Quick Guide to Cigna Id Cards

QUICK GUIDE TO CIGNA ID CARDS

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We pack a lot of important information on Table of contents our ID cards. Managed care plans 2 This brochure can help define and clarify information that �� appears on Cigna’s most common customer ID cards. It Networks: can also help you understand the requirements associated Network Open Access ��2 with our various plans, allowing you to quickly and efficiently serve your patients. Open Access Plus ��2 We may occasionally update this brochure during the year. HMO Open Access or POS Open Access ��2 Download the most current version at Cigna.com > Health HMO, POS, or HMO POS �� 4 Care Providers > Coverage and Claims > ID Cards. Network or Network POS �� 6 Important information about this guide PPO or EPO �� 6 Cigna SureFit® �� 8 Please note: Some Cigna ID cards include a “G” in the upper-right corner, and may have different service Individual & Family Plans 10 channels, including customer service phone numbers �� and claim appeal addresses. Networks: Sample standard Cigna ID card images are shown in this Connect ��10 guide. However, the actual content may vary to conform Cigna Plus ��10 to a state’s legislative and regulatory requirements. An ID card is not a guarantee of coverage, and benefits should Medicare plans ��12 be verified. Medicaid plans �� 14 Always be sure to check the back of your patient’s ID card ® for the correct contact information. You can also refer to Cigna Global Health Benefits plans �� 16 the Important contact information page in the back of this Networks: guide, or refer to the Cigna Reference Guide for physicians, Networks in the U.S.: PPO or OAP ��16 hospitals, ancillaries, and other health care professionals by logging in to the Cigna for Health Care Professionals Networks outside the U.S.: Vary by location ��16 website (CignaforHCP.com) > Resources > Reference Guides > Medical Reference Guides > Health Care Cigna Choice Fund® plans ��18 Professional Reference Guides. Networks: Vary by plan ��18

Shared Administration Repricing plans ��18

Networks: Shared Administration Open Access Plus ��18 Shared Administration PPO ��18 Shared Administration Local Plus ��18

Strategic alliance plans �� 20

Networks: Vary by plan �� 20

Cigna + Oscar ��22

Indemnity plans �� 24

The myCigna® App �� 26

Important contact information ��28

1 MANAGED CARE PLANS

Network: Network Open Access

18 WWW.CIGNA.COM CSN logo TPV logo Client You may be asked to present this card when you receive care. The card does not guarantee coverage. 11 logo Tiered Benefits 6 You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. 12 INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Legal entity name 55 Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents Coverage eﬀective date: MM/DD/CCYY 7 Network Open Access for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your Group: 1234567 No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Issuer (80840) PCP Visit $10/$25 For information about mental health services and coverage, call 1-XXX-XXX-XXXX Specialist $10/$25 ID: U23456789 01 1 Med Group: Sunset Med Group Name: John Public Hospital ER 4 $50 Send Claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 Urgent Care $25 13 8 For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) PCP: James Smith Vision Yes PCP Name Ln2 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) Rx $10/20%/40%/100% PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna Vision PO Box 385018, Birmingham, AL 35238-5018 ID card acct name 10 Cigna Claims: PO Box XXXXX, Anytown, USA 12345-6789 3 TPV Name, PO Box XXXXX, Anytown, USA 12345-6789 RxBIN XXXXXX RxPCN XXXXXXXX NSP Coinsurance applies logo 9 CSN Name, PO Box XXXXX, Anytown, USA 12345-6789 DOI Network Savings Program SAR Customer Service: 1-XXX-XXX-XXXX 14 MH/SA: 1-XXX-XXX-XXXX

PCP required Referral required Away from Home Care Out-of-network benefits Encouraged No No No For more information, see the next page.

Network: Open Access Plus

WWW.CIGNA.COM 18 CSN logo You may be asked to present this card when you receive care. The card does not guarantee coverage. TPV logo 11 Client You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. Tiered Benefits 6 logo 12 INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Legal entity name 5 Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents Coverage eﬀective date: MM/DD/CCYY 7 Open Access Plus for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your Group: 1234567 No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Issuer (80840) PCP visit $10/$25 For information about mental health services and coverage, call 1-XXX-XXX-XXXX Specialist $10/$25 ID: U23456789 01 1 Med Group: Sunset Med Group Hospital ER $50 4 Send Claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 Name: John Public Urgent care $25 Vision Yes For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) PCP: James Smith For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) PCP Name Ln2 8 Rx $10/20/30 Network Coinsurance: Cigna Vision PO Box 385018, Birmingham, AL 35238-5018 PCP phone: XXX.XXX.XXXX In 90%/10% Cigna Claims: PO Box XXXXX, Anytown, USA 12345-6789 ID card acct name 10 Out 3 70%/30% TPV Name, PO Box XXXXX, Anytown, USA 12345-6789 13 RxBIN XXXXXX RxPCN XXXXXXXX Med/Rx deductible applies CSN Name, PO Box XXXXX, Anytown, USA 12345-6789 DOI 9 Cat# Customer Service: 1-XXX-XXX-XXXX 14 MH/SA: 1-XXX-XXX-XXXX 15 AWAY FROM HOME CARE

PCP required Referral required Away from Home Care Out-of-network benefits Encouraged No Yes Yes For more information, see the next page.

Networks: HMO Open Access or POS Open Access

WWW.CIGNA.COM CSN logo You may be asked to present this card when you receive care. The card does not guarantee coverage. TPV logo Client You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. Tiered Benefits 2 logo 12 INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Legal entity name 5 Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents Coverage eﬀective date: MM/DD/CCYY POS (or HMO) Open Access for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your 7 primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Group: 1234567 No referral required Issuer (80840) PCP Visit $15/$25 For information about mental health services and coverage, call 1-XXX-XXX-XXXX Specialist 4 $15/$25 Med Group: Sunset Med Group 13 ID: U23456789 01 1 Name: John Public Hospital ER $50 Send Claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 Urgent Care $25 For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) PCP: James Smith 8 Vision Yes PCP Name Ln2 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) Rx $10/20%/40%/100% PCP Phone: XXX.XXX.XXXX Cigna Vision PO Box 385018, Birmingham, AL 35238-5018 Rx Indiv Deduct $50 Cigna Claims: PO Box XXXXX, Anytown, USA 12345-6789 ID card acct name 10 TPV Name, PO Box XXXXX, Anytown, USA 12345-6789 NSP Coinsurance applies 3 RxBIN XXXXXX RxPCN XXXXXXXX logo 9 CSN Name, PO Box XXXXX, Anytown, USA 12345-6789 DOI Network Savings Program SAR Customer Service: 1-XXX-XXX-XXXX 14 MH/SA: 1-XXX-XXX-XXXX

PCP required Referral required Away from Home Care Out-of-network benefits HMO Encouraged No No No POS Encouraged No No Yes For more information, see the next page.

2 *PCP selection and referrals are encouraged in Missouri.

Key Managed care plans Refer to this key for explanations of the information found on the sample Cigna ID cards Managed care plans are designed to manage cost, utilization, featured in this brochure. and quality. Depending on the plan, customers may have coverage for participating providers only, or have both 1 Use this ID number for all claims and inquiries. in‑network and out‑of‑network benefits. Some plans require 2 Indicates a seamless network where a patient referrals for specialty care and the selection of a primary care can receive in-network care on a regional or provider (PCP). statewide basis. Network: Network Open Access 3 For patients with coinsurance, submit claims Plans that use this network offer customers access to participating to Cigna or its designee, and receive an providers, with no referrals required. explanation of payment (EOP), which will show any remaining amount due from the patient. › Flexible plan designs allow for an array of cost-sharing options, 4 including copayments, coinsurance, and deductibles. Collect any copayment at the time of service. 5 › Customers can select a PCP to help coordinate care; May read as: “Cigna Health and Life Insurance it’s recommended, but not required. Company” or “Connecticut General Life Insurance Co.” or “Cigna HealthCare of Referrals are not required to see participating specialists. › XXXX, Inc.” › Precertification may still be required for certain services 6 ID cards with the Cigna Care Network® logo and procedures. indicate the patient’s liability varies based › No out-of-network coverage, except for emergencies.* on the provider’s Cigna Care designation For a directory of providers who participate in this network, status. Refer to the online provider directory visit Cigna.com > Find a Doctor. at Cigna.com > Find a Doctor to determine a physician’s Cigna Care designation status. Network: Open Access Plus 7 Effective date of coverage. Plans that use this network offer customers access to a large, 8 Name of patient‘s primary care provider (PCP). national network of providers. The plans include health advocacy programs to help customers engage in wellness initiatives and 9 Network Savings Program (NSP) logo indicates manage chronic conditions. that out-of-network discounts may be available to the customer. › Customers can select a PCP to help coordinate care; it’s recommended, but not required. 10 Employer name. › Referrals are not required to see specialists. 11 If a third party administers services in › Precertification may still be required for certain services conjunction with Cigna, the ID card may and procedures. include multiple logos, and show a different claim address or telephone number on the For a directory of providers who participate in this network, back of the card. visit Cigna.com > Find a Doctor. 12 Precertification requirements may be shown Networks: Health Maintenance Organization (HMO) as either “Inpatient Admission” or “Inpatient Open Access or Point of Service (POS) Open Access Admission and Outpatient Procedures.’’ Plans that use these networks offer customers access to local 13 Submit claims to the claim submission address providers and a variety of different benefit options. The plans shown on the card. include negotiated network-specific discounts and fee schedules, 14 Call the customer service number(s) indicated along with robust medical management, to help reduce use of on the card. Some plans have dedicated nonessential procedures. numbers for accessing information. Always › Customers can select a PCP to help coordinate care; check the card for the correct number or refer it’s recommended, but not required. to the Important contact information page in this guide. › Referrals are not required to see specialists. 15 › Precertification may still be required for certain services “Away From Home Care” indicates the patient and procedures. has access to the Cigna national Away From Home Care feature. For a directory of providers who participate in these networks, visit Cigna.com > Find a Doctor. 16 Indicates shared administration repricing. 17 Union identifier. * Emergency services as defined in their plan. 18 Client-specific network (CSN) logo. 3 4 MANAGED CARE PLANS (CONTINUED)

Networks: LocalPlus® or LocalPlusIN

WWW.CIGNA.COM CAD logo TPV logo 11 18 Client You may be asked to present this card when you receive care. The card does not guarantee coverage. logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT PRECEDURES: 12 Legal entity name Your Network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents Coverage eﬀective date: MM/DD/CCYY LocalPlus (or LocalPlusIN) for your pre-certication requirements. Failure to do so may aect benets. In an emergency, seek care immediately, then call your Group: 1234567 No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ## hours. Issuer (80840) PCP Visit $10 Carve out 1 Prt Line 13 ID: U23456789 01 1 Specialist $15 4 Carve out 2 Prt Line Name: John Public Hospital ER $50 Urgent Care $25 Send claims to: PCP: James Smith Vision Yes CAD Name, PO Box XXXX, Anytown, USA 12345-6789 Jane Smith Rx $10/20/30 TPV Name, PO Box XXXX, Anytown, USA 12345-6789 PCP Phone: 860.123.4567 Network coinsurance: All Other: PO Box XXXX, Anytown, USA 12345-6789 9 In 90%/10% ABC12 & Sons Company Customer Service: 800.XXX.XXXX MH/SA: 800.XXX.XXXX NSP Out 70%/30% 14 RxBIN XXXXXX RxPCN XXXXXXXX logo Med/Rx deductible applies We encourage you to use a PCP as a valuable resource and personal health advocate. Open Access Plus 15 DOI Label Network Savings Program Cat # AWAY FROM HOME CARE

PCP required Referral required Away from Home Care Out-of-network benefits LocalPlus Encouraged No Yes Yes LocalPlusIN Encouraged No Yes No

For more information, see the next page.

