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Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.

If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossaryat www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.

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Open Access Plus: Connecticut General Life Insurance Co. Coverage Period: 01/01/2013 - 12/31/2013Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for:Individual/Individual + Family |Plan Type:OAP

This is only a summary.If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document atwww.myCigna.com or by calling 1-800-Cigna24

Important Questions Answers Why this Matters:

What is the overalldeductible?

For in-network providers$2,500person /$5,000familyFor out-of-network providers$10,000person /$20,000familyDeductible per person applies when the employee is theonly person covered under the plan.Does not apply to in-network preventive care, in-networkoffice visits, emergency room visits, urgent care facilityvisits, prescription drugsCo-payments don't count toward thedeductible.

You must pay all the costs up to the deductibleamount before this planbegins to pay for covered services you use. Check your policy or plandocument to see when thedeductiblestarts over (usually, but notalways, January 1st). See the chart starting on page 2 for how much youpay for covered services after you meet thedeductible.

Are there otherdeductiblesfor specific services?

Yes, in-network prescription drugs -$100person /$200familyThere are no other specificdeductibles.

You must pay all of the costs for these services up to the specific deductibleamount before this plan begins to pay for these services.

Is there anout-of-pocket limiton my expenses?

Yes. For in-network providers$5,000person /$10,000family / For out-of-network providers$30,000person /$60,000family.Out-of-pocket limit for person applies when the employeeis the only person covered under the plan.

Theout-of-pocket limitis the most you could pay during a coverageperiod (usually one year) for your share of the cost of covered services.This limit helps you plan for health care expenses.

What is not included in theout-of-pocket limit?

Premium, balance-billed charges, penalties for no pre-authorization, and health care this plan doesn't cover.

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

Is there an overallannuallimiton what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will payforspecificcovered services, such as office visits.

Does this plan use anetworkofproviders?

Yes. For a list of participating providers, seewww.myCigna.comor call 1-800-Cigna24

If you use an in-network doctor or other health care provider, this plan willpay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-networkproviderfor someservices. Plans use the term in-network,preferred, or participating forprovidersin theirnetwork. See the chart starting on page 2 for how thisplan pays different kinds ofproviders.
http://www.mycigna.com/http://www.mycigna.com/

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Important Questions Answers Why this Matters:Do I need a referral to see aspecialist?

No. You don't need a referral to see a special ist. You can see thespecialistyou choose without permission from this plan.

Are there services this plandoesn't cover?

Yes.Some of the services this plan doesn't cover are listed on page 4. Seeyour policy or plan document for additional information aboutexcluded

services.

Co-paymentsare fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountof the service. For example, if the health

plan'sallowed amountfor an overnight hospital stay is $1,000, yourco-insurancepayment of 20% would be $200. This may change if you haven'tmet yourdeductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than theallowedamount, you may have to pay the difference. For example, if an out-of-network hospital charge is $1,500 for an overnight stay and the allowedamountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to usein-network providersby charging you lowerdeductibles,co-paymentsandco-insuranceamounts.

Your Cost if you use anCommon Medical Event Services You May Need

In-Network Provider Out-of-Network Provider Limitations & Exceptions

Primary care visit to treat aninjury or illness

$50 co-pay/visit 50% co-insurance -----------none-----------

Specialist visit $50 co-pay/visit 50% co-insurance -----------none-----------

Other practitioner office visit $50 co-pay/visit for chiropractor 50% co-insuranceCoverage for Chiropracticservices is limited to 20 daysannual max.

