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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesSlalom, LLC: Open Access Plus

Coverage Period: 01/01/2020 - 12/31/2020Coverage for: Individual/Individual + Family |

Plan Type: Medical Plan I

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general

definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.Important Questions Answers Why This Matters:

What is the overall deductible?

For in-network providers: $750/individual or $2,250/family;For out-of-network providers: $2,250/individual or $6,750/family

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. In-network preventive care & immunizations, office visits, diagnostic test, prescription drugs, in-network urgent care facility visits.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For in-network providers $3,750/individual or $10,250/family;For out-of-network providers $11,250/individual or $30,750/family Combined medical/behavioral and pharmacy out-of-pocket limit

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Penalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

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Important Questions Answers Why This Matters:

Will you pay less if you use a network provider?

Yes. See www.myCigna.com or call 1-800-Cigna24 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will PayCommonMedical Event Services You May Need In-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & Other Important Information

Primary care visit to treat an injury or illness

$20 copay/visitDeductible does not apply 50% coinsurance None

Specialist visit $20 copay/visitDeductible does not apply 50% coinsurance None

No charge/visit** 50% coinsurance/visit NoneNo charge/screening** 50% coinsurance/screening NoneNo charge/immunizations** 50% coinsurance/

immunizations NoneIf you visit a health care provider's office or clinic

Preventive care/ screening/ immunization **Deductible does not apply

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

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CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Diagnostic test (x-ray, blood work)

20% coinsurance/x-ray**No charge/blood work**20% coinsurance/independent lab****Deductible does not apply

50% coinsurance NoneIf you have a test

Imaging (CT/PET scans, MRIs) No charge 50% coinsurance None

Generic drugs (Tier 1)

$10 copay/prescription (retail 30 days), $30 copay/prescription (retail 90 days); $20 copay/prescription (home delivery 90 days)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

Preferred brand drugs (Tier 2)

$30 copay/prescription (retail 30 days), $90 copay/prescription (retail 90 days); $60 copay/prescription (home delivery 90 days)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

Non-preferred brand drugs (Tier 3)

$60 copay/prescription (retail 30 days), $180 copay/prescription (retail 90 days); $120 copay/prescription (home delivery 90 days)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.myCigna.com

Specialty drugs (Tier 4)$75 copay/prescription (retail); $150 copay/prescription (home delivery)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90-day supply (home delivery) for Specialty drugs.Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits.

Facility fee (e.g., ambulatory surgery center)

No charge****Deductible does not apply 50% coinsurance NoneIf you have outpatient

surgery Physician/surgeon fees 20% coinsurance 50% coinsurance None

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CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Emergency room care $150 copay/visit, plus 20% coinsurance

$150 copay/visit, plus 20% coinsurance Per visit copay is waived if admitted

Emergency medical transportation 20% coinsurance 20% coinsurance NoneIf you need immediate

medical attention

Urgent care $20 copay/visitDeductible does not apply 50% coinsurance None

Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance $750 penalty for no precertification.If you have a hospital stayPhysician/surgeon fees 20% coinsurance 50% coinsurance $750 penalty for no precertification.

Outpatient services$20 copay/office visit** No charge/all other services****Deductible does not apply

50% coinsurance/office visit 50% coinsurance/all other services

NoneIf you need mental health, behavioral health, or substance abuse services Inpatient services 20% coinsurance 50% coinsurance $750 penalty for no precertification.

Office visits 20% coinsurance 50% coinsuranceChildbirth/delivery professional services 20% coinsurance 50% coinsurance

If you are pregnantChildbirth/delivery facility services 20% coinsurance 50% coinsurance

Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy.Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

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CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Home health care 20% coinsurance 50% coinsurance

Coverage is limited to 130 days annual max.16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.)

Rehabilitation services $20 copay/visitDeductible does not apply 50% coinsurance/visit

Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days annual max for Chiropractic care services

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Habilitation services $20 copay/visitDeductible does not apply 50% coinsurance/visit

Services are covered when Medically Necessary to treat a mental health condition (e.g. autism).

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Skilled nursing care 20% coinsurance 50% coinsurance$750 penalty for no precertification.Coverage is limited to 60 days annual max.

Durable medical equipment 20% coinsurance 50% coinsurance None

If you need help recovering or have other special health needs

Hospice services20% coinsurance/inpatient; 20% coinsurance/outpatient services

50% coinsurance/inpatient; 50% coinsurance/outpatient services

$750 penalty for no precertification.