Networks: HMO, POS, or HMO POS

Select WWW.CIGNA.COM Client 2 You may be asked to present this card when you receive care. The card does not guarantee coverage. Preferred Hospital logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT SERVICES Legal Entity Name 5 12 Your network provider must call the toll-free number listed below to pre-certify the above services. Coverage Eﬀective Date MM/DD/CCYY 7 HMO Refer to your plan documents for your pre-certication requirements. Failure to do so may aect Group: 1234567 No Referred Required benets. In an emergency, seek care immediately, then call your primary care doctor as soon as Issuer (80840) PCP Visit $15 possible for further assistance and directions on follow-up care within ### hours. Specialist $15 ID: U23456789 01 For information about mental health services and coverage, call XXX.XXX.XXXX 1 Hospital ER 4 $50 Name: John Public Urgent Care $25 MedGroup: Sunset Med Group PCP: James Smith 8 Vision Yes Send claims to: 123 Main Street, Suite 999, Anytown, USA 12345-678 13 PCP Name Ln2 Rx $10/20/40 For Pharmacy call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) PCP Phone: XXX-XXX-XXXX Rx Indiv Deduct $50 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) ID Card Acct Name Cigna Vision P.O. Box 385018, Birmingham, AL 32538/5018 10 Coinsurance Applies 3 RxBIN 017010 RxPCN 0215COMM NSP Cigna: PO Box XXXXX, Anytown, USA 12345-6789 RxGroup: 1234567 logo 9 DOI Label Network Savings Program Cat# Member Services: 1-XXX-XXX-XXXX MH/SA: 1-XXX-XXX-XXXX C

PCP required Referral required Away from Home Care Out-of-network benefits HMO Yes Yes No No POS Yes Yes No Yes HMO POS Yes Yes No Yes

For more information, see the next page.

4 Key Networks: LocalPlus® or LocalPlusIN Refer to this key for explanations of the information found on the sample Cigna ID cards Plans that use these networks offer customers access featured in this brochure. to participating providers in their local area, or in any area in the country where one exists, for coverage at the 1 Use this ID number for all claims and inquiries. in‑network cost. 2 Indicates a seamless network where a patient › In areas where these networks are not available, can receive in-network care on a regional or customers can access care through our Away From statewide basis. Home Care feature for coverage at the in-network cost. 3 For patients with coinsurance, submit claims › If customers choose to access care from providers to Cigna or its designee, and receive an outside the LocalPlus network (or outside the Away explanation of payment (EOP), which will show From Home Care feature when the LocalPlus network any remaining amount due from the patient. isn’t available), they will likely pay more. (Customers 4 Collect any copayment at the time of service. with the LocalPlusIN plan will pay the full cost of their care.*) 5 May read as: “Cigna Health and Life Insurance Company” or “Connecticut General Life › Referrals are not required to see specialists. Insurance Co.” or “Cigna HealthCare of › Precertification may still be required for certain services XXXX, Inc.” and procedures. 6 ID cards with the Cigna Care Network® logo For a directory of providers who participate in these indicate the patient’s liability varies based networks, visit Cigna.com > Find a Doctor. on the provider’s Cigna Care designation status. Refer to the online provider directory Networks: HMO, POS, or HMO POS at Cigna.com > Find a Doctor to determine a Plans that use these networks offer customers cost savings physician’s Cigna Care designation status. and access to a local network of providers. 7 Effective date of coverage. Customers must select a network-participating PCP to › 8 Name of patient‘s primary care provider (PCP). coordinate care for coverage at the in-network cost. 9 Network Savings Program (NSP) logo indicates Referrals are required to see specialists except › that out-of-network discounts may be available OB/GYNs. to the customer. › HMO POS plans include benefits and features similar to 10 Employer name. HMO plans, plus out-of-network coverage at reduced benefit levels. 11 If a third party administers services in conjunction with Cigna, the ID card may For a directory of providers who participate in these include multiple logos, and show a different networks, visit Cigna.com > Find a Doctor. claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. * Except for emergency services as defined by their plan. 18 Client Arranged Deal (CAD) network logo. 5 MANAGED CARE PLANS (CONTINUED)

Networks: Network or Network POS

WWW.CIGNA.COM CSN logo 18 TPV logo 11bl 2 Client You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all Tiered Benefits 6 logo terms and conditions of the plan. Willful misuse of this card is considered fraud. 12INPATIENT ADMISSION: Legal entity name 5 Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your Coverage eﬀective date: MM/DD/CCYY 7 pre-certication requirements. Failure to do so may aect benets. In an emergency, seek care immediately, then call your primary Group: 1234567 Network care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Issuer (80840) PCP Visit $15/$20 Specialist 4 $15/$20 For information about mental health services and coverage, call MHSA Stmt Tel ID: U23456789 01 Med Group: Sunset Med Group Name: John Public 1 Hospital ER $50 Urgent Care $25 Send claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 13 PCP: James Smith Vision Yes For Pharmacy, call ABC Company 800.XXX.XXXX (Not a Cigna Company) PCP Name Ln2 8 Rx $10/20%/40%/100% For Vision, call ABC Company 800.XXX.XXXX (Not a Cigna Company) PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna Claims: PO Box XXXX, Anytown, USA 12345-6789 ID card acct name 10 TPV Name, PO Box XXXX, Anytown, USA 12345-6789 RxBIN XXXXXX RxPCN XXXXXXXX Coinsurance applies 3 CSN Name, PO Box XXXX, Anytown, USA 12345-6789 Customer Service: 800.XXX.XXXX MH/SA: 800.XXX.XXXX DOI 9 OAP# 14bo

PCP required Referral required Away from Home Care Out-of-network benefits Network Yes Yes No No

Network Yes Yes No Yes POS For more information, see the next page.

Networks: PPO or EPO

SELF FUNDED NJ Arbitrations: YES WWW.CIGNA.COM as of: MM/DD/CCYY CAD or NBN logo 18 Client You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. TPV LOGO 11 logo Tiered Benefit s 6 12 INPATIENT ADMISSION: or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Your Network provider must call the toll-free number listed below to pre-certify the above services. Refer Legal Entity Name 5 to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an Coverage Eﬀective Date: MM/DD/CCYY 7 PPO emergency, seek care immediately, then call your primary care doctor as soon as possible for further Group: 1234567 Dr. Visit $15 assistance and directions on follow up care within ## hours. Issuer (80840) Specialist $10/$25 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds. Hospital ER $50 ID: U23456789 01 1 4 For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) Urgent Care $25 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company) Name: John Public Vision Yes Cigna Vision P.O. Box 385018, Birmingham, AL 35238-5018 Rx $10/20/30 Send Claims to: Network Coinsurance: ID Card Acct Name10 CAD Name, P.O. BOX XXXX, ANYTOWN, USA 12345-6789 13 9 In 90%/10% TPV Name, P.O. BOX XXXX, ANYTOWN, USA 12345-6789 RxBIN 017010 RxPCN 0215COMM 3 NSP Out 70%/30% All Others: P.O. BOX XXXXX, ANYTOWN, USA 12345-6789 14 15 RxGroup: 1234567 logo Med/Rx Deductible Applies Customer Service: 1-800-XXX-XXXX MH/SA: 1-800-XXX-XXXX AWAY FROM HOME CARE DOI Label Network Savings Program Cat #

PCP required Referral required Away from Home Care Out-of-network benefits PPO No No Yes Yes EPO Encouraged No Yes No

For more information, see the next page.

6 Key Networks: Network or Network POS Refer to this key for explanations of the information found on the sample Cigna ID cards Plans that use these networks offer customers cost featured in this brochure. savings, local convenience, and choice. 1 Use this ID number for all claims and inquiries. › Customers must select a network-participating PCP to coordinate care for coverage at the in-network cost. 2 Indicates a seamless network where a patient can receive in-network care on a regional or › Referrals are required to see specialists except statewide basis. OB/GYNs. 3 For patients with coinsurance, submit claims Network POS plans include benefits and features similar › to Cigna or its designee, and receive an to Network plans, plus out-of-network coverage at explanation of payment (EOP), which will show reduced benefit levels. any remaining amount due from the patient. For a directory of providers who participate in these 4 Collect any copayment at the time of service. networks, visit Cigna.com > Find a Doctor. 5 May read as: “Cigna Health and Life Insurance Networks: PPO or Exclusive Provider Organization (EPO) Company” or “Connecticut General Life Insurance Co.” or “Cigna HealthCare of Plans that use these networks offer customers access to XXXX, Inc.” participating providers across the country. 6 ID cards with the Cigna Care Network® logo PPO: indicate the patient’s liability varies based › Both in- and out-of-network benefits are available. on the provider’s Cigna Care designation › Customers can access services from providers who status. Refer to the online provider directory Cigna.com do not participate in the network, but will assume at > Find a Doctor to determine a additional costs and be reimbursed at a lower physician’s Cigna Care designation status. coinsurance level. 7 Effective date of coverage. EPO: 8 Name of patient‘s primary care provider (PCP). 9 › No out-of-network coverage, except in emergencies.* Network Savings Program (NSP) logo indicates that out-of-network discounts may be available › Referrals are not required to see network-participating to the customer. specialists. 10 For a directory of providers who participate in these Employer name. networks, visit Cigna.com > Find a Doctor. 11 If a third party administers services in conjunction with Cigna, the ID card may include multiple logos, and show a different claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. 18 Client-specific network (CSN) or Client * Emergency services as defined in their plan. Arranged Deal (CAD) network logo. 7 MANAGED CARE PLANS (CONTINUED)