If you visit a health careprovider's office or clinic

Preventive

care/screening/immunization No charge 50% co-insurance -----------none-----------Diagnostic test (x-ray, bloodwork)

No charge 50% co-insurance Deductible is waivedIf you have a test

Imaging (CT/PET scans,MRIs)

30% co-insurance 50% co-insurance -----------none-----------

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Common Medical Event Services You May NeedYour Cost if you use an

Limitations & ExceptionsIn-Network Provider Out-of-Network Provider

Generic drugs$20 co-pay/prescription (retail),$40 co-pay/prescription (homedelivery)

50% co-insuranceCoverage is limited up to a 30 -day supply (retail) and up to a 90-day supply (home delivery)

Preferred brand drugs $40 co-pay/prescription (retail),$80 co-pay/prescription (homedelivery)

50% co-insurance Coverage is limited up to a 30 -day supply (retail) and up to a 90-day supply (home delivery)

If you need drugs to treatyour illness or condition

More information aboutprescription drugcoverageis available atwww.myCigna.com Non-preferred brand drugs

$70 co-pay/prescription (retail),$140 co-pay/prescription (homedelivery)

50% co-insuranceCoverage is limited up to a 30 -day supply (retail) and up to a 90-day supply (home delivery)

Facility fee (e.g., ambulatorysurgery center)


If you have outpatientsurgery

Physician/surgeon fees 30% co-insurance 50% co-insurance -----------none-----------

Emergency room services $100 co-pay/visit $100 co-pay/visitPer visit co-pay is waived if

admittedEmergency medicaltransportation

30% co-insurance 30% co-insurance -----------none-----------If you need immediatemedical attention

Urgent care $50 co-pay/visit $50 co-pay/visitPer visit co-pay is waived ifadmitted

Facility fee (e.g., hospitalroom)

30% co-insurance 50% co-insurance -----------none-----------If you have a hospital stay

Physician/surgeon fees 30% co-insurance 50% co-insurance -----------none-----------

Mental/Behavioral health

outpatient services

$50 co-pay/office visit and 30%co-insurance/other outpatient

services

50% co-insurance -----------none-----------

Mental/Behavioral healthinpatient services


Substance use disorderoutpatient services

$50 co-pay/office visit and 30%co-insurance/other outpatientservices

50% co-insurance -----------none-----------

If you have mental health,behavioral health, orsubstance abuse needs

Substance use disorderinpatient services


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Common Medical Event Services You May NeedYour Cost if you use an

Limitations & ExceptionsIn-Network Provider Out-of-Network Provider

Prenatal and postnatal care 30% co-insurance 50% co-insurance -----------none-----------If you are pregnant Delivery and all inpatient

services30% co-insurance 50% co-insurance -----------none-----------

Home health care 30% co-insurance 50% co-insurance -----------none-----------

Rehabilitation services $50 co-pay/visit 50% co-insuranceCoverage for Rehabilitationservices is limited to 60 daysannual max.

Habilitation services Not Covered Not Covered -----------none-----------

Skilled nursing care 30% co-insurance 50% co-insuranceCoverage is limited to 90 daysannual max

Durable medical equipment 30% co-insurance 50% co-insurance -----------none-----------

If you need helprecovering or have otherspecial health needs

Hospice services 30% co-insurance 50% co-insurance -----------none-----------Eye Exam Not Covered Not Covered -----------none-----------

Glasses Not Covered Not Covered -----------none-----------If your child needs dentalor eye careDental check-up Not Covered Not Covered -----------none-----------

Excluded Services & Other Covered Services

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

Acupuncture Bariatric surgery Cosmetic surgery

Dental care (Adult) Dental care (Children) Eye care (Children)

Habilitation services Hearing aids 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 (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Chiropractic care Infertility treatment

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Your Rights to Continue Coverage

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage.Any such rights may be limited in duration and will require you to pay apremium, which may be significantly higher than the premium you pay while covered under theplan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-Cigna24. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 orwww.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 orwww.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appealor file agrievance. For questions about yourrights, this notice, or assistance, you can contact Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor's Employee BenefitsSecurity Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreformor the New Jersey Department of Banking and Insurance at (609) 292-5316.

Additionally, a consumer assistance program can help you file your appeal. Contact the program for this plan's situs state: New Jersey Department of Banking andInsurance at 800-446-7467. However, for information regarding your own state's consumer assistance program refer towww.healthcare.gov.