Children's eye exam Not covered Not covered NoneChildren's glasses Not covered Not covered NoneIf your child needs dental

or eye care Children's dental check-up Not covered Not covered None

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Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Bariatric surgery Cosmetic surgery Dental care (Adult) Dental care (Children)

Eye care (Children) Long-term care Non-emergency care when traveling outside the

U.S. Private-duty nursing

Routine eye care (Adult) Routine foot care Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture (20 days) Chiropractic care (20 days)

Hearing aids (2 devices per 36 months, through age 18)

Infertility treatment

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Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For questions about your rights, this notice, or assistance, you can contact Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? YesIf you don't have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? YesIf your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.

----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-----------

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About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Managing Joe's type 2 Diabetes(a year of routine in-network care of a well-

controlled condition)

Mia's Simple Fracture(in-network emergency room visit and follow up

care)

■ The plan's overall deductible $750■ Specialist copayment $20■ Hospital (facility) coinsurance 20%■ Other coinsurance 20%

■ The plan's overall deductible $750■ Specialist copayment $20■ Hospital (facility) coinsurance 20%■ Other coinsurance 20%

■ The plan's overall deductible $750■ Specialist copayment $20■ Hospital (facility) coinsurance 20%■ Other coinsurance 20%

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

This EXAMPLE event includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost $12,800

In this example, Peg would pay:Cost Sharing

Deductibles $750Copayments $40Coinsurance $2,400

What isn't covered Limits or exclusions $10The total Peg would pay is $3,200

Total Example Cost $7,400

In this example, Joe would pay: Cost Sharing

Deductibles $0Copayments $900Coinsurance $30

What isn't covered Limits or exclusions $200The total Joe would pay is $1,130

Total Example Cost $1,900

In this example, Mia would pay: Cost Sharing

Deductibles $750Copayments $300Coinsurance $100

What isn't covered Limits or exclusions $0The total Mia would pay is $1,150

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: OAP Plan 1 Ben Ver: 16 Plan ID: 8459515

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, 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). ATENCIÓN: Si usted habla un idioma que no sea inglés, 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).

896375a 05/17 © 2017 Cigna.

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:– Qualified sign language interpreters– Written information in other formats (large print,

audio, accessible electronic formats, other formats)• Provides free language services to people whose

primary language is not English, such as:– Qualified interpreters– Information written in other languages

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file

DISCRIMINATION IS AGAINST THE LAWMedical coverage

a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:

CignaNondiscrimination Complaint CoordinatorPO Box 188016Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, DC 202011.800.368.1019, 800.537.7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Proficiency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).

Cigna برجاء الانتباه خدمات الترجمة المجانية متاحة لكم. لعملاء – Arabicالحاليين برجاء الاتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. او اتصل ب

1.800.244.6224 (TTY: اتصل ب 711).

896375a 05/17

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711） まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

Persian (Farsi) – توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه می شود. برای مشتريان فعلی ٬Cigna لطفاً با شماره ای که در پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره 1.800.244.6224 تماس بگيريد (شماره تلفن ويژه ناشنوايان: شماره 711 را

شماره گيری کنيد).

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesSlalom, LLC: Open Access Plus

Coverage Period: 01/01/2020 - 12/31/2020Coverage for: Individual/Individual + Family |

Plan Type: Medical Plan II

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general

definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.Important Questions Answers Why This Matters:

What is the overall deductible?

For in-network providers: $300/individual or $900/family;For out-of-network providers: $900/individual or $2,700/family

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. In-network preventive care & immunizations, office visits, diagnostic test, prescription drugs, in-network urgent care facility visits.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For in-network providers $2,800/individual or $8,400/family;For out-of-network providers $8,400/individual or $25,200/family Combined medical/behavioral and pharmacy out-of-pocket limit

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Penalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

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Important Questions Answers Why This Matters:

Will you pay less if you use a network provider?

