit Identification card,








Appeals Procedure

Cigna has a two-step appeals procedure for coverage




Cigna


PO Box 188011








Level One Appeal














You may request that the appeal process be expedited if: (a)


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

the opinion of your Physician, would cause you severe pain


(b) your appeal involves non-authorization of an admission or






medical condition.

Cigna's Physician Reviewer, in consultation with the treating




Level Two Appeal




If the appeal involves a coverage decision based on issues of

Medical Necessity, clinical appropriateness or experimental

treatment, a medical review will be conducted by a Physician

Reviewer in the same or similar specialty as the care under

consideration, as determined by Cigna’s Physician Reviewer.

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

review will be conducted by someone who was not involved

in any previous decision related to your appeal and who was

not a subordinate of previous decision makers. Provide all

relevant documentation with your second-level appeal request.

For required pre-service and concurrent care coverage

determinations, the review will be completed within 15

calendar days. For post-service claims, the review will be

completed within 30 calendar days. If more time or







with the level-two appeal, Cigna will provide this information

to you as soon as possible and sufficiently in advance of the

decision, so that you will have an opportunity to respond.

Also, if any new or additional rationale is considered by

Cigna, Cigna will provide the rationale to you as soon as

possible and sufficiently in advance of the decision so that you

will have an opportunity to respond.

myCigna.com 18

You will be notified in writing of the decision within five

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

time frames above if Cigna does not approve the requested

coverage.

You may request that the appeal process be expedited if: the


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

the opinion of your Physician, would cause you severe pain


your appeal involves non-authorization of an admission or

continuing inpatient Hospital stay. Cigna's Physician

Reviewer, in consultation with the treating Physician will




Your Right To An Independent External Review

Please read this notice carefully. It describes a procedure

for review of a disputed health claim by a qualified

professional who has no affiliation with your health plan.

If you request an independent external review of your

claim, the decision made by the independent reviewer will

be binding and final on the health carrier. Except in

limited circumstances, you will have no further right to

have further review of your claim reviewed by a court,

arbitrator, mediator or other dispute resolution entity only

if your plan is subject to the Employee Retirement Income

Security Act of 1974 (ERISA), as more fully explained

below under “Binding Nature of the External Review

Decision."

If we issue a final adverse benefit determination of your

request to provide or pay for a health care service or supply,

you may have the right to have our decision reviewed by

health care professionals who have no association with us.

You have this right only if our denial decision involved:

The Medical Necessity, appropriateness, health care setting,

level of care, or effectiveness of your health care service or

supply, or

Our determination your health care service or supply was

investigational.

You must first exhaust our internal grievance and appeal

process. Exhaustion of that process includes completing all

levels of appeal, or unless you requested or agreed to a delay,

our failure to respond to a standard appeal within 35 days in

writing or to an urgent appeal within three (3) business days of

the date you filed your appeal. We may also agree to waive the

exhaustion requirement for an external review request. You

may file for an internal urgent appeal with us and for an

expedited external review with the Idaho Department of

Insurance at the same time if your request qualifies as an

“urgent care request” defined below.

You may submit a written request for an external review to:

Idaho Department of Insurance

ATTN: External Review

700 W State St., 3rd Floor

Boise, Idaho 83720-0043

For more information and for an external review request form:

See the department’s website at: http://www.doi.idaho.gov,

or

Call the department’s telephone number, (208) 334-4250, or

toll-free in Idaho, 1-800-721-3272.

You may represent yourself in your request or you may name

another person, including your treating health care provider, to

act as your authorized representative for your request. If you

want someone else to represent you, you must include a signed

“Appointment of an Authorized Representative” form with

your request.

Your written external review request to the Department of

Insurance must include a completed form authorizing the

release of any of your medical records the independent review

organization may require to reach a decision on the external

review, including any judicial review of the external review

decision pursuant to ERISA, if applicable. The department

will not act on an external review request without your

completed authorization form.

If your request qualifies for external review, our final adverse

benefit determination will be reviewed by an independent

review organization selected by the department. We will pay

the costs of the review.

Standard External Review Request: You must file your

written external review request with the department within

four months after the date we issue a final notice of denial.

Within seven (7) days after the department receives your

request, the department will send a copy to us.

Within 14 days after we receive your request from the

department, we will review your request for eligibility.

Within five business days after we complete that review, we

will notify you and the department in writing if your request

is eligible or what additional information is needed. If we

deny your eligibility for review, you may appeal that

determination to the department.

If your request is eligible for review, the department will

assign an independent review organization to your review

within seven days of receipt of our notice. The department

will also notify you in writing.

Within seven (7) days of the date you receive the

department’s notice of assignment to an independent review

organization, you may submit any additional information in

writing to the independent review organization that you

want the organization to consider in its review.

myCigna.com 19

The independent review organization must provide written

notice of its decision to you, to us and to the department

within 42 days after receipt of an external review request.

Expedited External Review Request: You may file a written

“urgent care request” with the department for an expedited

external review of a pre-service or concurrent service denial.

You may file for an internal urgent appeal with us and for an

expedited external review with the department at the same

time.

Urgent care request means a claim relating to an admission,

availability of care, continued stay or health care service for

which the covered person received emergency services but has

not been discharged from a facility, or any pre-service or

concurrent care claim for medical care or treatment for which

application of the time periods for making a regular external

review determination:

Could seriously jeopardize the life or health of the covered

person or the ability of the covered person to regain

maximum function;

In the opinion of the treating health care professional with

knowledge of the covered person’s medical condition,

would subject the covered person to severe pain that cannot

be adequately managed without the disputed care or

treatment; or

The treatment would be significantly less effective if not

promptly initiated.

The department will send your request to us. We will

determine, no later than the second full business day, if your

request is eligible for review. We will notify you and the

department no later than one (1) business day after our

decision if your request is eligible. If we deny your eligibility

for review, you may appeal that determination to the

department.

If your request is eligible for review, the department will

assign an independent review organization to your review

upon receipt of our notice. The department will also notify

you. The independent review organization must provide notice

of its decision to you, to us and to the department within 72

hours after the date of receipt of the external review request.

The independent review organization must provide written

confirmation of its decision within 48 hours of notice of its

decision. If the decision reverses our denial, we will notify

you and the department of the approval of coverage (and our

intent to pay the covered benefit) as soon as reasonably

practicable but not later than one (1) business day after

making the determination receiving notice of the decision.

Binding Nature of the External Review Decision: If your

plan is subject to federal ERISA laws (generally, any plan

offered through an employer to its employees), the external

review decision by the independent review organization will

be final and binding on us. You may have additional review

rights provided under federal ERISA laws.

If your plan is not subject to ERISA requirements, the external

review decision by the independent review organization will

be final and binding on both you and us. This means that if

you elect to request external review, you will be bound by

the decision of the independent review organization. You

will not have any further opportunity for review of our

denial after the independent review organization issues its

final decision. If you choose not to use the external review

process, other options for resolving a disputed claim may

include mediation, arbitration or filing an action in court.

Under Idaho law, the independent review organization is

immune from any claim relating to its opinion rendered or acts

or omissions performed within the scope of its duties unless

performed in bad faith or involving gross negligence.






























Administrator.






myCigna.com 20









determination.

Legal Action





until you have completed the level one and level two Appeal

processes. If your Appeal is expedited, there is no need to

complete the level two process prior to bringing legal action.

However, no action will be brought at all unless brought

within three years after a claim is submitted for In-Network

services or within three years after proof of claim is required

under the Plan for Out-of-Network services.

HC-APL234 1-15

ET



Cigna)

CERTIFICATE RIDER – Illinois Residents

Rider Eligibility: Each Employee who is located in Illinois



your health status.


Cigna.


requirements of Illinois group insurance plans covering

insureds located in Illinois. These provisions supersede any



HC-ETILRDR

The Schedule

If your medical plan is subject to a Lifetime Maximum or

Preventive Care Maximum, The Schedule is amended to

indicate that Mammogram charges do not accumulate towards

those maximums. In addition, In-Network Preventive Care

Related (i.e. “routine”) Mammograms will be covered at “No

charge”.

SCHEDIL-ETC

Covered Expenses

charges made for or in connection with low-dose

mammography screening for detecting the presence of

breast cancer. Coverage shall include: a baseline

mammogram for women ages 35 to 39; an annual

mammogram for women age 40 and older; and

mammograms at intervals considered Medically Necessary

for women less than age 40 who have a family history of

breast cancer, prior personal history of breast cancer,

positive genetic testing or other risk factors. Coverage also

includes a comprehensive ultrasound screening of an entire

breast or breasts if a mammogram demonstrates

heterogeneous or dense breast tissue, when determined

Medically Necessary by a Physician licensed to practice

medicine in all of its branches.

Low dose mammography means the x-ray examination of

the breast using equipment dedicated specifically for

mammography, including the x-ray tube, compression

device and image receptor, with radiation exposure

delivery of less than one rad per breast for two views of

an average size breast.

charges made for complete and thorough clinical breast

exams performed by a Physician licensed to practice

medicine in all its branches, an advanced practice nurse who

has a collaborative agreement with a collaborating

Physician that authorizes breast examinations, or a

Physician assistant who has been delegated authority to

provide breast examinations. Coverage shall include such an

exam at least once every three years for women ages 20 to

40; and annually for women 40 years of age or older.

HC-COV430 08-15

V1-ET2

myCigna.com 21



Cigna)

CERTIFICATE RIDER – Kansas Residents

Rider Eligibility: Each Employee who is located in Kansas



your health status.


Cigna.


requirements of Kansas group insurance plans covering

insureds located in Kansas. These provisions supersede any



HC-ETKSRDR

Covered Expenses

abortion when a Physician certifies in writing that the

pregnancy would endanger the life of the mother, or when

the expenses are incurred to treat medical complications due

to abortion.

HC-COV103 04-10

V1-ET2



Cigna)

CERTIFICATE RIDER – Kentucky Residents

Rider Eligibility: Each Employee who is located in Kentucky



your health status.


Cigna.


requirements of Kentucky group insurance plans covering

insureds located in Kentucky. These provisions supersede any



HC-ETKYRDR

Covered Expenses

charges for cochlear implants for persons age 2 and over

with the diagnosis of profound sensorineural deafness or

postlingual deafness in adults. Cochlear implants for

children under age 2 will be covered when, upon review,

they are determined to be Medically Necessary.

charges for the diagnosis and treatment of Autism Spectrum

Disorders:

treatment for Autism Spectrum Disorders includes

medical care, habilitative or rehabilitative care, pharmacy

if covered by the plan, psychiatric care, psychological

care, therapeutic care, and applied behavior analysis

prescribed or ordered by a licensed health professional.

coverage is not subject to visit limits. Coverage is not

subject to copayments, deductibles, or coinsurance that is

less favorable than those applied to other covered

services.

Cigna may request utilization review of the treatment

once every 12 months, unless Cigna and the covered

person’s licensed Physician, psychiatrist, or psychologist

agree that a more frequent review is necessary

myCigna.com 22

Liaisons are available to facilitate communication between

You and Cigna regarding Autism Spectrum Disorder

coverage. The responsibilities of the liaison include:

explaining to the member the benefits for the treatment of

autism under the member's health benefit plan and the

specific process to access those benefits;

explaining to the member the process for prior authorization

of treatment, including communicating specific

documentation needed from the member or provider for the

insurer to consider the request;

monitoring the adjudication of a member’s claims for the

treatment of autism services;

explaining to the member the proper coding to use when

submitting claims for applied behavioral analysis therapy

and any supporting documentation required to be attached

to the claim;

explaining to the member, upon request, how claims for the

treatment of autism services were adjudicated, including the

application of any deductibles, copayments, coinsurance,

and benefit limitations; and

explaining to the member, upon request, any appeal rights

the member may have regarding coverage for the treatment

of autism that has been denied or limited.

charges for a telehealth consultation provided the treating

Physician or other provider facilitating the use of telehealth

ensures that: informed consent of the patient or another

person with authority to make the health care treatment

decision for the patient, is obtained before covered services

are provided through telehealth; and that the confidentiality

of the patient's medical information and quality of care

protocols are maintained. Telehealth means the use of

interactive, audio, video or other electronic media to deliver

health care. It includes the use of electronic media for

diagnosis, consultation, treatment, transfer of medical data

and medical education.

charges for the necessary care and treatment of medically

diagnosed inherited metabolic diseases. Coverage must

include amino acid modified preparations and low protein

modified food products for the treatment of inherited

metabolic diseases provided that the amino acid products

are prescribed as Medically Necessary for the therapeutic

treatment of inherited metabolic diseases, and are

administered under the direction of a Physician.

HC-COV523 05-15

ET1


Appeal




noted.


















Appeals Procedure

Cigna has a one step appeal procedure for coverage decisions.

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

in writing, within 365 days of receipt of a denial notice, to the

following address:

Cigna


PO Box 188011


You may also initiate an appeal when Cigna has not made and

provided written notice of an initial utilization review

determination within allowable time frames. You should state

the reason why you feel your appeal should be approved and

include any information supporting your appeal. If you are

unable or choose not to write, you may ask to register your

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

Benefit Identification card, explanation of benefits or claim

form.

Internal Appeals

You, an authorized person, or a provider, acting on your

behalf, may request an internal appeal if you are dissatisfied

with the initial Medical Necessity or clinical appropriateness

decision or a coverage denial decision, or we have failed to

make and communicate in writing an initial Medical Necessity

or clinical appropriateness determination within allowable

time frames.

myCigna.com 23

Under federal law, you are allowed up to four (4) months after

the date of receipt of a notice of adverse determination or final

adverse determination to file a request for external review.

Coverage Denial Appeals

Your appeal of a Coverage Denial determination for which a

service, treatment, prescription drug, or device is specifically

limited, excluded or denied under the plan will be reviewed

and the decision made by someone not involved in the initial

decision and not a subordinate of previous decision makers.

Provide all relevant documentation with your appeal request.


determinations, Cigna’s review will be completed within 30

calendar days of the receipt of your appeal request. For

postservice claims, Cigna’s review will be completed within

30 calendar days. In the event any new or additional

information (evidence) is considered, relied upon or generated

by Cigna in connection with the appeal, Cigna will provide

this information to you as soon as possible and sufficiently in








time frames above. Notification of the appeal review decision

will be provided to you and any designated representative and

provider(s) acting on your behalf.

Medical Necessity Appeals

Your appeal of Cigna's adverse determination, decision to

deny, reduce or terminate a medical service based on a

determination that it is not Medically Necessary or is

experimental or investigational, will be considered by a

Physician, or upon your request, by a reviewer, in the same or

similar specialty as the care under consideration, who was not

involved in the initial decision as determined by Cigna's

Physician Reviewer.



calendar days of the receipt of your appeal request. For

postservice claims, Cigna’s review will be completed within

30 calendar days. In the event any new or additional


by Cigna in connection with your appeal, Cigna will provide

this information to you as soon as possible and sufficiently in






You will be notified in writing of the decision to uphold or

reverse the decision of the Physician Reviewer within five


time frames above. Notification of the appeal review decision

will be provided to you and any designated representative and

provider(s) acting on your behalf.

Expedited Internal Appeals

An expedited appeal will be provided when you are

hospitalized or as requested when the treating provider is of

the opinion that review under a standard time frame could, in

the absence of immediate medical attention, result in any of

the effects listed in the following paragraph.

You may request that the appeal process be expedited for an

appeal of a Medical Necessity Adverse Determination or an

appeal of a Coverage Denial if: (a) the time frames under this

process would seriously jeopardize your life or health, or with

respect to a pregnant woman, the life or health of the unborn

child; or the ability to regain maximum function; or result in

serious impairment to bodily functions or serious dysfunction

of a bodily organ or part; or in the opinion of your Physician

would cause you severe pain which cannot be managed

without the requested services; or (b) your appeal involves

nonauthorization of an admission or continuing inpatient

Hospital stay.




an expedited internal appeal would be detrimental to your

medical condition.


decision within 72 hours of receipt of the appeal request,

followed up in writing within three working days.

Reconsideration of an Internal Review Medical Necessity

or Clinical Appropriateness Appeal Decision

You may present new clinical information regarding an

adverse internal review appeal determination decision prior to

the initiation of the external review process conducted by an

Independent Review Entity in the process described in the

following paragraph entitled, "External Review by an

Independent Review Entity." If you do, Cigna will provide

written notice of a reconsideration decision within five

working days of receiving additional information related to the

request for reconsideration. If a reconsideration is requested,

the four months time frame for requesting an external review

by an Independent Review Entity shall not begin until Cigna

provides the reconsideration decision. If we do not provide a

written reconsideration decision within the allowable time

frame, then you may request an external review by an

Independent Review Entity. Notification of the

reconsideration of the appeal review decision will be provided

myCigna.com 24

to you and any designated representative or provider(s) acting

on your behalf.

External Review by an Independent Review Entity


internal appeal decision or reconsideration decision regarding

your Medical Necessity or clinical appropriateness issue, you

may request that your appeal be referred to an Independent

Review Entity (IRE).

Your appeal of Cigna's adverse determination, decision to

deny, reduce or terminate a medical service based on a

determination that it is not Medically Necessary or is

experimental or investigational, will be considered by a

Physician or upon your request, by a reviewer, in the same or

similar specialty as the care under consideration, who was not

involved in the initial decision as determined by Cigna's

Physician Reviewer. The Independent Review Entities that

Kentucky Department of Insurance assigns in rotation to

requests for external independent review are: certified by the

Kentucky Department of Insurance, and composed of persons



not affect the claimant's rights of any other benefits under the

plan.

An IRE will provide an expedited review of an external appeal

when requested, and any of the following apply: the treating

Physician believes that independent review under a standard

time frame would seriously jeopardize your life or health, or

with respect to a pregnant woman, the life or health of the

unborn child; or the ability to regain maximum function; or

result in serious impairment to bodily functions or serious

dysfunction of a bodily organ or part; or would cause you

severe pain which cannot be managed without the requested

services; or your appeal involves nonauthorization of an

admission or continuing inpatient Hospital stay.

Cigna will pay the cost of the review of an Independent

Review Entity, however, there is a $25 filing fee for you to

initiate this independent review process, and you will be billed

for this directly by the IRE. The IRE will waive the fee if

financial hardship can be demonstrated and will refund the fee

if their review results in a decision favorable for you. Cigna

will abide by the decision of the IRE, and will provide notice

to the Kentucky Department of Insurance of its

implementation of the decision within 30 days of the IRE's

decision in your favor. Cigna will provide coverage of the

treatment, service, drug or device as required by the binding

decision of the IRE, if you are currently enrolled for coverage

by Cigna or you have disenrolled. If you have disenrolled,

Cigna will only provide the treatment, service, drug, or device

for a period of 30 days.

Call the toll-free number on your Benefit Identification card or

contact the appeals representative indicated on your appeal

decision notification letter for information about how to

request an external review appeal by an IRE.

In order to request a referral to an IRE the following

conditions apply: you must submit your request in writing to

Cigna, within 60 days of the date of this letter (except that

requests for expedited appeals may be requested verbally,

followed up by an abbreviated written request). However,

when a reconsideration of this decision is requested due to the

submission of new clinical information, the 60-day time frame

limit for requesting an external review by an IRE will not

begin until Cigna has provided a reconsideration decision; you

provide a signed copy of the medical release form which

provides permission for the IRE to obtain all of the necessary

medical records in order to complete its review; you were

insured at time of service, or when you or your provider

requested the service you have exhausted the Cigna internal

review process and received an adverse decision regarding

your request involving a Medical Necessity issue; or Cigna

has not completed its review of your internal review appeal

within the required 30 days; or the Kentucky Department of

Insurance has provided notice that Cigna's Coverage Denial

determination is not valid because the requested service or

coverage is available under the plan. If you believe that you

are entitled to an IRE review and Cigna has denied your

request for an IRE review, you may file a complaint with the

Kentucky Department of Insurance, which shall issue a

decision within five days of the receipt of your complaint. If

the Department agrees that you are entitled to an IRE review,

it shall require Cigna to provide one, as noted above.

If both Cigna and you agree to waive the internal appeal

requirement, you may also request that your eligible issue be

referred directly to an IRE without initiating or exhausting the

internal appeals process.

Cigna will not provide an external review by an IRE if the

request for review of the adverse determination has previously

gone through the external review process and the IRE found in

favor of Cigna and no new clinical information has been

submitted since the IRE found in favor of Cigna.

Cigna will forward your request and the file to the IRE, after

the Department of Insurance assigns an IRE to your review

request.

If you believe that you are entitled to an IRE review and Cigna

has denied your request for an IRE review, you may file a

complaint with the Kentucky Department of Insurance, which

shall issue a decision within five days of the receipt of your

complaint. If the Department agrees that you are entitled to an

IRE review, it shall require Cigna to provide one, as noted

above.

The IRE will render an opinion within 21 calendar days,

unless you and Cigna agree to an extension of up to 14

calendar days more. When requested, and when your provider

believes that review under a standard time frame would be

myCigna.com 25

detrimental to your medical condition, Cigna shall forward

your request for an IRE review to the IRE within 24 hours of

receiving it, and the IRE will make a decision within 24 hours

of receipt of all information required from Cigna. If you agree

to a 24-hour extension for the expedited review, then the IRE

will provide an expedited decision of the review request

within 48 hours of receipt of all information required from

Cigna, but no later than 72 hours of receiving your request for

an IRE from Cigna.

The external review process shall be confidential.

External Review of a Coverage Denial by the Kentucky

Department of Insurance

You have the right to ask the Kentucky Department of

Insurance to review a Coverage Denial determination that has

been made following an internal appeal. A Coverage Denial

means a determination that a service, treatment, prescription

drug or device is specifically limited or excluded under the

Plan. You, or an authorized person or provider on your behalf,

may submit a written request for review of a Coverage Denial

to the Kentucky Department of Insurance at the following

address:

Kentucky Department of Insurance

Attn: Coverage Denial Coordinator

P.O. Box 517

Frankfort, KY 40602-0517

Include a copy of the initial Cigna denial notice and the appeal

notice with your written request for review of a Coverage

Denial. Upon Cigna's receipt of the Kentucky Department of

Insurance's (DOI's) determination decision of your Coverage

Denial review request, Cigna will: provide the disputed

coverage if the DOI has concluded that the treatment, service,

drug or device is not specifically limited or excluded by the

plan or offer you the opportunity to seek an external review by

an Independent Review Entity; or not provide the disputed

coverage if the DOI has concluded that the treatment, service,

drug or device is not specifically limited or excluded by the

Plan. When Cigna provides the coverage because the DOI has

determined the treatment, service, drug or device is not

specifically limited or excluded by the plan, it will provide

coverage if you are currently enrolled for coverage by Cigna

or you have disenrolled. If you have disenrolled, Cigna will

only provide coverage for the treatment, service, drug, or

device for a period of 30 days.

Appeal to the State of Kentucky

You have the right to contact the Kentucky Department of

Insurance for assistance at any time. The Kentucky

Department of Insurance may be contacted at the following

address and telephone number:

Kentucky Department of Insurance

P.O. Box 517

Frankfort, KY 40602-0517

1-800-595-6053

Hearing Impaired: 1-800-462-2081















making the adverse determination regarding your appeal; an



experimental treatment or other similar exclusion or limit; date

of the review decision; name and title of the person making

the review decision and for Medical Necessity determinations,

the name, state of licensure, medical license number and the

title of the person making the determination and, as applicable

to managed care plans, the signature of a Kentucky-licensed

Medical Director; a description of alternative benefits,

supplies or services covered by the plan; instructions for

requesting an external review by either an IRE or the

Kentucky Department of Insurance, as applicable, including

applicable time frames and instructions to complete any

required forms and whether the request for review of the

appeal decision must be in writing; for Medical Necessity

appeal determinations, a release of medical records form for

provision to the IRE; the name and phone number of a contact

person who can provide information about a Coverage Denial

determination or about external review by an IRE, as

applicable; and for Coverage Denial appeal notices,

instructions to include a copy of the initial Coverage Denial

notice and the Coverage Denial notice with the written request

to the Department of Insurance to conduct a review of a

Coverage Denial appeal determination; and information about

any office of health insurance consumer assistance or

ombudsman available to assist you in the appeal process.

myCigna.com 26








Administrator.














determination.