----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.-----------
http://www.healthcare.gov/http://www.healthcare.gov/http://www.dol.gov/ebsa/healthreformhttp://www.dol.gov/ebsa/healthreformhttp://www.cciio.cms.gov/http://www.cciio.cms.gov/http://www.dol.gov/ebsahttp://www.dol.gov/ebsa

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Coverage ExamplesAbout these Coverage Examples:

These examples show how this plan might covermedical care in given situations. Use these examples

to see, in general, how much financial protection asample patient might get if they are covered underdifferent plans.

This is not a cost estimator.

Don't use these examples to estimate youractual costs under this plan. The actual care youreceive will be different from these examples, andthe cost of that care will also be different.

See the next page for important information aboutthese examples.

Note:These numbers assume enrollment inindividual-only coverage.

Having a baby(normal delivery)

Amount owed to providers:$7,540 Plan pays:$4,210 Patient pays:$3,330

Sample care costs:

Hospital charges (mother) $2,700Routine Obstetric Care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200

Radiology $200

Vaccines, other preventive $40Total $7,540

Patient pays:Deductible $2,600Co-pays $90

Co-insurance $610Limits or exclusions $30Total $3,330

Managing type 2 diabetes(routine maintenance of a well-controlled

condition)

Amount owed to providers:$5,400 Plan pays:$3,460 Patient pays:$1,940

Sample care costs:Prescriptions $2,900Medical equipment and supplies $1,300

Office visits & procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductible $100Co-pays $1,520Co-insurance $0Limits or exclusions $320Total $1,940

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Questions and answers about the Coverage Examples:What are some of the assumptions behindthe Coverage Examples?

Costs don't includepremiums.

Sample care costs are based on nationalaverages supplied by the U.S. Department ofHealth and Human Services, and aren'tspecific to a particular geographic area orhealth plan.

The patient's condition was not an excludedor pre existing condition.

All services and treatments started andended in the same coverage period.

There are no other medical expenses for any

member covered under this plan. Out-of-pocket expenses are based only on

treating the condition in the example. The patient received all care from in-network

providers. If the patient had received carefrom out-of-networkproviders, costs wouldhave been higher.

What does a Coverage Example show?For each treatment situation, the Coverage Examplehelps you see howdeductibles,co-payments, andco-insurancecan add up. It also helps you see whatexpenses might be left up to you to pay because theservice or treatment isn't covered or payment islimited.

Does the Coverage Example predict myown care needs?

No.Treatments shown are just examples. Thecare you would receive for this condition could bedifferent based on your doctor's advice, your age,

how serious your condition is, and many otherfactors.

Does the Coverage Example predict myfuture expenses?

No.Coverage Examples arenotcost estimators.You can't use the examples to estimate costs for anactual condition. They are for comparative purposesonly. Your own costs will be different depending on

the care you receive, the prices yourproviderscharge, and the reimbursement your health planallows.

Can I use Coverage Examples to compareplans?

Yes.When you look at the Summary of Benefits

and Coverage for other plans, you'll find the sameCoverage Examples. When you compare plans, checkthe "Patient Pays" box in each example. The smallerthat number, the more coverage the plan provides.

Are there other costs I should considerwhen comparing plans?

Yes.An important cost is thepremiumyou pay.Generally, the lower yourpremium, the more you'll pay

in out-of-pocket costs, such asco-payments,deductibles, andco-insurance. You also shouldconsider contributions to accounts such as healthsavings accounts (HSAs), flexible spendingarrangements (FSAs) or health reimbursementaccounts (HRAs) that help you pay out-of-pocketexpenses.

Plan ID:46375Plan Name:OAP

GM5800/6000 9/23/12

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SUMMARY OF BENEFITS

Connecticut General Life Insurance Co.For Employees of - CollaberaOpen Access Plus Plan

Selection of a Primary Care Provider- Your plan may require or allow the designation of a primary care provider. You have the right to designate any primary careprovider who participates in the network and who is available to accept you or your family members. If your plan requires designation of a primary care provider,Cigna may designate one for you until you make this designation. For information on how to select a primary care provider, and for a list of the participating primary

care providers, visit www.mycigna.comor contact customer service at the phone number listed on the back of your ID card.