Network: Cigna SureFit®

Market-specific network name You may have to show this card when you receive care. This doesn’t guarantee coverage. Not In Network Only using this card correctly is fraud. For emergencies, call 911 or get immediate care. Contact your doctor after you get emergency services. If you don’t know if your situation is an emergency, Administered by Cigna Health and Life Insurance Company G call your doctor or our 24/7 Health Information Line. Customers: Check your plan documents for out-of-network (OON) precertification requirements. This may affect your OON benefits. Group: 00699999 Health Care Professionals: Check your provider contract for precertification requirements. Issuer (80840) Primary Care $25/0% Customers: myCigna.com ID: 666666666 1 A Specialist $50/0% Health Care Professionals: CignaforHCP.com Name: John Doe Urgent Care $15/0% PCP: Jeremiah B Johnson MD 8 ER Ded/20% Referral Required Medical Claims PO Box 188061 Chattanooga, TN 37422-8061 Payer ID #62308 Hospital Ded/10% 13 Cigna SureFit HCA of the FrontRange Rx Claims: Pharmacy Service Center, PO Box 188053, Chattanooga TN 37422-8053 RxBIN 017010 RxPCN 05180000 Customers & Health Care Professionals call 866-494-2111 14 RxGrp 00699999 RxID 222222222 00 For Pharmacists Only 800-351-9170

Mask 606 Issue Date: 10/25/17

Market-specific WWW.CIGNA.COM network name You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Administered by Cigna Health and Life Insurance Company Your network provider mst call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your pre-certification requirements Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. 1 For pharmacy, call ABC Company 800.XXX.XXXX (Not a Cigna Company) For vision, call ABC Company 800.XXX.XXXX (Not a Cigna Company) 8 Send claims to: CAD name, PO Box XXXX, Anytown, USA 12345-6789 13 3 TPV name, PO Box XXXX, Anytown, USA 12345-6789 All others: PO Box XXXX, Anytown, USA 12345-6789 Customer service: 1-XXX.XXX.XXXX MH/SA: 1-XXX.XXX.XXXX 14

To find the market-specific network name that will appear on the ID card, refer to the table below. In the first column, identify your market area. In the second column, you will see the corresponding market‑specific network name that should appear on the Cigna SureFit ID card.

Market Market-specific network name Arizona (Phoenix) with and affiliates California (Southern California) Southern California Central Florida (Orlando)

Colorado (Boulder, Denver, and Colorado Springs)

of the Front Range

Kansas and Missouri (Kansas City) Kansas City Mid-Atlantic (Northern Virgina, Richmond and Washington, DC) Missouri (St. Louis)

South Florida South Florida

PCP required Referral required Away from Home Care Out-of-network benefits Yes Yes No No

For more information, see the next page.

8 Key Network: Cigna SureFit® Refer to this key for explanations of the information found on the sample Cigna ID cards Plans that use this network offer customers access featured in this brochure. to local physician and hospital groups for personal, patient‑centered care. 1 Use this ID number for all claims and inquiries. › Customers must select a network-participating PCP 2 Indicates a seamless network where a patient to coordinate their care. can receive in-network care on a regional or › Referrals are required to see specialists. statewide basis. › No out-of-network coverage or Away From Home Care, 3 For patients with coinsurance, submit claims except in emergencies.* to Cigna or its designee, and receive an For a directory of providers who participate in these explanation of payment (EOP), which will show networks, visit Cigna.com > Find a Doctor. any remaining amount due from the patient. 4 Collect any copayment at the time of service. 5 May read as: “Cigna Health and Life Insurance Company” or “Connecticut General Life Insurance Co.” or “Cigna HealthCare of XXXX, Inc.” 6 ID cards with the Cigna Care Network® logo indicate the patient’s liability varies based on the provider’s Cigna Care designation status. Refer to the online provider directory at Cigna.com > Find a Doctor to determine a physician’s Cigna Care designation status. 7 Effective date of coverage. 8 Name of patient‘s primary care provider (PCP). 9 Network Savings Program (NSP) logo indicates that out-of-network discounts may be available to the customer.

10 Employer name. 11 If a third party administers services in conjunction with Cigna, the ID card may include multiple logos, and show a different claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. * Emergency services as defined in their plan. 18 Client-specific network (CSN) logo. 9

this network(s) will be utilized with the Cigna Dental Choice Plan Choice Dental Cigna the with utilized be will network(s) this this network(s) will be utilized with the Cigna Dental Choice Plan Choice Dental Cigna the with utilized be will network(s) this

The Cigna Dental PPO Network(s) is a national reference to our network; in Texas in network; our to reference national a is Network(s) PPO Dental Cigna The The Cigna Dental PPO Network(s) is a national reference to our network; in Texas in network; our to reference national a is Network(s) PPO Dental Cigna The

by CGLIC and CHLIC is referred to as the 'Cigna Dental Choice Plan'. Choice Dental 'Cigna the as to referred is CHLIC and CGLIC by by CGLIC and CHLIC is referred to as the 'Cigna Dental Choice Plan'. Choice Dental 'Cigna the as to referred is CHLIC and CGLIC by

(CGLIC) or 'CH Dental PPO' (CHLIC). In Texas, the insured dental product oﬀered product dental insured the Texas, In (CHLIC). PPO' Dental 'CH or (CGLIC) (CGLIC) or 'CH Dental PPO' (CHLIC). In Texas, the insured dental product oﬀered product dental insured the Texas, In (CHLIC). PPO' Dental 'CH or (CGLIC)

this network(s) will be utilized with the Cigna Dental Choice Plan Choice Dental Cigna the with utilized be will network(s) this

Louisiana, the insured Dental PPO product is referred to as the 'CG Dental PPO' Dental 'CG the as to referred is product PPO Dental insured the Louisiana, Louisiana, the insured Dental PPO product is referred to as the 'CG Dental PPO' Dental 'CG the as to referred is product PPO Dental insured the Louisiana,

The Cigna Dental PPO Network(s) is a national reference to our network; in Texas in network; our to reference national a is Network(s) PPO Dental Cigna The

Dental Health, Inc., and certain of its operating subsidiaries. In Arizona and Arizona In subsidiaries. operating its of certain and Inc., Health, Dental Dental Health, Inc., and certain of its operating subsidiaries. In Arizona and Arizona In subsidiaries. operating its of certain and Inc., Health, Dental

by CGLIC and CHLIC is referred to as the 'Cigna Dental Choice Plan'. Choice Dental 'Cigna the as to referred is CHLIC and CGLIC by

by CGLIC and CHLIC is referred to as the 'Cigna Dental Choice Plan'. Choice 09/08/20 Dental 'Cigna the as to referred is CHLIC and CGLIC by 09/07/20

by CGLIC or CHLIC with network management services provided by Cigna by provided services management network with CHLIC or CGLIC by by CGLIC or CHLIC with network management services provided by Cigna by provided services management network with CHLIC or CGLIC by

(CGLIC) or 'CH Dental PPO' (CHLIC). In Texas, the insured dental product oﬀered product dental insured the Texas, In (CHLIC). PPO' Dental 'CH or (CGLIC)

and Cigna Dental Health, Inc. The Cigna Dental PPO is underwritten or administered or underwritten is PPO Dental Cigna The Inc. Health, Dental Cigna and and Cigna Dental Health, Inc. The Cigna Dental PPO is underwritten or administered or underwritten is PPO Dental Cigna The Inc. Health, Dental Cigna and

Louisiana, the insured Dental PPO product is referred to as the 'CG Dental PPO' Dental 'CG the as to referred is product PPO Dental insured the Louisiana,

Cigna Health and Life Insurance (CHLIC), Cigna Health Management, Inc. Management, Health Cigna (CHLIC), Insurance Life and Health Cigna Cigna Health and Life Insurance (CHLIC), Cigna Health Management, Inc. Management, Health Cigna (CHLIC), Insurance Life and Health Cigna

Dental Health, Inc., and certain of its operating subsidiaries. In Arizona and Arizona In subsidiaries. operating its of certain and Inc., Health, Dental

subsidiaries include Connecticut General Life Insurance Company (CGLIC) Company Insurance Life General Connecticut include subsidiaries subsidiaries include Connecticut General Life Insurance Company (CGLIC) Company 09/08/20 Insurance Life General Connecticut include subsidiaries 09/07/20

by CGLIC or CHLIC with network management services provided by Cigna by provided services management network with CHLIC or CGLIC by

by CGLIC or CHLIC with network management services provided by Cigna by provided Issue Date: services management network with CHLIC or CGLIC by Issue Date:

such operating subsidiaries and not by Cigna Corporation. Such operating Such Corporation. Cigna by not and subsidiaries operating such such operating subsidiaries and not by Cigna Corporation. Such operating Such Corporation. Cigna by not and subsidiaries operating such

and its operating subsidiaries. All products and services are provided by or through or by provided are services and products All subsidiaries. operating its and

*117* through or by provided are services and products All subsidiaries. operating its and *116* Cigna Health and Life Insurance (CHLIC), Cigna Health Management, Inc. Management, Health Cigna (CHLIC), Insurance Life and Health Cigna

Cigna Health and Life Insurance (CHLIC), Cigna Health Management, Inc. Management, Health Cigna (CHLIC), Insurance Life and Health Cigna

Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation Cigna by use for licensed Inc., Property, Intellectual Cigna Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation Cigna by use for licensed Inc., Property, Intellectual Cigna 13 13

subsidiaries include Connecticut General Life Insurance Company (CGLIC) Company Insurance Life General Connecticut include subsidiaries

subsidiaries include Connecticut General Life Insurance Company (CGLIC) Company Insurance Life General Connecticut include subsidiaries 14 14

Issue Date: 'Cigna' and the 'Tree of Life' logo are registered service marks of marks service registered are logo Life' of 'Tree the and 'Cigna' 'Cigna' and the 'Tree of Life' logo are registered service marks of marks service registered are logo Life' of 'Tree the and 'Cigna' Issue Date:

No No

and its operating subsidiaries. All products and services are provided by or through or by provided are services and products All subsidiaries. operating its and and its operating subsidiaries. All products and services are provided by or through 62308 or by provided are services and products All subsidiaries. operating its and 62308

*117*

*116*

AMOUNTS UP TO THE PROVIDER'S REGULAR BILLED CHARGES. BILLED REGULAR PROVIDER'S THE TO UP AMOUNTS AMOUNTS UP TO THE PROVIDER'S REGULAR BILLED CHARGES. BILLED REGULAR PROVIDER'S THE TO UP AMOUNTS

Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation Cigna by use for licensed Inc., Property, Intellectual Cigna

CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR YOU BILL TO PROVIDER YOUR ALLOW MAY AGREEMENT THIS CIRCUMSTANCES, CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR YOU BILL TO PROVIDER YOUR ALLOW MAY AGREEMENT THIS CIRCUMSTANCES,

'Cigna' and the 'Tree of Life' logo are registered service marks of marks service registered are logo Life' of 'Tree the and 'Cigna' 'Cigna' and the 'Tree of Life' logo are registered service marks of marks service registered are logo Life' of 'Tree the and 'Cigna'

THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. UNDER CERTAIN UNDER PROVIDER. YOUR AND PLAN HEALTH YOUR BETWEEN AGREEMENT THE THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. UNDER CERTAIN UNDER PROVIDER. YOUR AND PLAN HEALTH YOUR BETWEEN AGREEMENT THE

NOTICE: YOUR SHARE OF THE PAYMENT FOR HEATHCARE SERVICE MAY BE BASED ON BASED BE MAY SERVICE HEATHCARE FOR PAYMENT THE OF SHARE YOUR NOTICE:

62308 ON BASED BE MAY SERVICE HEATHCARE FOR PAYMENT THE OF SHARE YOUR NOTICE:

62308

THE FOLLOWING NOTICE APPLIES TO CUSTOMERS COVERED UNDER LOUISIANA PLANS LOUISIANA UNDER COVERED CUSTOMERS TO APPLIES NOTICE FOLLOWING THE THE FOLLOWING NOTICE APPLIES TO CUSTOMERS COVERED UNDER LOUISIANA PLANS LOUISIANA UNDER COVERED CUSTOMERS TO APPLIES NOTICE FOLLOWING THE AMOUNTS UP TO THE PROVIDER'S REGULAR BILLED CHARGES. BILLED REGULAR PROVIDER'S THE TO UP AMOUNTS AMOUNTS UP TO THE PROVIDER'S REGULAR BILLED CHARGES. BILLED REGULAR PROVIDER'S THE TO UP AMOUNTS

CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR YOU BILL TO PROVIDER YOUR ALLOW MAY AGREEMENT THIS CIRCUMSTANCES,

Rx- Pharmacy Rx-

THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. UNDER CERTAIN UNDER PROVIDER. YOUR AND PLAN HEALTH YOUR BETWEEN AGREEMENT THE Questions please call: 1-877-484-5967 CERTAIN UNDER PROVIDER. YOUR AND PLAN HEALTH YOUR BETWEEN AGREEMENT THE Questions please call: 1-877-900-1237

Mask 606 call: 1-866-494-2111 Mask 606

Out-of-network benefits Out-of-network Out-of-network benefits Out-of-network NOTICE: YOUR SHARE OF THE PAYMENT FOR HEATHCARE SERVICE MAY BE BASED ON BASED BE MAY SERVICE HEATHCARE FOR PAYMENT THE OF SHARE YOUR NOTICE: NOTICE: YOUR SHARE OF THE PAYMENT FOR HEATHCARE SERVICE MAY BE BASED ON BASED BE MAY SERVICE HEATHCARE FOR PAYMENT THE OF SHARE YOUR NOTICE: Hospital or Hospital Stay - Inpatient hospital Inpatient - Stay Hospital or Hospital

Hospital or Hospital Stay - Inpatient hospital Inpatient - Stay Hospital or Hospital

call: 1-866-494-2111 THE FOLLOWING NOTICE APPLIES TO CUSTOMERS COVERED UNDER LOUISIANA PLANS LOUISIANA UNDER COVERED CUSTOMERS TO APPLIES NOTICE FOLLOWING THE THE FOLLOWING NOTICE APPLIES TO CUSTOMERS COVERED UNDER LOUISIANA PLANS LOUISIANA UNDER COVERED CUSTOMERS TO APPLIES NOTICE FOLLOWING THE

ER - Emergency Room Emergency - ER ER - Emergency Room Emergency - ER

Rx- Pharmacy Rx-

Questions please call: 1-877-484-5967 Pharmacy Rx- Questions please call: 1-877-900-1237 Urgent Care - After hours/urgent care hours/urgent After - Care Urgent

Mask 606 care hours/urgent After - Care Urgent call: 1-866-494-2111 Mask 606

Hospital or Hospital Stay - Inpatient hospital Inpatient - Stay Hospital or Hospital

PCP - Primary Care Physician Care Primary - PCP

call: 1-866-494-2111 Physician Care Primary - PCP

ER - Emergency Room Emergency - ER ER - Emergency Room Emergency - ER

Copay - Subject to the copayment amount copayment the to Subject - Copay Copay - Subject to the copayment amount copayment the to Subject - Copay

Urgent Care - After hours/urgent care hours/urgent After - Care Urgent Urgent Care - After hours/urgent care hours/urgent After - Care Urgent

Coin - Subject to the plan coinsurance amount coinsurance plan the to Subject - Coin Coin - Subject to the plan coinsurance amount coinsurance plan the to Subject - Coin

PCP - Primary Care Physician Care Primary - PCP PCP - Primary Care Physician Care Primary - PCP

PO Box 188061 Chattanooga, TN 37422-8061 Payer ID # PO Box 188061 Chattanooga, TN 37422-8061 Payer Ded - Subject to the plan deductible amount deductible plan the to Subject - Ded PO Box 188061 Chattanooga, TN 37422-8061 Payer ID # Ded - Subject to the plan deductible amount deductible plan the to Subject - Ded

Copay - Subject to the copayment amount copayment the to Subject - Copay Pharmacy Service Center, PO Box 188053, Chattanooga TN 37422-8053 Pharmacy Service Center, PO Box 188053, Chattanooga amount copayment the to Subject - Copay Pharmacy Service Center, PO Box 188053, Chattanooga TN 37422-8053

Ded/Coin - Subject to the plan deductible and/or coinsurance and/or deductible plan the to Subject - Ded/Coin

Ded/Coin - Subject to the plan deductible and/or coinsurance and/or deductible plan the to Subject - Ded/Coin 20200908

20200907 N Coin - Subject to the plan coinsurance amount coinsurance plan the to Subject - Coin N

Coin - Subject to the plan coinsurance amount coinsurance plan the to Subject - Coin Tue Sep 08, 2020 @ 11:30:45 Mon Sep 07, 2020 @ 12:45:50

What does it mean? it does What

PO Box 188061 Chattanooga, TN 37422-8061 Payer ID # PO Box 188061 Chattanooga, TN 37422-8061 Payer mean? it does What Ded - Subject to the plan deductible amount deductible plan the to Subject - Ded PO Box 188061 Chattanooga, TN 37422-8061 Payer ID # Ded - Subject to the plan deductible amount deductible plan the to Subject - Ded

Pharmacy Service Center, PO Box 188053, Chattanooga TN 37422-8053 Pharmacy Service Center, PO Box 188053, Chattanooga Pharmacy Service Center, PO Box 188053, Chattanooga TN 37422-8053

606 606 Ded/Coin - Subject to the plan deductible and/or coinsurance and/or deductible plan the to Subject - Ded/Coin Medical Claims Rx Claims For Premium, Billing and Enrollment For Beneﬁt and Claim questions please coinsurance For Pharmacists Only: 800-351-9170 and/or deductible plan the to Subject - Ded/Coin Medical Claims Rx Claims For Premium, Billing and Enrollment For Beneﬁt and Claim questions please For Pharmacists Only: 800-351-9170

20200908 20200907

N N

Tue Sep 08, 2020 @ 11:30:45 Mon Sep 07, 2020 @ 12:45:50 What does it mean? it does What What does it mean? it does What No No 606 606 Medical Claims Rx Claims For Premium, Billing and Enrollment For Beneﬁt and Claim questions please For Pharmacists Only: 800-351-9170 Medical Claims Rx Claims For Premium, Billing and Enrollment For Beneﬁt and Claim questions please For Pharmacists Only: 800-351-9170 Home Care from Away 1 00500-0005-L Care Home from Away 1 00500-0005-L G G 1 00500-0005-L 1 00500-0005-L Network: Connect Network: G G Cigna Plus Network: 4 4 3 3 PLANS FAMILY & INDIVIDUAL (Market Name) For more information, see the next page. see the next information, more For Name) Connect (Market $25-0% $60-0% $50-0% Ded-$600-0% Ded-20% Ded-50% Ded-50% Ded-50% Ded-50% Ded-50% $25-0% $60-0% $50-0% Ded-$600-0% Ded-20% Ded-50% Ded-50% Ded-50% Ded-50% Ded-50% Lorem ipsum Lorem Primary Care Specialist Urgent Care ER Hospital Primary Care Specialist Urgent Care ER Hospital required Referral • Present this ID card each time you visit a health care professional. • Present this ID card each time you visit a required Referral health care professional. • If you have questions or to elect or change your PCP, please visit • If you have questions or to elect or change your PCP, please visit our website or call the toll-free customer service number located our website or call the toll-free customer service number located Lorem ipsum Lorem Primary Care Specialist Urgent Care ER Hospital on your ID card. Primary Care Specialist Urgent Care ER Hospital • Present this ID card each time you visit a health care professional. • Presenton your thisID card. ID card each time you visit a health care professional. • If you have questions or to elect or change your PCP, please visit 8 • 8 If you have questions or to elect or change your PCP, please visit our website or call the toll-free customer service number located our website or call the toll-free customer service number located DIRECT on your ID card. on your ID card. DIRECT RxPCN 0518GWH RxID 456789123 00 RxPCN 0518GWH >000001 9091187 003040 >000002 9090436 003040 RxID 234567891 00 DIRECT 00000000 00000000 DIRECT 1 1 USPS USPS RxPCN 0518GWH RxID 456789123 00 RxPCN 0518GWH >000001 9091187 003040 >000002 9090436 003040 RxID 234567891 00 No* No* No* No* 00000000 00000000 JOHN E DOE JOHN M DOE USPS USPS 456789123 234567891 PCP required PCP required Name: RxBIN 017010 RxGrp 00881200 Group: 00881200 Issuer (80840) ID: No Referral Required Florida Connect Cigna Health and Life Insurance Company Cigna Health and Life Medical/Rx Group: 00881700 Issuer (80840) ID: Name: PCP: Jessica A. Doright DO RxBIN 017010 RxGrp 00881700 Referral Required Cigna Plus Cigna HealthCare of Illinois, Inc. Medical/Rx JOHN DOE 9999 SPINDLETOP DR ORLANDO, FL 32819 JOHN DOE 9999 W FARWELL AVE APT 999 CHICAGO, IL 60626 JOHN E DOE JOHN M DOE 456789123

234567891 *PCP selection and referrals are required only in Illinois. only in required are *PCP selection and referrals *PCP selection and referrals are required only in Illinois. required are *PCP selection and referrals Name: RxBIN 017010 RxGrp 00881200 Group: 00881200 Issuer (80840) ID: No Referral Required Florida Connect Cigna Health and Life Insurance Company Cigna Health and Life Medical/Rx Group: 00881700 Issuer (80840) ID: Name: PCP: Jessica A. Doright DO RxBIN 017010 RxGrp 00881700 Referral Required Cigna Plus Cigna HealthCare of Illinois, Inc. Medical/Rx JOHN DOE 9999 SPINDLETOP DR ORLANDO, FL 32819 JOHN DOE 9999 W FARWELL AVE APT 999 CHICAGO, IL 60626