Legal Action





until you have completed the Internal Review Appeal process.

However, no action will be brought at all unless brought

within 3 years after a claim is submitted for In-Network

Services or within three years after proof of claim is required

under the Plan for Out-of-Network services.

HC-APL261 05-15

ET



Cigna)

CERTIFICATE RIDER – Louisiana Residents

Rider Eligibility: Each Employee who is located in Louisiana



your health status.


Cigna.


requirements of Louisiana group insurance plans covering

insureds located in Louisiana. These provisions supersede any



HC-ETLARDR

Covered Expenses

charges for electronic imaging/telemedicine health care

services, including, but not limited to, diagnostic testing and

treatment. The Physician must be physically present with

the patient and communicating with a Physician at the

facility receiving the transmission. Payment shall not be less

than 75% of the reasonable and customary payment

received for an intermediate office visit. These

electronic/telemedicine benefits are subject to utilization

review requirements.

charges for treatment of severe mental illness, on the same

basis as other sickness covered under the plan. “Severe

mental illness” includes any of the following:

schizophrenia or schizoaffective disorder;

bipolar disorder;

panic disorder;

obsessive-compulsive disorder;

major depressive disorder;

anorexia/bulimia;

intermittent explosive disorder;

post-traumatic stress disorder;

myCigna.com 27

psychosis NOS (not otherwise specified) when diagnosed

in a child under age 17;

Rett’s Disorder;

Tourette’s Disorder.

Autism Spectrum Disorder

Charges for the diagnosis and treatment of Autism Spectrum

Disorders, including applied behavioral analysis, in

individuals less than 17 years of age. Such coverage shall

include the following care prescribed, provided or ordered by

a physician or a psychologist who is licensed in this state who

shall supervise provision of such care:

Medically Necessary assessments, evaluations, or tests to

diagnose an Autism Spectrum Disorder;

Habilitative or rehabilitative care;

Pharmacy care;

Psychiatric care;

Psychological care;

Therapeutic care.

Autism Spectrum Disorders include any of the pervasive

developmental disorders as defined by the most recent edition

of the Diagnostic and Statistical Manual of Mental Disorders

(DSM), including Autistic Disorder, Asperger’s Disorder and

Pervasive Developmental Disorder – Not Otherwise Specified.

Benefits for the diagnosis and treatment of Autism Spectrum

Disorders are payable on the same basis as any other sickness

covered under the plan.

HC-COV190 04-10

V1-ET1

Termination of Insurance

Continuation

Continuation of Medical Insurance during Active Military

Duty

If your coverage would otherwise cease because you are a

Reservist in the United States Armed Forces and are called to

active duty, the insurance for you and your Dependents will be

continued during your active duty only if you elect it in

writing, and will continue until the earliest of the following

dates:

90 days from the date your military service ends;

the last day for which you made any required contribution

for the insurance; or

the date the group policy cancels.

Additionally, a Dependent who is called to active duty will not

cease to qualify for Dependent coverage due to his/her active

duty status if he or she has elected to continue coverage in

writing. Coverage will be continued for that Dependent during

his or her active duty until the earliest of the following dates:

the date insurance ceases.

the last day for which the Dependent has made any required

contribution for the insurance;

the date the Dependent no longer qualifies as a Dependent;

or

the date Dependent Insurance is canceled.

Reinstatement of Medical Insurance

If your coverage ceases because you are a Reservist in the

United States Armed Forces and are called to active duty, the

insurance for you and your Dependents will be automatically

reinstated after your deactivation, provided that you return to

Active Service within 90 days.

If coverage for your Dependent has ceased because he or she

was called to active duty, the insurance for that Dependent

will be automatically reinstated after his or her deactivation, provided that he or she otherwise continues to qualify for

coverage.

Such reinstatement will be without the application of: a new

waiting period, or a new Pre-existing Condition Limitation. A

new Pre-existing Condition Limitation will not be applied to

any condition that you or your Dependent developed while

coverage was interrupted. The remainder of a Pre-existing

Condition Limitation which existed prior to interruption of

coverage may still be applied.

HC-TRM81 04-10

V1-ET1

Definitions

Dependent

The term child includes any grandchild of yours provided such

child is under 26 years of ag e and is in your legal custody and

resides with you or any grandchild of yours who is in your

legal custody and resides with you, and is incapable of self-

sustaining employment by reason of mental or physical

handicap which existed prior to the child’s 26th

birthday.

HC-DFS427 04-10

V1-ET1

myCigna.com 28



Cigna)

CERTIFICATE RIDER – Maine Residents

Rider Eligibility: Each Employee who is located in Maine



your health status.


Cigna.


requirements of Maine group insurance plans covering

insureds located in Maine. These provisions supersede any



HC-ETMERDR

Short-Term Rehabilitative Therapy and Chiropractic

Care Services

charges made for Short-term Rehabilitative Therapy that is

part of a rehabilitative program, including physical, speech,

occupational, cognitive, osteopathic manipulative, cardiac

rehabilitation and pulmonary rehabilitation therapy, when

provided in the most medically appropriate setting. Also

included are services that are provided by a chiropractic

Physician when provided in an outpatient setting. Services

of a chiropractic Physician include the conservative

management of acute neuromusculoskeletal conditions

through manipulation and ancillary physiological treatment

that is rendered to restore motion, reduce pain and improve

function.

The following limitation applies to Short-term Rehabilitative

Therapy and Chiropractic Care Services:

occupational therapy is provided only for purposes of

enabling persons to perform the activities of daily living

after an Injury or Sickness.

Short-term Rehabilitative Therapy and Chiropractic Care

services that are not covered include but are not limited to:

sensory integration therapy, group therapy; treatment of

dyslexia; behavior modification or myofunctional therapy

for dysfluency, such as stuttering or other involuntarily

acted conditions without evidence of an underlying medical

condition or neurological disorder;

treatment for functional articulation disorder such as

correction of tongue thrust, lisp, or verbal apraxia or

swallowing dysfunction that is not based on an underlying

diagnosed medical condition or Injury;

maintenance or preventive treatment consisting of routine,

long term or non-Medically Necessary care provided to

prevent recurrences or to maintain the patient’s current

status.

The following are specifically excluded from Chiropractic

Care Services:

services of a chiropractor which are not within his scope of

practice, as defined by state law;

charges for care not provided in an office setting;

vitamin therapy.

If multiple outpatient services are provided on the same day

they constitute one day.

The following applies to Network and Network Point of

Service plans, and to Preferred Provider, Exclusive Provider

and Open Access Provider copay plans:

A separate Copayment will apply to the services provided by

each provider.

HC-COV112 04-10

V1-ET

Medical Conversion Privilege

The provision in your certificate, if any, entitled "Medical

Conversion Privilege" will not apply to Maine residents.

HC-CNV 04-10

ET


Appeal




noted.







myCigna.com 29




Free Number that appears on your Benefit Identification








Appeals Procedure



an appeal in writing, after receipt of a denial notice, to the

following address:

Cigna

National Appeals Unit (NAU)

PO Box 188011








Level One Appeal








determination (decision). We will respond within 20 working

















medical condition.

Cigna's Physician reviewer, in consultation with the treating



decision within 72 hours, followed up in writing within two

working days of the oral response.

Level Two Appeal










as the care under consideration, as determined by Cigna's




have received your request and schedule a Committee review.




Committee review will be completed within 20 working days.





the review. In the event any new or additional information

(evidence) is considered, relied upon or generated by Cigna in

connection with the level-two appeal, Cigna will provide this

information to you as soon as possible and sufficiently in










You may request that the appeal process be expedited if the








myCigna.com 30



followed up in writing within two working days of the oral

response.


You also have the right to appeal an unfavorable decision,

including denials based on experimental or pre-existing

conditions, by way of the State of Maine's independent review

process. Your request must be in writing and sent to the State

of Maine, Bureau of Insurance, 34 State House Station,

Augusta, ME 04330. A request for an independent review

must be submitted within 12 months of the date that you

receive an adverse determination (decision) under Cigna's

complaint and appeals process. When you request an

independent review from the Maine's Bureau of Insurance,

you may submit additional information for consideration. You

may attend the review in person, by telephone, by

teleconference or other appropriate electronic means, ask

questions of the representatives and have outside assistance.

The Independent Review Organization will issue a written

decision within 30 days of receipt of a completed review from

Maine's Bureau of Insurance.

You may request an expedited independent review of your

appeal prior to exhausting all levels of Cigna's appeals

procedure if: Cigna has failed to make a decision on a

complaint or an appeal within the time period required; you

and Cigna mutually agreed to bypass the appeals procedure;





the patient has died.

You may call Cigna at the toll-free telephone number on your

ID card for assistance in filing a request for an independent

review with the Maine's Bureau of Insurance. There is no

charge for you to initiate this independent review process.

Cigna will abide by the decision of the Independent Review

Organization. The Independent Review Program is a voluntary

program arranged by Cigna.

You may also call Maine's Bureau of Insurance at 1-800-300-

5000 for assistance.

Appeal to the State of Maine

You have the right to contact the Superintendent of Insurance

for assistance at any time. The Superintendent of Insurance

may be contacted at the following address and telephone

number:

State of Maine

Maine Bureau of Insurance

Superintendent of Insurance

34 State House Station

Augusta, ME 04333

1-800-300-5000






























Administrator.











myCigna.com 31




determination.

Legal Action








legal action.

HC-APL56 04-10

V1-ET



Cigna)

CERTIFICATE RIDER – Maryland Residents

Rider Eligibility: Each Employee who is located in Maryland



your health status.


Cigna.


requirements of Maryland group insurance plans covering

insureds located in Maryland. These provisions supersede any



HC-ETMDRDR

Important Notices

Qualified Medical Child Support Order (QMCSO)

Eligibility for Coverage Under a QMCSO

If a Qualified Medical Child Support Order (QMCSO) is

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

required by the order and you will not be considered a Late

Entrant for Dependent Insurance.

You, your child’s noninsuring parent, a state child support

enforcement agency or the Maryland Department of Health

and Mental Hygiene must notify your Employer and elect

coverage for that child. If you yourself are not already

enrolled, you must elect coverage for both yourself and your

child. We will enroll both you and your child within 20

business days of our receipt of the QMCSO from your

Employer.

Eligibility for coverage will not be denied on the grounds that

the child: was born out of wedlock; is not claimed as a

dependent on the Employee’s federal income tax return; does

not reside with the Employee or within the plan’s service area;

or is receiving, or is eligible to receive, benefits under the

Maryland Medical Assistance Program.

Qualified Medical Child Support Order Defined

A Qualified Medical Child Support Order is a judgment,

decree or order (including approval of a settlement agreement)

or administrative notice, which is issued pursuant to a state

domestic relations law (including a community property law),

or to an administrative process, which provides for child

support or provides for health benefit coverage to such child

and relates to benefits under the group health plan, and

satisfies all of the following:

the order recognizes or creates a child’s right to receive

group health benefits for which a participant or beneficiary

is eligible;

the order specifies your name and last known address, and

the child’s name and last known address, except that the

name and address of an official of a state or political

subdivision may be substituted for the child’s mailing

address;

the order provides a description of the coverage to be

provided, or the manner in which the type of coverage is to

be determined;

the order states the period to which it applies; and

if the order is a National Medical Support Notice completed

in accordance with the Child Support Performance and

Incentive Act of 1998, such Notice meets the requirements

above.

The QMCSO may not require the health insurance policy to

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

otherwise provided under the policy, except that an order may

require a plan to comply with State laws regarding health care

coverage.

Claims

Claims will be accepted from the noninsuring parent, from the

child’s health care provider or from the state child support

myCigna.com 32

enforcement agency. Payment will be directed to whomever

submits the claim.

Payment of Benefits

Any payment of benefits in reimbursement for Covered

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

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

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

address have been substituted for the name and address of the

child.

Termination of Coverage Under a QMCSO

Coverage required by a QMCSO will continue until we

receive written evidence that: the order is no longer in effect;

the child is or will be enrolled under a comparable health plan

which takes effect not later than the effective date of

disenrollment; dependent coverage has been eliminated for all

Employees; or you are no longer employed by the Employer,

except that if you elect to exercise the provisions of the federal

Consolidated Omnibus Budget Reconciliation Act of 1985

(COBRA), coverage will be provided for the child consistent

with the Employer’s plan for postemployment health

insurance coverage for Dependents.

HC-IMP89 04-10

V1-ET3

The Schedule

The Medical Schedule is amended to remove any of the

following OB/GYN notes if included:

Note: OB/GYN provider is considered a Specialist.

Note: OB/GYN providers will be considered either as a PCP

or Specialist, depending on how the provider contracts with

the Insurance Company.

Note: Well-Woman OB/GYN visits will be considered a

Specialist visit.

Note: Well-Woman OB/GYN visits will be considered either

a PCP or Specialist depending on how the provider contracts

with the Insurance Company.

The “Outpatient Facility Services” entry in the Medical

Schedule is amended to read as follows:

Outpatient Facility Services

Operating Room, Recovery Room, Procedures Room,

Treatment Room and Observation Room and when provided

instead of an inpatient service, when an attending physician’s

request for an inpatient admission has been denied.

The Medical Schedule is amended to include the following

note in the “Delivery – Facility” provision of the “Maternity

Care Services” section:

Note: Benefit levels will be the same as the benefit levels for

Inpatient Hospital Facility Services for any other covered

Sickness.

The Medical Schedule is amended to include the following

provision, covered at “No charge”, in the “Maternity Care

Services” section:

Home Visits, as required by law and as recommended by the

Physician

SCHEDMD-ET3

Covered Expenses

charges made for an outpatient service provided instead of

an inpatient service, when an attending physician’s request

for an inpatient admission is denied after utilization review

has been conducted.

charges for an objective second opinion, when required by a

utilization review program.

charges made for inpatient hospitalization services for a

mother and newborn child for a minimum of: 48 hours on

inpatient hospitalization care after an uncomplicated vaginal

delivery; and 96 hours of inpatient hospitalization care after

an uncomplicated cesarean section. A mother may request a

shorter length of stay than that provided if the mother

decides, in consultation with her attending provider, that

less time is needed for recovery.

If the mother and newborn child have a shorter hospital stay

than that provided, coverage is provided for: one home visit

scheduled to occur within 24 hours after hospital discharge;

and an additional home visit if prescribed by the attending

provider. The home visit must: be provided in accordance

with generally accepted standards of nursing practice for

home care of a mother and newborn child; be provided by a

registered nurse with at least one year of experience in

maternal and child health nursing or community health

nursing with an emphasis on maternal and child health; and

include any services required by the attending provider.

Unless you are enrolled in a Health Savings Account or a

High Deductible Health Plan, coverage for the home visits

described in this section are not subject to any deductible.

If the mother and newborn child remain in the hospital for at

least the minimum length of time provided, coverage is

provided for a home visit if prescribed by the attending

provider. The home visit must: be provided in accordance

with generally accepted standards of nursing practice for

home care of a mother and newborn child; be provided by a

registered nurse with at least one year of experience in

myCigna.com 33

maternal and child health nursing or community health

nursing with an emphasis on maternal and child health; and

included any services required by the attending provider.


High Deductible Health Plan, coverage for the home visits

described in this section are not subject to any deductible.

Additionally, whenever a mother is required to remain

hospitalized after childbirth for medical reasons and the

mother requests that the newborn also remain in the

hospital, coverage will be provided for additional

hospitalization for the newborn for up to four days.

HC-COV27 04-10

V1-ET3

HC-COV211



Cigna)

CERTIFICATE RIDER – Massachusetts Residents


Massachusetts



your health status.


Cigna.


requirements of Massachusetts group insurance plans covering

insureds located in Massachusetts. These provisions supersede



HC-ETMARDR

Eligibility - Effective Date

Dependent Insurance

Exception for Newborns

Any Dependent child including the newborn infant of a

Dependent, an adopted child or foster child born while you are

insured will become insured on the date of his birth if you

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

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

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

benefits for expenses incurred beyond the 31st day will be

payable.

HC-ELG12 04-10

V1-ET

Covered Expenses

Covered Expenses include expenses incurred at any of the

Approximate Intervals shown below for a Dependent child

who is age 5 or less for charges made for Child Preventive

Care Services consisting of the following services delivered or

supervised by a Physician, in keeping with prevailing medical

standards:

a history; physical examination; development assessment;

anticipatory guidance; and appropriate immunizations and

laboratory tests;

measurements; sensory screening; neuropsychiatric

evaluation; hereditary and metabolic screening at birth; TB

test; hematocrit; other appropriate blood tests and urinalysis;

special medical formulas approved by the Commissioner of

Public Health, prescribed by a Physician, and Medically

Necessary for treatment of PKU, tyrosinemia,

homocystinuria, maple syrup urine disease, and propionic

acidemia or methylmalonic acidemia in infants and children

or Medically Necessary to protect the unborn fetuses of

pregnant women with PKU.



Care Services at each of the Approximate Intervals up to a

total of 12 visits for each Dependent child;


this medical benefits section;

services for which benefits are not payable according to the


Approximate Intervals are:

six times during the first year of life;

three times during the second year of life;

annually each year thereafter through the fifth year of life.

Covered Expenses also include expenses incurred for

Dependent children from birth until the child's third birthday

for Early Intervention Services, up to the Medically Necessary

Early Intervention Services Maximum shown in The

Schedule, to include: occupational, physical and speech

therapy, nursing care and psychological counseling.

myCigna.com 34

These services must be delivered by certified early

intervention specialists, as defined by the early intervention

operational standards by the Massachusetts Department of

Public Health and in accordance with applicable certification

requirements.


breast cancer screening, not to exceed: one baseline

mammogram for women age 35 but less than 40, and a

mammogram annually for women age 40 and over.

charges made for screening for lead poisoning of a

Dependent child from birth until 6 years of age.

charges for treatment of an Injury or Sickness of an eligible

newborn or adopted child, including the necessary care and

treatment of medically-diagnosed congenital defects and

birth abnormalities or premature birth.

charges for a minimum of 48 hours of inpatient care

following a vaginal delivery and a minimum of 96 hours of

inpatient care following a caesarean section for a mother

and her newborn child. Any decision to shorten such

minimum coverage will be made in accordance with rules

and regulations promulgated by the Massachusetts

Department of Public Health relative to early discharge (less

than 48 hours for a vaginal delivery and 96 hours for a

caesarean delivery) and postdelivery care, including but not

limited to: home visits; parent education; assistance and

training in breast or bottle feeding; and the performance of

any necessary and appropriate clinical tests. The first home

visit may be conducted by a registered nurse, Physician or

certified nurse-midwife. Any subsequent home visit

determined to be clinically necessary must be provided by a

licensed health care provider.

charges made for cardiac rehabilitation, according to

standards developed by the Massachusetts Department of

Public Health. Cardiac rehabilitation means a

multidisciplinary, Medically Necessary treatment of persons

with documented cardiovascular disease, provided in either

a Hospital or other setting and meeting standards set forth

by the Massachusetts Commissioner of Public Health.

HC-COV250 01-14

V3-ET1

Short-Term Rehabilitative Therapy and Chiropractic

Care Services

charges made for Short-term Rehabilitative Therapy that is

part of a rehabilitative program, including physical, speech,

occupational, cognitive, osteopathic manipulative, and

pulmonary rehabilitation therapy, when provided in the

most medically appropriate setting. Also included are

services that are provided by a chiropractic Physician when

provided in an outpatient setting. Services of a chiropractic

Physician include the conservative management of acute

neuromusculoskeletal conditions through manipulation and

ancillary physiological treatment that is rendered to restore

motion, reduce pain and improve function.

The following limitation applies to Short-term

Rehabilitative Therapy and Chiropractic Care Services:

occupational therapy is provided only for purposes of

enabling persons to perform the activities of daily living

after an Injury or Sickness.

Short-term Rehabilitative Therapy and Chiropractic Care

services that are not covered include but are not limited to:

sensory integration therapy, group therapy; treatment of

dyslexia; behavior modification or myofunctional therapy

for dysfluency, such as stuttering or other involuntarily

acted conditions without evidence of an underlying medical

condition or neurological disorder;

treatment for functional articulation disorder such as

correction of tongue thrust, lisp, verbal apraxia or

swallowing dysfunction that is not based on an underlying

diagnosed medical condition or Injury;

maintenance or preventive treatment consisting of routine,

long term or non-Medically Necessary care provided to

prevent recurrences or to maintain the patient’s current

status.

The following are specifically excluded from Chiropractic

Care Services:

services of a chiropractor which are not within his scope of

practice, as defined by state law;

vitamin therapy.

If your plan is subject to Copayments, a separate Copayment

will apply to the services provided by each provider.

HC-COV86 04-10

V1-ET

Definitions

Dependent

Dependents include:

your former spouse, unless the divorce decree provides

otherwise.

A child includes:

a legally adopted child. Coverage for an adopted child will

begin: on the date of the filing of a petition to adopt such a

child, provided the child has been residing in your home as

a foster child, and for whom you have been receiving foster

care payments; or when a child has been placed in your

myCigna.com 35

home by a licensed placement agency for purposes of

adoption;

a child born to one of your Dependent children, as long as

your grandchild is living with you and: your Dependent

child is insured; or your grandchild is primarily supported

by you.

HC-DFS644 01-14

V1-ET1



Cigna)

CERTIFICATE RIDER – Minnesota Residents

Rider Eligibility: Each Employee who is located in Minnesota



your health status.


Cigna.


requirements of Minnesota group insurance plans covering

insureds located in Minnesota. These provisions supersede any



HC-ETMNRDR

Expenses For Which A Third Party May

Be Responsible

This plan does not cover:

expenses for which another party may be responsible as a

result of having caused or contributed to the Injury or

Sickness. If you incur a Covered Expense for which, in the

opinion of Cigna, another party may be liable, Cigna may,

at its sole discretion, pay the benefits otherwise payable

under the Policy. However, you must first agree in writing

to refund to Cigna the lesser of:

The amount actually paid for such Covered Expenses by

Cigna; or

The amount you actually receive from the third party for

such Covered Expenses;

at the time that the third party’s liability for medical

expenses is determined and satisfied, whether by settlement,

judgment, arbitration or award or otherwise.

Expenses incurred by a Participant to the extent any

payment is received for them either directly or indirectly

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

judgment or arbitration award in connection with any

automobile medical, automobile no-fault, uninsured or

underinsured motorist, homeowners, workers'

compensation, government insurance (other than Medicaid),

or similar type of insurance or coverage.

Cigna's claim rights under this provision will be valid only if

you are fully compensated for your loss. Your costs,

disbursements, attorney fees and other expenses incurred to

obtain recovery from the third party will be subtracted from

the amount of Cigna's claim right.

Cigna will only exercise its claim rights if the amount received

by you is specifically identified in the settlement or judgment

as amounts paid for medical expenses.

Subrogation/Right Of Reimbursement

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

opinion of the plan or its claim administrator, another party

may be responsible or for which the Participant may receive

payment as described above:

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

be subrogated to all rights, claims or interests that a

Participant may have against such party and shall

automatically have a lien upon the proceeds of any recovery

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

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

shall execute such documents as may be required to secure

the plan’s subrogation rights.

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.

Cigna's claim rights under this provision will be valid only if

you are fully compensated for your loss. Your costs,

disbursements, attorney fees and other expenses incurred to

obtain recovery from the third party will be subtracted from

the amount of Cigna's claim right.