Direct Access to Obstetricians and Gynecologists- You do not need prior authorization from the plan or from any other person (including a primary careprovider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology.The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following apre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visitwww.mycigna.comor contact customer service at the phone number listed on the back of your ID card.For children, you may designate a pediatrician as the primary care provider.

Plan Highlights In-Network Out-of-Network

Lifetime Maximum Unlimited Unlimited

CoinsuranceYou pay 30% coinsurance

You pay 50% coinsurance

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Maximum Reimbursable ChargeOut-of-network services are subject to a Calendar Year deductible andmaximum reimbursable charge limitations. Payments made to health careprofessionals not participating in Cigna's network are determined basedon the lesser of: the health care professional's normal charge for a similarservice or supply, or a percentage (150%) of a fee schedule developed byCigna that is based on a methodology similar to one used by Medicare to

determine the allowable fee for the same or similar service in ageographic area. In some cases, the Medicare based fee schedule is notused, and the maximum reimbursable charge for covered services isdetermined based on the lesser of: the health care professional's normalcharge for a similar service or supply, or the amount charged for thatservice by 80% of the health care professionals in the geographic areawhere it is received. The health care professional may bill the customer thedifference between the health care professional's normal charge and theMaximum Reimbursable Charge as determined by the benefit plan, inaddition to applicable deductibles, co-payments and coinsurance.

Not Applicable 150%

Calendar Year Deductiblel Only the amount you pay for in-network covered expenses counts

toward your in-network deductible. The amount you pay for out-of-network covered expenses counts toward both your in-network andout-of-network deductibles.

l All eligible family members contribute towards the family plandeductible. Once the family deductible has been met, the plan will payeach eligible family member's covered expenses based on thecoinsurance level specified by the plan.

Individual: $2,500Family: $5,000

Individual: $10,000Family: $20,000

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Calendar Year Out-of-Pocket Maximuml Only the amount you pay for in-network covered expenses counts

toward your in-network out-of-pocket maximum. The amount you payfor out-of-network covered expenses counts toward both your in-network and out-of-network out-of-pocket maximums.

l Plan Deductibles contribute towards your out-of-pocket maximum.l Copays and benefit deductibles contribute towards your out-of-pocket

maximum.l Mental health and substance abuse covered expenses contribute

towards your out-of-pocket maximum.l All eligible family members contribute towards the family out-of-pocket

maximum. Once the family out-of-pocket maximum has been met, theplan will pay each eligible family member's covered expenses at100%

Individual: $5,000

Family: $10,000

Individual: $30,000

Family: $60,000

Pre-Existing Condition Limitation (PCL)

Not applicable to anyone under 19 years old

PCL applies to any injury or sickness that you are diagnosed with and receive treatmentfor, or incur expenses for during the 90 days before you are insured by these benefits or

you begin an eligibility waiting period (whichever is earlier). Please refer to your plandocuments for specific details.

Pre-certification - Continued Stay Review - PHS+ Inpatient- requiredfor all inpatient admissions

Coordinated by your physician

Customer is responsible for contactingCigna Healthcare. Subject topenalty/reduction or denial for non-compliance.l 50% penalty applied to hospital

inpatient charges for failure to contactCigna Healthcare to precertifyadmission.

l 50% penalty for any admission

reviewed by Cigna Healthcare and notcertified.l 50% penalty for any additional days

not certified by Cigna Healthcare.

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Pre-certification - Continued Stay Review - PHS+ Outpatient PriorAuthorization- required for selected outpatient procedures anddiagnostic testing

Coordinated by your physician

Customer is responsible for contactingCigna Healthcare. Subject topenalty/reduction or denial for non-compliance.l 50% penalty applied to outpatient

procedures/diagnostic testing chargesfor failure to contact Cigna Healthcare

and to precertify admission.l Benefits are denied for any outpatient

procedures/diagnostic testingreviewed by Cigna Healthcare and notcertified.