Yes. See www.myCigna.com or call 1-800-Cigna24 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will PayCommonMedical Event Services You May Need In-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & Other Important Information

Primary care visit to treat an injury or illness

$15 copay/visitDeductible does not apply 50% coinsurance None

Specialist visit $15 copay/visitDeductible does not apply 50% coinsurance None

No charge/visit** 50% coinsurance/visit NoneNo charge/screening** 50% coinsurance/screening NoneNo charge/immunizations** 50% coinsurance/

immunizations NoneIf you visit a health care provider's office or clinic

Preventive care/ screening/ immunization **Deductible does not apply

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

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CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Diagnostic test (x-ray, blood work)

10% coinsurance/x-ray**No charge/blood work**10% coinsurance/independent lab****Deductible does not apply

50% coinsurance NoneIf you have a test

Imaging (CT/PET scans, MRIs) No charge 50% coinsurance None

Generic drugs (Tier 1)

$10 copay/prescription (retail 30 days), $30 copay/prescription (retail 90 days); $20 copay/prescription (home delivery 90 days)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

Preferred brand drugs (Tier 2)

$30 copay/prescription (retail 30 days), $90 copay/prescription (retail 90 days); $60 copay/prescription (home delivery 90 days)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

Non-preferred brand drugs (Tier 3)

$60 copay/prescription (retail 30 days), $180 copay/prescription (retail 90 days); $120 copay/prescription (home delivery 90 days)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.myCigna.com

Specialty drugs (Tier 4)$75 copay/prescription (retail); $150 copay/prescription (home delivery)Deductible does not apply

40% coinsurance/prescription (retail); Not covered (home delivery)Deductible does not apply

Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90-day supply (home delivery) for Specialty drugs.Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits.

Facility fee (e.g., ambulatory surgery center)

No charge****Deductible does not apply 50% coinsurance NoneIf you have outpatient

surgery Physician/surgeon fees 10% coinsurance 50% coinsurance None

4 of 8

CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Emergency room care $150 copay/visit, plus 10% coinsurance

$150 copay/visit, plus 10% coinsurance Per visit copay is waived if admitted

Emergency medical transportation 10% coinsurance 10% coinsurance NoneIf you need immediate

medical attention

Urgent care $15 copay/visitDeductible does not apply 50% coinsurance None

Facility fee (e.g., hospital room) 10% coinsurance 50% coinsurance $750 penalty for no precertification.If you have a hospital stayPhysician/surgeon fees 10% coinsurance 50% coinsurance $750 penalty for no precertification.

Outpatient services$15 copay/office visit** No charge/all other services****Deductible does not apply

50% coinsurance/office visit 50% coinsurance/all other services

NoneIf you need mental health, behavioral health, or substance abuse services Inpatient services 10% coinsurance 50% coinsurance $750 penalty for no precertification.

Office visits 10% coinsurance 50% coinsuranceChildbirth/delivery professional services 10% coinsurance 50% coinsurance

If you are pregnantChildbirth/delivery facility services 10% coinsurance 50% coinsurance

Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy.Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

5 of 8

CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Home health care 10% coinsurance 50% coinsurance

Coverage is limited to 130 days annual max.16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.)

Rehabilitation services $15 copay/visitDeductible does not apply 50% coinsurance/visit

Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days annual max for Chiropractic care services

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Habilitation services $15 copay/visitDeductible does not apply 50% coinsurance/visit

Services are covered when Medically Necessary to treat a mental health condition (e.g. autism).

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Skilled nursing care 10% coinsurance 50% coinsurance$750 penalty for no precertification.Coverage is limited to 60 days annual max.

Durable medical equipment 10% coinsurance 50% coinsurance None

If you need help recovering or have other special health needs

Hospice services10% coinsurance/inpatient; 10% coinsurance/outpatient services

50% coinsurance/inpatient; 50% coinsurance/outpatient services

$750 penalty for no precertification.

Children's eye exam Not covered Not covered NoneChildren's glasses Not covered Not covered NoneIf your child needs dental

or eye care Children's dental check-up Not covered Not covered None

6 of 8

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Bariatric surgery Cosmetic surgery Dental care (Adult) Dental care (Children)

Eye care (Children) Long-term care Non-emergency care when traveling outside the

U.S. Private-duty nursing

Routine eye care (Adult) Routine foot care Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture (20 days) Chiropractic care (20 days)

Hearing aids (2 devices per 36 months, through age 18)

Infertility treatment

7 of 8

Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For questions about your rights, this notice, or assistance, you can contact Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? YesIf you don't have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? YesIf your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.