NAME DOE ,JOHN RUN_DATE 20200908 11:30:45DATA_SEQ_NO 0000001CLIENT_NUMBER 003040UHG_TYPE DIG1CARDDOC_ID 9091187/000001-00DOC_ID 9091187/000001-01DOC_ID 9091187/000001-02DOC_SEQ_ID 0000001NAME DOE MAILSET_NUMBER 0000001CUST_KEY1 00881200CUST_KEY2 456789123CUST_KEY3 00CUST_KEY4 JOHNCUST_KEY5 ECUST_KEY6 DOECUST_KEY7 456789123CUST_KEY8 11/01/2020CUST_KEY9 M RUN_DATE 20200907 12:45:50 0000002 003040 0000002 ,JOHN 00000020088170023456789100JOHNMDOE23456789109/02/2020M RUN_DATE 20200907DATA_SEQ_NO CLIENT_NUMBER UHG_TYPE DIG1CARDDOC_ID 9090436/000002-00 DOC_ID 9090436/000002-01 DOC_ID 9090436/000002-02 DOC_SEQ_ID NAME DOE MAILSET_NUMBER CUST_KEY1 CUST_KEY2 CUST_KEY3 CUST_KEY4 CUST_KEY5 CUST_KEY6 CUST_KEY7 CUST_KEY8 CUST_KEY9 03040 9091187 0000 0000001 0000001 252 117 0000002 251 116 03040 9090436 0000 0000002 10 Key Individual & Family Plans Refer to this key for explanations of the information found on the sample Cigna ID cards Cigna offers Individual & Family Plans with medical, pharmacy, featured in this brochure. and (when applicable) pediatric dental benefits in Arizona, Colorado, Florida, Illinois, Kansas, Missouri, North Carolina, 1 Use this ID number for all claims and inquiries. Tennessee, Utah, and Virginia. Depending on the plan, 2 Indicates a seamless network where a patient customers will have access to providers who participate in our can receive in-network care on a regional or Connect network. The network name will appear on the top statewide basis. right of the ID card. 3 For patients with coinsurance, submit claims Network: Connect to Cigna or its designee, and receive an Plans that use this network offer customers access to providers in explanation of payment (EOP), which will show their local area. any remaining amount due from the patient. 4 › Customers do not have to select a PCP but are encouraged to Collect any copayment at the time of service. coordinate their care with a network-participating PCP. 5 May read as: “Cigna Health and Life Insurance › Referrals are encouraged but not required to see specialists. Company” or “Connecticut General Life › No out-of-network coverage or Away From Home Care, except Insurance Co.” or “Cigna HealthCare of in emergencies.** XXXX, Inc.” For a directory of providers who participate in this network, 6 ID cards with the Cigna Care Network® logo visit Cigna.com/IFP-Providers. indicate the patient’s liability varies based on the provider’s Cigna Care designation Network: Cigna Plus status. Refer to the online provider directory Plans that use this network offer customers access to providers in at Cigna.com > Find a Doctor to determine a their local area. physician’s Cigna Care designation status. › Customers must select a network-participating PCP 7 Effective date of coverage. to coordinate their care.* 8 Name of patient‘s primary care provider (PCP). › Referrals are required to see specialists.* 9 Network Savings Program (NSP) logo indicates › No out-of-network coverage or Away From Home Care, except that out-of-network discounts may be available in emergencies.** to the customer. For a directory of providers who participate in this network, 10 Employer name. visit Cigna.com/IFP-Providers. These listings will be available and 11 labeled as “Cigna Plus” within the network selection options. If a third party administers services in conjunction with Cigna, the ID card may include multiple logos, and show a different claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. * PCP selection and referrals are required in Illinois. ** Emergency services as defined in their plan. 18 Client-specific network (CSN) logo. 11 MEDICARE PLANS

Network: Prescription Drugs

an Namean Name car oe car not oearantee not arantee coerae coerae or ament or ament an ean e [Services may[Services require may [a referralrequire or][a referral[an] authorization or] [an] authorization by the Health by thePlan.] Health Plan.] Medicare limitingMedicare charges limiting apply. charges apply.7 Name Name Full Name> CtomerCtomer erce erce<--Toll Free<--Toll Number Free Number ---> (TTY ---> 711) (TTY 711) ID> 5 roerroer erce erce]] eat aneat(80840) an 1 3(80840) toratoneerratoratoneerra]] ecteecte ate]2 Date>] roerroer Meca Cam Meca

] Cam

] 6 N N armacarmac e ek e ek]] No C ereNo C ere CN CN armacarmac Cam Cam

]

] No eerraNo ereeerra ereC C4 enta erceenta erce ]] C C<$xx> <$xx> ecatecat<$xx> <$xx> roerroer enta Cam enta Cam

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] merencmerenc<$xx> <$xx> rent carerent<$xx> care <$xx>

INT_21_89795_CINT_21_89795_C

This card isThis used card for isall used True for Choice all True plans. Choice plans. Network: Medicare Advantage

an Namean Name car oe car not oearantee not arantee coerae coerae or ament or ament an ean e [/segment]> Name Name Full Name> [Services may[Services require may [a referralrequire or][a referral[an] authorization or] [an] authorization by the Health by thePlan.] Health Plan.] [Medicare limiting[Medicare charges limiting apply.] charges apply.] ID> 7 eat aneat(80840) an 1 3 (80840) CtomerCtomer erce erce<--Toll Free<--Toll Number Free Number ---> (TTY ---> 711)] (TTY 711)] ecteecte ate ] Date>] roerroer erce erce]] C C toratontoraton[eerra[]eerra ]] 3 art rart r 6 C oneC one roerroer Meca Cam Meca

] Cam

] N N]] C NetorkC Netork enta erceenta erce]] CN CN]] roerroer enta Cam enta

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INT_21_89709_CINT_21_89709_C This card is Thisused card for non-TrueChoice is used for non-TrueChoice MA Only plans. MA Only plans. Network: PPO

an Namean Name car oe car not oearantee not arantee coerae coerae or ament or ament an ean e [/segment]> [Services may[Services require may [a referralrequire or][a referral[an] authorization or] [an] authorization by the Health by thePlan.] Health Plan.] Name Name Full Name> [Medicare limiting[Medicare charges limiting apply.] charges apply.] ID> 7 3 <--Toll Free<--Toll Number Free Number ---> (TTY ---> 711)] (TTY 711)] eat aneat(80840) an 1 (80840) 5 CtomerCtomer erce erce [ecte[ ecteate ] Date>] [ [ ] ] roerroer erce erce]] toratontoraton[eerra[]eerra ]] C C 3 6 C oneC one roerroer Meca Cam Meca

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] N N C NetorkC Netork armacarmac e ek e ek]] CN CN armacarmac Cam Cam

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INT_21_89712_CINT_21_89712_C This card is Thisused card for all is plansused forecet all plans True ecet Choice, True EGW Choice,P, Leon EGW PCPandP Arizona, Leon required and plans. Arizona plans. Referral required Prescription Drug Plan MAPD Yes Yes* Part D

MA Yes Yes* Part B

PPO No No

*Referral requirements are indicated on the customer’s Cigna ID Card. *Select service areas do not require the use of referrals.

For more information, see the next page.

12 947178947178

947177947177

947176947176 Key Medicare Plans Refer to this key for explanations of the information found on the sample Cigna ID cards Cigna contracts with the Centers for Medicare & Medicaid featured in this brochure. Services (CMS) to offer Medicare Advantage (MA) plans. Customers are able to select one of several plans offered 1 Use this ID number for all claims and inquiries. based on their location, budget and health care needs. 2 Effective date of coverage. For more information and to access the directory of 3 Name of patient‘s primary care provider (PCP). participating providers, visit Medicareproviders.cigna.com. 4 Collect any copayment at the time of service. 5 Prescription Drug Coverage. 6 Submit claims to the claim submission address shown on the card. 7 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number.

13 MEDICAID PLANS

Medicaid Eligible Only

1 In case of emergency,In case of emergency, call 911 or gocall to 911 the or closest go to theemergency closest emergency room. After room. 7 After treatment, calltreatment, your PCP call withinyour PCP 24 hours within or 24 as hours soon oras as possible. soon as possible. is a Plan)> is a managed caremanaged plan thatcare contracts plan that withcontracts both with both [ [ ] ] En caso deEn emergencia, caso de emergencia, llame al 911 llame o vaya al 911 a la o sala vaya de a emergencia la sala de emergencia mas cercana. mas cercana. Después deDespués recibir cuidado, de recibir llame cuidado, a su llamePCP dentro a su PCP de 24 dentro horas de o 24lo anteshoras posible.o lo antes posible. Medicare andMedicare Texas andMedicaid. Texas Medicaid. Memer NameMemer Name 3 N N Memer erceercoMemer erceerco a Memro a <1-877-653-0327>Memro <1-877-653-0327>8 Memer Memer CN CN eaoraeaora eata eata e Comortamento e Comortamento <1-877-725-2539> <1-877-725-2539>10 Meca Meca Medicaid ID> 2 erce CoornatonCoornerce CoornatonCoornaor e ercoaor e erco<1-877-725-2688> <1-877-725-2688>9 C NameC Name rovider Name> earn maearnireerona maireerona con roema con roema e a cn e a cn<7-1-1> <7-1-1> C ecteC ateecte Effective Date> 6 or ror toratoneor ror toratone toracon toracon rea <1-877-653-0331> rea <1-877-653-0331>11 C oneC one Phone #> etetoeteto e e MMMM CNN CNN C C armacarmac e ek e <1-800-922-1557> ek <1-800-922-1557> Cost sharing/Copays:Cost sharing/Copays: $0 for and pharmacy> en Camen to ] Paso, TX 79998-1709>]12 Cam nrCam <1-877-653-0331> nr <1-877-653-0331>

Medicare and Medicaid Dual Eligible Member

Memer Memererceeartamento erceeartamento e erco e erco 4 <1-877-653-0327>] <1-877-653-0327>] 1 a o Memroa o Memro [earn mareerona[earn mareerona con roema con roema ato ato <7-1-1>] <7-1-1>]5 erce CoornatonCoornacnerce CoornatonCoornacn e erco e erco6 <1-877-725-2688>] <1-877-725-2688>] ermorermor 80840 80840 [eaora[eaora eat an eat tance an tance eerco eerco 7 <1-877-725-2539>] <1-877-725-2539>] Memer MemerN e entcacnN e entcacn e memro e memro e a ementa a aomenta e ao tanca e tanca NameNomreNameNomre 3 Available 24Available hours a24 day, hours 7 days a day, a week 7 days a week C NameNomreC NameNomre e C e C DisponibleDisponible las 24 horas las del24 horasdía, los del 7 díasdía, losde 7la díassemana de la semana C oneeeonoC oneeeono e C e C Phone Number> C ecteC ecte ateeca ateeca e enca e encae C e C or roror tor roriatonara toriatonara atoracon atoracon rea 8 rea<1-877-562-4402>]<1-877-562-4402>] n cae on emerenc cae o emerenc ca orca go to the or goclosest to the emergency closest emergency room. room. Cna Cna Cam Cam re recrt crt After treatment,After treatment, call your PCPcall your within PCP 24 withinhours 24or ashours soon or asas possible.soon as possible. - STAR+PLUS> N N]] n cao ne emerencacao e emerenca ame a ame o vayaa a ola vayasala dea la emergencias sala de emergencias 79998 -1709> CN CN]] más cercana.más cercana.Después Despuésde recibir de tratamiento, recibir tratamiento, llame al PCP llame dentro al PCP de dentro de 9 roro]] las 24 horaslas 24o tan horas pronto o tan como pronto sea como posible. sea posible.