Benefit In-Network Out-of-Network

Physician Services

Primary Care Physician (PCP) Office Visit You pay $50 PCP copayYou pay 50% coinsurance after plandeductible is met

Specialty Care Physician Office Visit You pay $50 Specialist copay You pay 50% coinsurance after plandeductible is met

Surgery Performed in Physician's Office You pay $50 PCP or $50 Specialist copayYou pay 50% coinsurance after plandeductible is met

Allergy Treatment/InjectionsYou pay lesser of $50 PCP or $50Specialist copay or actual charge

You pay 50% coinsurance after plandeductible is met

Allergy SerumDispensed by the physician in the office

Plan pays 100%You pay 50% coinsurance after plandeductible is met


Preventive Care

Routine Preventive Care - All Agesl Includes well-baby, well-child, well-woman and adult preventive carel Includes coverage of additional services, such as urinalysis, EKG, and

other laboratory tests, supplementing the standard Preventive Carebenefit.


Immunizations - All Ages Plan pays 100%You pay 50% coinsurance after plandeductible is met

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Mammogram, PAP, PSA Testsl Coverage includes the associated Preventive Outpatient Professional

Services.l Diagnostic-related services are covered at the same level of benefits

as other x-ray and lab services, based on place of service.



Inpatient

Inpatient Hospital Facility You pay 30% coinsurance after plandeductible is met


Inpatient Hospital Physician's Visit/ConsultationYou pay 30% coinsurance after plandeductible is met


Inpatient Professional Servicesl For services performed by Surgeons, Radiologists, Pathologists and

Anesthesiologists



Multiple Surgical ReductionMultiple surgeries performed during one operating session result in payment reductionof 50% to the surgery of lesser charge. The most expensive procedure is paid as anyother surgery.


Outpatient

Outpatient Facility ServicesYou pay 30% coinsurance after plandeductible is met


Outpatient Professional Servicesl For services performed by Surgeons, Radiologists, Pathologists and

Anesthesiologists



Short-Term Rehabilitation

l Includes physical therapy, speech therapy, occupational therapy,pulmonary rehabilitation and cognitive therapyl 60 days maximum per Calendar Yearl Therapy days, provided as part of an approved Home Health Care

plan, accumulate to the outpatient short term rehab therapy maximum

You pay $50 PCP or $50 Specialist copay You pay 50% coinsurance after plandeductible is met

Chiropractic Carel 20 days maximum per Calendar Year

You pay $50 PCP or $50 Specialist copay You pay 50% coinsurance after plandeductible is met

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Other Health Care Facilities/Services

Home Health Care(includes outpatient private duty nursing days when approved as medicallynecessary)l Unlimited days maximum per Calendar Yearl 16 hour maximum per day



Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilityl 90 days maximum per Calendar Year



Durable Medical Equipmentl Unlimited maximum per Calendar Year



Breast Feeding Equipment and Suppliesl Limited to the rental of one breast pump per birth as ordered or

prescribed by a physician.l Includes related supplies


External Prosthetic Appliances (EPA)l Unlimited maximum per Calendar Year



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Other Health Care Facilities/Services

Place of Service - You pay based on where you receive services.

Benefit Physician's Office Outpatient FacilityEmergency Room/ Urgent

Care FacilityIndependent Lab Inpatient Hospital

In-NetworkOut-of-

NetworkIn-Network

Out-of-

NetworkIn-Network

Out-of-

NetworkIn-Network

Out-of-

NetworkIn-Network

Out-of-

Network

Lab and X-ray

Plan pays100%

You pay 50%coinsuranceafter plandeductible ismet

Plan pays100%


Plan pays 100%Plan pays100%


Coveredunder plan'sInpatientHospitalbenefit

Coveredunder plan'sInpatientHospitalbenefit

AdvancedRadiologyImaging(MRI, MRA,

CAT Scan,PET Scan,etc.)