----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-----------

8 of 8

About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Managing Joe's type 2 Diabetes(a year of routine in-network care of a well-

controlled condition)

Mia's Simple Fracture(in-network emergency room visit and follow up

care)

■ The plan's overall deductible $300■ Specialist copayment $15■ Hospital (facility) coinsurance 10%■ Other coinsurance 10%

■ The plan's overall deductible $300■ Specialist copayment $15■ Hospital (facility) coinsurance 10%■ Other coinsurance 10%

■ The plan's overall deductible $300■ Specialist copayment $15■ Hospital (facility) coinsurance 10%■ Other coinsurance 10%

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

This EXAMPLE event includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost $12,800

In this example, Peg would pay:Cost Sharing

Deductibles $300Copayments $30Coinsurance $1,200

What isn't covered Limits or exclusions $10The total Peg would pay is $1,540

Total Example Cost $7,400

In this example, Joe would pay: Cost Sharing

Deductibles $0Copayments $800Coinsurance $10

What isn't covered Limits or exclusions $200The total Joe would pay is $1,010

Total Example Cost $1,900

In this example, Mia would pay: Cost Sharing

Deductibles $300Copayments $200Coinsurance $90

What isn't covered Limits or exclusions $0The total Mia would pay is $590

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: OAP Plan 2 Ben Ver: 16 Plan ID: 8459521

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, 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). ATENCIÓN: Si usted habla un idioma que no sea inglés, 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).

896375a 05/17 © 2017 Cigna.

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:– Qualified sign language interpreters– Written information in other formats (large print,

audio, accessible electronic formats, other formats)• Provides free language services to people whose

primary language is not English, such as:– Qualified interpreters– Information written in other languages

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file

DISCRIMINATION IS AGAINST THE LAWMedical coverage

a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:

CignaNondiscrimination Complaint CoordinatorPO Box 188016Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, DC 202011.800.368.1019, 800.537.7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Proficiency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).

Cigna برجاء الانتباه خدمات الترجمة المجانية متاحة لكم. لعملاء – Arabicالحاليين برجاء الاتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. او اتصل ب

1.800.244.6224 (TTY: اتصل ب 711).

896375a 05/17

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711） まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

Persian (Farsi) – توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه می شود. برای مشتريان فعلی ٬Cigna لطفاً با شماره ای که در پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره 1.800.244.6224 تماس بگيريد (شماره تلفن ويژه ناشنوايان: شماره 711 را

شماره گيری کنيد).

1 of 8

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesSlalom, LLC: Open Access Plus

Coverage Period: 01/01/2020 - 12/31/2020Coverage for: Individual/Individual + Family |

Plan Type: HSA Plan

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general

definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.Important Questions Answers Why This Matters:

What is the overall deductible?

For in-network providers: $1,500/individual or $3,000/family;For out-of-network providers: $3,000/individual or $6,000/family Combined medical/behavioral and pharmacy deductible Deductible per individual applies when the employee is the only individual covered under the plan.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.

Are there services covered before you meet your deductible?

Yes. In-network preventive care & immunizations.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For in-network providers $4,000/individual or $8,000/family (no more than $6,850 per individual in the family);For out-of-network providers $12,000/individual or $24,000/family (no more than $20,550 per individual in the family) Combined medical/behavioral and pharmacy out-of-pocket limit

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Penalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

2 of 8

Important Questions Answers Why This Matters:

Will you pay less if you use a network provider?

Yes. See www.myCigna.com or call 1-800-Cigna24 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will PayCommonMedical Event Services You May Need In-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Limitations, Exceptions, & Other Important Information

Primary care visit to treat an injury or illness 20% coinsurance/visit 50% coinsurance None

Specialist visit 20% coinsurance/visit 50% coinsurance NoneNo charge/visit** 50% coinsurance/visit NoneNo charge/screening** 50% coinsurance/screening NoneNo charge/immunizations** 50% coinsurance/

immunizations NoneIf you visit a health care provider's office or clinic Preventive care/ screening/

immunization **Deductible does not applyYou may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

Diagnostic test (x-ray, blood work) 20% coinsurance 50% coinsurance None

If you have a test Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance None

3 of 8

CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Generic drugs (Tier 1)

20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail 90 days); 20% coinsurance/prescription (home delivery 90 days)

40% coinsurance/prescription (retail); Not covered (home delivery)

Preferred brand drugs (Tier 2)

20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail 90 days); 20% coinsurance/prescription (home delivery 90 days)

40% coinsurance/prescription (retail); Not covered (home delivery)

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.myCigna.com

Non-preferred brand drugs (Tier 3)

20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail 90 days); 20% coinsurance/prescription (home delivery 90 days)

40% coinsurance/prescription (retail); Not covered (home delivery)

Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90-day supply (home delivery) for Specialty drugs.Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits.