For more information, see the next page.

14 947183947183

947185947185 Key Medicaid Plans Refer to this key for explanations of the information found on the sample Cigna ID cards Cigna works with the state of Texas to help people and featured in this brochure. families get health coverage in the Texas STAR+PLUS Program. STAR+PLUS is a Texas Medicaid managed care program that Medicaid Eligible Only provides health care, acute care and long term services and 1 Cigna and STAR+Plus logos. supports. Through STAR+PLUS, Cigna provides members with many quality health care services. We work closely with our 2 Member’s Medicaid Member ID#, issued network of health care providers to ensure our members get by HHSC. personalized care and benefits that meet their health needs. 3 Member’s name.

For more information and to access the directory of participating 4 Name of member’s primary care provider providers, visit Starplus.cigna.com. (PCP). 5 Phone number of member’s primary care provider (PCP). 6 Date member is assigned to their PCP. 7 Member Services phone number, available Monday to Friday, 8 a.m. to 5 p.m. Central Time. 8 TTY number for Hearing Impaired Members. For additional Hearing Impaired services, please contact TTY/Texas Relay at 1-800-735-2989 (English) or 1-800-662-4954 (Spanish). 9 Service Coordination Department phone number.

10 Behavioral Health Crisis Hotline number. 11 Prior Authorization phone number. 12 Submit claims to the claim submission address shown on the card.

Medicare and Medicaid Dual Eligible

1 Cigna and STAR+Plus logos. 2 Member’s Medicaid Member ID#, issued by HHSC. 3 Member’s name. 4 Member Services phone number, available Monday to Friday, 8 a.m. to 5 p.m. Central Time. 5 TTY number for Hearing Impaired Members. For additional Hearing Imapired services, please contact TTY/Texas Relay at 1-800-735-2989 (English) or 1-800-662-4954 (Spanish). 6 Service Coordination Department phone number.

7 Behavioral Health Crisis Hotline number. 8 Prior Authorization phone number. 9 Submit claims to the claim submission address shown on the card.

15 Medical Benefits Abroad

Policy No: CIGNA GLOBAL HEALTH BENEFITS® PLANS Employer: Networks in the U.S.: PPO or OAP To verify benefits, please see the contact information on the back of this card. Cigna Global Health Benefits plans that use these networks offer medical coverage to individuals, for unexpectedwww.CignaEnv oillnessy.com and injuries that occur while traveling in the U.S. on international business outside of their home or permanent assignment country.

Preferred care network in the U.S.: Cigna HealthCare PPO

All benefits are subject to verification of eligibility, definitions, exclusions, and contract limitation. Card possession does not certify eligibility Medical Benefits Abroad for benefits. For U.S.-inpatient services pre-authorization required. Memer an roer Policy No: 6238 8.243.6998 1.32.9.31 8.243.1348 1.32.9.33 .. Employer: 32.9.33 .. 1111 198111 3 1989318 To verify benefits, please see the contact information on the back of this card. www.CignaEnvoy.com www.CignaEnvoy.com

AWAY FROM HOME CARE

Preferred care network in the U.S.: Cigna HealthCareNetworks PPO outside the U.S.: Vary by location

All benefits are subject to verification of eligibility, definitions, exclusions, Cignaand contract Global limitation. Health Card possession Benefits does not certifyplans eligibility that use these networks offer medical coverage outside the U.S. for globally mobile customers,for benefits. For includingU.S.-inpatient services U.S. pre-authorization expatriates required. and inpatriates to the U.S., and their dependents. Members and Providers US Provider: Payor ID# Cigna – 62308 Fax Claims: 1.800.243.6998 (toll-free) or 001.302.797.3150 (direct fax) Contact: 1.800.243.1348 (toll-free) or 001.302.797.3535 (outside the U.S.) 302.797.3535 (inside the U.S.) Mail Claims: Cigna PO Box 15111, Wilmington, DE 19850-5111 12 Courier: Cigna 300 Bellevue1 Parkway, Wilmington DE 19809-3718 Website: www.CignaEnvoy.com

AWAY FROM HOME CARE Network Savings Program 10

14 13

9 15

PCP required Referral required Away from Home Care Out-of-network benefits Encouraged No Yes Yes For more information, see the next page.

112094 11/15

16 112094 11/15 Key Cigna Global Health Benefits® plans Refer to this key for explanations of the information found on the sample Cigna ID cards We offer Cigna Global Health Benefits plans for globally featured in this brochure. mobile employees, including U.S. expatriates and inpatriates to the U.S. There are multiple coverage options encompassing 1 Use this ID number for all claims and inquiries. medical, business travel medical, dental, life, accidental death 2 Indicates a seamless network where a patient and dismemberment, and a range of ancillary coverage. The can receive in-network care on a regional or network name will appear on the ID card. statewide basis. For more information and to access the directory of participating 3 For patients with coinsurance, submit claims providers, visit CignaEnvoy.com. to Cigna or its designee, and receive an explanation of payment (EOP), which will show any remaining amount due from the patient. 4 Collect any copayment at the time of service. 5 May read as: “Cigna Health and Life Insurance Company” or “Connecticut General Life Insurance Co.” or “Cigna HealthCare of XXXX, Inc.” 6 ID cards with the Cigna Care Network® logo indicate the patient’s liability varies based on the provider’s Cigna Care designation status. Refer to the online provider directory at Cigna.com > Find a Doctor to determine a physician’s Cigna Care designation status. 7 Effective date of coverage. 8 Name of patient‘s primary care provider (PCP). 9 Network Savings Program (NSP) logo indicates that out-of-network discounts may be available to the customer.

10 Employer name. 11 If a third party administers services in conjunction with Cigna, the ID card may include multiple logos, and show a different claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. 18 Client-specific network (CSN) logo. 17 CIGNA CHOICE FUND® PLANS

Networks: Vary by plan

WWW.CIGNA.COM CAD logo 18 TPV logo 11 Client You may be asked to present this card when you receive care. The card does not guarantee coverage. Tiered Benefits 6 logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. 12 INPATIENT ADMISSION: Legal entity name 5 Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your Coverage eﬀective date: MM/DD/CCYY 7 C OA pre-certication requirements. Failure to do so may aect benets. In an emergency, seek care immediately, then call your primary Group: 1234567 N care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Issuer (80840) C 3 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds. ID: U23456789 01 1 For Pharmacy, call ABC Company 800.XXX.XXXX (Not a Cigna Company) Name: John Public For Vision, call ABC Company 800.XXX.XXXX (Not a Cigna Company) PCP: John Smith Send claims to: PCP Name Ln2 8 N C 13 I CAD Name, PO Box XXXX, Anytown, USA 12345-6789 PCP Phone: XXX.XXX.XXXX TPV Name, PO Box XXXX, Anytown, USA 12345-6789 9 O ID card acct name 10 M All Others: PO Box XXXX, Anytown, USA 12345-6789 15 RxBIN XXXXXX RxPCN XXXXXXXX Customer Service: 800.XXX.XXXX 14 MH/SA: 800.XXX.XXXX DOI Cat# We encourage you to use a PCP as a valuable resource and personal health advocate. AWAY FROM HOME CARE

For more information, see the next page.

PCP required Referral required Away from Home Care Out-of-network benefits PPO No No Yes Yes EPO Encouraged No Yes No OAP Encouraged No Yes Yes LocalPlus Encouraged No Yes Yes

Indemnity No No N/A Yes

SHARED ADMINISTRATION REPRICING PLANS

Network: Shared Administration Open Access Plus, Shared Administration PPO, or LocalPlus

You may be asked to present this card when you receive care. The card does not guarantee coverage. 11 TPV logo Client You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. 5 logo 12 INPATIENT ADMISSION Legal entity name Your provider must call the toll-free number below to precertify your medical benets or benets may be aected. Coverage effective date: MM/DD/CCYY 7 Refer to your plan documents for your plan's precertication requirements. In an emergency, seek care immediately, Group: 1234567 Open Access Plus then notify Cigna within ## hours. Issuer (80840) No referral required Mail all non-medical claims and correspondence to: ID Card Account Name ID: U23456789 01 1 C 4 SAR Fund Address Submit/Mail claims to: Cigna Payor 62308, P.O. Box 188004, Chattanooga, TN 37422-8004 Name: John Public 13 All other: S 16 TPV Name PO Box XXXXX, Anytown, USA 12345-6789 PCP: James Smith Network coinsurance: PCP name Ln2 I Pre-certification: 1-XXX-XXX-XXXX Pharmacy Questions: 1-XXX-XXX-XXXX 14 3 Eligibility, Benefit and Claim Questions: 1-XXX-XXX-XXXX PCP phone: 860-555-1212 O Fund Name To access the online provider directory go to www.cignasharedadministration.com Deductible applies To access member pharmacy tools go to www.cigna.com Fund #: Fund number We encourage you to use a PCP as a valuable resource and personal health advocate. RxBIN XXXXXX RxPCN XXXXXXXX AWAY FROM HOME CARE DOI Cat# 15 17

PCP required Referral required Away from Home Care Out-of-network benefits Encouraged No Yes Yes For more information, see the next page.