Lien Of The Plan

By accepting benefits under this plan, a Participant:

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

benefits paid under the plan against any recovery made by

or on behalf of the Participant which is binding on any

myCigna.com 36

attorney or other party who represents the Participant

whether or not an agent of the Participant or of any

insurance company or other financially responsible party

against whom a Participant may have a claim provided said

attorney, insurance carrier or other party has been notified

by the plan or its agents;

agrees that this lien shall constitute a charge against the

proceeds of any recovery and the plan shall be entitled to

assert a security interest thereon;

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

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

plan.

Additional Terms

No adult Participant hereunder may assign any rights that it

may have to recover medical expenses from any third party

or other person or entity to any minor Dependent of said

adult Participant without the prior express written consent

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

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

settlements or recoveries.

No Participant shall make any settlement, which specifically

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

benefits provided by the plan.

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

proceeds recovered by the Participant. This right of

recovery shall not be defeated nor reduced by the

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

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

defeat the plan’s recovery rights by allocating the proceeds

exclusively to non-medical expense damages.

No Participant hereunder shall incur any expenses on behalf

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

specifically; no court costs, attorneys' fees or other

representatives' fees may be deducted from the plan’s

recovery without the prior express written consent of the

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

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

Doctrine”.

The plan shall recover the full amount of benefits provided

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

any Participant, whether under comparative negligence or

otherwise.

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

obligations hereunder, then the plan shall be entitled to

recover any costs incurred in enforcing the terms hereof

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

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

offset the reimbursement obligation against any entitlement

to future medical benefits hereunder until the Participant has

fully complied with his reimbursement obligations

hereunder, regardless of how those future medical benefits

are incurred.

Any reference to state law in any other provision of this

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

governed by ERISA. By acceptance of benefits under the

plan, the Participant agrees that a breach hereof would cause

irreparable and substantial harm and that no adequate

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

entitled to invoke such equitable remedies as may be

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

limited to, specific performance, restitution, the imposition

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

injunctive relief.

HC-SUB1 04-10

V3-ET

Termination of Insurance and Special

Continuation

Reinstatement of Insurance

If your coverage ceases because of active duty in: the armed

forces of the United States, or the National Guard, the

insurance for you and your Dependents will be reinstated after

your deactivation, provided that:

you apply for such reinstatement within 90 days after

deactivation; and

you are otherwise eligible.

Such reinstatement will be without the application of: a new

waiting period, or a new Pre-existing Condition Limitation. A

new Pre-existing Condition Limitation will not be applied to a

condition that you or your Dependent may have developed

while coverage was interrupted, excluding any condition that

the Veterans Administration has determined to be military

related. The remainder of a Pre-existing Condition Limitation

which existed prior to interruption of coverage may still be

applied.

HC-TRM70 09-14

V2-ET1

myCigna.com 37



Cigna)

CERTIFICATE RIDER – Missouri Residents

Rider Eligibility: Each Employee who is located in Missouri



your health status.


Cigna.


requirements of Missouri group insurance plans covering

insureds located in Missouri. These provisions supersede any



HC-ETMORDR

Missouri First Steps Program

Cigna participates in Missouri’s Part C Early Intervention

System, “First Steps.” “First Steps” provides coverage for

Early Intervention Services described in this section that are

delivered by early intervention specialists who are health care

professionals licensed by the state of Missouri and acting

within the scope of their professions for children from birth to

age three identified by the Part C Early Intervention System as

eligible services for persons under Part C of the Individuals

with Disabilities Education Act.

Early Intervention Services means Medically Necessary

speech and language therapy, occupational therapy, physical

therapy, and assistive technology devices for children from

birth to age three who are identified by the Part C Early

Intervention System as eligible for services under Part C of the

Individuals with Disabilities Education Act and shall include

services under an active individualized family service plan

that enhances functional ability without effecting a cure. An

individualized family service plan is a written plan for

providing early intervention services to an eligible child and

the child's family that is adopted in accordance with 20 U.S.C.

Section 1436.


Medical Plan

Direct Access for OB/GYN Services

Female insureds covered by this plan are allowed direct access

to a licensed/certified Participating Provider for covered

OB/GYN services. There is no requirement to obtain an

authorization of care from your Primary Care Physician (if

you have selected one) for visits to the Participating Provider

of your choice for those services defined by the published

recommendations of the accreditation council for graduate

medical education for training an obstetrician, gynecologist or

obstetrician/gynecologist, including but not limited to

diagnosis, treatment and referral for such services.

Direct Access for Chiropractic Care Services

Insureds covered by this plan are allowed direct access to a

licensed/certified Participating Provider for In-Network

covered Chiropractic Care services. There is no requirement to

obtain an authorization of care from your Primary Care

Physician (if you have selected one) for visits to the

Participating Provider of your choice for Chiropractic Care.

Covered Expenses

charges made by a Hospital or an Ambulatory Surgical

Facility for anesthesia for inpatient Hospital dental

procedures for: a child under the age of five; a person with a

severe disability; or a person with a behavioral or medical

condition that requires hospitalization or general anesthesia

when dental care is provided. Cigna may require prior

authorization for hospitalization for dental procedures.

charges for immunizations (including the associated office

visit) for children from birth to age 5 will include

poliomyelitis, rubella, rubeola, mumps, tetanus, pertussis,

diphtheria, hepatitis B, Haemophilus influenzae type b

(Hib), and varicella. This includes the office visit in

connection with immunizations. There will be no deductible

and no copay.

charges for or in connection with the diagnosis, treatment

and appropriate management of osteoporosis for persons

with a condition or medical history for which bone mass

measurement is Medically Necessary, provided such

services are received by a Physician licensed to practice

medicine and surgery in Missouri.

charges for a colorectal examination and laboratory tests for

cancer in accordance with current American Cancer Society

guidelines for any nonsymptomatic person covered under

the Plan.

charges for a pelvic examination and Pap smear in

accordance with current American Cancer Society

myCigna.com 38

guidelines for any nonsymptomatic woman covered under

the Plan.

charges for telehealth (telemedicine) will be covered on the

same basis as covered services provided through a face to

face consultation or contact with participating provider.

Coverage does not include telehealth site origination fees or

costs for the provision of telehealth services. Utilization

may be utilized to determine the appropriateness of

telehealth as a means of delivering a health care service on

the same basis as when the same services is delivered in

person.

charges for prostate cancer examinations and laboratory

tests for any insured nonsymptomatic male, in accordance

with current American Cancer Society guidelines. Men age

50 and older should discuss getting an annual PSA blood

test and a digital rectal exam with their Physician. Men who

are at risk, which includes African American or men who

have a family history of prostate cancer, should consider

being tested at a younger age.

charges made by a Hospital or other facility that provides

obstetrical care for inpatient Hospital services will include

Covered Expenses for a mother and her newborn child for

48 hours following a vaginal delivery or for 96 hours

following a cesarean delivery. A longer stay will be covered

if deemed Medically Necessary. The mother may request an

earlier discharge if, after consulting with her Physician, it is

determined that less time is needed for recovery. If

discharged early, at least 2 post discharge visits will be

covered, one of which will be a home visit by either a

registered nurse with experience in maternal and child

health nursing or a Physician. These visits will include, but

are not limited to, a physical assessment of the mother and

the newborn; parent education; assistance and training in

breast and bottle feeding; education and services for

complete childhood immunizations; Medically Necessary

clinical tests; and the submission of a metabolic specimen to

the state laboratory.

Autism Spectrum Disorder and Applied Behavior Analysis

Coverage is provided for the diagnosis and treatment of autism

spectrum disorders, and care prescribed or ordered for a

Member diagnosed with an autism spectrum disorder by a

licensed Physician or licensed psychologist, including

equipment Medically Necessary for such care, pursuant to the

powers granted under such licensed Physician’s or licensed

psychologist’s license, including but not limited to:

psychiatric care; psychological care; habilitative or

rehabilitative care, including behavior analysis therapy;

therapeutic care; and pharmacy care. Coverage cannot be

denied on the basis that it is educational or habilitative in

nature.

The terms used above are defined as follows:

Autism spectrum disorders means a neurobiological

disorder, an illness of the nervous system, which includes

Autistic Disorder, Asperger's Disorder, Pervasive

Developmental Disorder Not Otherwise Specified, Rett's

Disorder, and Childhood Disintegrative Disorder, as defined

in the most recent edition of the Diagnostic and Statistical

Manual of Mental Disorders of the American Psychiatric

Association.

Diagnosis of autism spectrum disorders means Medically

Necessary assessments, evaluations, or tests in order to

diagnose whether an individual has an autism spectrum

disorder.

Treatment for autism spectrum disorders means care

prescribed or ordered for an individual diagnosed with an

autism spectrum disorder by a licensed Physician or

licensed psychologist, including equipment Medically

Necessary for such care, pursuant to the powers granted

under such licensed Physician's or licensed psychologist's

license, including, but not limited to: psychiatric care;

psychological care; habilitative or rehabilitative care,

including applied behavior analysis therapy; therapeutic

care; and pharmacy care.

Autism service provider means any person, entity, or

group that provides diagnostic or treatment services for

autism spectrum disorders who is licensed or certified by

the state of Missouri; or any person who is licensed under

chapter 337 as a board-certified behavior analyst by the

behavior analyst certification board or licensed under

chapter 337 as an assistant board-certified behavior analyst.

Applied behavior analysis means the design,

implementation, and evaluation of environmental

modifications, using behavioral stimuli and consequences,

to produce socially significant improvement in human

behavior, including the use of direct observation,

measurement, and functional analysis of the relationships

between environment and behavior.

Habilitative or rehabilitative care is professional,

counseling, and guidance services and treatment programs,

including applied behavior analysis, that are necessary to

develop the functioning of an individual.

Line therapist means an individual who provides

supervision of an individual diagnosed with an autism

diagnosis and other neurodevelopmental disorders pursuant

to the prescribed treatment, and implements specific

behavioral interventions as outlined in the behavior plan

under the direct supervision of a licensed behavior analyst.

Pharmacy care means medications used to address

symptoms of an autism spectrum disorder prescribed by a

licensed Physician, and any health-related services deemed

Medically Necessary to determine the need or effectiveness

myCigna.com 39

of the medications, only to the extent that such medications

are included in the insured's health benefit plan.

Psychiatric care means direct or consultative services

provided by a psychiatrist licensed in the state in which the

psychiatrist practices.

Psychological care means direct or consultative services

provided by a psychologist licensed in the state in which the

psychologist practices.

Therapeutic care means services provided by licensed

speech therapists, occupational therapists, or physical

therapists.



Cigna)

CERTIFICATE RIDER – Nebraska Residents

Rider Eligibility: Each Employee who is located in Nebraska



your health status.


Cigna.


requirements of Nebraska group insurance plans covering

insureds located in Nebraska. These provisions supersede any



HC-ETNERDR

Covered Expenses

charges made for one screening test for hearing loss for a

Dependent child from birth through 30 days old.

charges for the screening, diagnosis, and treatment of

autism spectrum disorder.

Treatment means evidence-based care, including related

equipment, that is prescribed or ordered for a covered

person diagnosed with an autism spectrum disorder by a

licensed Physician or a licensed Psychologist including:

Behavioral health treatment; pharmacy care; psychiatric

care; psychological care, and therapeutic care.

Behavioral health treatment means counseling and treatment

programs, including applied behavior analysis, that are:

necessary to develop, maintain, or restore, to the maximum

extent practicable, the functioning of an individual; and

provided by a certified behavior analyst or a licensed

Psychologist if the services performed are within the

boundaries of the Psychologist's competency.

Pharmacy care means a medication that is prescribed by a

licensed Physician and any health related service deemed

Medically Necessary to determine the need or effectiveness

of the medication.

Psychiatric care means a direct or consultative service

provided by a psychiatrist licensed in the state in which he

or she practices.

Psychological care means a direct or consultative service

provided by a Psychologist licensed in the state in which he

or she practices.

Therapeutic care means a service provided by a licensed

speech-language pathologist, occupational therapist, or

physical therapist.

HC-COV469 05-15

V1-ET



Cigna)

CERTIFICATE RIDER – New Hampshire Residents

Rider Eligibility: Each Employee who is located in New

Hampshire



your health status.


Cigna.

myCigna.com 40


requirements of New Hampshire group insurance plans

covering insureds located in New Hampshire. These

provisions supersede any provisions in your certificate to the

contrary unless the provisions in your certificate result in

greater benefits.

HC-ETNHRDR

Continuation of Coverage Under New

Hampshire State Law

High Risk Pool

If you or your Dependents have been covered for 60 days, you

or your Dependent may apply to the New Hampshire High

Risk Pool within 31 days after termination of coverage,

without having to provide evidence of insurability.

HC-TRM45 04-10

V1-ET1



Cigna)

CERTIFICATE RIDER – New Jersey Residents


Jersey



your health status.


Cigna.


requirements of New Jersey group insurance plans covering

insureds located in New Jersey. These provisions supersede



HC-ETNJRDR

Definitions

Dependent

Dependents include:

your lawful spouse or civil union partner; or



26 years old, but less than 26, not married nor in a civil

union partnership nor in a Domestic Partnership, enrolled

in school as a full-time student and primarily supported

by you.

26 or more years old, not married nor in a civil union

partnership nor in a Domestic Partnership, and primarily

supported by you and incapable of self-sustaining

employment by reason of mental or physical disability

which arose while the child was covered as a Dependent

under this Plan, or while covered as a dependent under a

prior plan with no break in coverage.







adopted by you. It also includes a stepchild. If your civil union

partner has a child, that child will also be included as a

Dependent.

HC-DFS646 01-15

V1-ET



Cigna)

CERTIFICATE RIDER – New Mexico Residents


Mexico



your health status.


Cigna.

myCigna.com 41


requirements of New Mexico group insurance plans covering

insureds located in New Mexico. These provisions supersede



HC-ETNMRDR

When You Have a Complaint or an

Appeal (Grievance)


or "Member" also refers to Grievant.

Information about Appeals (Grievance) Procedures

Cigna is responsible for:

including a clear and concise description of all grievance

procedures, both internal and external, in boldface type in

the enrollment materials, including in member handbooks or

evidence of coverage issued to Grievants;

for a person who has been denied coverage, providing him

or her with a copy of the grievance procedures;

notifying Grievants that a representative of Cigna and the

Managed Health Care Bureau of the insurance division are

available upon request to assist with grievance procedures

by including such information, and a toll-free telephone

number for obtaining such assistance, in the enrollment

materials and Summary of Benefits issued to Grievants;

providing a copy of its grievance procedures and all

necessary grievance forms at each decision point in the

grievance process and immediately upon request, at any

time, to a Grievant, Provider, or other interested person;

providing a detailed written explanation of the appropriate

grievance procedures and a copy of the grievance form to a

Grievant or Provider when Cigna makes either an adverse

determination or adverse administrative decision. The

written explanation will describe how Cigna reviews and

resolves grievances and provide a toll-free number,

facsimile number, e-mail address, and mailing address of

Cigna's consumer assistance office;

providing consumer education brochures and materials

developed and approved by the superintendent, annually, or

as directed by the superintendent in consultation with Cigna

for distribution;

providing notice to enrollees in a Culturally and

Linguistically Appropriate Manner;

providing continued coverage for an ongoing course of

treatment pending the outcome of an internal appeal;

not reducing or terminating an ongoing course of treatment

without first notifying the Grievant sufficiently in advance

of the reduction or termination to allow the Grievant to

appeal and obtain a determination on review of the proposed

reduction or termination;

allowing individuals in urgent care situations and receiving

an ongoing course of treatment to proceed with an expedited

external review at the same time as the internal review

process.

Timeframes for Initial Utilization Management

Determinations

For initial Utilization Management Determinations, we will

respond in writing with a decision within 5 working days. If

more time or information is needed to make the determination,

and the delay is due to a reasonable cause beyond our control,

and does not result in increased medical risk to you we will

notify you in writing as to the reason for the delay, and to

request an extension of up to 10 working days. If there is a

delay, you will be provided a written progress report within

the original five (5) working day review period.

You may request, either verbally or in writing, that the initial

determination be expedited, and we will make a determination

within 24 hours after receiving your request, if the time frames

under this process would seriously jeopardize your life, health

or ability to regain maximum function; or your Physician

makes a reasonable request; or it is the opinion of your

Physician, who has knowledge of your medical condition, that

you would be subject to severe pain that cannot be adequately

managed without the care or treatment in question; or the

medical exigencies of your case require an expedited

determination; or your claim involves urgent care.

When considering whether to certify a Health Care Service

requested by a Provider or Grievant, Cigna will determine

whether the requested Health Care Service is covered by the

Health Benefits Plan. Before denying a Health Care Service

requested by a Provider or Grievant on grounds of a lack of

coverage, Cigna will determine that there is no provision of

the Health Benefits Plan under which the requested Health

Care Service could be covered. If Cigna finds that the

requested Health Care Service is not covered by the Health

Benefits Plan, Cigna need not address the issue of Medical

Necessity.

If Cigna finds that the requested Health Care Service is

covered by the Health Benefits Plan, then when considering

whether to certify a Health Care Service requested by a

Provider or Grievant, a physician, registered nurse, or other

Health Care Professional shall, within the timeframe required

by the medical exigencies of the case, determine whether the

requested Health Care Service is Medically Necessary.

Before Cigna denies a Health Care Service requested by a

Provider or Grievant on grounds of a lack of Medical

Necessity, a physician shall render an opinion as to Medical

Necessity, either after consultation with specialists who are

myCigna.com 42

experts in the area that is the subject of review, or after

application of Uniform Standards used by Cigna. The

physician shall be under the clinical authority of the medical

director responsible for Health Care Services provided to

Grievants.

Notice of Initial Utilization Management Determination

You and your Provider will be notified within two (2) working

days of the date a Health Care Service has been certified,

unless earlier notice is required due to the medical exigencies

of your case.

You will be notified by telephone, or as required by the

medical exigencies of your case, no later than twenty-four

hours after an adverse determination decision has been made,

followed by a written or electronic communication within one

(1) working day of the telephone notice, unless you fail to

provide sufficient information to determine whether, or to

what extent, benefits are covered under the plan. If you fail to

provide such information, you will be afforded a reasonable

amount of time, but not less than forty-eight (48) hours to

provide the specified information.

If the adverse determination is based on Medical Necessity,

the notice will include a clear and complete explanation as to

why the requested service is not Medically Necessary. If the

adverse determination is based on lack of coverage, the notice

will identify all plan provisions relied upon, and include a

clear and complete explanation as to why the requested service

is not covered by the plan provisions. A statement that the

requested Health Care Service is not covered under the Health

Benefits Plan will not be sufficient. The notice will include the

date of service, the health care Provider, the claim amount (if

applicable) and a statement describing the availability (upon

request) of the diagnosis code and its corresponding meaning,

and the treatment code and its corresponding meaning. It will

also include a description of the Cigna standard that was used

in denying the claim and provide a summary of the discussion

which triggered the final determination. The notice will also

advise you of your rights to request an internal or external

review of the adverse determination. Appeals procedures and

any required forms will be sent along with the notice.

Customer Service


receive. If you have a concern regarding a person, a service,

the quality of care, contractual benefits, or a Rescission of

Coverage, you may call our toll-free number 1-888-992-4462

and explain your concern to one of our Customer Service

representatives.

When You Have a Complaint or an Appeal (Grievance)


you can start the appeals procedure, without being subject to

retaliation for any reason related to the appeal.

You must submit a request for an appeal in writing. If you

need help completing the forms required to initiate an internal

review, we will assist you. If you are unable or choose not to

write, you may ask to register your appeal by telephone. Call

us at the toll-free number 1-888-992-4462 or write to:

Cigna


PO Box 188011


The New Mexico Managed Health Care Bureau is also

available for assistance:

Office of Superintendent of Insurance

Managed Health Care Bureau

Post Office Box 1689

Santa Fe, New Mexico 87504-1689

E-mail: [email protected]

Phone: 1-855-427-5674

Fax: (505) 827-3833

Website: http://www.osi.state.nm.us/managed-

healthcare/contact-us.html.

Once we receive your appeal, we will determine whether it is

an adverse determination appeal, or an administrative appeal.

If your appeal involves both an administrative appeal and an

adverse determination appeal, we will initiate separate

complaints, which will be explained to you in one

acknowledgement letter.

Under federal law, you are allowed up to four (4) months after

the date of receipt of a notice of adverse determination or final

adverse determination to file a request for external review.

Adverse Determination Appeal

An adverse determination means any of the following: any

Rescission of Coverage (whether or not a rescission has any

adverse effect on any particular benefit at the time); a denial,

reduction, or termination of, or a failure to provide or make

payment (in whole or in part) for a benefit, including any such

denial, reduction, termination, or failure to provide or make

payments, that is based on a determination of a participant’s or

beneficiary’s eligibility to participate in a plan, and including

a denial, reduction, or termination of, or a failure to provide or

make payment (in whole or in part) for, a benefit resulting

from the application of any utilization review, as well as a

failure to cover an item or service for which benefits are

otherwise provided because it is determined to be

Experimental or Investigational or not Medically Necessary or

appropriate.

An adverse determination appeal means an oral or written

complaint submitted by or on behalf of a Grievant regarding

an adverse determination.

We will review your appeal in accordance with the procedures

for adverse determination appeals outlined below and as

myCigna.com 43

required by 13.10.17.17 NMAC through 13.10.17.22 NMAC.

The adverse determination appeals procedures include an

internal appeal, an appeal to Cigna, an internal panel review,

and an external appeal.

Administrative Appeal

If the appeal is not based on an adverse determination of a pre-

or post- Health Care Service, it is an administrative appeal.

An administrative appeal means an oral or written complaint

submitted by or on behalf of a Grievant regarding any aspect

of a Health Benefits Plan other than a request for Health Care

Services, including but not limited to:

administrative practices of Cigna that affects the

availability, delivery, or quality of Health Care Services;

claims payment, handling or reimbursement for Health Care

Services; and

Terminations of Coverage; including Rescissions of

Coverage.

Administrative appeals procedures will be reviewed in

accordance with the procedures outlined below in the section,

“Administrative Appeal (Grievance) Procedures” and as

required by 13.10.17.33 NMAC through 13.10.17.36

NMAC.

Internal Appeal of an Adverse Determination

You have the right to request an internal review (appeal) of an

adverse determination if you are dissatisfied.

Upon receipt of a request for internal review of an adverse

determination, Cigna will date and time stamp the request and,

within one (1) working day from receipt, send you an

acknowledgment that the request has been received. The

acknowledgment will contain the name, address, and direct

telephone number of a Cigna representative who may be

contacted regarding the appeal.

To ensure that you receive a full and fair internal review, we

will allow you to review the claim file and present evidence

and testimony as part of the internal claims and appeals

process, and we will provide you, free of charge, with any new

or additional evidence, and any new or additional rationale,

considered, relied upon, or generated by Cigna, as soon as

possible and sufficiently in advance of the date of the notice of

final internal adverse benefit determination to allow you a

reasonable opportunity to respond before the final internal

adverse determination is made.

We will ensure that all internal claims and appeals are

adjudicated in a manner designed to ensure the independence

and impartiality of the persons involved in making the

decisions in such a way that decisions regarding hiring,

compensation, termination, promotion, or other similar matters

with respect to any individual (such as a claims adjudicator or

medical expert), must not be made based upon the likelihood

that the individual will support the denial of benefits.