Facility fee (e.g., ambulatory surgery center) 20% coinsurance 50% coinsurance NoneIf you have outpatient

surgery Physician/surgeon fees 20% coinsurance 50% coinsurance NoneEmergency room care 20% coinsurance 20% coinsurance NoneEmergency medical transportation 20% coinsurance 20% coinsurance NoneIf you need immediate

medical attentionUrgent care 20% coinsurance 50% coinsurance NoneFacility fee (e.g., hospital room) 20% coinsurance 50% coinsurance $750 penalty for no precertification.If you have a hospital stayPhysician/surgeon fees 20% coinsurance 50% coinsurance $750 penalty for no precertification.

Outpatient services20% coinsurance/office visit 20% coinsurance/all other services

50% coinsurance/office visit 50% coinsurance/all other services

NoneIf you need mental health, behavioral health, or substance abuse services Inpatient services 20% coinsurance 50% coinsurance $750 penalty for no precertification.

4 of 8

CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Office visits 20% coinsurance 50% coinsuranceChildbirth/delivery professional services 20% coinsurance 50% coinsurance

If you are pregnantChildbirth/delivery facility services 20% coinsurance 50% coinsurance

Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy.Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

5 of 8

CommonMedical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationIn-Network Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

Home health care 20% coinsurance 50% coinsurance

Coverage is limited to 130 days annual max.16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.)

Rehabilitation services 20% coinsurance/visit 50% coinsurance/visit

Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days annual max for Chiropractic care services

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Habilitation services 20% coinsurance/visit 50% coinsurance/visit

Services are covered when Medically Necessary to treat a mental health condition (e.g. autism).

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Skilled nursing care 20% coinsurance 50% coinsurance$750 penalty for no precertification.Coverage is limited to 60 days annual max.

Durable medical equipment 20% coinsurance 50% coinsurance None

If you need help recovering or have other special health needs

Hospice services20% coinsurance/inpatient; 20% coinsurance/outpatient services

50% coinsurance/inpatient; 50% coinsurance/outpatient services

$750 penalty for no precertification.

Children's eye exam Not covered Not covered NoneChildren's glasses Not covered Not covered NoneIf your child needs dental

or eye care Children's dental check-up Not covered Not covered None

6 of 8

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Bariatric surgery Cosmetic surgery Dental care (Adult) Dental care (Children)

Eye care (Children) Long-term care Non-emergency care when traveling outside the

U.S. Private-duty nursing

Routine eye care (Adult) Routine foot care Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture (20 days) Chiropractic care (20 days)

Hearing aids (2 devices per 36 months, through age 18)

Infertility treatment

7 of 8

Your Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For questions about your rights, this notice, or assistance, you can contact Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? YesIf you don't have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? YesIf your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.

----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-----------

8 of 8

About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

Managing Joe's type 2 Diabetes(a year of routine in-network care of a well-

controlled condition)

Mia's Simple Fracture(in-network emergency room visit and follow up

care)

■ The plan's overall deductible $1,500■ Specialist coinsurance 20%■ Hospital (facility) coinsurance 20%■ Other coinsurance 20%

■ The plan's overall deductible $1,500■ Specialist coinsurance 20%■ Hospital (facility) coinsurance 20%■ Other coinsurance 20%

■ The plan's overall deductible $1,500■ Specialist coinsurance 20%■ Hospital (facility) coinsurance 20%■ Other coinsurance 20%

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

This EXAMPLE event includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost $12,800

In this example, Peg would pay:Cost Sharing

Deductibles $1,500Copayments $0Coinsurance $2,200

What isn't covered Limits or exclusions $10The total Peg would pay is $3,710

Total Example Cost $7,400

In this example, Joe would pay: Cost Sharing

Deductibles $1,500Copayments $0Coinsurance $1,100

What isn't covered Limits or exclusions $200The total Joe would pay is $2,800

Total Example Cost $1,900

In this example, Mia would pay: Cost Sharing

Deductibles $1,500Copayments $0Coinsurance $90

What isn't covered Limits or exclusions $0The total Mia would pay is $1,590

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: HDHPQ Plan Ben Ver: 16 Plan ID: 8459529

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, 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). ATENCIÓN: Si usted habla un idioma que no sea inglés, 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).