18 Key Cigna Choice Fund® plans Refer to this key for explanations of the information found on the sample Cigna ID cards These plans combine an employer-funded health reimbursement featured in this brochure. account (HRA) or employer/employee-funded tax-advantaged health savings account (HSA) with PPO, EPO, Open Access 1 Use this ID number for all claims and inquiries. Plus, LocalPlus, or indemnity plans. Customers will have 2 Indicates a seamless network where a patient access to providers who participate in the network aligned can receive in-network care on a regional or to their plan. statewide basis. Networks: Vary by plan 3 For patients with coinsurance, submit claims Plans that use these networks offer customers access to a suite of to Cigna or its designee, and receive an providers, and allow them to be in charge of how and when they explanation of payment (EOP), which will show spend their health fund dollars. any remaining amount due from the patient. 4 › Referrals are not required to see specialists. Collect any copayment at the time of service. 5 › Typically, no copayments are required. May read as: “Cigna Health and Life Insurance Company” or “Connecticut General Life › Providers should bill Cigna directly. Insurance Co.” or “Cigna HealthCare of › Precertification may still be required for certain services and XXXX, Inc.” procedures. 6 ID cards with the Tiered Benefits® logo indicate For a directory of providers who participate in these networks, the patient’s liability varies based on the visit Cigna.com > Find a Doctor. provider’s Cigna Care designation status. Refer to the online provider directory at Shared Administration Repricing plans Cigna.com > Find a Doctor to determine a physician’s Cigna Care designation status. Shared Administration Repricing plans are offered by the Cigna Taft-Hartley and Federal Business Segment. They 7 Effective date of coverage. are designed for Taft-Hartley and federal plan employers that 8 Name of patient‘s primary care provider (PCP). want to continue processing and paying their own claims, and 9 Network Savings Program (NSP) logo indicates retain customer and provider services, or use a third-party that out-of-network discounts may be available administrator to perform these functions. to the customer.

Networks: Shared Administration Open Access Plus, 10 Employer name. Shared Administration PPO, or LocalPlus 11 If a third party administers services in Plans that use these networks offer customers access to a national conjunction with Cigna, the ID card may network of providers. include multiple logos, and show a different › Referrals are not required to see specialists. claim address or telephone number on the back of the card. › Both in- and out-of-network benefits are available. Customers can access providers that participate in a national network, 12 Precertification requirements may be shown which includes Away From Home Care. as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ For a directory of providers who participate in these networks, visit CignaSharedAdministration.com. 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. 18 Client Arranged Deal (CAD) network logo. 19 STRATEGIC ALLIANCE PLANS

Networks: Vary by plan The sample below shows an ID card for a customer with a Cigna-administered plan. If it displays a Strategic Alliance logo,* the customer may use that Strategic Alliance’s network when outside the service area for Cigna network-participating providers.

WWW.CIGNA.COM TPV / Alliance CareLink Client logo You may be asked to present this card when you receive care. The card does not guarantee coverage. 11 logo logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. 12 INPATIENT ADMISSION: Legal entity name 5 Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents Coverage eﬀective date: MM/DD/CCYY O A for your pre-certication requirements. Failure to do so may aect benets. In an emergency, seek care immediately, then call your Group: 1234567 N primary care doctor as soon as possible for further assistance and directions on follow-up care within 48 hours. Issuer (80840) 7 C 4 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds. ID: U23456789 01 1 Name: John Public 13 For pharmacy: Call ABC Company 1.800.XXX.XXXX (Not a Cigna Company) For vision: Call ABC Company 1.800.XXX.XXXX (Not a Cigna Company) PCP: John Smith PCP name Ln2 Send claims to: CSN name, PO Box XXXXX, Anytown, USA 12345-6789 PCP phone: 860.555.1212 All other: PO Box XXXXX, Anytown, USA 12345-6789 ID card acct name 10 N 3 Customer service: 1.800.XXX.XXXX 14 MH/SA: 1.800.XXX.XXXX RxBIN XXXXXX RxPCN XXXXXXXX I DOI 9 Cat# We encourage you to use a PCP as a valuable resource and personal health advocate. 15 AWAY FROM HOME CARE

PCP required Referral required Away from Home Care Out-of-network benefits Encouraged No Yes Yes

Sample ID cards for Cigna's Strategic Alliances These samples show ID cards for people whose health plans are administered by one of our Strategic Alliances with HealthPartners, Tufts Health Plan, MVP Health Care, or Priority Health (effective January 1, 2021). The Cigna logo on the card indicates they may visit a Cigna-participating provider when in the Cigna service area.

*Logos include HealthPartners, Tufts Health Plan, Priority Health (effective January 1, 2021), and MVP.

For more information, see the next page.

20 Key Strategic alliance plans Refer to this key for explanations of the information found on the sample Cigna ID cards Cigna has entered into strategic alliances with several nationally featured in this brochure. recognized health care companies. These plans give our customers access to an alliance’s network of providers and 1 Use this ID number for all claims and inquiries. discounts in specific geographic areas. They also provide the 2 Indicates a seamless network where a patient alliance’s customers with access to Cigna’s national provider can receive in-network care on a regional or network and discounts outside their specific geographic area. statewide basis. Networks: Vary by plan 3 For patients with coinsurance, submit claims to Cigna or its designee, and receive an › Referrals are not required to see specialists. explanation of payment (EOP), which will show › Precertification may still be required for certain services any remaining amount due from the patient. and procedures. 4 Collect any copayment at the time of service. › Claims should be submitted to the payer ID on the customer’s 5 May read as: “Cigna Health and Life Insurance ID card. Company” or “Connecticut General Life Insurance Co.” or “Cigna HealthCare of XXXX, Inc.” 6 ID cards with the Cigna Care Network® logo indicate the patient’s liability varies based on the provider’s Cigna Care designation status. Refer to the online provider directory at Cigna.com > Find a Doctor to determine a physician’s Cigna Care designation status. 7 Effective date of coverage. 8 Name of patient‘s primary care provider (PCP). 9 Network Savings Program (NSP) logo indicates that out-of-network discounts may be available to the customer.

10 Employer name. 11 If a third party administers services in conjunction with Cigna, the ID card may include multiple logos, and show a different claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. 18 Client-specific network (CSN) logo. 21 CIGNA + OSCAR

Networks: LocalPlus and Open Access Plus Sample ID Cards Member ID cards will include details about the network the plan aligns with and will look like the samples below:

Open Access Plus Plans LocalPlus Plans

PCP required Referral required Away from Home Care Out-of-network benefits Encouraged No Yes Yes

22 Cigna + Oscar Cigna has entered into a strategic partnership with Oscar Health to jointly provide commercial health solutions to small businesses. These plans are available in select markets. They provide affordable, seamless, fully insured health benefits under the Cigna + Oscar brand to the small group market. For a directory of providers who participate in this network, visit www.hioscar.com/providers.

Networks: Vary by plan › Referrals are not required to see specialists. › Precertification may still be required for certain services and procedures. › Claims should be submitted to the payer ID on the customer’s ID card.

23 INDEMNITY PLANS

Network: No network requirements

WWW.CIGNA.COM Client You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all logo terms and conditions of the plan. Willful misuse of this card is considered fraud. 5 12 INPATIENT ADMISSION: Legal entity name Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your Coverage eﬀective5 date: MM/DD/CCYY 7 I pre-certication requirements. Failure to do so may aect benets. In an emergency, seek care immediately, then call your primary Group: 1234567 care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Issuer (80840) I 3 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds. ID: U23456789 01 1 Note: You can reduce your out-of-pocket expenses if you use a Network Savings Program provider. Use of a Network Savings Name: John Public1 Program provider does not aect your benet coverage. For help nding a participating provider, please visit our website, or call the toll-free number listed on this card. C For Pharmacy, call ABC Company 800.XXX.XXXX (Not a Cigna Company) M 13 ID card acct name 10 9 For Vision, call ABC Company 800.XXX.XXXX (Not a Cigna Company)

RxBIN XXXXXX RxPCNbk XXXXXXXX NSP M Send Claims to: PO Box XXXX, Anytown, USA 12345-6789 logo DOI Customer Service: 800.XXX.XXXX 14 MH/SA: 800.XXX.XXXX Network Savings Program Cat#

PCP required Referral required Away from Home Care Out-of-network benefits No* No N/A Yes For more information, see the next page.

*This ID card will not display the name of a PCP if one is chosen.

24 Key Indemnity plans Refer to this key for explanations of the information found on the sample Cigna ID cards These plans give customers the freedom to choose featured in this brochure. any provider. 1 › No network requirements. Use this ID number for all claims and inquiries. 2 › Referrals are not required to see specialists. Indicates a seamless network where a patient can receive in-network care on a regional or statewide basis. 3 For patients with coinsurance, submit claims to Cigna or its designee, and receive an explanation of payment (EOP), which will show any remaining amount due from the patient. 4 Collect any copayment at the time of service. 5 May read as: “Cigna Health and Life Insurance Company” or “Connecticut General Life Insurance Co.” or “Cigna HealthCare of XXXX, Inc.” 6 ID cards with the Cigna Care Network® logo indicate the patient’s liability varies based on the provider’s Cigna Care designation status. Refer to the online provider directory at Cigna.com > Find a Doctor to determine a physician’s Cigna Care designation status. 7 Effective date of coverage. 8 Name of patient‘s primary care provider (PCP). 9 Network Savings Program (NSP) logo indicates that out-of-network discounts may be available to the customer.

10 Employer name. 11 If a third party administers services in conjunction with Cigna, the ID card may include multiple logos, and show a different claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the customer service number(s) indicated on the card. Some plans have dedicated numbers for accessing information. Always check the card for the correct number or refer to the Important contact information page in this guide. 15 “Away From Home Care” indicates the patient has access to the Cigna national Away From Home Care feature. 16 Indicates shared administration repricing. 17 Union identifier. 18 Tiered Benefits logo. 25 The myCigna® App The myCigna® App gives Cigna customers a simple way to personalize, organize, and access their important health and coveragemyCigna information - ID Cards – on the - Print go. Youror Request patients may present their Cigna ID card claims information andPage 1 of 1 coveragemyCigna -eligibility ID Cards to - Printyou orvia Request the app on their smartphone or tablet. Page 1 of 1

Sample ID card information you might see on your patients’ myCigna App

ID Cards - Print or Request ID Cards - Print or Request

Click the "Print" button below to print your card. Click the "Print" button below to print your card.

Please note:PleaseTemporary note: cardsTemporary are not an cards exact arecopy not of youran exact permanent copy ofID your card permanentand do not contain ID card all and the dosame not information contain all as the same information as your permanentyour ID permanentcard. Your temporary ID card. Yourcard willtemporary expire in card ten days will expireor on your in ten coverage days or end on date, your whichever coverage is end first. date, To reques whichevert is first. To request a permanent IDa permanent card, go to IDID Cards--Print card, go to orID Request Cards--Print. or Request.