We will complete your Internal Appeal of an Adverse

Determination and if utilized, your Internal Panel Appeal of

Adverse Determination within 20 working days after we

receive a request for an internal review for a required

preservice, or concurrent care coverage determination

(decision) that is not expedited. We will respond within 40

working days after we receive an appeal for a postservice

coverage determination. If more time or information is needed

to make the determination, and the delay is due to a reasonable

cause beyond our control, and does not result in increased

medical risk to you, we will notify you in writing as to the

reason for the delay, and to request an extension of up to 10

working days for pre-service claims, and 20 working days for

post service claims. If there is a delay, you will be provided a

written progress report within the original thirty (30) day

review period for pre-service and concurrent appeals; or the

sixty (60) day review period for post service appeals.

We will expedite your appeal if appropriate based on the

medical exigencies of your case and make a decision no later

than seventy-two (72) hours from the time your appeal is

received, whenever: the standard time frames under this

process would seriously jeopardize the life, health or ability to

regain maximum function of the Grievant; the Provider

reasonably requests an expedited decision; in the opinion of

the physician with knowledge of the Grievant’s medical

condition, would subject the Grievant to severe pain that

cannot be adequately managed without the care or treatment

that is the subject of the claim; or the medical exigencies of

the case require an expedited decision.

If you request that your appeal be expedited, you may also ask

for an expedited external Independent Review at the same

time, if the time to complete an expedited level-one appeal

would be detrimental to your medical condition.

If we fail to comply with the appeal deadlines outlined above,

the requested Health Care Service will be deemed approved,

unless you, after being informed of your rights, have agreed in

writing to extend the deadline.


Cigna will complete the review of the adverse determination

within the timeframes required by the medical exigencies of

your case.

If the initial adverse determination was based on a lack of

coverage, Cigna will review the Health Benefits Plan and

determine whether there is any provision in the plan under

which the requested Health Care Service could be certified.

If the initial adverse determination was based on a lack of

Medical Necessity, Cigna will render an opinion as to Medical

Necessity, either after consultation with specialists who are

experts in the area that is the subject of review, or after

application of Uniform Standards used by Cigna.

myCigna.com 44

If Cigna reverses the initial adverse determination and certifies

the service, we will notify you within the timeframes

discussed above.

If Cigna upholds the initial adverse determination to deny the

requested Health Care Service, within the timeframes

discussed above, we will notify you, and ascertain if you wish

to pursue an Internal Panel Appeal.

If you do not want to appeal further, we will mail you written

notification of our decision, along with confirmation of your

decision within three (3) working days of our decision.

If we are unable to contact you by phone within seventy-two

hours of making the decision to uphold the determination, we

will notify you by mail of our decision, along with a self-

addressed stamped response form with a box for checking

“yes”, and a box for checking “no”, which you may use to

indicate whether or not you want to appeal further. If you do

not return the response form within 10 working days, we will

again attempt to contact you by phone.

If you respond via telephone or response form, that you do

wish to appeal further, we will select a medical panel to

further review your adverse determination.

If you do not respond by telephone; or return the response

form:

for expedited reviews, we will select a medical panel to

further review your adverse determination.

If you do not make an immediate decision to pursue the

appeal, or you have requested additional time to supply

supporting documents or information, or postponement, the

required timeframe outlined above will be extended to include

the additional time you require.

Internal Panel Appeal of Adverse Determination

If we uphold the initial adverse determination to deny the

requested Health Care Service, we will notify you of your

right to an internal panel review (appeal) within the time

frames described in the internal appeal of an adverse

determination section.

If you choose to pursue the appeal, we will notify you of the

date, time, and place of the internal panel review. If Cigna will

be represented by an attorney, the notice will advise you that

you may want to also seek legal representation.

We will select one or more of Cigna’s representatives and one

or more health care or other professionals who have not been

previously involved in the adverse determination being

reviewed to serve on the internal panel. At least one of the

Health Care Professionals selected shall practice in a specialty

that would typically manage the case that is the subject of the

appeal, unless we mutually agree otherwise.

The internal review panel shall review the Health Benefits

Plan and determine whether there is any provision in the plan

under which the requested Health Care Service could be

certified.

The internal review panel shall render an opinion as to

Medical Necessity, either after consultation with specialists

who are experts in the area that is the subject of review, or

after application of Uniform Standards used by Cigna.

No fewer than three (3) working days prior to the internal

panel review, we will provide you copies of:

pertinent medical records;

the treating Provider’s recommendation;

Health Benefits Plan;

Cigna’s notice of adverse determination;

Uniform Standards relevant to your medical condition that

is used by the internal panel in reviewing the adverse

determination;

questions sent to or reports received from any medical

consultants retained by Cigna; and

all other evidence or documentation relevant to reviewing

the adverse determination, including any new or additional

rationale considered by Cigna.

We will not unreasonably deny your request for postponement

of the internal panel review. The timeframes for internal panel

review will be extended during the period of any

postponement.

You have the right to:

attend and participate in the internal panel review;

present your case to the internal panel;

submit supporting material both before and at the internal

panel review;

ask questions of any of Cigna’s representatives;

ask questions of any Health Care Professionals on the

internal panel;

be assisted or represented by a person of your choice,

including legal representation; and

hire a specialist to participate in the internal review panel

review at your own expense, but such specialist may not

participate in making the decision.

The internal panel will complete its review of the adverse

determination as required by the medical exigencies of your

case and within the timeframes described in the internal appeal

of an adverse determination section. Internal review panel

members must be present physically or by video or telephone

conferencing to hear the appeal. An internal review panel

member who is not present to hear the grievance either

physically or by video or telephone conferencing cannot

participate in the decision.

myCigna.com 45

In an expedited review, we will transmit required information

to you using the most expeditious method available.

If an expedited review is conducted during a patient’s hospital

stay or course of treatment, Health Care Services shall be

continued without cost (except for applicable co-payments and

deductibles) to the Grievant until Cigna makes a final decision

and notifies you of that decision.

Cigna will not conduct an expedited review of an adverse

determination made after Health Care Services have been

provided to a Grievant.

Within the time period allotted for completion of its internal

review, we will notify you of the internal panel’s decision by

telephone within twenty-four (24) hours of the panel’s

decision and in writing or by electronic means within one (1)

working day of the telephone notice.

The written notice will contain:

information sufficient for you to identify the claim;

the names, titles, and qualifying credentials of the persons

on the internal review panel;

a statement of the internal panel's understanding of the

nature of the appeal and all pertinent facts;

a description of the evidence relied on by the internal

review panel in reaching its decision;

a clear and complete explanation of the rationale for the

internal review panel's decision;

every provision of your Health Benefits Plan relevant to the

issue of coverage in the case under review, and an

explanation as to why each provision did or did not support

the panel’s decision regarding coverage of the requested

Health Care Service;

the notice shall cite the Uniform Standards relevant to your

medical condition and explain whether each supported or

did not support the panel’s decision regarding the Medical

Necessity of the requested Health Care Service;

notice of your right to request an external review by the

superintendent, including the address and telephone number

of the Managed Health Care Bureau of the insurance

division, a description of all procedures and time deadlines

necessary to pursue external review, and copies of any

forms required to initiate external review;

information about the New Mexico Managed Health Care

Bureau available to assist you in the appeal process.

External Review of Adverse Determination Procedure

If you are dissatisfied with the results of an internal panel

review, you may request, at no cost to you, an external review

by the superintendent. There is no minimum claim dollar

amount that must be met before you exercise this right to

external review.

The superintendent may require that you exhaust any of

Cigna’s appeals procedures, as appropriate, before accepting a

request for external review.

If exhaustion of internal appeals is required prior to external

review, exhaustion will be unnecessary and the internal

appeals process will be deemed exhausted if: Cigna waives the

exhaustion requirement; or if we are considered to have

exhausted the internal appeals process by failing to comply

with the requirements of the internal appeals process; or you

simultaneously request an expedited internal appeal and an

expedited external review.

An exception to the exhaustion requirement is as follows. The

internal claims and appeals process will not be deemed

exhausted based on violations of Cigna that are minor and do

not cause, and are not likely to cause prejudice or harm to you,

so long as Cigna demonstrates that the violation was for good

cause or due to matters beyond its control, and the violation

occurred in the context of an ongoing, good faith exchange of

information between Cigna and you, the Grievant, unless the

violation is part of a pattern or practice of violations by Cigna.

You may request a written explanation of the violation by

Cigna and we will provide it within ten (10) days, including a

specific description of its basis, if any, for asserting that the

violation should not cause the internal claims and appeals

process to be deemed exhausted. If an external reviewer or

court rejects your request for immediate review on the basis

that Cigna met the standards for an exception, you have the

right to resubmit and pursue the internal appeal of the claim.

In such a case, within a reasonable amount of time, not to

exceed ten (10) days, Cigna will provide you with notice of

the opportunity to resubmit and pursue the internal appeal of

the claim. Time periods for re-filing the claim will begin to

run upon your receipt of such notice.

If required by the medical exigencies of your case, you may

telephonically request an expedited review by calling the

Managed Health Care Bureau at 1-855-427-5674.

In all other cases, to initiate an external review, you must file a

written request for external review with the superintendent

within one hundred and twenty (120) calendar days from

receipt of the written notice of internal review decision unless

extended by the superintendent for good cause shown, or

unless a longer time frame is permitted under federal law.

Cigna will bear the cost of the external review.

The request shall be:

mailed to the Office of Superintendent of Insurance, Attn:

Managed Health Care Bureau - External Review Request,

New Mexico Public Regulation Commission, Post Office

Box 1689, Santa Fe, New Mexico 87504-1689; or

e-mailed to [email protected], subject External

Review Request; or

myCigna.com 46

faxed to the Office of Superintendent of Insurance, Attn:

Managed Health Care Bureau - External Review Request, at

(505) 827-3833; or

completed on-line with a NM PRC, Division of Insurance

Complaint Form available at

http://www.osi.state.nm.us/managed-healthcare/contact-

us.html.

You must file the request for external review on the forms

provided by Cigna, and you must also file:

a copy of the notice of internal review decision;

a fully executed release form authorizing the superintendent

to obtain any necessary medical records from Cigna or any

other relevant Provider; and

if the appeal involves an experimental or investigational

treatment adverse determination, the Provider’s

Certification and recommendation.

You may also file any other supporting documents or

information you wish to submit to the superintendent for

review.

If you wish to supply supporting documents or information

subsequent to the filing of the request for external review, the

timeframes for external review shall be extended up to 90 days

from the receipt of the complaint form, or until you submit all

supporting documents, whichever occurs first.

Upon receipt of a request for external review, the

superintendent will immediately send:

you an acknowledgment that the request has been received;

Cigna a copy of the request for external review.

Upon receipt of the copy of the request for external review,

Cigna will, within five (5) working days for standard review

or the time limit set by the superintendent for expedited

review, provide to you and the superintendent, by any

available expeditious method:

the Summary of Benefits;

the complete Health Benefits Plan, which may be in the

form of a member handbook/evidence of coverage;

all pertinent medical records, internal review decisions and

rationales, consulting physician reports, and documents and

information submitted by you or Cigna;

Uniform Standards relevant to your medical condition that

were used by the internal panel in reviewing the adverse

determination; and

any other documents, records, and information relevant to

the adverse determination and the internal review decision

or intended to be relied on at the external review hearing.

If Cigna fails to comply with the requirements of this section,

the superintendent may reverse the adverse determination. The

superintendent may waive the requirements of this section if

necessitated by the medical exigencies of the case.

The superintendent shall conduct either a standard or

expedited external review of the adverse determination, as

required by the medical exigencies of the case.

The superintendent shall complete an external review as

required by the medical exigencies of the case but in no case

later than seventy-two (72) hours of receipt of the external

review request whenever:

the Grievant’s life would be jeopardized; or

the Grievant’s ability to regain maximum function would be

jeopardized.

If the superintendent’s initial decision is made orally, written

notice of the decision must be provided within forty-eight (48)

hours of the oral notification.

The superintendent shall conduct a standard review in all cases

not requiring expedited review. Insurance division staff shall

complete the initial review within ten (10) working days from

receipt of the request for external review and the information

required by you and Cigna. If a hearing is held, the

superintendent will complete the external review within forty-

five (45) working days from receipt of the complete request

for external review. The superintendent may extend the

external review period for up to an additional ten (10) working

days when the superintendent has been unable to schedule the

hearing within the required timeframe and the delay will not

result in increased medical risk to the Covered Person.

Upon receipt of the request for external review, insurance

division staff shall review the request to determine whether:

you have provided the documents required;

the individual is or was insured by Cigna at the time the

Health Care Service was requested or provided;

the Grievant has exhausted Cigna’s internal review

procedure and any applicable appeal review procedure; and

the Health Care Service that is the subject of the appeal

reasonably appears to be a covered benefit under the Health

Benefits Plan.

If the request is for external review of an experimental or

investigational treatment adverse determination, insurance

division staff shall also consider whether the recommended or

requested Health Care Service:

reasonably appears to be a covered benefit under the

Grievant’s Health Benefit Plan except for Cigna’s

determination that the Health Care Service is experimental

or investigational for a particular medical condition; and

myCigna.com 47

is not explicitly listed as an excluded benefit under the

Grievant’s Health Benefit Plan; and the Grievant’s treating

Provider has certified that:

standard Health Care Services have not been effective in

improving the Grievant’s condition; or

standard Health Care Services are not medically

appropriate for the Grievant; or

there is no standard Health Care Service covered by

Cigna that is as beneficial or more beneficial than the

Health Care Service:

recommended by the Grievant’s treating Provider that

the treating Provider certifies in writing is likely to be

more beneficial to the Grievant, in the treating

Provider’s opinion, than standard Health Care Services;

or

requested by the Grievant regarding which the

Grievant’s treating Provider, who is a licensed, board

certified or board eligible physician qualified to

practice in the area of medicine appropriate to treat the

Grievant’s condition, has certified in writing that

scientifically valid studies using accepted protocols

demonstrate that the Health Care Service requested by

the Grievant is likely to be more beneficial to the

Grievant than available standard Health Care Services.

If the request for external review is incomplete, insurance

division staff will immediately notify you and Cigna and

require that you submit the required information within the

specified period of time.

If the request for external review does not meet the prescribed

criteria and, if applicable, insurance division staff will so

inform the superintendent. The superintendent will notify you

and Cigna that the request does not meet the criteria for

external review and is thereby denied, and that you have the

right to request a hearing within thirty-three (33) days from

the date the notice was mailed.

If the request for external review is complete and meets the

required criteria and, if applicable, insurance division staff

shall so inform the superintendent. The superintendent shall

notify you and Cigna that the request meets the criteria for

external review and that an informal hearing has been set to

determine whether, as a result of Cigna’s adverse

determination, you were deprived of Medically Necessary

covered services. Prior to the hearing, insurance division staff

shall attempt to informally resolve the appeal.

The notice of hearing shall be mailed no later than eight (8)

working days prior to the hearing date. The notice shall state

the date, time, and place of the hearing and the matters to be

considered and shall advise the Grievant and Cigna of the

rights. The superintendent shall not unreasonably deny a

request for postponement of the hearing made by you or

Cigna.

The superintendent may designate a Hearing Officer who shall

be an attorney licensed to practice in New Mexico. The

hearing may be conducted by telephone conference call, video

conferencing, or other appropriate technology at the insurance

division’s expense.

The superintendent may designate two (2) Independent Co-

Hearing Officers (ICOs) who must be licensed Health Care

Professionals and who must maintain independence and

impartiality in the process. If the superintendent designates

two (2) ICOs, at least one of them shall practice in a specialty

that would typically manage the case that is the subject of the

appeal.

The superintendent or attorney Hearing Officer shall regulate

the proceedings and perform all acts and take all measures

necessary or proper for the efficient conduct of the hearing.

The superintendent or attorney Hearing Officer may:

require the production of additional records, documents, and

writings relevant to the subject of the appeal;

exclude any irrelevant, immaterial, or unduly repetitious

evidence; and

if you or Cigna fails to appear, proceed with the hearing or

adjourn the proceedings to a future date, giving notice of the

adjournment to the absent party.

Staff may attend the hearing, ask questions, and otherwise

solicit evidence from the parties, but shall not be present

during deliberations among the superintendent or his

designated Hearing Officer and any ICOs.

Testimony at the hearing shall be taken under oath. The

superintendent or Hearing Officers may call and examine you,

Cigna, and other witnesses.

The hearing shall be stenographically recorded at the

insurance division’s expense.

Both you and Cigna have the right to:

attend the hearing; Cigna shall designate a person to attend

on its behalf and you may designate a person to attend on

your behalf if you choose not to attend personally;

be assisted or represented by an attorney or other person;

and

call, examine and cross-examine witnesses; and

submit to the ICO, prior to the scheduled hearing, in

writing, additional information that the ICO must consider

when conducting the internal review hearing and require

that the information be submitted to Cigna and the MHCB

staff..

You and Cigna must each stipulate on the record that the

Hearing Officers shall be released from civil liability for all

communications, findings, opinions, and conclusions made in

the course and scope of the external review. The

superintendent shall consult with appropriate professional

myCigna.com 48

societies, organizations, or associations to identify licensed

health care and other professionals who are willing to serve as

ICOs in external reviews.

The superintendent will provide for maintenance of a list of

licensed professionals qualified to serve as Independent Co-

Hearing Officers. The superintendent will select appropriate

professional societies, organizations or associations to identify

licensed health care and other professionals willing to serve as

Independent Co-Hearing Officers in external reviews who

maintain independent and impartiality of the process.

Prior to accepting designation as an ICO, each potential ICO

shall provide to the superintendent a list identifying all Health

Care Insurers and Providers with whom the potential ICO

maintains any health care related or other professional

business arrangements and briefly describe the nature of each

arrangement. Each potential ICO shall disclose to the

superintendent any other potential conflict of interest that may

arise in hearing a particular case, including any personal or

professional relationship to the Grievant or Cigna or Providers

involved in a particular external review.

The superintendent shall consult with appropriate professional

societies, organizations, or associations in New Mexico to

determine reasonable compensation for health care and other

professionals who are appointed as ICOs for external appeal

reviews and shall annually publish a schedule of ICO

compensation in a bulletin.

Upon completion of an external review, the attorney and ICO

shall each complete a statement of ICO compensation form

prescribed by the superintendent detailing the amount of time

spent participating in the external review and submit it to the

superintendent for approval. The superintendent shall send the

approved statement of ICO compensation to Cigna. Within

thirty (30) days of receipt of the statement of ICO

compensation, Cigna will remit the approved compensation

directly to the ICO.

If the parties provide written notice of a settlement up to three

(3) working days prior to the date set for external review

hearing, compensation will be unavailable to the Hearing

Officers or ICOs.

The Hearing Officer and ICOs must maintain written records

for a period of three (3) years and make them available upon

request.

At the close of the hearing, the Hearing Officers shall review

and consider the entire record and prepare findings of fact,

conclusions of law, and a recommended decision. Any

Hearing Officer may submit a supplementary or dissenting

opinion to the recommended decision.

Within the time period allotted for external review, the

superintendent shall issue an appropriate order. If the order

requires action by Cigna, the order shall specify the timeframe

for compliance.

The order shall be binding on you and Cigna and shall state

that you and Cigna have the right to judicial review and that

state and federal law may provide other remedies.

Neither you nor Cigna may file a subsequent request for

external review of the same adverse determination that was the

subject of the superintendent’s order.

Administrative Appeal (Grievance) Procedures

If you are dissatisfied with a decision, action or inaction by

Cigna, including Termination of Coverage, you have the right

to request an internal review of an administrative appeal orally

or in writing.

Within three (3) working days after receipt of an

administrative appeal, we will send you a written

acknowledgment that we have received the administrative

appeal. The acknowledgment shall contain the name, address,

and direct telephone number of a Cigna representative you

may contact regarding the administrative appeal.

Cigna will promptly review the administrative appeal. The

initial review will:

be conducted by a Cigna representative authorized to take

corrective action on the administrative appeal; and

allow you to present any information pertinent to the

administrative appeal.

Cigna will mail a written decision to you within fifteen (15)

calendar days after we receive an appeal for a required

preservice administrative appeal. Cigna will mail a written

decision to you within fifteen (15) working days of receipt of

the postservice administrative appeal. The fifteen (15) day

period may be extended when there is a delay in obtaining

documents or records necessary for the review of the

administrative appeal, provided we notify you in writing of the

need and reasons for the extension and the expected date of

resolution, or by our mutual written agreement.

The written decision shall contain:


the name, title, and qualifications of the person conducting

the initial review;

a statement of the reviewer’s understanding of the nature of

the administrative appeal and all pertinent facts;


reviewer’s decision;

identification of the Health Benefits Plan provisions relied

upon in reaching the decision;

reference to evidence or documentation considered by the

reviewer in making the decision;

a statement that the initial decision will be binding unless

you submit a request for reconsideration within twenty (20)

working days of receipt of the initial decision;

myCigna.com 49

a description of the procedures and deadlines for requesting

reconsideration of the initial decision, including any

necessary forms; and

information about the New Mexico Managed Health Care

Bureau available to assist you in the appeal process.

Upon receipt of a request for reconsideration, we appoint a

reconsideration committee consisting of one or more Cigna

employees who have not participated in the initial decision.

We may include one or more employees other than the

Grievant to participate on the reconsideration committee.

The reconsideration committee shall schedule and hold a

hearing within fifteen (15) calendar days after receiving a

request for a reconsideration of a preservice administrative

appeal, and within fifteen (15) working days after receipt of a

request for reconsideration of a postservice administrative

appeal. The hearing shall be held during regular business

hours at a location reasonably accessible to you, and we will

offer you the opportunity to communicate with the committee,

at our expense, by conference call, video conferencing, or

other appropriate technology. We will not unreasonably deny

any request you make for postponement of the hearing. If

Cigna will be represented by an attorney, the notice will

advise you that you may want to also seek legal

representation.

We will notify you in writing of the hearing date, time and

place at least ten (10) working days in advance. The notice

shall advise you of your rights.

No fewer than three (3) working days prior to the hearing, we

will provide you all documents and information that the

committee will rely on in reviewing the case. Specifically, in

the event any new or additional information (evidence) is


with the reconsideration, Cigna will provide this information







You have the right to:

attend the reconsideration committee hearing;

present your case to the reconsideration committee;

submit supporting material both before and at the

reconsideration committee hearing;

ask questions of any Cigna representative; and

be assisted or represented by a person of your choice.

We will mail a written decision to you within seven (7)

working days after the reconsideration committee hearing. The

written decision shall include:


the names, titles, and qualifications of the persons on the

reconsideration committee;

the reconsideration committee’s statement of the issues

involved in the administrative appeal;


reconsideration committee's decision;

the Health Benefits Plan provision relied on in reaching the

decision;

references to the evidence or documentation relied on in

reaching the decision;

a statement that the initial decision will be binding unless

you submit a request for external review by the

superintendent within twenty (20) working days of receipt

of the reconsideration decision; and

a description of the procedures and deadlines for requesting

external review by the superintendent, including any

necessary forms.

The notice will also contain the toll free telephone number and

address of the superintendent’s office.

External Review of Administrative Appeal by

Superintendent

If you are dissatisfied with the results of the internal review of

an administrative decision you have the right to request

external review by the superintendent. The superintendent

may require that you exhaust any of Cigna’s appeal

procedures before accepting an administrative appeal for

external review.

If exhaustion of internal appeals is required prior to external

review, exhaustion will be unnecessary and the internal

appeals process will be deemed exhausted if: Cigna waives the

exhaustion requirement; or if we are considered to have

exhausted the internal appeals process by failing to comply

with the requirements of the internal appeals process; or you

simultaneously request an expedited internal appeal and an

expedited external review.