896375a 05/17 © 2017 Cigna.

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:– Qualified sign language interpreters– Written information in other formats (large print,

audio, accessible electronic formats, other formats)• Provides free language services to people whose

primary language is not English, such as:– Qualified interpreters– Information written in other languages

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file

DISCRIMINATION IS AGAINST THE LAWMedical coverage

a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:

CignaNondiscrimination Complaint CoordinatorPO Box 188016Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, DC 202011.800.368.1019, 800.537.7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Proficiency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).

Cigna برجاء الانتباه خدمات الترجمة المجانية متاحة لكم. لعملاء – Arabicالحاليين برجاء الاتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. او اتصل ب

1.800.244.6224 (TTY: اتصل ب 711).

896375a 05/17

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711） まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

Persian (Farsi) – توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه می شود. برای مشتريان فعلی ٬Cigna لطفاً با شماره ای که در پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره 1.800.244.6224 تماس بگيريد (شماره تلفن ويژه ناشنوايان: شماره 711 را

شماره گيری کنيد).

Delta Dental of Washington | PO Box 75983 | Seattle WA 98175-0983 | 800.554.1907 | DeltaDentalWA.com DD LG PPO 2020

Slalom LLC Group #09357

Delta Dental PPO℠ Plan Benefit Summary

Effective Date January 1, 2020 Benefit Period January 1, 2020 – December 31, 2020 Benefit Period Maximum (Per Person) $2,000 TMJ Annual Maximum (Per Person) Lifetime Maximum (Per Person)

50% $1,000 $5,000

Orthodontia – Adults & Children Lifetime Maximum (Per Person)

50% $1,000

aa

Dental Network

Delta Dental PPO℠ Dentist

Delta Dental Premier® Dentist

Non-Participating Dentist

Benefit Period Deductible Does Not Apply to Class I (Per Person/Per Family) $50/$150 $50/$150 $50/$150

Class I – Diagnostic & Preventive Exams

100% 100% 100% Cleaning Fluoride X-Rays Sealants

Class II – Restorative Fillings

90% 80% 80% Endodontics (Root Canal) Periodontics Oral Surgery General Anesthesia/IV Sedation

Class III – Major Dentures

50% 50% 50% Partial Dentures Implants Bridges Crowns

This is a summary of benefits for comparison and isn’t a contract. Once you’re enrolled, you can get a benefits booklet that will provide all the details of your dental plan. Please feel free to call our customer service department or visit our website at DeltaDentalWA.com if you have any questions.

Keep in mind, you will likely experience the greatest savings when you see a Delta Dental PPO dentist.

Delta Dental of Washington | PO Box 75983 | Seattle WA 98175-0983 | 800.554.1907 | DeltaDentalWA.com DD LG PPO 2020

Get the most from your benefits! Create a MySmile® account It gives you secure, 24/7 access to your ID card, benefits information, out-of-pocket cost estimates, and more! Our “Find your member ID” tool makes registration easy. Visit DeltaDentalWA.com to create your account.

Choose an in-network dentist Your plan gives you access to the Delta Dental PPO℠ network. Your benefits go farthest when you visit a Delta Dental PPO dentist which gives you the most bang for your buck. If you see a NON-Delta Dental PPO dentist, you won’t maximize your benefits. Your annual maximum won’t go as far and you’ll likely have greater out-of-pocket costs.

Delta Dental PPO Delta Dental Premier Non-Delta Dental

Your plan’s network

Benefits go farthest which means least out-of-pocket costs

Files claims forms for you

Comes with our quality management and cost protection

No cost protection which means greatest out-of-pocket costs

Find an in-network dentist near you:

1. Visit DeltaDentalWA.com 2. Click on ‘Online Tools’ and use our ‘Find a Dentist’ tool 3. Select ‘Delta Dental PPO’ to filter your search results

Visit your dentist regularly Your plan covers preventive care visits each year. Regular cleanings and check-ups are essential to keeping your smile healthy and preventing painful, expensive problems down the road.

Get out-of-pocket cost estimates Knowing your cost upfront helps you and your dentist plan treatments to maximize your benefits.

MySmile Cost Genie℠ gives you instant, cost estimates. It’s great for basic treatments like fillings. Simply sign in to MySmile account to get your personalized estimate.