$0 per scancopay, plan

pays 100%

You pay 50%coinsuranceafter plan

deductible ismet

$0 per scancopay thenyou pay 30%coinsurance

after plandeductible ismet

You pay 50%coinsuranceafter plan

deductible ismet

$0 per scan copay, planpays 100%

NotApplicable

NotApplicable

Coveredunder plan'sInpatient

Hospitalbenefit

Coveredunder plan'sInpatient

Hospitalbenefit


Physician's Office Emergency Room

Outpatient ProfessionalServices

(Radiologist, Pathologist, ERPhysician)

*Ambulance

Benefit In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

EmergencyCare

You pay $50 PCP or $50Specialist copay

You pay $100 per visit (copaywaived if admitted)

You pay 30% coinsurance afterplan deductible is met


* - Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered

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Physician's Office Urgent Care FacilityOutpatient Professional

Services*Ambulance


Urgent CareYou pay $50 PCP or $50Specialist copay

You pay $50 per visit (copaywaived if admitted)



* - Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered


Initial Visit to ConfirmPregnancy

All Subsequent Prenatal Visits,Postnatal Visits and Physician's

Delivery Charges

Office Visits in Addition toGlobal Maternity Fee

(Performed by OB/GYN orSpecialist)

Delivery - Facility

(Inpatient Hospital, BirthingCenter)


Maternity

You pay $50

PCP or $50Specialist copay

You pay 50%coinsurance






You pay $50

PCP or $50Specialist copay



Covered sameas plan'sInpatientHospital benefit

Covered sameas plan'sInpatientHospital benefit


Inpatient Hospital and Other Health Care Facilities Outpatient Services

Benefit In-Network Out-of-Network In-Network Out-of-Network

Hospice (provided as part ofHospice Care Program)





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BenefitPhysician' s Services -

Office VisitInpatient Hospital Facility

Outpatient FacilityServices

Inpatient ProfessionalServices

Outpatient ProfessionalServices

In-NetworkOut-of-

NetworkIn-Network

Out-of-Network

In-NetworkOut-of-

NetworkIn-Network

Out-of-Network

In-NetworkOut-of-

Network

Family

Planning -Men'sServices

You pay $50

PCP or $50Specialistcopay



















Includes surgical services, such as vasectomy (excludes reversals).

FamilyPlanning -Women'sServices

Plan pays100%


Plan pays100%


Plan pays100%


Plan pays100%


Plan pays100%


Includes surgical services, such as tubal ligation (excludes reversals).

Contraceptive devices as ordered or prescribed by a physician.

Infertility

You pay $50PCP or $50Specialistcopay










Infertility covered services: lab and radiology test, counseling, surgical treatment, includes artificial insemination, in-vitro fertilization, GIFT, ZIFT, etc.

Unlimited lifetime maximum

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Benefit Physician's Office Inpatient Facility Outpatient FacilityInpatient Professional

ServicesOutpatient Professional

Services

In-NetworkOut-of-

NetworkIn-Network

Out-of-Network

In-NetworkOut-of-

NetworkIn-Network

Out-of-Network

In-NetworkOut-of-

Network

TMJ,Surgicaland Non-Surgical

Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered


Benefit Inpatient

Outpatient - Physician's Office(includes individual, group therapy

mental health and intensive outpatientmental health)

Outpatient Facility(includes individual, group therapy

mental health and intensive outpatientmental health)

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Mental Health You pay 30%coinsurance afterplan deductible is met

You pay 50%coinsurance afterplan deductible is met

You pay $50 copay You pay 50%coinsurance afterplan deductible is met



l Unlimited maximum per calendar yearl Mental Health services are paid at 100% after you reach your out-of-pocket maximum


Benefit InpatientOutpatient - Physician's Office

(includes individual and intensiveoutpatient substance abuse)

Outpatient Facility(includes individual and intensive

outpatient substance abuse)

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Substance AbuseYou pay 30%coinsurance afterplan deductible is met