An exception to the exhaustion requirement is as follows. The

internal claims and appeals process will not be deemed

exhausted based on violations of Cigna that are minor and do

not cause, and are not likely to cause prejudice or harm to you,

so long as Cigna demonstrates that the violation was for good

cause or due to matters beyond its control, and the violation

occurred in the context of an ongoing, good faith exchange of

information between Cigna and you, the Grievant, unless the

violation is part of a pattern or practice of violations by Cigna.

myCigna.com 50

You may request a written explanation of the violation by

Cigna and we will provide it within ten (10) days, including a

specific description of its basis, if any, for asserting that the

violation should not cause the internal claims and appeals

process to be deemed exhausted. If an external reviewer or

court rejects your request for immediate review on the basis

that Cigna met the standards for an exception, you have the

right to resubmit and pursue the internal appeal of the claim.

In such a case, within a reasonable amount of time, not to

exceed ten (10) days, Cigna will provide you with notice of

the opportunity to resubmit and pursue the internal appeal of

the claim. Time periods for re-filing the claim will begin to

run upon your receipt of such notice.

To initiate an external review, you must file a written request

for external review with the superintendent within twenty (20)

working days from receipt of the written notice of

reconsideration decision.

The request shall either be:

mailed to the Office of Superintendent of Insurance, Attn:

Managed Health Care Bureau – External Review Request,

New Mexico Public Regulation Commission, Post Office

Box 1689, Santa Fe, New Mexico 87504-1689; or

e-mailed to [email protected], subject External

Review Request; or

faxed to the Office of Superintendent of Insurance, Attn:

Managed Health Care Bureau - External Review Request,

(505) 827-3833; or

completed on-line using a NM PRC, Division of Insurance

Complaint Form available at

http://www.osi.state.nm.us/managed-healthcare/contact-

us.html.

You must file the request for external review on the forms

Cigna provides to you. You may also file any other supporting

documents or information you wish to submit to the

superintendent for review. If you wish to supply supporting

documents or information subsequent to the filing of the

request for external review, the timeframes for external review

will be extended up to 90 days from the receipt of the

complaint form, or until you submit all supporting documents,

whichever occurs first.

Upon receipt of a request for external review, the

superintendent will immediately send:

you an acknowledgment that the request has been received;

Cigna a copy of the request for external review.

Upon receipt of the copy of the request for external review,

Cigna will provide you and the superintendent, by any

available expeditious method within five (5) working days all

necessary documents and information considered in arriving at

the administrative appeal decision.

The superintendent shall review the documents submitted by

you or Cigna, and may conduct an investigation or inquiry or

consult with you, as appropriate. The superintendent shall

issue a written decision on the administrative appeal within

twenty (20) working days of receipt of the complete request

for external review.

Confidentiality

Health Care Insurers, the superintendent, Independent Co-

Hearing Officers, and all others who acquire access to

identifiable medical records and information of Grievants

when reviewing grievances shall treat and maintain such

records and information as confidential except as otherwise

provided by federal and New Mexico law.

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Definitions

Certification

The term Certification means a decision by Cigna that a

Health Care Service requested by a Provider or Grievant has

been reviewed and, based upon the information available,

meets Cigna’s requirements for coverage and Medical

Necessity, and the requested Health Care Service is therefore

approved.

HC-DFS476V2 05-12

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Covered Person

The term Covered Person means a policyholder, subscriber,

enrollee, or other individual entitled to receive health care

benefits provided by a Health Benefits Plan, and includes

Medicaid recipients enrolled in a Health Care Insurer's

Medicaid plan and individuals whose health insurance

coverage is provided by an entity that purchases or is

authorized to purchase health care benefits pursuant to the

New Mexico Health Care Purchasing Act.

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myCigna.com 51

Culturally and Linguistically Appropriate Manner of

Notice

The term Culturally and Linguistically Appropriate Manner of

Notice means:

A grievance related notice that meets the following

requirements:

oral language services provided by Cigna (such as a

telephone customer assistance hotline) that includes

answering questions in any applicable non-English

language and providing assistance with filing claims and

appeals (including external review) in any applicable non-

English language;

a grievance related notice provided by Cigna, upon

request, in any applicable non-English language;

included in the English versions of all grievance related

notices provided by Cigna, a statement prominently

displayed in any applicable non-English language clearly

indicating how to access the language services provided

by Cigna; and

for purposes of this definition, with respect to an address

in any New Mexico county to which a grievance related

notice is sent, a non-English language is an applicable

non-English language if ten percent (10%) or more of the

population residing in the county is literate only in the

same non-English language, as determined by the

department of health and human services (HHS); the

counties that meet this ten percent (10%) standard, as

determined by HHS, are found at

http://cciio.cms.gov/resources/factsheets/clas-data.html

and any necessary changes to this list are posted by HHS

annually.

HC-DFS609 05-12

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Grievant

The term Grievant means any of the following:

A policyholder, subscriber, enrollee, or other individual, or

that person’s authorized representative or provider, acting

on behalf of that person with that person’s consent, entitled

to receive health care benefits provided by Cigna;

An individual, or that person’s authorized representative,

who may be entitled to receive health care benefits provided

by Cigna;

Medicaid recipients enrolled in a Cigna Medicaid plan, if

Cigna offers such a plan.

If Cigna purchases or is authorized to purchase health care

coverage pursuant to the New Mexico Health Care Purchasing

Act, a Grievant includes individuals whose health insurance

coverage is provided by such coverage.

HC-DFS477V2 05-12

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Health Benefits Plan

The term Health Benefit Plan means a health plan or a policy,

contract, certificate or agreement offered or issued by a Health

Care Insurer or plan administrator to provide, deliver, arrange

for, pay for, or reimburse the costs of Health Care Services;

this includes a Traditional Fee-For-Service Health Benefits

Plan.

HC-DFS479V2 05-12

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Health Care Insurer

The term Health Care Insurer means a person that has a valid

certificate of authority in good standing issued pursuant to the

Insurance Code to act as an insurer, health maintenance

organization, nonprofit health care plan, fraternal benefit

society, vision plan, or pre-paid dental plan.

HC-DFS480 04-10

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Health Care Professional

The term Health Care Professional means a Physician or other

health care practitioner, including a pharmacist, who is

licensed, certified or otherwise authorized by the state to

provide Health Care Services consistent with state law.

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Health Care Services

The term Health Care Services means services, supplies, and

procedures for the diagnosis, prevention, treatment, cure or

relief of a health condition, illness, injury, or disease, and

includes, to the extent offered by the Health Benefits Plan,

physical and mental health services, including community-

based mental health services, and services for developmental

disability or developmental delay.

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myCigna.com 52

Hearing Officer, Independent Co-Hearing Officer or ICO

The terms Hearing Officer, Independent Co-Hearing Officer

or ICO mean a health care or other professional licensed to

practice medicine or another profession who is willing to

assist the superintendent as a Hearing Officer in understanding

and analyzing Medical Necessity and coverage issues that

arise in external review hearings.

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Medical Necessity or Medically Necessary

The terms Medical Necessity or Medically Necessary mean

Health Care Services determined by a Provider, in

consultation with the Health Care Insurer, to be appropriate or

necessary, according to any applicable generally accepted

principles and practices of good medical care or practice

guidelines developed by the federal government, national or

professional medical societies, boards and associations, or any

applicable clinical protocols or practice guidelines developed

by the Health Care Insurer consistent with such federal,

national, and professional practice guidelines, for the

diagnosis or direct care and treatment of a physical,

behavioral, or mental health condition, illness, injury, or

disease.

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Provider

The term Provider means a duly licensed Hospital or other

licensed facility, Physician, or other Health Care Professional

authorized to furnish Health Care Services within the scope of

their license.

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Rescission of Coverage

The term Rescission of Coverage means a cancellation or

discontinuance of coverage that has retroactive effect; a

cancellation or discontinuance of coverage is not a rescission

if:

the cancellation or discontinuance of coverage has only a

prospective effect; or

the cancellation or discontinuance of coverage is effective

retroactively to the extent it is attributable to a failure to

timely pay required premiums or contributions towards the

cost of coverage.

HC-DFS608 05-12

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Termination of Coverage

The term Termination of Coverage means the cancellation or

non-renewal of coverage provided by Cigna to a Grievant but

does not include a voluntary termination by a Grievant or

termination of a Health Benefits Plan that does not contain a

renewal provision.

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Traditional Fee-For-Service Indemnity Benefit

The term Traditional Fee-For-Service Indemnity Benefit

means a fee-for-service indemnity benefit, not associated with

any financial incentives that encourage Grievants to utilize

preferred Providers, to follow pre-authorization rules, to

utilize prescription drug formularies or other cost-saving

procedures to obtain prescription drugs, or to otherwise

comply with a plan's incentive program to lower cost and

improve quality, regardless of whether the benefit is based on

an indemnity form of reimbursement for services.

HC-DFS486V2 05-12

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Uniform Standards

The term Uniform Standards means all generally accepted

practice guidelines, evidence-based practice guidelines or

practice guidelines developed by the federal government or

national and professional medical societies, boards and

associations, and any applicable clinical review criteria,

policies, practice guidelines, or protocols developed by the

Health Care Insurer consistent with the federal, national, and

professional practice guidelines that are used by a Health Care

Insurer in determining whether to certify or deny a requested

Health Care Service.

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Utilization Management Determinations

The term Utilization Management Determinations means the

outcome, including Certification and adverse determination, of

myCigna.com 53

the review and evaluation of Health Care Services and settings

for Medical Necessity, appropriateness, efficacy, and

efficiency.

HC-DFS475 04-10

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Cigna)

CERTIFICATE RIDER – North Carolina Residents

Rider Eligibility: Each Employee who is located in North

Carolina



your health status.


Cigna.


requirements of North Carolina group insurance plans

covering insureds located in North Carolina. These provisions

supersede any provisions in your certificate to the contrary

unless the provisions in your certificate result in greater

benefits.

HC-ETNCRDR


Medical Plan





authorization of care from your Primary Care Physician for

visits to the Participating Provider of your choice for

pregnancy, well-woman gynecological exams, primary and

preventive gynecological care, and acute gynecological

conditions.

Primary Care Physician

Choice of Primary Care Physician:

If you are diagnosed with a serious or chronic degenerative,

disabling, or life-threatening disease or condition, which

requires specialized medical care, you can select a Specialist

with expertise in treating the disease or condition to serve as

your PCP. Cigna will consult with you or your designee and

the Specialist to determine if your care would appropriately

be coordinated by that Specialist.

An extended or standing authorization of care for a

Participating Specialist Physician may be obtained from the

PCP. The extended authorization can be obtained if the

insured has a serious or chronic degenerative, disabling, or

life-threatening disease or condition which, in the opinion of

the PCP who consults with the Specialist, requires ongoing

specialty care. The extended period for access to the

Participating Specialist shall not exceed 12 months.

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Covered Expenses

charges made for Family Planning, including medical

history, physical exam, related laboratory tests, medical

supervision in accordance with generally accepted medical

practices, other medical services, information and

counseling on contraception, implanted/injected

contraceptives, after appropriate counseling, medical

services connected with surgical therapies (tubal ligations,

vasectomies).

charges made by a Hospital or Ambulatory Surgical Facility

for anesthesia and facility charges for services performed in

the facility in connection with dental procedures for:

Dependent children below age 9; covered persons with

serious mental or physical conditions; or covered persons

with significant behavioral problems. The treating provider

must certify that hospitalization or general anesthesia is

required in order to safely and effectively perform the

procedure because of the person's age, condition or

problem.

charges made for or in connection with: the treatment of

congenital defects and abnormalities, including those

charges for your newborn child from the moment of birth;

and with the treatment of cleft lip or cleft palate.

charges for prescription contraceptives and devices

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

charges for the insertion and/or removal of a prescription

contraceptive device and any Medically Necessary exam

associated with use of the prescription contraceptive device.

myCigna.com 54

charges made for surgical and nonsurgical care of

Temporomandibular Joint Dysfunction (TMJ) excluding

appliances and orthodontic treatment.

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Definitions

Dependent

A child includes an adopted child or foster child including that

child from the first day of placement in your home regardless

of whether the adoption has become final.

HC-DFS700 07-14

V1-ET



Cigna)

CERTIFICATE RIDER – Ohio Residents

Rider Eligibility: Each Employee who is located in Ohio



your health status.


Cigna.


requirements of Ohio group insurance plans covering insureds

located in Ohio. These provisions supersede any provisions in



HC-ETOHRDR

Covered Expenses

charges made for or in connection with: an annual cytologic

screening (Pap smear) for detection of cervical cancer; a

single baseline mammogram for women ages 35 to 39; a

mammogram every two years for women ages 40 through

49, or an annual mammogram if a licensed Physician has

determined the woman to be at risk; and an annual

mammogram for women ages 50 through 64.

charges for any drug approved by the Food and Drug

Administration (FDA) which has not been approved by the

FDA for the treatment of the particular indication for which

the drug has been prescribed, provided the drug has been

recognized as safe and effective for treatment of that

indication in one or more of the standard medical reference

compendia adopted by the Department of Health and

Human Services (HHS) under 42 U.S.C. 1395x(t)(2), as

amended, or in medical literature only if all of the following

apply:

Two articles from major peer-reviewed professional

medical journals have recognized, based on scientific or

medical criteria, the drug's safety and effectiveness for

treatment of the indication for which it has been

prescribed;

No article from a major peer-reviewed professional

medical journal has concluded, based on scientific or

medical criteria, that the drug is unsafe or ineffective or

that the drug's safety and effectiveness cannot be

determined for the treatment of the indication for which it

has been prescribed;

Each article meets the uniform requirements for

manuscripts submitted to biomedical journals established

by the international committee of medical journal editors

or is published in a journal specified by the HHS pursuant

to section 1861(t)(2)(B) of the "Social Security Act," 107

Stat. 591 (1993), 42 U.S.C. 1395x(t)(2)(B), as amended,

as acceptable peer-reviewed medical literature.

Coverage includes Medically Necessary services associated

with the administration of the drug.

Such coverage shall not be construed to do any of the

following:

Require coverage for any drug if the FDA has

determined its use to be contraindicated for the

treatment of the particular indication for which the drug

has been prescribed;

Require coverage for experimental drugs not approved

for any indication by the FDA;

Alter any law with regard to provisions limiting the

coverage of drugs that have not been approved by the

FDA;

Require reimbursement or coverage for any drug not

included in the drug formulary or list of covered drugs

specified in the policy;

myCigna.com 55

Prohibit Cigna from limiting or excluding coverage of a

drug, provided that the decision to limit or exclude

coverage of the drug is not based primarily on the

coverage of drugs described in this provision.

HC-COV123

HC-COV124 04-10

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Special Continuation of Medical Insurance for Military

Reservists and Their Dependents

If you are a Reservist, and if your Medical Insurance would

otherwise cease because you are called or ordered to active

military duty, you may continue Medical Insurance for

yourself and your Dependents, upon payment of the required

premium to your Employer, until the earliest of the following

dates:

18 months from the date your insurance would otherwise

cease, except that coverage for a Dependent may be

extended to 36 months as provided in the section below

entitled “Extension of Continuation to 36 months”;

the last day for which the required premium has been paid;

the date you or your Dependent becomes eligible for

insurance under another group policy that does not contain

any pre-existing condition limitation, other than the Civilian

Health and Medical Program of the Uniformed Services;

the date the group policy is cancelled.

The continuation of Medical Insurance will provide the same

benefits as those provided to any similarly situated person

insured under the policy who has not been called to active

duty.

“Reservist” means a member of a reserve component of the

armed forces of the United States. “Reservist” includes a

member of the Ohio National Guard and the Ohio Air

National Guard.

Extension of Continuation to 36 Months

If your Dependent’s insurance is being continued as outlined

above, such Dependent may extend the 18-month continuation

to a total of 36 months if any of the following occur during the

original 18-month period:

you die;

you are divorced or legally separated from your spouse; or

your Dependent ceases to qualify as an eligible Dependent

under the policy.

Provisions Regarding Notification and Election of Special

Continuation

Your Employer will notify you of your right to elect

continuation of Medical Insurance. To elect the continuation,

you or your Dependent must notify the Employer and pay the

required premium within 31 days after the date your insurance

would otherwise cease, or within 31 days after the date you

are notified of your right to continue, if later.

Special Continuation of Medical Insurance

If your Active Service ends because of involuntary

termination of employment, and if:

you have been insured under the policy (or under the policy

and any similar group coverage replaced by the policy)

during the entire 3 months prior to the date your Active

Service ends; and

you pay the Employer the required premium;

your Medical Insurance will be continued until:

you become eligible for similar group medical benefits or

for Medicare;

the last day for which you have made the required payment;

12 months from the date your Active Service ends; or

the date the policy cancels;

whichever occurs first.

At the time you are given notice of termination of

employment, your Employer will give you written notice of

your right to continue the insurance. To elect this option, you

must apply in writing and make the required monthly payment

to the Employer within 31 days after the date your Active

Service ends.

If your insurance is being continued under this section, the

Medical Insurance for Dependents insured on the date your

insurance would otherwise cease may be continued, subject to

the provisions of this section. The insurance for your

Dependents will be continued until the earlier of:

the date your insurance for yourself ceases; or

with respect to any one Dependent, the date that Dependent

no longer qualifies as a Dependent.

This option will not reduce any continuation of insurance

otherwise provided.

Dependent Medical Insurance After Divorce

In the case of divorce, annulment, dissolution of marriage or

legal separation you may be required to continue the insurance

for any one of your Dependents.

myCigna.com 56

Conversion Available After Continuation

The provisions of the “Medical Conversion Privilege” section

will apply when the insurance ceases.

HC-TRM48 04-10

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Appeal

Definitions

“Adverse benefit determination” means a decision by a

health plan issuer:

To deny, reduce, or terminate a requested health care

service or payment in whole or in part, including all of the

following:

A determination that the health care service does not meet

the health plan issuer’s requirements for medical

necessity, appropriateness, health care setting, level of

care, or effectiveness, including experimental or

investigational treatments;

A determination of an individual’s eligibility for

individual health insurance coverage, including coverage

offered to individuals through a non-employer group, to

participate in a plan or health insurance coverage;

A determination that a health care service is not a covered

benefit;

The imposition of an exclusion, including exclusions for

pre-existing conditions, source of injury, network, or any

other limitation on benefits that would otherwise be

covered.

Not to issue individual health insurance coverage to an

applicant, including coverage offered to individuals through

a non-employer group;

To rescind coverage on a health benefit plan.

“Authorized representative” means an individual who

represents a covered person in an internal appeal or external

review process of an adverse benefit determination who is any

of the following:

A person to whom a covered individual has given express,

written consent to represent that individual in an internal

appeals process or external review process of an adverse

benefit determination;

A person authorized by law to provide substituted consent

for a covered individual;

A family member or a treating health care professional, but

only when the covered person is unable to provide consent.

“Covered person” means a policyholder, subscriber, enrollee,

member, or individual covered by a health benefit plan.

“Covered person” does include the covered person’s

authorized representative with regard to an internal appeal or

external review.

“Covered benefits” or “benefits” means those health care

services to which a covered person is entitled under the terms

of a health benefit plan.

“Final adverse benefit determination” means an adverse

benefit determination that is upheld at the completion of a

health plan issuer’s internal appeals process.

“Health benefit plan” means a policy, contract, certificate, or

agreement offered by a health plan issuer to provide, deliver,

arrange for, pay for, or reimburse any of the costs of health

care services.

“Health care services” means services for the diagnosis,

prevention, treatment, cure, or relief of a health condition,

illness, injury, or disease.

“Health plan issuer” means an entity subject to the insurance

laws and rules of this state, or subject to the jurisdiction of the

superintendent of insurance, that contracts, or offers to

contract to provide, deliver, arrange for, pay for, or reimburse

any of the costs of health care services under a health benefit

plan, including a sickness and accident insurance company, a

health insuring corporation, a fraternal benefit society, a self-

funded multiple employer welfare arrangement, or a

nonfederal, government health plan. “Health plan issuer”

includes a third party administrator to the extent that the

benefits that such an entity is contracted to administer under a

health benefit plan are subject to the insurance laws and rules

of this state or subject to the jurisdiction of the superintendent.

“Independent review organization” means an entity that is

accredited to conduct independent external reviews of adverse

benefit determinations.

“Rescission” or “to rescind” means a cancellation or

discontinuance of coverage that has a retroactive effect.

“Rescission” does not include a cancellation or discontinuance

of coverage that has only a prospective effect or a cancellation

or discontinuance of coverage that is effective retroactively to

the extent it is attributable to a failure to timely pay required

premiums or contributions towards the cost of coverage.

“Stabilize” means the provision of such medical treatment as

may be necessary to assure, within reasonable medical

probability that no material deterioration of a covered person’s

medical condition is likely to result from or occur during a

transfer, if the medical condition could result in any of the

following:

Placing the health of the covered person or, with respect to a

pregnant woman, the health of the woman or her unborn

child, in serious jeopardy;

myCigna.com 57

Serious impairment to bodily functions;

Serious dysfunction of any bodily organ or part.

In the case of a woman having contractions, “stabilize” means

such medical treatment as may be necessary to deliver,

including the placenta.

“Superintendent” means the superintendent of insurance.

When You Have a Complaint




noted.





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

regarding a person, a service, the quality of care, contractual

benefits, or a rescission of coverage, you may call our toll-free

number and explain your concern to one of our Customer

Service representatives. Please call us at the Customer Service

Toll-Free Number that appears on your Benefit Identification








Internal Appeals Procedure





Cigna HealthCare, Inc.

National Appeals Unit

P.O. Box 188011








Level One Appeal








determination (decision).

We will respond within 30 calendar days after we receive an

appeal for a postservice coverage determination. If more time

or information is needed to make the determination, we will















medical condition.





Level Two Appeal





medical necessity, clinical appropriateness or experimental


reviewer in the same or similar specialty as the care under

consideration, as determined by Cigna’s Physician reviewer.



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

subordinate of previous decision makers. Provide all relevant

documentation with your second-level appeal request.



calendar days. For postservice claims, the review will be





needed by us to complete the review.




myCigna.com 58










coverage.







continuing inpatient Hospital stay. Cigna's Physician reviewer

or your treating Physician will decide if an expedited appeal is

necessary. When an appeal is expedited, we will respond

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

Understanding the External Review Process

Under Chapter 3922 of the Ohio Revised Code all health plan

issuers must provide a process that allows a person covered

under a health benefit plan or a person applying for health

benefit plan coverage to request an independent external

review of an adverse benefit determination. This is a summary

of that external review process. An adverse benefit

determination is a decision by Cigna to deny benefits because

services are not covered, are excluded, or limited under the

plan, or the covered person is not eligible to receive the

benefit.

The adverse benefit determination may involve an issue of

medical necessity, appropriateness, health care setting, or level

of care or effectiveness. An adverse benefit determination can

also be a decision to deny health benefit plan coverage or to

rescind coverage.

Opportunity for External Review

An external review may be conducted by an Independent

Review Organization (IRO) or by the Ohio Department of

Insurance. The covered person does not pay for the external

review. There is no minimum cost of health care services

denied in order to qualify for an external review. However, the

covered person must generally exhaust the health plan issuer’s

internal appeal process before seeking an external review.

Exceptions to this requirement will be included in the notice

of the adverse benefit determination.

External Review by an IRO - A covered person is entitled to

an external review by an IRO in the following instances:

The adverse benefit determination involves a medical

judgment or is based on any medical information.

The adverse benefit determination indicates the requested

service is experimental or investigational, the requested

health care service is not explicitly excluded in the covered

person’s health benefit plan, and the treating physician

certifies at least one of the following:

Standard health care services have not been effective in

improving the condition of the covered person.

Standard health care services are not medically

appropriate for the covered person.

No available standard health care service covered by

Cigna is more beneficial than the requested health care

service.

There are two types of IRO reviews, standard and expedited.

A standard review is normally completed within 30 days. An

expedited review for urgent medical situations is normally

completed within 72 hours and can be requested if any of the

following applies:

The covered person’s treating physician certifies that the

adverse benefit determination involves a medical condition

that could seriously jeopardize the life or health of the

covered person or would jeopardize the covered person’s

ability to regain maximum function if treatment is delayed

until after the time frame of an expedited internal appeal.