When you need extensive treatment, like a crown, ask your dentist for a “Predetermination.” You’ll get a Confirmation of Treatment and Cost from us. It details your dentist’s treatment plan, what your benefits cover, and how much you may owe your dentist for the treatment.

Have a question? Give us a call at 800.554.1907, Monday – Friday from 7am to 5pm, Pacific Time. We’re

happy to help.

SEE HEALTHY AND LIVE HAPPYWITH HELP FROM SLALOM, LLC AND VSP.

As a VSP® member, you get personalized care from aVSP network doctor at low out-of-pocket costs.

VALUE AND SAVINGS YOU LOVE.Save on eyewear and eye care when you see a VSP networkdoctor. Plus, take advantage of Exclusive Member Extrasfor additional savings.

PROVIDER CHOICES YOU WANT.With an average of five VSP network doctors within sixmiles of you, it’s easy to find a nearby in-network doctoror retail chain. Plus, maximize your coverage with bonusoffers and additional savings that are exclusive to PremierProgram locations.

Prefer to shop online? Use your vision benefits onEyeconic®—the VSP preferred online retailer.

QUALITY VISION CARE YOU NEED.You’ll get great care from a VSP network doctor, includinga WellVision Exam®—a comprehensive exam designed todetect eye and health conditions.

+ GET YOUR PERFECT PAIR

EXTRA $20TO SPEND ON

FEATURED FRAME BRANDS*

SEE MORE BRANDS AT VSP.COM/OFFERS.

UP TO 40%

SAVINGS ON LENSENHANCEMENTS

Using your benefit is easy!

Create an account on vsp.comto view your in-networkcoverage, find the VSP networkdoctor who’s right for you, anddiscover savings with exclusivemember extras. At yourappointment, just tell them youhave VSP.

A LOOK AT YOURVSP VISION COVERAGE

Contact us: 800.877.7195 or vsp.com

YOUR VSP VISION BENEFITS SUMMARYSLALOM, LLC and VSP provide you with an affordablevision plan.

FrequencyCopayDescriptionBenefitYour Coverage with a VSP Provider

Every 12 months$25 for examand glassesWellVision Exam Focuses on your eyes and overall wellness

PRESCRIPTION GLASSES

Every 12 monthsCombined withexamFrame

$150 allowance for a wide selection of frames$170 allowance for featured frame brands20% savings on the amount over your allowance$80 Costco® frame allowance

Every 12 monthsCombined withexamLenses Single vision, lined bifocal, and lined trifocal lenses

Polycarbonate lenses for dependent children

Every 12 months

$50

Lens Enhancements

Standard progressive lenses$80 - $90Premium progressive lenses

$120 - $160Custom progressive lensesAverage savings of 35-40% on other lens enhancements

Every 12 monthsUp to $60Contacts (instead ofglasses)

$130 allowance for contacts; copay does not applyContact lens exam (fitting and evaluation)

As needed$20DIABETIC EYECAREPLUS PROGRAM

Services related to diabetic eye disease, glaucoma andage-related macular degeneration (AMD). Retinal screening foreligible members with diabetes. Limitations and coordinationwith medical coverage may apply. Ask your VSP doctor fordetails.

Every 12 months$25SUNCARE $150 allowance for ready-made non-prescription sunglassesinstead of prescription glasses or contacts

Glasses and Sunglasses

EXTRA SAVINGS

Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details.30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provideron the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your lastWellVision Exam.

Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam

Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price; discounts only available from contractedfacilities

YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERSGet the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details.

Coverage with a retail chain may be different or not apply. Once your benefit is effective, visit vsp.com for details. VSP guarantees coverage from VSP network providers only. Coverageinformation is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicablelaws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

*Only available to VSP members with applicable plan benefits. Frame brands and promotions are subject to change. Savings based on doctor’s retail price and vary by plan and purchaseselection; average savings determined after benefits are applied. Ask your VSP network doctor for more details.

©2019 Vision Service Plan. All rights reserved.VSP, VSP Vision Care for life, Eyeconic, and WellVision Exam are registered trademarks, VSP Diabetic Eyecare Plus Program is servicemark of Vision Service Plan. Flexon is a registeredtrademark of Marchon Eyewear, Inc. All other brands or marks are the property of their respective owners.

PROVIDER NETWORK:

VSP Signature

EFFECTIVE DATE:

01/01/2020