You pay $50 copayYou pay 50%coinsurance afterplan deductible is met



Note:Detox is covered under medicall Unlimited maximum per calendar yearl Substance Abuse services are paid at 100% after you reach your out-of-pocket maximum

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Cigna Pharmacy Plus three-tier copay planl Generic Pushl Self Administered injectable drugs - includes infertility drugsl Oral Contraceptives includedl Includes Oral Contraceptives - with specific products covered 100%l Insulin, glucose test strips, lancets, insulin needles & syringes, insulin

pens and cartridges included

Retail- 30 day supplyGeneric: You pay $20Preferred Brand: You pay $40Non-Preferred Brand: You pay $70

Home delivery- 90 day supplyGeneric: You pay $40Preferred Brand: You pay $80Non-Preferred Brand: You pay $140

RetailYou pay 50%Plan pays 50%

Home DeliveryNot covered

Pharmacy Deductiblel Applies to in-network pharmacy costsl Retail pharmacy costs contribute to the pharmacy deductible and

home delivery pharmacy cost does not contribute to the pharmacydeductible.

Individual- $100Family- $200

Individual- NAFamily- NA

Pharmacy Clinical Management and Prior Authorizationl Your plan is subject to certain clinical edits and prior authorization requirements

Clinical Outcome Programs:l Includes complex psychiatric case management

l Includes narcotic therapy managementSpecialty Pharmacy Management:l Clinical Programs

Prior authorization is required on specialty medications but quantity limits may apply. Theracare Program

l Medication Access Option Retail and/or Home Delivery

Definitions

Coinsurance- After you've reached your deductible, you and your plan share some of your medical costs. The portion of covered expenses you are responsible foris called coinsurance.

Copay- A flat fee you pay for certain covered services such as doctor's visits or prescriptions.Deductible- A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered services.Out-of-Pocket Maximum- Specific limits for the total amount you will pay out of your own pocket before your plan coinsurance percentage no longer applies. Onceyou meet these maximums, your plan then pays 100 percent of the "maximum reimbursable charges" or negotiated fees for covered services.Prescription Drug List- The list of prescription brand and generic drugs covered by your pharmacy plan.Transition of Care- Provides in-network health coverage to new customers when the customer's doctor is not part of the Cigna network and there are approvedclinical reasons why the customer should continue to see the same doctor.

Dollars & Sense

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DOLLARS & SENSE: Easy ways to decrease your out-of-pocket health care expenses.In-network careUsing doctors, hospitals and facilities that participate in the Cigna network can save you money. In addition, choosing Cigna Care designated specialists - doctorsin 19 specialties who have been identified for their superior performance in quality and cost efficiency - may save you even more. You can verify that a doctor orfacility is in Cigna's network and learn more about the Cigna Care designation by checking the directory on myCigna.com or Cigna.com, or by calling the customerservice number on the back of your Cigna ID card. Cigna is open 24/7.Urgent care(Average urgent care center cost $131 / Average hospital ER cost $1,523)Many people use the emergency room (ER) for conditions that are not serious or life-threatening. Using an urgent care center or your doctor's office instead of an ERcan save you hundreds of dollars and provides the same quality of care as an ER. If you need care and are not sure if you need to go to the ER, speak with yourdoctor or call Cigna's 24-hour nurse line at the number on the back your Cigna ID card to determine the most appropriate location for urgent care.Convenience care or retail clinics(Average convenience care clinic cost $61 / Average hospital ER cost $1,523)Convenience care clinics provide quick and easy access to high quality treatment for common medical conditions when your doctor is not available. These clinicsare located in department stores, grocery stores and pharmacies. To locate convenience care clinics, you can check the Directory on myCigna.com or Cigna.com,or call the customer service number on the back of your Cigna ID card. Cigna is open 24/7.Laboratory and pathology tests(Average LabCorp/Quest cost $9 / Average other lab cost $24 / Average outpatient hospital lab cost $48) Two of the nation's largest and most prominent laboratories, Quest Diagnostics, Inc. (Quest) and Laboratory Corporation of America (LabCorp), participate in theCigna network. Services at these labs can cost 70-75% less and offer the same or better quality than hospital laboratories. When you need lab services, discuss