The covered person’s treating physician certifies that the

final adverse benefit determination involves a medical

condition that could seriously jeopardize the life or health of

the covered person or would jeopardize the covered

person’s ability to regain maximum function if treatment is

delayed until after the time frame of a standard external

review.

The final adverse benefit determination concerns an

admission, availability of care, continued stay, or health

care service for which the covered person received

emergency services, but has not yet been discharged from a

facility.

An expedited internal appeal is already in progress for an

adverse benefit determination of experimental or

investigational treatment and the covered person’s treating

physician certifies in writing that the recommended health

care service or treatment would be significantly less

effective if not promptly initiated.

NOTE: An expedited external review is not available for

retrospective final adverse benefit determinations (meaning

the health care service has already been provided to the

covered person).

myCigna.com 59

External Review by the Ohio Department of Insurance - A

covered person is entitled to an external review by the

Department in the either of the following instances:

The adverse benefit determination is based on a contractual

issue that does not involve a medical judgment or medical

information.

The adverse benefit determination for an emergency

medical condition indicates that medical condition did not

meet the definition of emergency AND Cigna’s decision has

already been upheld through an external review by an IRO.

Request for External Review

Regardless of whether the external review case is to be

reviewed by an IRO or the Department of Insurance, the

covered person, or an authorized representative, must request

an external review through Cigna within 180 days of the date

of the notice of final adverse benefit determination issued by

Cigna.

All requests must be in writing, except for a request for an

expedited external review. Expedited external reviews may be

requested electronically or orally; however written

confirmation of the request must be submitted to Cigna no

later than five (5) days after the initial request. The covered

person will be required to consent to the release of applicable

medical records and sign a medical records release

authorization.

If the request is complete Cigna will initiate the external

review and notify the covered person in writing, or

immediately in the case of an expedited review, that the

request is complete and eligible for external review. The

notice will include the name and contact information for the

assigned IRO or the Ohio Department of Insurance (as

applicable) for the purpose of submitting additional

information. When a standard review is requested, the notice

will inform the covered person that, within 10 business days

after receipt of the notice, they may submit additional

information in writing to the IRO or the Ohio Department of

Insurance (as applicable) for consideration in the review.

Cigna will also forward all documents and information used to

make the adverse benefit determination to the assigned IRO or

the Ohio Department of Insurance (as applicable).

If the request is not complete Cigna will inform the covered

person in writing and specify what information is needed to

make the request complete. If Cigna determines that the

adverse benefit determination is not eligible for external

review, Cigna must notify the covered person in writing and

provide the covered person with the reason for the denial and

inform the covered person that the denial may be appealed to

the Ohio Department of Insurance.

The Ohio Department of Insurance may determine the request

is eligible for external review regardless of the decision by

Cigna and require that the request be referred for external

review. The Department’s decision will be made in

accordance with the terms of the health benefit plan and all

applicable provisions of the law.

IRO Assignment

When Cigna initiates an external review by an IRO, the Ohio

Department of Insurance web based system randomly assigns

the review to an accredited IRO that is qualified to conduct the

review based on the type of health care service. An IRO that

has a conflict of interest with Cigna, the covered person, the

health care provider or the health care facility will not be

selected to conduct the review.

IRO Review and Decision

The IRO must consider all documents and information

considered by Cigna in making the adverse benefit

determination, any information submitted by the covered

person and other information such as; the covered person’s

medical records, the attending health care professional’s

recommendation, consulting reports from appropriate health

care professionals, the terms of coverage under the health

benefit plan, the most appropriate practice guidelines, clinical

review criteria used by the health plan issuer or its utilization

review organization, and the opinions of the IRO’s clinical

reviewers.

The IRO will provide a written notice of its decision within 30

days of receipt by Cigna of a request for a standard review or

within 72 hours of receipt by Cigna of a request for an

expedited review. This notice will be sent to the covered

person, Cigna and the Ohio Department of Insurance and must

include the following information:

A general description of the reason for the request for

external review.

The date the independent review organization was assigned

by the Ohio Department of Insurance to conduct the

external review.

The dates over which the external review was conducted.

The date on which the independent review organization's

decision was made.

The rationale for its decision.

References to the evidence or documentation, including any

evidence-based standards, that was used or considered in

reaching its decision.

NOTE: Written decisions of an IRO concerning an adverse

benefit determination that involves a health care treatment or

service that is stated to be experimental or investigational also

includes the principle reason(s) for the IRO’s decision and the

written opinion of each clinical reviewer including their

recommendation and their rationale for the recommendation.

myCigna.com 60

Binding Nature of External Review Decision

An external review decision is binding on Cigna except to the

extent Cigna has other remedies available under state law. The

decision is also binding on the covered person except to the

extent the covered person has other remedies available under

applicable state or federal law.

A covered person may not file a subsequent request for an

external review involving the same adverse benefit

determination that was previously reviewed unless new

medical or scientific evidence is submitted to Cigna.

If You Have Questions About Your Rights or Need

Assistance

You may contact Cigna:

Cigna HealthCare Inc.


PO Box 188011


1-800-Cigna24

www.Cigna.com

You may also contact the Ohio Department of Insurance:

Ohio Department of Insurance

ATTN: Consumer Affairs

50 West Town Street, Suite 300, Columbus, OH 43215

800-686-1526 / 614-644-2673

614-644-3744 (fax)

614-644-3745 (TDD)

Contact ODI Consumer Affairs:

https://secured.insurance.ohio.gov/ConsumServ/ConServCo

mments.asp

File a Consumer Complaint:

http://insurance.ohio.gov/Consumer/OCS/Pages/ConsComp

l.aspx



writing or electronically and, if an adverse benefit

determination, will include: information sufficient to identify

the claim; the specific reason or reasons for the adverse

benefit determination; reference to the specific plan provisions

on which the determination is based; a statement that the

claimant is entitled to receive, upon request and free of charge,


other Relevant Information as defined; a statement describing

any voluntary appeal procedures offered by the plan and the


502(a); and upon request and free of charge, a copy of any

internal rule, guideline, protocol or other similar criterion that

was relied upon in making the adverse benefit determination

regarding your appeal, and an explanation of the scientific or

clinical judgment for a determination that is based on a

Medical Necessity, experimental treatment or other similar

exclusion or limit; limit; and information about any office of

health insurance consumer assistance or ombudsman available

to assist you in the appeal process. A final notice of adverse

determination will include a discussion of the decision.








Administrator.














determination.

Legal Action








legal action.

HC-APL66

HC-APL65 04-10

V1-ET

myCigna.com 61

Definitions

Dependent

A child includes an adopted child including that child from the

first day of placement in your home regardless of whether the

adoption has become final.

HC-DFS272 04-10

V2-ET



Cigna)

CERTIFICATE RIDER – Oregon Residents

Rider Eligibility: Each Employee who is located in Oregon



your health status.


Cigna.


requirements of Oregon group insurance plans covering

insureds located in Oregon. These provisions supersede any



HC-ORM-04-11 HC-ETORRDR


Exception to Late Entrant Definition

A person will not be considered a Late Entrant when enrolling

outside a designated enrollment period if: he had existing

coverage, and he certified in writing, if applicable, that he

declined coverage due to other available coverage; Employer

contributions toward the other coverage have been terminated;

he no longer qualifies in an eligible class for prior coverage; or

if such prior coverage was continuation coverage and the

continuation period has been exhausted; and he enrolls for this

coverage within 30 days after losing or exhausting prior

coverage; or if he is a Dependent spouse or minor child

enrolled due to court order, within 30 days after the order is

issued.

If you acquire a new Dependent through marriage, birth,

adoption or placement for adoption, you may enroll your

eligible Dependents and yourself, if you are not already

enrolled, within 30 days of such event. Coverage will be

effective, on the date of marriage, birth, adoption, or

placement for adoption.

An adopted child, or a child placed for adoption before age 19

will not be subject to any Pre-existing Condition limitation if

such child was covered within 30 days of adoption or

placement for adoption. Such waiver will not apply if 63 days

elapse between coverage during a prior period of Creditable

Coverage and coverage under this plan.

Any applicable Pre-existing Condition limitation will apply to

you and your Dependents upon enrollment, reduced by prior

Creditable Coverage, but will not be extended as for a Late

Entrant.

Pre-Existing Condition Limitation for Late Entrant

For plans which include a Pre-existing Condition limitation,

the 6-month waiting period before coverage begins for such

conditions, will be increased to 12 months for a Late Entrant.

For plans which do not include a Pre-existing Condition

limitation, you may be required to wait until the next plan

enrollment period, but no longer than 12 months, to enroll for

coverage under the plan, if you are a Late Entrant.

For plans which do not standardly include a Pre-existing

Condition limitation and which do not include an annual open

enrollment period, a Pre-existing condition limitation of 12

months will apply for a Late Entrant.

HC-ELG5 04-10

V1-ET

Certification Requirements


Pre-Admission Certification/Continued Stay Review for

Hospital Confinement

Any PAC determination will be binding on Cigna for:

the lesser of: 5 business days; or in the event your coverage

will terminate sooner than 5 business days, the period your

coverage remains in effect, provided that when PAC is

authorized:

Cigna has specific knowledge that your coverage will

terminate sooner than 5 business days; and

the termination date is specified in the PAC; or

the time period your coverage remains in effect, subject to a

maximum of 30 calendar days.

myCigna.com 62

For purposes of counting days, day 1 occurs on the first

business or calendar day, as applicable, following the day on

which Cigna issues a PAC.

Cigna will respond to a PAC request for a non-emergency

admission within two business days of the date of the request.

Qualified health care personnel will be available for same-day

telephone responses to CSR inquiries.

HC-PAC4 11-14

V2-ET

When You Have a Complaint or Appeal




noted; and "Physician reviewers" are licensed Physicians.




Start with Member Services


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

you can call our toll-free number and explain your concern to

one of our Customer Service representatives. You can also

express that concern in writing. Please call or write to us at the

following:

Customer Services Toll-free Number or address that appears

on your Benefit Identification card, explanation of benefits

or claim form.







Appeals Procedure



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




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

the toll-free number or address on your Benefit Identification


Level One Appeal





For level one appeals, we will acknowledge receipt of an

appeal within 7 days of its receipt and respond in writing with

a decision within 15 calendar days after we receive an appeal




determination. However, for postservice appeals involving

Medical Necessity, we will respond in writing within 20

working days. If more time or information is needed to make











in consultation with the treating Physician, will decide if an




Level Two Appeal










as the care under consideration, as determined by Cigna’s




have received your request within 7 days of its receipt and

schedule a Committee review. For required preservice and

concurrent care coverage determinations, the Committee

review will be completed within 15 calendar days. For

postservice claims, the Committee review will be completed

within 30 calendar days. If more time or information is needed

to make the determination, we will notify you in writing to

request an extension of up to 15 calendar days and to specify

any additional information needed by the Committee to

complete the review. You will be notified in writing of the

Committee's decision within five working days after the

Committee meeting, and within the Committee review time

myCigna.com 63

frames above if the Committee does not approve the requested

coverage.









expedited appeal is necessary. Cigna’s Physician reviewer will

consult with a Physician reviewer in the same or similar

specialty as the care under consideration to make a decision.




You have the right to apply for external review by an

Independent Review Organization if you are not fully

satisfied with the decision of Cigna's level two appeal

review regarding your Medical Necessity or clinical

appropriateness issue. The Independent Review

Organization is composed of persons who are not employed

by Cigna HealthCare or any of it’s affiliates. A decision to use

the voluntary level of appeal will not affect the claimant's

rights to any other benefits under the plan.


process. Cigna agrees to be bound by the Independent

Review Organization's decision notwithstanding the

definition of Medical Necessity in the plan.



denial by Cigna must be based on a Medical Necessity

determination, issues of clinical appropriateness, or whether a

course or plan of treatment that an insured is undergoing is an

active course of treatment for the purpose of continuity of

care. Administrative, eligibility or benefit coverage limits or

exclusions are not eligible for an independent review under

this process.


in writing within 180 days of your receipt of Cigna's level two

appeal review denial. You must also sign a waiver granting the

Independent Review Organization access to your medical

records.



detrimental to your condition, as determined by a provider

with an established clinical relationship to the insured, the

review shall be completed within three days.


arranged by Cigna.

Appeal to the State of Oregon

You have the right to file a complaint or seek other assistance

from the Oregon agency. Assistance is available:

by calling (503) 947-7984 or the toll free message line at

(888) 877-4894;

by writing to the Oregon agency, Consumer Protection Unit,

350 Winter Street NE, Room 440-2, Salem, OR 97301-

3883;

through the Internet at

http://www.cbs.state.or.us/external/ins/; or

by e-mail at: [email protected]




include: the specific reason or reasons for the adverse

determination; reference to the specific plan provisions on

which the determination is based; a statement that the claimant

is entitled to receive, upon request and free of charge,


other Relevant Information as defined; upon request and free

of charge, a copy of any internal rule, guideline, protocol or

other similar criterion that was relied upon in making the

adverse determination regarding your appeal, and an



experimental treatment or other similar exclusion or limit.

You or your plan may have other voluntary alternative dispute

resolution options such as Mediation. One way to find out

what may be available is to contact your local U.S.

Department of Labor office and your state insurance


Administrator.














determination.

Legal Action

In most instances, you may not initiate a legal action against

Cigna until you have completed the Level One and Level Two


myCigna.com 64


legal action.

HC-APL4 04-10

V1-ET

Definitions

Dependent


adopted by you including that child from the date of

placement. Coverage for such child will include the necessary

care and treatment of medical conditions existing prior to the

date of placement including medically diagnosed congenital

defects or birth abnormalities. It also includes a stepchild.

HC-DFS74 04-10

V1-ET1



Cigna)

CERTIFICATE RIDER – Pennsylvania Residents


Pennsylvania



your health status.


Cigna.


requirements of Pennsylvania group insurance plans covering

insureds located in Pennsylvania. These provisions supersede



HC-ETPARDR

Covered Expenses


breast cancer screening and diagnosis, not to exceed: a

baseline mammogram annually for women age 40 and over;

and a mammogram upon a Physician’s recommendation for

women under age 40.

charges for childhood immunizations, including the

immunizing agents and Medically Necessary booster doses.

Immunizations provided in accordance with Advisory

Committee on Immunization Practices (ACIP) standards are

covered for any insured person under age 21 and are exempt

from deductibles or dollar limits.

HC-COV136 04-10

V1-ET2


Appeal




noted.


















Appeals Procedure





Cigna


PO Box 188011





myCigna.com 65




Level One Appeal














You may request that the appeal process be expedited if: (a)











medical condition.

Cigna's Physician reviewer, or your treating Physician, will




Level Two Appeal










review will be conducted by someone who was: not involved

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





calendar days. For postservice claims, the review will be





needed by us to complete the review.











working days after the decision is made, and within the

review time frames above if Cigna does not approve the

requested coverage.










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


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








plan.











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



myCigna.com 66




Physician reviewer, the review shall be completed within three

days.


arranged by Cigna.

Appeal to the State of Pennsylvania

You have the right to contact the Pennsylvania Insurance

Department for assistance at any time. The Pennsylvania

Insurance Department may be contacted at the following


Pennsylvania Insurance Department

Bureau of Consumer Services

1321 Strawberry Square

Harrisburg, PA 17120

717-787-5193

Toll-Free Number: 888-466-2787






























Administrator.














determination.

Legal Action








legal action.

HC-APL71 04-10

V1-ET

Definitions

Dependent


adopted by you including that child, from the date of

placement in your home, regardless of whether the adoption

has become final.

HC-DFS276 01-15

V2-ET

myCigna.com 67



Cigna)

CERTIFICATE RIDER – South Carolina Residents

Rider Eligibility: Each Employee who is located in South

Carolina



your health status.


Cigna.


requirements of South Carolina group insurance plans

covering insureds located in South Carolina. These provisions

supersede any provisions in your certificate to the contrary

unless the provisions in your certificate result in greater

benefits.

HC-ETSCRDR

Definitions

Dependent

A child includes a legally adopted child, including that child

from the first day of placement in your home regardless of

whether the adoption has become final, or an adopted child of

whom you have custody according to the decree of the court

provided you have paid premiums. Adoption proceedings

must be instituted by you, and completed within 31 days after

the child's birth date, and a decree of adoption must be entered

within one year from the start of proceedings, unless extended

by court order due to the child's special needs.

HC-DFS273 04-10

V1-ET



Cigna)

CERTIFICATE RIDER – Texas Residents

Rider Eligibility: Each Employee who is located in Texas



your health status.


Cigna.


requirements of Texas group insurance plans covering

insureds located in Texas. These provisions supersede any



HC-ETTXRDR

Important Notice

Notice of Coverage for Acquired Brain Injury

Your health benefit plan coverage for an acquired brain injury

includes the following services:

cognitive rehabilitation therapy;

cognitive communication therapy;

neurocognitive therapy and rehabilitation;

neurobehavioral, neurophysiological, neuropsychological

and psychophysiological testing and treatment;

neurofeedback therapy and remediation;

post-acute transition services and community reintegration

services, including outpatient day treatment services or

other post-acute care treatment services; and

reasonable expenses related to periodic reevaluation of the

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

date, at which time the cognitive rehabilitation services

would be a covered benefit.

The fact that an acquired brain injury does not result in

hospitalization or acute care treatment does not affect the right

of the insured or the enrollee to receive the preceding

treatments or services commensurate with their condition.

myCigna.com 68

Post-acute care treatment or services may be obtained in any

facility where such services may legally be provided,

including acute or post-acute rehabilitation hospitals and

assisted living facilities regulated under the Health and Safety

Code.

The following words and terms shall have the following

meanings:

Acquired brain injury - A neurological insult to the brain,

which is not hereditary, congenital, or degenerative. The

injury to the brain has occurred after birth and results in a

change in neuronal activity, which results in an impairment of

physical functioning, sensory processing, cognition, or

psychosocial behavior.

Cognitive communication therapy - Services designed to

address modalities of comprehension and expression,

including understanding, reading, writing, and verbal

expression of information.

Cognitive rehabilitation therapy - Services designed to

address therapeutic cognitive activities, based on an

assessment and understanding of the individual's brain-

behavioral deficits.

Community reintegration services - Services that facilitate

the continuum of care as an affected individual transitions into

the community.

Enrollee - A person covered by a health benefit plan.

Health benefit plan - As described in the Insurance Code §

1352.001 and § 1352.002.

Issuer - Those entities identified in the Insurance Code §

1352.001.

Neurobehavioral testing - An evaluation of the history of

neurological and psychiatric difficulty, current symptoms,

current mental status, and premorbid history, including the

identification of problematic behavior and the relationship

between behavior and the variables that control behavior. This

may include interviews of the individual, family, or others.

Neurobehavioral treatment - Interventions that focus on

behavior and the variables that control behavior.

Neurocognitive rehabilitation - Services designed to assist

cognitively impaired individuals to compensate for deficits in

cognitive functioning by rebuilding cognitive skills and/or

developing compensatory strategies and techniques.

Neurocognitive therapy - Services designed to address

neurological deficits in informational processing and to

facilitate the development of higher level cognitive abilities.

Neurofeedback therapy - Services that utilize operant

conditioning learning procedure based on

electroencephalography (EEG) parameters, and which are

designed to result in improved mental performance and

behavior, and stabilized mood.

Neurophysiological testing - An evaluation of the functions

of the nervous system.

Neurophysiological treatment - Interventions that focus on

the functions of the nervous system.

Neuropsychological testing - The administering of a

comprehensive battery of tests to evaluate neurocognitive,

behavioral, and emotional strengths and weaknesses and their

relationship to normal and abnormal central nervous system

functioning.

Neuropsychological treatment - Interventions designed to

improve or minimize deficits in behavioral and cognitive

processes.

Other similar coverage - The medical/surgical benefits

provided under a health benefit plan. This term recognizes a

distinction between medical/surgical benefits, which

encompass benefits for physical illnesses or injuries, as

opposed to benefits for mental/behavioral health under a

health benefit plan.

Outpatient day treatment services - Structured services

provided to address deficits in physiological, behavioral,

and/or cognitive functions. Such services may be delivered in

settings that include transitional residential, community

integration, or non-residential treatment settings.

Post-acute care treatment services - Services provided after

acute care confinement and/or treatment that are based on an

assessment of the individual's physical, behavioral, or

cognitive functional deficits, which include a treatment goal of

achieving functional changes by reinforcing, strengthening, or

re-establishing previously learned patterns of behavior and/or

establishing new patterns of cognitive activity or

compensatory mechanisms.

Post-acute transition services - Services that facilitate the

continuum of care beyond the initial neurological insult

through rehabilitation and community reintegration.

Psychophysiological testing - An evaluation of the

interrelationships between the nervous system and other

bodily organs and behavior.

Psychophysiological treatment - Interventions designed to

alleviate or decrease abnormal physiological responses of the

nervous system due to behavioral or emotional factors.

Remediation - The process(es) of restoring or improving a

specific function.

Services - The work of testing, treatment, and providing

therapies to an individual with an acquired brain injury.

Therapy - The scheduled remedial treatment provided

through direct interaction with the individual to improve a

pathological condition resulting from an acquired brain injury.

myCigna.com 69

Examinations for Detection of Cervical Cancer

Benefits are provided for each covered female age 18 and over

for an annual medically recognized diagnostic examination for

the early detection of cervical cancer. Benefits include at a

minimum: a conventional Pap smear screening; or a screening

using liquid-based cytology methods, as approved by the

United States Food and Drug Administration, alone or in

combination with a test approved by the United States Food

and Drug Administration for the detection of the human

papillomavirus.

If any person covered by this plan has questions concerning

the above, please call Cigna at 1-800-244-6224, or write us at

the address on the back of your ID card.

HC-IMP16 04-10

V2-ET1


Medical Plan





authorization of care from your Primary Care Physician for

visits to the Participating Provider of your choice for

pregnancy, well-woman gynecological exams, primary and

preventive gynecological care, and acute gynecological

conditions.

HC-IMP3 04-10

V8-ET

The Schedule

The following sentence is added to the “Hospital Emergency

Room” section under the “Emergency and Urgent Care

Services” section of The Schedule shown in your medical

certificate:

Emergency and Urgent Care Services

Hospital Emergency Room

(including a properly licensed freestanding emergency

medical care facility)

The Schedule is amended to indicate the following:

Cardiovascular Disease Screening

Charges for Cardiovascular Disease Screenings are payable at

100%, with one screening every 5 years, not to exceed $200.

The Medical Schedule is amended to indicate that no separate

maximum/deductible shall apply to Diabetic Equipment.

If you are enrolled in a plan which excludes Pharmacy

provisions, the Medical Schedule is amended to indicate that a

$10 copay shall apply for In-Network Diabetic Medications.

The Nutritional Evaluation annual maximum shown in the

Medical Schedule is amended to indicate the following:

“3 visits per person however, the 3 visit limit will not apply to

treatment of diabetes.”