Issue Date: 07/21/2015Issue Date: 07/21/2015 You may be asked to Youpresent may this be card asked when to youpresent access this card when you access care. This card doesn't guarantee coverage. You must For coverage info:For coverage info: care. This card doesn't guarantee coverage. You must comply with all items and conditions of the plan. Willful Review your coverageReviewon theyour coverage on the comply with all items and conditions of the plan. Willful misuse of this card is considered fraud. myCigna website or mobile app, misuse of this card is considered fraud. myCigna website or mobileHospital app, Admission: Prior to any non-emergency hospital or or Hospital Admission: Prior to any non-emergency hospital Nov Eleven admission, you or your doctor must call the toll-free Nov Elevencall 1.866.494.2111.866.494.2111. admission, you or your doctor must call the toll-free ID:100654369 call 1.866.494.2111. Customers and Health Care Professionals number shown ID:100654369 below to request "precertification."Customers and In the Health case ofCare an Professionals number shown PREFERRED below to request "precertification." In the case of an PROVIDER PREFERRED emergency, you, your family, or your doctor must call within PROVIDER 48 hours of hospital admission.emergency, Failure you, to your contact family, Cigna or willyour doctor must call within ORGANIZATION 48 hours of hospital admission. Failure to contact Cigna will Group Number:ORGANIZATION affect your coverage. affect your coverage. 00617573 Group Number: In an Emergency: Seek care immediately. Go directly to the Coverage Effective00617573 Date: nearest emergency facilityIn an or Emergency: call 911. Seek care immediately. Go directly to the 01/01/2014 Coverage Effective Date: Health Care Professionals:.nearest Visitemergency www.CignaforHCP.com facility or call 911. or Issuer: 80840 01/01/2014 call 800-882-4462. Health Care Professionals:. Visit www.CignaforHCP.com or Issuer: 80840 Customers and Healthcall 800-882-4462.Send Medical Claims To: Cigna Care Professionals:Customers and Health Send Medical Claims To: ID card features 1.866.494.2111 1000 Great-West Drive (24 hours a day, 365 daysCare Professionals:Kennett, MO 63857 Cigna Quickly view ID card information (front and back)a year) 866.494.21111.866.494.2111 1000 Great-West Drive › (24 hours a day, 365 days Kennett, MO 63857 for family members a year)

› Easily print, email, or scan right from a smartphone Payer ID: #62308 or tablet Payer ID: #62308 Additional app features: PRINT CANCEL The myCigna App includes features that help your patients – and you – have an easier health carePRINT experience. CANCEL

Provider directory Trackers › Locate network-participating doctors and health › View in-network and out-of-network medical care facilities and dental year-to-date deductibles, as well as © 2015 Cigna. All rights reserved. › Access maps for instant driving directions out‑of‑pocket and annual maximums Selecting these links will take you away from myCigna.com. Cigna does not control the linked sites' content or links. Details Health wallet© 2015 Cigna. All rights reserved. Coverage

› Store and organizeSelecting theseall contact links will takeinformation you away from for myCigna.com. Cigna› Seedoes plannot control coverage the linked and sites' benefit content or information links. Details for doctors, hospitals, and pharmacies medical, dental, pharmacy, behavioral health, substance abuse, and disability › Add providers to contact list right from a claim or directory search › Access and view health fund balances › Review plan deductibles, coinsurance, Claims and copayments › View and search recent and past medical, dental, and pharmacy claims › Bookmark and group claims for easy reference 26 http://a-mycigna-0024.cigna.com/web/secure/my/profile/id-cards/!ut/p/a1/hc9ND4IwDAb... 7/21/2015

http://a-mycigna-0024.cigna.com/web/secure/my/profile/id-cards/!ut/p/a1/hc9ND4IwDAb... 7/21/2015 Additional app features (continued) Customers can download the free Drug search myCigna App** › View medication costs based on their plan and see lower-cost alternatives* › Find closest network-participating pharmacy location using GPS › Research medicine and dosages › Speed dial Cigna Home Delivery PharmacySM The Apple logo is a trademark of Apple Inc., registered in the U.S. and other countries. App * Prices are not guaranteed, nor is the display of a price a guarantee of coverage. Store is a registered service mark of Apple Inc. Android and Google Play are trademarks of Medication costs and coverage may vary at the time prescriptions are filled at the Google Inc. Amazon, Kindle, Fire and all related logos are trademarks of Amazon.com, Inc. pharmacy, and pricing at individual pharmacies may vary. Coverage and pricing terms or its affiliates. The downloading and use of the myCigna App is subject to the terms and are subject to change. conditions of the app, and the online store from which it is downloaded. Standard mobile ** The myCigna App is available to Cigna health plan customers. Actual features may vary phone carrier and data usage charges apply. depending on their plan.

More ways to access patient information when you need it Use our electronic tools Learn more › Log in to the Cigna for Health Care Professionals To access our educational resources, log in to website (CignaforHCP.com) CignaforHCP.com > Resources > eCourses. Select › Connect with us through electronic data interchange courses about EDI, eligibility and benefits, estimating (EDI): Visit Cigna.com/EDIVendors to learn more patient out-of-pocket costs, precertification, electronic claim submission, claim status inquiry, enrolling in and › Call our automated phone system: 800.88Cigna managing EFT, online remittance reports, and more. (882.4462)

Conduct administrative transactions electronically Cigna’s convenient eServices tools help you manage the administrative details of health care. › Access patient eligibility and benefits › Estimate patient out-of-pocket costs › View and submit precertification requests › Check claim status › Enroll online for electronic funds transfer (EFT), then view, print, and share online remittance reports the same day you receive electronic payments › Receive electronic remittance advices and automatically load them to your accounts receivable system › Submit questions about fee schedules and specific patient benefits

27 Important contact information Find the contacts you need to get in touch with us for information about your patients with Cigna coverage.* Please note that call, claim, and service channels may differ based on the Cigna participant’s identification (ID) card.

If you want to: Use the following:

Update your contact or demographic information, or notify Submit demographic changes to Cigna electronically by logging in to us of errors/changes to the way you are currently listed in our CignaforHCP.com > Working With Cigna > Update Directory Information. provider directories, including:** If you have not registered, please go to the registration page to begin › Name the process. › Type/Degree Or Practitioner & Group Changes: › Specialty Fax: 877.358.4301 › Product and network tier Email: [email protected] › National Provider Identifier (NPI) number Hospital & Ancillary Changes: › Medical group or hospital affiliation Fax: 646.459.2180 › Office email address Exceptions › Address If you are located in the following markets, submit updates electronically on › Office phone number CignaforHCP.com or as directed below. › Whether you are accepting new patients U.S. Virgin Islands Email: [email protected] Fax: 340.774.7175 Mail: V.I. Equicare, Inc. V.I. Medical Foundation Bldg, Ste 209A PO Box 9620 St. Thomas, VI 00801 California Email: [email protected]

Perform online transactions:*** Cigna for Health Care Professionals website: CignaforHCP.com › Verify patient eligibility › Inquire about patient coverage and covered services › Predict the total cost of service and patient liability for specific medical procedures › Request precertification for services › Inquire about precertification for services › View claim-coding policies and payment guidelines › Review medical or pharmacy coverage positions › View the prescription drug list › View sample ID cards › Obtain a Reference Guide › Request a copy of your contract › Request fee schedule information

Perform transactions using a multipayer website or vendor via Refer to Cigna.com/EDIvendors for a list of directly connected Cigna vendors. electronic data interchange (EDI):*** › Verify patient eligibility and coverage › Inquire about patient coverage and covered services › Check the status of a claim › Request precertification for services › Submit claims electronically › Receive electronic remittance advice › View list of EDI vendors

28 If you want to: Use the following:

Enroll to receive electronic funds transfer (EFT) or direct deposit Log in to CignaforHCP.com > Working with Cigna > Electronic Funds Transfer > Enroll in Electronic Funds Transfer (EFT) Options.

Perform telephone transactions:*** Phone: 800.88Cigna (882.4462) › Learn about electronic services For patients with “G” ID cards: › Verify patient eligibility and coverage Phone: 866.494.2111 › Check the status of a claim Customer Service numbers are also included on the patient’s ID card. › Request precertification for services › Request an exception to the prescription drug list › In the Texas market, request the Texas SB 418 Written Verification; a representative is available Monday to Friday, from 6 a.m. to 6 p.m. and from 9 a.m. to 12 p.m. on weekends and holidays

Submit a paper claim Refer to patient’s ID card

Submit or inquire about an appeal or dispute Phone: 800.88Cigna (882.4462) Website: CignaforHCP.com Fax: 877.815.4827 Mail: Cigna National Appeals PO Box 188011 Chattanooga, TN 37422 For patients with “G” ID cards: Fax: 877.804.1679 Mail: Cigna National Appeals PO Box 188062 Chattanooga, TN 37422-8062

Submit or inquire about provider credentialing** Phone: 800.88Cigna (882.4462)

Obtain information about organ and tissue transplant network Cigna LifeSOURCE Transplant Network® Phone: 800.668.9682 Website: CignaLifeSOURCE.com

Contact a dental network Phone: 800.Cigna24 (244.6224) Website: CignaforHCP.com For patients with “G” ID cards: Phone: 866.494.2111

Obtain other telephone numbers and addresses Refer to the patient’s ID card

Other important contacts: Use the following:

Cigna Behavioral Health Phone: 800.926.2273 Website: CignaforHCP.com

Home delivery pharmacy Cigna Home Delivery Pharmacy: 800.285.4812 Express Scripts Pharmacy, a Cigna company: 800.211.1456

Accredo, a Cigna specialty pharmacy Accredo Physician Service Center: 844.516.3319 Website: Accredo.com > Prescribers

29 Other important contacts: Use the following:

Medical management (including precertification) Phone: 800.88Cigna (882.4462) Website: CignaforHCP.com For patients with “G” ID cards: Phone: 866.494.2111 Customer service numbers are also included on the patient’s ID card.

eviCore healthcare Diagnostic cardiology, high-tech radiology, musculoskeletal, and (diagnostic cardiology, gastroenterology, high-tech radiology, gastroenterology integrated oncology, musculoskeletal, and radiation therapy Phone: 888.693.3297 services) Website: eviCore.com Effective February 1, 2021, eviCore will begin managing home Radiation therapy and integrated oncology health, durable medical equipment (DME), home infusion, and sleep services for Cigna customers. Phone: 866.668.9250 Website: eviCore.com Home health, DME & Sleep Management Services (effective 02.01.21) Phone: 800.298.4806 Website: evicore.com/ep360 Exceptions For CareLink customers in MA and RI and Cigna customers in Hawaii and Puerto Rico, use the following contact information: Phone: 800.88Cigna (882.4462) Website: CignaforHCP.com

Pharmacy prior authorizations Electronic medical record or electronic health record: CoverMyMeds® or Surescripts® Website: CoverMyMeds.com/epa/Cigna Phone: 800.244.6224

Specialty pharmacy condition counseling Accredo Therapeutic Resource Centers: 844.516.3319 Cigna specialty condition counseling: 800.633.6521

* Excluding customers with third party administrator plans. ** Excluding providers contracted through a Cigna Strategic Alliance. *** Not all transactions are available for all Cigna plans.

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., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 591795 z 04/21 PCOMM 2021-232 © 2021 Cigna. Some content provided under license.