these options with your doctor. To find the nearest Quest and LabCorp locations, check the directory on myCigna.com or Cigna.com.Radiology services (MRI or CT scan)(Average independent radiology facility cost $591 / Average outpatient hospital cost $1,198) If you need to have an MRI or CT scan, you can save hundreds of dollars by using an independent radiology center. While Cigna contracts with all types of facilitiesthat provide radiology services, using independent radiology centers will save you money, without any difference in quality. Discuss location options with your doctor.For help locating the most cost effective facility in which to have an MRI or CT scan, you can use the cost comparison tools on myCigna.com or call the customerservice number on the back of your Cigna ID card.Colonoscopy, endoscopy or arthroscopy(Average freestanding surgery center cost $1,438 / Average outpatient hospital cost $2,821) When a doctor recommends a colonoscopy, GI endoscopy or arthroscopy, make sure you know your options. Using a freestanding outpatient surgery center forthese procedures instead of a hospital can often save hundreds of dollars, while maintaining the same high quality as a hospital. Talk with your doctor about options.For help locating the most appropriate facility, you can use our cost comparison tools on myCigna.com or call the customer service number on the back of yourCigna ID card.Cigna Home Delivery PharmacyYou can save money and enjoy convenient home delivery by using Cigna Home Delivery Pharmacy for your prescription medications. You can get up to a 90-daysupply of your medication.

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Exclusions

What's Not Covered (not all-inclusive):Your plan provides coverage for most medically necessary services. Examples of things your plan does not cover, unless required by law or covered under thepharmacy benefit, include (but aren't limited to):l Cosmetic servicesl Custodial and other non-skilled servicesl Dental care, unless due to accidental injury to sound natural teethl Experimental, investigational or unproven services

l Eyeglass lenses and frames, contact lenses and surgical vision correctionl Genetic screeningsl Non-prescription and anti-obesity drugsl Reversal of sterilization proceduresl Services for an injury or illness that occurs while working for pay or profit including services covered by worker's compensation benefitsl Services provided through government programsl Services that aren't medically necessaryl Telephone, email and internet consultations in the absence of a specific benefitl Travel immunizationsl Treatment of TMJ Disorderl Treatment of sexual dysfunctionl Weight loss programsl Hearing aidsl Acupuncturel Obesity surgery and services

These are only the highlightsThis summary outlines the highlights of your plan. For a complete list of both covered and not-covered services, including benefits required by your state, see youremployer's insurance certificate or summary plan description -- the official plan documents. If there are any differences between this summary and the plandocuments, the information in the plan documents takes precedence. This summary provides additional information not provided in the Summary of Benefits andCoverage document required by the Federal Government.

"Cigna," "Cigna Healthcare," "Cigna Care Network," "Cigna Behavioral Health," "Cigna Choice Fund," "Cigna Well Aware for Better Health" and "myCigna.com"

are registered service marks, and "Cigna Pharmacy," Cigna Home Delivery Pharmacy," "Cigna Well Informed," "Cigna Behavioral Advantage", "Your Health

First" and the "Tree of Life" logo are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. Allproducts and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut

General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna Behavioral Health, Inc., Tel-Drug, Inc., Tel-Drug ofPennsylvania, L.L.C. and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. In Arizona, HMO plans are offered

by Cigna HealthCare of Arizona, Inc. In Connecticut, HMO plans are offered by Cigna HealthCare of Connecticut, Inc. In North Carolina, HMO plans are offeredby Cigna HealthCare of North Carolina, Inc. In California, HMO and Network plans are offered by Cigna HealthCare of California, Inc. All other medical plans inthese states are insured or administered by CGLIC or CHLIC. "Cigna Home Delivery Pharmacy" refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

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Documents

OAP Summary - 020113