SCHEDTX-ET

Covered Expenses

charges made for annual mammogram for women 35 years

of age and older.

charges made for reconstructive surgery of craniofacial

abnormalities for a child who is younger than 18 years of

age to improve the function of, or to attempt to create a

normal appearance for an abnormal structure caused by

congenital defects, developmental deformities, trauma,

tumors, infection or disease.

charges made for an acquired brain injury including:

cognitive rehabilitation therapy; cognitive communication

therapy; neurocognitive therapy and rehabilitation;

neurobehavioral, neurophysiological, neuropsychological

and psychophysiological testing and treatment;

neurofeedback therapy and remediation; post-acute

transition services and community reintegration services,

including outpatient day treatment services or other post-

acute care treatment services; and reasonable expenses

related to periodic reevaluation of the care of an individual

covered under the plan who has incurred an acquired brain

injury, has been unresponsive to treatment, and becomes

myCigna.com 70

responsive to treatment at a later date, at which time the

cognitive rehabilitation services would be a covered benefit.

charges made for an annual medically recognized diagnostic

examination for the early detection of cervical cancer for

each covered female age 18 and over. Such coverage shall

include at a minimum: a conventional Pap smear screening;

or a screening using liquid-based cytology methods, as

approved by the United States Food and Drug

Administration, alone or in combination with a test

approved by the United States Food and Drug

Administration for the detection of the human

papillomavirus.

charges for a screening test for hearing loss from birth

through the date the child is 30 days old, and necessary

diagnostic follow-up care related to the screening test

from birth through the date the child is 24 months old.


High Deductible Health Plan, a deductible will not apply.

charges for or in connection with a medically recognized

screening exam for the detection of colorectal cancer for

each insured who is at least 50 years of age and at normal

risk for developing colon cancer. Coverage will include: an

annual fecal occult blood test; and either a flexible

sigmoidoscopy performed every five years; or a

colonoscopy performed every 10 years.

charges for a drug that has been prescribed for the treatment

of a covered chronic, disabling or life-threatening Sickness,

provided that drug is Food and Drug (FDA) approved for at

least one indication and is recognized for treatment in one

of the standard reference compendia (The United States

Pharmacopoeia Drug Information, The American Medical

Association Drug Evaluations, or the American Hospital

Formulary Service Drug Information) or supported by

articles in accepted, peer-reviewed medical literature.

Coverage will also be provided for any medical services

necessary to administer the drug.

charges made for all generally recognized services

prescribed in relation to Autism Spectrum Disorder for

Dependent children through age 9. Such coverage must be

prescribed by a Physician in a treatment plan and shall

include evaluation and assessment services; applied

behavior analysis; behavior training and behavior

management; speech therapy; occupational therapy;

physical therapy; or medications or nutritional supplements

used to address symptoms of autism spectrum disorder.

Autism Spectrum Disorder means a neurobiological

disorder that includes autism, Asperger's syndrome, or

Pervasive Developmental Disorder--Not Otherwise

Specified. Neurobiological disorder means an illness of the

nervous system caused by genetic, metabolic, or other

biological factors.

charges for a service provided through Telemedicine for

diagnosis, consultation, treatment, transfer of medical data,

and medical education.

These benefits may not be subject to a greater deductible,

copayment, or coinsurance than for the same service under

this plan provided through a face-to-face consultation.

The term Telemedicine means the practice of health care

delivery, diagnosis, consultation, treatment, transfer of

medical data, and medical education through the use of

interactive audio, video, or other electronic media. It does

not include the use of telephone or fax.

charges for Hospital Confinement of a mother and her

newborn child for 48 hours following an uncomplicated

vaginal delivery, or for 96 hours following an

uncomplicated cesarean delivery. After consulting with her

attending Physician the mother may request an earlier

discharge if it is determined that less time is needed for

recovery. If medical necessity requires the mother and/or

newborn to remain confined for longer than 48 hours, the

additional confinement will be covered. If the mother is

discharged prior to the 48 or 96 hours described above, a

postpartum home care visit will be covered. Postpartum

home care services include parent education; assistance and

training in breast feeding and bottle feeding; and the

performance of any necessary and appropriate clinical tests.

charges for diagnostic and surgical treatment for conditions

effecting temporomandibular joint and craniomandibular

disorders which are a result of: an accident; trauma; a

congenital defect; a developmental defect; or a pathology.

charges made for or in connection with annual diagnostic

examinations for the detection of prostate cancer, regardless

of medical necessity; and a prostate-specific antigen (PSA)

test for a man who is at least 50 years of age and

asymptomatic or at least 40 years of age with a family

history of prostate cancer, or another prostate risk factor.

charges for a minimum of 48 hours of inpatient care

following a mastectomy and a minimum 24 hours following

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

both agree it is appropriate.

charges for immunizations for children from birth through

age 5. These immunizations will include: diphtheria;

Haemophilus influenzae type b; hepatitis B; measles;

mumps; pertussis; polio; rubella; tetanus; varicella (chicken

pox); rotavirus; and any other children's immunizations

required by the State Board of Health. A deductible,

copayment, or coinsurance is not required for

immunizations.

myCigna.com 71

Biologically Based Mental Illness

Charges for treatment of Biologically-Based Mental Illness at

the same rate as for other illnesses. A Biologically-Based

Mental Illness is defined as: schizophrenia, paranoid and other

psychotic disorders, bipolar disorders (hypomanic, manic,

depressive, and mixed), major depressive disorder,

schizoaffective disorders (bipolar or depressive), obsessive-

compulsive disorders, and depression in childhood or

adolescence.

Diabetes

The following benefits will apply to insulin and non-insulin

dependent diabetics as well as covered individuals who have

elevated blood sugar levels due to pregnancy or other medical

conditions:

Diabetes Equipment and Supplies:

Blood glucose monitors, including those designed to be

used by the legally blind;

Test strips specified for use with a corresponding glucose

monitor;

Lancets and lancet devices;

Visual reading strips and urine testing strips and tablets

which test for glucose, ketones and protein;

Insulin and insulin analog preparations;

Injection aids, including devices used to assist with insulin

injection and needleless systems;

Insulin syringes;

Biohazard disposal containers;

Insulin pumps, both external and implantable, and

associated appurtenances which include insulin infusion

devices, batteries, skin preparation items, adhesive supplies,

infusion sets, insulin cartridges, durable and disposable

devices to assist in the injection of insulin, and other

required disposable supplies;

Repairs and necessary maintenance of insulin pumps (not

otherwise provided under warranty) and rental fees for

pumps during the repair and maintenance. This shall not

exceed the purchase price of a similar replacement pump;

Prescription and non-prescription medications for

controlling blood sugar level;

Podiatric appliances, including up to two pair of therapeutic

footwear per year, for the prevention of complications

associated with diabetes;

Glucagon emergency kits.

If determined as medically necessary by a treating physician,

new or improved treatment and monitoring equipment or

supplies (approved by the FDA) shall be covered.

The training program for diabetes self-management shall be

recognized by the American Diabetes Association and shall be

performed by a certified diabetes educator (CDE), a

multidisciplinary team coordinated by a CDE (e.g., a dietician,

nurse educator, pharmacist, social worker), or a licensed

healthcare professional (e.g., physician, physician assistant,

registered nurse, registered dietician, pharmacist) determined

by his or her licensing board to have recent experience in

diabetes clinical and educational issues. All individuals

providing training must be certified, licensed or registered to

provide appropriate health care services in Texas.

Self-management training shall include the development of an

individual plan, created in collaboration with the member, that

addresses:

Nutrition and weight evaluation;

Medications;

An exercise regimen;

Glucose and lipid control;

High risk behaviors;

Frequency of hypoglycemia and hyperglycemia;

Compliance with applicable aspects of self-care;

Follow-up on referrals;

Psychological adjustment;

General knowledge of diabetes;

Self-management skills;

Referral for a funduscopic eye exam.

myCigna.com 72

This training shall be provided/covered upon the initial

diagnosis of diabetes or, the written order of the

practitioner/physician when a change in symptoms or

conditions warrant a change in the self-management regime

or, the written order of a practitioner/physician that periodic or

episodic continuing education is needed.

Clinical Trials

Charges made for routine patient care costs in connection

with a phase I, II, III or IV clinical trial if the clinical trial

is conducted in relation to the prevention, detection or

treatment of a life threatening disease or condition. The

clinical trial must be approved by: the Centers for Disease

Control and Prevention of the U.S. Department of Health

and Human Services; the National Institutes of Health; the

U.S. Food and Drug Administration; the U.S. Department

of Defense; the U.S. Department of Veterans Affairs; or an

institutional review board of an institution in this state that

has an agreement with the Office for Human Research

Protections of the U.S. Department of Health and Human

Services.

HC-COV416 01-15

V1-ET3

Inpatient Mental Health Services

Services that are provided by a Hospital while you or your

Dependent is Confined in a Hospital for the treatment and

evaluation of Mental Health. Inpatient Mental Health Services

include Partial Hospitalization and Mental Health Residential

Treatment Services.

Partial Hospitalization sessions are services that are provided

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

hour period.

Mental Health Residential Treatment Services are services

provided by a Hospital for the evaluation and treatment of the

psychological and social functional disturbances that are a

result of subacute Mental Health conditions.

Mental Health Residential Treatment Center means an

institution which specializes in the treatment of psychological

and social disturbances that are the result of Mental Health

conditions; provides a subacute, structured, psychotherapeutic

treatment program, under the supervision of Physicians;

provides 24-hour care, in which a person lives in an open

setting; and is licensed in accordance with the laws of the

appropriate legally authorized agency as a residential

treatment center.

A person is considered confined in a Mental Health


patient in a Mental Health Residential Treatment Center upon

the recommendation of a Physician.

HC-COV7 04-10

V5-ET

Breast Reconstruction and Breast Prostheses

charges made for reconstructive surgery following a

mastectomy; benefits include: surgical services for

reconstruction of the breast on which surgery was

performed; surgical services for reconstruction of the

nondiseased breast to produce symmetrical appearance;

postoperative breast prostheses; and mastectomy bras and

external prosthetics, limited to the lowest cost alternative

available that meets external prosthetic placement needs.

During all stages of mastectomy, treatment of physical

complications, including lymphedema therapy, are covered.

Such coverage shall be provided in a manner determined to

be appropriate in consultation with the Physician and the

insured.

Reconstructive Surgery

charges made for reconstructive surgery or therapy to repair

or correct a severe physical deformity or disfigurement

which is accompanied by functional deficit; (other than

abnormalities of the jaw or conditions related to TMJ

disorder) provided that: the surgery or therapy restores or

improves function; reconstruction is required as a result of

Medically Necessary, noncosmetic surgery; or the surgery

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

result of the congenital absence or agenesis (lack of

formation or development) of a body part.

HC-COV14 04-10

V2


Special Continuation of Medical Insurance

If Medical Insurance for you or your Dependent would

otherwise cease for any reason except due to involuntary

termination for cause or due to discontinuance in entirety of

the policy or an insured class, coverage may be continued if:

the person was covered by this policy and/or a prior policy

for the three months immediately prior to the date coverage

would otherwise cease, and

the person elects continuation coverage and pays the first

monthly premium within 60 days of the later of either the

myCigna.com 73

date coverage would otherwise cease or the date required

notice is provided.

Coverage will continue until the earliest of the following:

6 months after continuation coverage is elected for plans

with COBRA and 9 months after continuation coverage is

elected for those without;

the end of the period for which premium is paid;

the date the policy is discontinued and not replaced;

the date the person becomes eligible for Medicare; and

the date the person becomes insured under another similar

policy or becomes eligible for coverage under a group plan

or a state or federal plan.

Texas – Special Continuation of Dependent Medical

Insurance

If your Dependent's Medical Insurance would otherwise cease

because of your death or retirement, or because of divorce or

annulment, his insurance will be continued upon payment of

required premium, if: he has been insured under the policy, or

a previous policy sponsored by your Employer, for at least one

year prior to the date the insurance would cease; or he is a

Dependent child less than one year old. The insurance will be

continued until the earliest of:

three years from the date the insurance would otherwise

have ceased;

the last day for which the required premium has been paid;

with respect to any one Dependent, the earlier of the dates

that Dependent: becomes eligible for similar group

coverage; or no longer qualifies as a Dependent for any

reason other than your death or retirement or divorce or

annulment; or

the date the policy cancels.

If, on the day before the Effective Date of the policy, medical

insurance was being continued for a Dependent under a group

medical policy: sponsored by your Employer; and 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.

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

of the death, retirement, divorce or annulment, notify your

Dependent of his right to elect continuation as set forth above.

Your Dependent may elect in writing such continuation within

60 days after the date the insurance would otherwise cease, by

paying the required premium to your Employer.

HC-TRM27 04-10

V1-ET

Medical Benefits Extension Upon Policy

Cancellation

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

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

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

Sickness, Medical Benefits will be paid for Covered Expenses

incurred in connection with that Injury or Sickness. However,

no benefits will be paid after the earliest of:

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

the Schedule;

the date you are covered for medical benefits under another

group policy;

the date you are no longer Totally Disabled;

90 days from the date your Medical Benefits cease; or

90 days from the date the policy is canceled.

Totally Disabled

You will be considered Totally Disabled if, because of an

Injury or a Sickness:

you are unable to perform the basic duties of your

occupation; and

you are not performing any other work or engaging in any

other occupation for wage or profit.

Your Dependent will be considered Totally Disabled if,

because of an Injury or a Sickness:

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

the same age, sex and ability; or

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

profit, he is not performing such work.

HC-BEX17 04-10

V1-ET






noted.




When You Have a Complaint

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

regarding a person, a service, the quality of care, a rescission

myCigna.com 74

of coverage, or contractual benefits not related to Medical

Necessity, you can call our toll-free number and explain your

concern to one of our Customer Service representatives. A

complaint does not include: a misunderstanding or problem of

misinformation that can be promptly resolved by Cigna by

clearing up the misunderstanding or supplying the correct

information to your satisfaction; or you or your provider's

dissatisfaction or disagreement with an adverse determination.

You can also express that complaint in writing. Please call us

at the Customer Service Toll-Free Number that appears on

your Benefit Identification card, explanation of benefits or

claim form, or write to us at the following address:

Cigna


PO Box 188011




complaint, we will send you a letter acknowledging the date

on which we received your complaint no later than the fifth

working day after we receive your complaint. We will respond

in writing with a decision 30 calendar days after we receive a

complaint for a postservice coverage determination. If more

time or information is needed to make the determination, we

will notify you in writing to request an extension of up to 15














medical condition.

Cigna's Physician reviewer, or your treating Physician, will

decide if an expedited appeal is necessary. When a complaint

is expedited, we will respond orally with a decision within the

earlier of: 72 hours; or one working day, followed up in

writing within 3 calendar days.


you can start the complaint appeals procedure.

Complaint Appeals Procedure

To initiate an appeal of a complaint resolution decision, you

must submit a request for an appeal in writing to the following

address:

Cigna


PO Box 188011








Your complaint appeal request will be conducted by the

Complaint Appeals Committee, which consists of at least three

people. Anyone involved in the prior decision, or subordinates

of those people, may not vote on the Committee. You may

present your situation to the Committee in person or by

conference call.

We will acknowledge in writing that we have received your

request within five working days after the date we receive

your request for a Committee review and schedule a

Committee review. The Committee review will be completed

within 30 calendar days. If more time or information is needed

to make the determination, we will notify you in writing to

request an extension of up to 15 calendar days and to specify

any additional information needed by the Committee to

complete the review. In the event any new or additional


by Cigna in connection with the complaint appeal, Cigna will

provide this information to you as soon as possible and

sufficiently in advance of the decision, so that you will have

an opportunity to respond. Also, if any new or additional

rationale is considered by Cigna, Cigna will provide the

rationale to you as soon as possible and sufficiently in advance

of the decision so that you will have an opportunity to

respond.










your appeal involves non-authorization of an admission or

continuing inpatient Hospital stay. Cigna's Physician reviewer



myCigna.com 75

orally with a decision within the earlier of: 72 hours; or one

working day, followed up in writing within three calendar

days.

When You have an Adverse Determination Appeal

An Adverse Determination is a decision made by Cigna that

the 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 Cigna of a request to cover a specific prescription drug

prescribed by your Physician. If you are not satisfied with the

Adverse Determination, you may appeal the Adverse

Determination orally or in writing. You should state the reason

why you feel your appeal should be approved and include any

information supporting your appeal. We will acknowledge the

appeal in writing within five working days after we receive the

Adverse Determination Appeal request.

Your appeal of an Adverse Determination will be reviewed

and the decision made by a health care professional not

involved in the initial decision. In the event any new or

additional information (evidence) is considered, relied upon or

generated by Cigna in connection with the appeal, Cigna will

provide this information to you as soon as possible and

sufficiently in advance of the decision, so that you will have

an opportunity to respond. Also, if any new or additional

rationale is considered by Cigna, Cigna will provide the

rationale to you as soon as possible and sufficiently in advance

of the decision so that you will have an opportunity to

respond.

We will respond in writing with a decision within 30 calendar

days after receiving the Adverse Determination appeal

request.







continuing inpatient Hospital stay. If you request that your

appeal be expedited based on (a) above, you may also ask for

an expedited external Independent Review at the same time, if

the time to complete an expedited level-one appeal would be

detrimental to your medical condition.

Cigna's Physician reviewer or your treating Physician will


expedited, we will respond orally with a decision within the

earlier of: 72 hours; or 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

review is voluntary. If the specialty reviewer upholds the

initial adverse determination and you remain dissatisfied, you

are still eligible to request a review by an Independent Review

Organization.



Adverse Determination appeal process or if you feel your

condition is life-threatening, you may request that your appeal

be referred to an Independent Review Organization. In

addition, your treating Physician may request in writing that

Cigna conduct a specialty review. The specialty review

request must be made within 10 days of receipt of the Adverse

Determination appeal decision letter.

Cigna must complete the specialist review and send a written

response within 15 days of its receipt of the request for

specialty review. If the specialist upholds the initial Adverse

Determination, you are still eligible to request a review by an

Independent Review Organization. The Independent Review

Organization is composed of persons who are not employed

by Cigna or any of its affiliates. A decision to use the

voluntary level of appeal will not affect the claimant's rights to

any other benefits under the plan.


process and the decision to use the process is voluntary. Cigna

will abide by the decision of the Independent Review

Organization.






eligible for appeal under this process. You will receive

detailed information on how to request an Independent

Review and the required forms you will need to complete with

every Adverse Determination notice.


arranged by Cigna.

Appeal to the State of Texas

You have the right to contact the Texas Department of

Insurance for assistance at any time for either a complaint or

an Adverse Determination appeal. The Texas Department of

Insurance may be contacted at the following address and

telephone number:

Texas Department of Insurance

333 Guadalupe Street

P.O. Box 149104

Austin, TX 78714-9104

1-800-252-3439

myCigna.com 76


Every notice of an appeal decision will be provided in writing

or electronically and, if an adverse determination, will include:

information sufficient to identify the claim; the specific reason

or reasons for the denial decision; reference to the specific

plan provisions on which the decision is based; a statement

that the claimant is entitled to receive, upon request and free

of charge, reasonable access to and copies of all documents,

records, and other Relevant Information as defined; a

statement describing any voluntary appeal procedures offered

by the plan and the claimant's right to bring an action under

ERISA section 502(a); upon request and free of charge, a copy

of any internal rule, guideline, protocol or other similar


determination regarding your appeal, and an explanation of the

scientific or clinical judgment for a determination that is based

on a Medical Necessity, experimental treatment or other

similar exclusion or limit; and information about any office

of health insurance consumer assistance or ombudsman

available to assist you in the appeal process. A final notice

of adverse determination will include a discussion of the

decision.








Administrator.














determination.

Legal Action Under Federal Law





until you have completed the Complaint or Adverse

Determination Appeal process. If your Complaint is expedited,

there is no need to complete the Complaint Appeal process

prior to bringing legal action.

HC-APL132 04-10

V1-ET

Definitions

Dependent

Dependents include:



26 or more years old, unmarried, and primarily supported

by you and incapable of self-sustaining employment by

reason of mental or physical disability which arose while

the child was covered as a Dependent under this Plan, or

while covered as a dependent under a prior plan with no

break in coverage.






The term child means a child born to you; a child legally

adopted by you; the child for whom you are the legal

guardian; the child who is the subject of a lawsuit for adoption

by you; the child who is supported pursuant to a court order

imposed on you (including a qualified medical child support

order), or your grandchild who is your Dependent for federal

income tax purposes at the time of application. It also includes

a stepchild.

HC-DFS414 04-10

V5-ET

myCigna.com 77



Cigna)

CERTIFICATE RIDER – Utah Residents

Rider Eligibility: Each Employee who is located in Utah



your health status.


Cigna.


requirements of Utah group insurance plans covering insureds

located in Utah. These provisions supersede any provisions in



HC-ETUTRDR


Appeal




noted.





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

regarding a person, a service, the quality of care, or

contractual benefits, or a rescission of coverage, you can call

our toll-free number and explain your concern to one of our

Customer Service representatives. Please call us at the

Customer Service Toll-Free Number that appears on your

Benefit Identification card, explanation of benefits or claim

form.







Appeals Procedure





Cigna HealthCare Inc.


PO Box 188011






number or address on your Benefit Identification card,


Level-One Appeal





For level-one appeals, we will respond in writing with a




















medical condition.





myCigna.com 78

Level Two Appeal











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





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


















coverage.

You may request that the appeal process be expedited if the












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








plan.











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






Physician reviewer, the review shall be completed within three

days.


arranged by Cigna.

Appeal to the State of Utah

You have the right to contact the Utah State Department of

Insurance for assistance at any time. The Utah State

Department of Insurance may be contacted at the following


Utah State Department of Insurance

State Office Building, Room 3110

Salt Lake City, UT 84114-6901

800-439-3805

















myCigna.com 79














Administrator.














determination.

Legal Action








legal action.

HC-APL135 01-11

V1-ET

Definitions

Dependent

A child also includes a legally adopted child, including that

child from the date of placement for adoption. Coverage for an

adopted child will begin from:

the moment of birth, if adoption occurs within 30 days of

the child's birth; or

the date of placement, if placement for adoption occurs 30

days or more after the child's birth.

This coverage requirement ends if the child is removed from

placement prior to the child being legally adopted.

"Placement for Adoption" means the assumption and retention

by a person of a legal obligation for total or partial support of

a child in anticipation of the adoption of the child.

HC-DFS699 01-15

V1-ET1



Cigna)

CERTIFICATE RIDER – Vermont Residents


Vermont

You will become insured on the date you become

eligible, including if you are not in Active Service on

that date due to your health status.


Cigna.

The provisions set forth in this rider comply with the

legal requirements of Vermont group insurance plans

covering insureds located in Vermont. These provisions

supersede any provisions in your certificate to the

contrary unless the provisions in your certificate result in

greater benefits.

HC-ETVTRDR

Important Notices

Vermont Mandatory Civil Unions Endorsement for

Health Insurance

Purpose:

Vermont law requires that health insurers offer coverage

to parties to a civil union that is equivalent to coverage

provided to married persons. This endorsement is part of

myCigna.com 80

and amends this policy, contract or certificate to comply

with Vermont law.

Definitions, Terms, Conditions and Provisions

The definitions, terms, conditions and any other

provisions of the policy, contract, certificate and/or

riders and endorsements to which this mandatory

endorsement is attached are hereby amended and

superseded as follows:

Terms that mean or refer to a marital relationship, or

that may be construed to mean or refer to a marital

relationship, such as “marriage,” “spouse,” “husband,”

“wife,” “dependent,” “next of kin,” “relative,”

“beneficiary,” “survivor,” “immediate family” and any

other such terms include the relationship created by a

civil union established according to Vermont law.

Terms that mean or refer to the inception or

dissolution of a marriage, such as “date of marriage,”

“divorce decree,” “termination of marriage” and any

other such terms include the inception or dissolution of

a civil union established according to Vermont law.

Terms that mean or refer to family relationships

arising from a marriage, such as “family,” “immediate

family,” “dependent,” “children,” “next of kin,”

“relative,” “beneficiary,” “survivor” and any other

such terms include family relationships created by a

civil union established according to Vermont law.

“Dependent” means a spouse, party to a civil union

established according to Vermont law, and a child or

children (natural, stepchild, legally adopted or a minor

or disabled child who is dependent upon the insured

for support and maintenance) who is born to or

brought to a marriage or to a civil union established

according to Vermont law.

“Child” or “covered child” means a child (natural,

stepchild, legally adopted or a minor or disabled child

who is dependent upon the insured for support and

maintenance) who is born to or brought to a marriage

or to a civil union established according to Vermont

law.

Caution: Federal Rights May or May Not Be

Available

Vermont law grants parties to a civil union the same

benefits, protections and responsibilities that flow from

marriage under state law. However, some or all of the

benefits, protections and responsibilities related to health

insurance that are available to married persons under

federal law may not be available to parties to a civil

union. For example, federal law, the Employee

Retirement Income Security Act of 1974 known as

"ERISA," controls the employer/employee relationship

with regard to determining eligibility for enrollment in

private employer health benefit plans. Because of

ERISA, Act 91 does not state requirements pertaining to

a private employer's enrollment of a party to a civil

union in an ERISA employee welfare benefit plan.

However, governmental employers (not federal

government) are required to provide health benefits to

the dependents of a party to a civil union if the public

employer provides health benefits to the dependents of

married persons. Federal law also controls group health

insurance continuation rights under "COBRA" for

employers with 20 or more employees as well as the

Internal Revenue Code treatment of health insurance

premiums. As a result, parties to a civil union and their

families may or may not have access to certain benefits

under this policy, contract, certificate, rider or

endorsement that derive from federal law. You are

advised to seek expert advice to determine your rights

under this contract.

HC-IMP26 04-10

V4-ET

The Schedule

Any deductible or coinsurance applicable to annual

routine or diagnostic mammograms does not apply.

SCHED-VTET

Covered Expenses

charges made for or in connection with mammograms

for breast cancer screenings, not to exceed an annual

mammogram for women age 40 or over, or

mammograms for women less than age 40 upon

recommendation of a health care provider.

Cancer Clinical Trials

Routine patient care services directly associated with a

patient’s participation in a phase I, II, III or IV approved

cancer clinical trial.

An “approved cancer clinical trial” is an organized,

systematic, scientific study of therapies, tests, or other

myCigna.com 81

clinical interventions for purposes of treatment,

palliation, or prevention of cancer in human beings.

The approved trial must:

seek to answer a credible and specific medical or

scientific question for the purpose of advancing cancer

care;

enroll only those patients for whom there is no clearly

superior, noninvestigational treatment alternative;

have available clinical or preclinical data that provides

a reasonable expectation that the treatment obtained in

the approved trial will be at least as effective as the

noninvestigational alternative;

be conducted under the auspices of one of the

following Vermont cancer care providers: Vermont

Cancer Center at Fletcher Allen Health Care, the

Norris Cotton Cancer Center at Dartmouth-Hitchcock

Medical Center, or approved clinical trials being

administered by a Vermont hospital and its affiliated,

qualified Vermont cancer care providers;

be conducted by a facility and personnel capable of

conducting such a trial by virtue of experience,

training and volume of patients treated to maintain

such expertise;

be conducted under the auspices of a peer-reviewed

protocol that has been approved by one of the

following entities: one of the National Institutes of

Health (NIH); an NIH-affiliated cooperative group that

is a formal network of facilities that collaborate on

research projects and have an established NIH-

approved peer-review program operating within the

group; the FDA in the form of an investigational new

drug application or exemption; or the federal

department of Veterans Affairs or Defense.

“Routine patient care services” are any Covered

Expenses under this plan, including any Medically

Necessary health care service that is incurred as a result

of the treatment being provided to the patient for the

purposes of the approved cancer clinical trial. Routine

patient care services do not include the following:

the cost of investigational new drugs that have not

been approved for market for any indication by the

FDA, or the costs of any drug being studied under an

FDA-approved investigational new drug exemption

for the purpose of expanding the drug’s labeled

indications.

the costs of nonhealth care services that may be

required as a result of the treatment being provided for

the purposes of the approved cancer clinical trial.

the costs of the services that are clearly inconsistent

with widely accepted and established regional or

national standards of care for a particular diagnosis

and performed specifically to meet the requirements of

the approved cancer clinical trial.

the costs of any tests or services performed

specifically to meet the needs of the approved cancer

clinical trial protocol.

the costs of running the approved cancer clinical trial

and collecting and analyzing data.

the costs associated with managing the research

associated with the approved clinical trial.

the costs for noninvestigational treatments or services

that would not otherwise be covered under the

patient’s health benefit plan.

any product or service paid for by the trial sponsor.

HC-COV70 04-10

V1-ET3


Appeal (Grievance)

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

"your" or "Member" also refers to a representative or

provider designated by you to act on your behalf, unless

otherwise noted.

We want you to be completely satisfied with the care

you receive. That is why we have established a process

for addressing your concerns and solving your problems.

Customer Service

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

regarding a person, a service, the quality of care, or

contractual benefits, you are welcome to call our toll-

free number and explain your concern to one of our

Customer Service representatives. You can also express

that concern in writing. Please call or write to us at the

following:

Customer Services Toll-Free Number or address that

appears on your Benefit Identification card,


myCigna.com 82

We will do our best to resolve the matter on your

initial contact. If we need more time to review or

investigate your concern, we will get back to you as

soon as possible, but in any case within 30 days.

You must pay for services given by a Participating

Provider or non-Participating Provider if your claim is

denied.

If you are not satisfied with the results of a coverage

decision, you can start the appeals procedure.

Prescription Drug Benefit Management Disclosure

Cigna will allow an exception to a benefit management

requirement described in this certificate that applies to

coverage for Prescription Drugs and Related Supplies,

and will provide coverage on the same basis as Cigna

would have for the benefit management requirement, if

your Physician certifies, based on relevant clinical

information about you and sound medical or scientific

evidence or the known characteristics of the drug, that

the benefit management requirement:

has been ineffective, or is reasonably expected to be

ineffective or significantly less effective in treating

your condition, such that an exception is Medically

Necessary; or

has caused you, or is reasonably expected to cause

you, adverse or harmful reactions.

To request an exception, your Physician should contact:

Cigna Pharmacy Management

Attn: Pharmacy Services Center

P.O. Box 29030

Phoenix, AZ 85038-9030

Tel. (800) 244-6224

Cigna will accept the Physician’s advance certification

telephonically, when the Physician designates the

situation to be an emergency. Cigna has the right to

require the certification to be later confirmed in writing.

A denial of a request for an exception to a benefit

management requirement is a determination subject to

independent external review under Vermont law. In this

situation, the terms of the “External Review Procedure

For Non-Mental Health/Substance Abuse Issues”

provision, and the “Notice of Benefit Determination on

Appeal” provision, both contained in this section of your

certificate, apply.

If you or your Dependent have a grievance relating to

Cigna's pharmaceutical benefit management program,

you should refer to the following “Appeals Procedure”

provisions. These provisions also apply to initiating this

type of grievance.

Appeals Procedure


decisions.

While a level one appeal is a required part of the

process, a level two appeal is completely voluntary. For

example, if a level one appeal is not resolved to your

satisfaction, you may choose to make an external appeal

to an Independent Panel of Mental Health Care

Providers or to an Independent Review Organization, as

described later in this provision, rather than pursuing

Cigna’s voluntary level two appeal process.

The voluntary level two appeal review will be done

without deference to the initial adverse benefit

determination or to the adverse determination of a level

one appeal.

The appeal review takes into account all comments,

documents, records, and other information relating to the

appeal that you submit, regardless of whether that

information was submitted or considered: in the initial

benefit determination (for a level one or a voluntary

level two appeal); or during the level one appeal (for a

voluntary level two appeal). Additional assistance is also

available from the Vermont Department of Financial

Regulation (DFR), as described later in this provision.

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

appeal in writing within 365 days of receipt of a denial

notice. You should state the reason why you feel your

appeal should be approved and include any information

supporting your appeal, including any written comments,

documents, records and other information relating to

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

you may ask to register your appeal by telephone.

Reasonable accommodations will be made to help a

person with a disability participate in the appeal process.

Additionally, if English is not your primary language,

we will provide you with information about how to file

an appeal and how to participate in the appeal process, in

your primary language, upon your request. Call or write

to us at the toll-free number or address on your Benefit

Identification card, explanation of benefits or claim

form. We will document the appeal for you and provide

copies of that documentation to you, or to your

representative.

myCigna.com 83

For any appeal related to an adverse benefit

determination, should a reversal of that decision be

made during any step of the appeal process, Cigna

will promptly authorize or otherwise arrange for

coverage of a covered service that was denied or

restricted. Neither you nor your treating provider

will be liable for any services provided before

notification to you of the adverse benefit

determination and the final outcome of any appeal or

independent external review. However, if your

treating provider or his or her designee refuse or

repeatedly fail to communicate with us, when the

opportunity to communicate with us has been offered

in a time and manner convenient to them, your

treating provider will be liable for any services

provided to you. You will not be liable in either case.

You must pay for services given by a Participating

Provider or a non-Participating Provider in the event

of a final denial of your claim.

Level One Appeal


someone not involved in the initial decision. This person

will also not be the subordinate of any individual who

was involved with the initial decision or other issue that

is the subject of the appeal. Appeals involving an

adverse benefit determination that is based in whole or

in part on a medical judgment will be considered by a

health care professional who is a clinical peer of your

treating provider.

You may request that we identify to you any clinical

expert whose advice we obtained in connection with

your adverse benefit determination, regardless of

whether or not that expert’s advice was relied on when

the determination was made. Any clinical expert we ask

to consult with us regarding your level one appeal will

not be the same clinical expert (if any) we consulted

with regarding the adverse benefit determination that is

the subject of your appeal, or the subordinate of that

clinical expert (if any).

A Cigna medical director or his or her designee will

offer to directly communicate with your treating

provider, or your treating provider’s designee, before the

appeal is decided.

You will have reasonable access to, and may obtain

copies of, all documents, records and other information

relevant to your appeal upon request and free of charge,

within two business days. In the case of a concurrent or

urgent preservice review, you will have access to or may

obtain the materials immediately upon request.

Level One Urgent, Preservice Appeal

For an urgent preservice level one appeal, we will orally

notify you and your treating provider (if known) of our

determination as soon as is possible based on your

medical condition, but in no case later than 72 hours

after we receive the appeal. We will send written

confirmation of the determination to you and your

treating provider (if known), within 24 hours of our oral

notification to you.

Mental health/substance abuse and pharmacy benefit

requests are generally considered urgent under Vermont

regulatory requirements.

Level One Non-Urgent, Preservice Appeal

For a non-urgent preservice level one appeal, we will

send written confirmation to you and your treating

provider (if known) of our determination as soon as is

possible based on your medical condition, but in no case

later than 30 calendar days after we receive the appeal.

Level One Concurrent Review Appeal

For a level one appeal related to a request to continue or

extend a course of treatment (i.e. a concurrent review),

we will orally notify you and your treating provider (if

known) of our determination as soon as is possible based

on your medical condition, but in no case later than 24

hours after we receive the appeal. We will send written




Level One Post-Service Appeal

For a level one post-service appeal, we will send written

confirmation to you and your treating provider (if

known) of our determination within a reasonable time

period, but in no case later than 60 calendar days after

we receive the appeal.

Level One Appeal Not Related to an Adverse Benefit

Determination

For a level one appeal not related to an adverse benefit

determination, we will send written confirmation to you

within 60 calendar days after we receive the appeal.

Voluntary Level Two Appeal

If you are dissatisfied with our level one appeal decision,

you may request a voluntary second review. To start a

voluntary level two appeal, follow the same process

myCigna.com 84

required for a level one appeal. If you decide to pursue a

voluntary second level appeal review, that decision has

no effect on your right to any other benefits under this

plan.

The voluntary level two appeal review will be done

without deference to the initial adverse benefit

determination or to the adverse determination of a level

one appeal.

Neither you nor your provider acting on your behalf are

responsible for any fees or costs associated with a

voluntary level two appeal, should you choose to pursue

one.

You will have reasonable access to, and may obtain

copies of, all documents, records and other information

relevant to your appeal upon request and free of charge,

within two business days. In the case of a concurrent or

urgent preservice review, you will have access to or may

obtain the materials immediately upon request.

Most requests for a second review will be conducted by

the Appeals Committee, which consists of at least three

people. Anyone who is a member of the Committee may

not: have been involved in the initial adverse benefit

determination or other issue that is the subject of the

appeal; have been involved in the adverse determination

of the level one appeal; or be the subordinate of any

person involved with the initial determination or other

issue that is the subject of the appeal. For appeals

involving Medical Necessity or clinical appropriateness,

the Committee will consult with at least one Physician

reviewer in the same or similar specialty as the care

under consideration, as determined by Cigna's Physician

reviewer.

You may request that we identify to you any clinical

expert whose advice we obtained in connection with

your adverse benefit determination, regardless of

whether or not that expert’s advice was relied on when

the determination was made. Any clinical expert we ask

to consult with us regarding your voluntary level two

appeal will not be the same clinical expert (if any) we

consulted with regarding the adverse benefit

determination that is the subject of your appeal, or the

subordinate of that clinical expert (if any).

For a voluntary level two appeal we will acknowledge in

writing that we have received your request and schedule

a Committee review. You will be consulted regarding

setting the meeting date for a voluntary second level

appeal review. You may present your situation to the

Committee in person or by conference call; however,

participating in person or via telephone is not a

requirement for the voluntary second level appeal

meeting to proceed.

Voluntary Level Two Urgent, Preservice Appeal

For an urgent preservice voluntary level two appeal, we

will orally notify you and your treating provider (if

known) of our determination as soon as is possible based

on your medical condition, but in no case later than 72

hours after we receive the appeal. We will send written




Mental health/substance abuse and pharmacy benefit

requests are generally considered urgent under Vermont

regulatory requirements.

Voluntary Level Two Non-Urgent, Preservice Appeal

For a non-urgent preservice voluntary level two appeal,

we will send written confirmation to you and your

treating provider (if known) of our determination as soon

as is possible based on your medical condition, but in no

case later than 30 calendar days after we receive the

appeal.

Voluntary Level Two Concurrent Review Appeal

For a voluntary level two appeal related to a request to

continue or extend a course of treatment (i.e. a

concurrent review), we will orally notify you and your

treating provider (if known) of our determination as soon

as is possible based on your medical condition, but in no

case later than 24 hours after we receive the appeal. We

will send written confirmation of the determination to

you and your treating provider (if known), within 24

hours of our oral notification to you.

Voluntary Level Two Post-Service Appeal

For a voluntary level two post-service appeal, we will

send written confirmation to you and your treating

provider (if known) of our determination within a

reasonable time period, but in no case later than 60

calendar days after we receive the appeal.

Voluntary Level Two Appeal Not Related to an

Adverse Benefit Determination

For a voluntary level two appeal not related to an

adverse benefit determination, we will send written

notification to you within 60 calendar days after we

receive the appeal.

myCigna.com 85

External Review Procedure For Mental

Health/Substance Abuse Issues

If you are dissatisfied with either a Level One Appeal

decision or a voluntary Level Two Appeal decision, you

may request an External Review of your issue by an

Independent Panel of Mental Health Care Providers (IP).

To start the External Review by an IP, you, your mental

health care provider or your representative on your

behalf, must file a written request with Cigna and the IP.

You must include your consent for Cigna to release

confidential patient files to the IP. The IP address is:

Independent Panel of Mental Health Care Providers

Vermont Department of Financial Regulation (DFR)

89 Main Street

Montpelier, VT 05620-3601

800-631-7788(toll-free) or 802-282-2900

When Cigna receives your request for an External

Review, Cigna will send the file supporting the initial

decision and the appeal decision(s) to the IP within: 24

hours of receiving the request in emergency situations;

and within five working days of receiving the request in

all other situations.

The IP may address inquiries to any of the parties (you,

your mental health care provider or your authorized

representative, or Cigna) and may set a reasonable time

period for a response. If Cigna does not provide all

necessary information in the required time periods, the

delay will result in a presumption in your favor and will

not delay the IP’s review of the issue. The IP also has

the authority to request any or all of the parties to meet

with the IP. The IP will make its review decision within

24 hours of receiving all necessary information in

emergency situations; and within 15 working days in all

other situations. The IP will send its decision by mail or

facsimile to Cigna and to the person who filed the

request for External Review. Emergency decisions will

be communicated by telephone, facsimile or delivered

by express mail as appropriate. Cigna is required to

abide by the IP’s decision. If you have a complaint about

a matter that is not related to Medical Necessity or

clinical appropriateness, you may file a consumer

complaint with the Insurance Consumer Services

Division at the following address:

Insurance Consumer Services Division


89 Main Street, Drawer 20

Montpelier, VT 05620-3101

802.828.3302

External Review Procedure For Non-Mental

Health/Substance Abuse Issues

If you are dissatisfied with a level one appeal or a

voluntary level two appeal decision, you may request an

External Review of your issue by an Independent

Review Organization (IRO).

You (or your authorized representative or your provider

on your behalf) may file a written request for External

Review within 90 days from the date you receive

Cigna’s final, written appeal decision. External Appeals

for non-Mental Health/Substance Abuse issues may be

requested for the following reasons:

The health care service is a covered benefit that Cigna

has determined to be not Medically Necessary.

A limitation is placed on the selection of a health care

provider that you claimed to be inconsistent with

limits imposed by this plan and any applicable laws

and regulations.

The health care treatment has been determined to be

experimental or investigational or an off-label use of a

drug.

myCigna.com 86

The health care service involves a medically-based

decision that a condition is preexisting.

The written request for External Review must be filed

with the DFR at the following address:

External Appeals Program


89 Main Street, Montpelier, VT 05620-3601

Telephone: 800-631-7788 (toll-free) or 802-828-2900

The insured must file on a form provided by the DFR

and include the $25 fee or a request for a waiver or

reduction of the fee, for the general release of medical

records relevant to the appeal, identification of insurer

and a copy of the denial level from the relevant level of

appeal. An oral request will also be accepted if made

within the 90-day period provided that the request is

confirmed in writing on the state request form within 10

calendar days. The External Appeal program is a

voluntary program.

Once notified by the DFR that the External Appeal has

been accepted for review by an IRO, Cigna must submit

all information relevant to the appeal, including: the

review criteria used in making the decision; copies of

any applicable policies or procedures; and copies of all

medical records considered in making the decision in the

appeal process. Cigna may request an extension of up to

10 days to submit information and documentation,

granted by the DFR for good cause.

Cigna must pay the costs of the External Appeal to the

DFR within 30 days of notification of the reasonable and

necessary costs of the review by the IRO.

The DFR will provide the request form for an External

Appeal. An oral request will also be accepted if made

within the 90-day period provided that the request is

confirmed in writing on the state request form within 10

calendar days. Within five working days of receiving the

External Appeal request the DFR will process the form

and materials, and accept the appeal for review by an

IRO after determining: that you are or were insured; the

service is a covered service under the plan; the External

Appeal involves an appealable decision; you have

exhausted the internal process; and all information has

been provided.

The DFR will notify you when the External Appeal

submission is complete, and whether the External

Appeal has been accepted for review by an IRO. Cigna

must submit any required documentation within 10

calendar days from the date Cigna receives the request

notice. Cigna may request a 10-calendar day extension

for good cause. You may have an extension for any

reason.

The DFR shall provide copies of documentation (and

follow-up information) to you and to Cigna; each will

have three working days to file responsive

documentation with the DFR.

The DFR will assign the External Appeal on a rotating

basis to an IRO for clinical review.

The DFR will review the determination of the IRO and

then issue the determination to you and to Cigna, which

will be binding on Cigna but not on you.

The IRO will conduct a full review, and may request any

additional information from you, Cigna, or the DFR. The

IRO will complete the review, and forward its written

determination to the DFR within five calendar days from

receipt if the External Appeal involves emergency or

urgently needed care; and 30 calendar days from receipt

for all other External Appeal requests. The IRO’s written

determination will include the clinical rationale for the

determination. The IRO may request an extension from

the Commissioner.

Additional Assistance

You have the right to contact the Health Insurance

Consumer Services unit within the DFR for assistance at

any time. This unit can help you if you need general

information about health insurance, have concerns about

our activities, or are not satisfied with how we resolved

your complaint. The DFR may be contacted at the

following address and telephone number:

Health Insurance Consumer Services Division


89 Main Street, Montpelier, VT 05620-3101

800-631-7788 (toll-free) or 802-828-2900

The Office of Health Care Ombudsman’s telephone

hotline service can also provide help to Vermonters who

have problems or questions about health care and health

insurance. Contact them at:

Office of Health Care Ombudsman

264 North Winooski Avenue

Burlington, VT 05402

Telephone: 888-917-7787 or 802-863-2316

TTY: 888-884-1955 or 802-863-2473

myCigna.com 87

Applies to All Issues


Every notice of a determination on appeal will be

provided in writing or electronically and, if an adverse

determination, will include: the specific reason or

reasons for the adverse determination; reference to the

specific plan provisions on which the determination is

based; a statement that the claimant is entitled to receive,

upon request and free of charge, reasonable access to

and copies of all documents, records, and other Relevant

Information as defined; a statement describing any

voluntary appeal procedures offered by the plan and the


502(a); and upon request and free of charge, a copy of

any internal rule, guideline, protocol or other similar


determination regarding your appeal, and an explanation

of the scientific or clinical judgment for a determination

that is based on a Medical Necessity, experimental

treatment or other similar exclusion or limit.

You also have the right to bring a civil action under

Section 502(a) of ERISA if you are not satisfied with the

decision on review. You or your plan may have other

voluntary alternative dispute resolution options such as

Mediation. One way to find out what may be available is

to contact your local U.S. Department of Labor office

and your state insurance regulatory agency. You may

also contact the Plan Administrator.




determination; was submitted, considered, or generated

in the course of making the benefit determination,

without regard to whether such document, record, or

other information was relied upon in making the benefit

determination; or constitutes a statement of policy or

guidance with respect to the plan concerning the denied

treatment option or benefit or the claimant's diagnosis,

without regard to whether such advice or statement was

relied upon in making the benefit determination.

Legal Action

If your plan is governed by ERISA, you have the right to

bring a civil action under Section 502(a) of ERISA if

you are not satisfied with the outcome of the Appeals

Procedure. In most instances, you may not initiate a

legal action against Cigna until you have completed the

Level One and Level Two Appeal processes. If your

Appeal is expedited, there is no need to complete the

Level Two process prior to bringing legal action.

HC-APL38 04-10

V2-ET

Definitions

Medically Necessary/Medical Necessity

Medically Necessary care means health care services,

including diagnostic testing, preventive services and

aftercare, that are appropriate in terms of type, amount,

frequency, level, setting, and duration to the person’s

diagnosis or condition. Medically Necessary care must

be informed by generally accepted medical or scientific

evidence and consistent with generally accepted practice

parameters as recognized by health care professions in

the same specialties as typically provide the procedure or

treatment, or diagnose or manage the medical condition;

must be informed by the unique needs of each individual

patient and each presenting situation; and:

help restore or maintain the person’s health; or

prevent deterioration of, or palliate, the person’s

condition; or

prevent the reasonably likely onset of a health problem

or detect an incipient problem.

HC-DFS155 04-10

V1-ET



Cigna)

CERTIFICATE RIDER – Wyoming Residents

Rider Eligibility: Each Employee who is located in Wyoming



your health status.


Cigna.

myCigna.com 88


requirements of Wyoming group insurance plans covering

insureds located in Wyoming. These provisions supersede any



HC-ETWYRDR

Covered Expenses

charges for cancer screening tests, including: a pelvic

examination, Pap smear and clinical breast cancer

examination, including a mammogram; a prostate

examination and laboratory tests; and a colorectal cancer

examination and laboratory tests for any nonsymptomatic

person.

HC-COV160 04-10

V1-ET1

Documents

Loudoun County School Board - Loudoun County Public Schools All... · PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna,