Welcome to SCHOOLCARE

SCHOOLCARE Health Benefit Plans of the New Hampshire School Health Care Coalition Welcome to SCHOOLCARE

SCHOOLCARE has been providing high quality health coverage for New Hampshire public entities for over 20 years. We are committed to offering excellent health plans, the highest level of service and information, as well as engaging wellness and education programs. In the enclosed documents, you will find details related to your SCHOOLCARE health coverage, including: • An enrollment form and instructions • Benefit plan summaries • Overview of the Good For You! wellness program • Preventive prescription drug list and mail order information • How to use your Employee Assistance Program • Identity fraud coverage information

SCHOOLCARE partners with Cigna to deliver the best health care service and claims administration. We use Cigna’s National Open Access Plus network of providers. This gives you access to care in every state across the country! Primary Care Physician (PCP) referrals are not required to seek care from a specialist.

2019 Updates • Updated best in class Good For You! wellness programs. • Reminder of options available as a SCHOOLCARE member.

Service Cigna provides first-contact customer service for SCHOOLCARE members. • If you have a question related to a claim, coverage or medical authorizations, call Cigna toll free 1-800-244-6224, 24/7 or visit the Cigna website at www.myCigna.com. Once logged in, you can find your medical claims, details about your coverage, home delivery of prescriptions, as well as provider cost and quality ratings.

370 Harvey Rd Suite 4, Manchester, NH 03103 | Phone: (800) 562-5254 | Fax: (603) 782-4079 | www.schoolcare.org

A Labor/Management Collaborative

SCHOOLCARE Enrollment Packet Contents – 2019 Click on any item to link to the desired document 1. Important Enrollment Requirements

2. SCHOOLCARE Enrollment/Change Form

3. Your Health Benefits  Cigna Medical & Dental o Plan Benefit Summaries o Finding a Doctor or Dentist o 2019 No Cost-Share Preventive Medications o Preventive Generic Drug List

4. Good For You! Wellness Programs by SCHOOLCARE  Notice Regarding Wellness Program  Summary of Incentives

5. Good To Know Info and Navigating Your Benefits  Preventive Health Care Guide  Cigna 90 Now Information  Cigna Telehealth Connection  MyCigna Information  Cigna Employee Assistance Program Brochure  Cigna Healthy Rewards  Identify Fraud Program Information

A Health Plan You Know and Trust

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IMPORTANT NOTICE

Special Enrollment Requirements from Cigna

This flyer contains important information you should read before you enroll. If you have any questions about this information, please contact your benefits manager.

If you are declining enrollment Effective April 1, 2009 or later, if you or your dependents lose eligibility for state Medicaid or Children’s Health If you are declining enrollment for yourself or your Insurance Program (CHIP) coverage or become eligible dependents (including your spouse) because of other for assistance with group health plan premium payment health insurance or group health plan coverage, you under a state Medicaid or CHIP plan, you may be able to may be able to enroll yourself and your dependents in enroll yourself and your dependents. However, you must this plan if: request enrollment within 60 days after the state › You or your dependents lose eligibility for that other Medicaid or CHIP coverage ends or you are determined coverage (or if the employer stops contributing eligible for premium assistance. toward your or your dependents’ other coverage). To request special enrollment or obtain more However, you must request enrollment within 30 information, contact our Customer Service Team days after your or your dependents’ other coverage at 800.Cigna24. ends (or after the employer stops contributing toward the other coverage). If the other coverage is Other late entrants COBRA continuation coverage, you and your dependents must complete your entire COBRA If you decide not to enroll in this plan now, then want coverage period before you can enroll in this plan, to enroll later, you must qualify for special enrollment. even if your former employer ceases contributions If you do not qualify for special enrollment, you may toward the COBRA coverage. have to wait until an open enrollment period, or you may not be able to enroll, depending on the terms and In addition, if you have a new dependent as a result of conditions of your health plan. Please contact your plan marriage, birth, adoption, or placement for adoption, administrator for more information. you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

558986 q NO PCL 10/14 Back to contents

Women’s Health and Cancer Rights Act (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: If you would like more information on WHCRA benefits, call our › All stages of reconstruction of the breast on which the Customer Service Team at mastectomy was performed; 800.Cigna24 (800.244.6224). › Surgery and reconstruction of the other breast to produce a symmetrical appearance; › Prostheses; and › Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance or copays applicable to other medical and surgical benefits provided under this plan as shown in the Summary of Benefits.

“Cigna” and the “Tree of Life” logo are registered service marks, and “Together, all the way.” is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc. (IL & IN), Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc. (MO, KS & IL), Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (TN & MS), and Cigna HealthCare of Texas, Inc. 558986 q NO PCL 10/14 © 2014 Cigna. Some content provided under license. Enrollment / Change Form

A FOR EMPLOYER Effective Date Hire Date Employer Name Employer Address USE ONLY New Hire Account Number Branch Code Billing Group Open Enrollment Active Retiree COBRA 3206140 Type of Change: See Qualifying Events on Reverse

Address Change Add Dependent(s): List names in Section B Retirement Cancel Employee* Cancel Dependent(s)* Other: *Must also complete COBRA Notification Request Form B Employee Name (last) (first) (M.I.) Social Security #

Cell Phone Home Phone E-Mail Address

Mailing Address (Street, Apt #, or PO Box) (City) (State) (Zip Code)

Relationship to Subscriber Last Name First Name M.I. Plan Social Security # Date of Birth Gender i.e. legally married, *domestic partner, biological, step or adopted child (*not all Employers offer DP coverage) Employee M Medical Spouse E-mail Address F Dental | | | | Spouse (whom you wish to cover) Medical M Legally Married Domestic Partner* Dental | | | | F Dependent (whom you wish to cover) Medical M Biological Step Adopted Dental | | | | F Dependent (whom you wish to cover) Medical M Biological Step Adopted Dental | | | | F Dependent (whom you wish to cover) Medical M Biological Step Adopted Dental | | | | F

C Traditiona l Plan Suite Options Consumer Driven Plan Suite Options If declining coverage, please initial below. Green Open Access Yellow Open Access with Choice Fund Dental (insert plan code) Yellow Open Access Decline Medical Coverage Red Open Access Orange Open Access Decline Dental Coverage

Other Health Care Coverage Will you or your covered dependents have other health insurance while on SCHOOLCARE? Yes No Other D Medicare Insurance Name of person covered ID Number or Medicare No. Effective Date Name of Carrier Part A Part B Medicaid Carrier 1.

2. Signature – The information provided above is true and correct to the best of my knowledge. E Employee’s Signature/ Date Employer’s Signature / Date

Please make a copy for both employee and employer then submit the original to SCHOOLCARE. Please review additional information on reverse side of this form. Back to contents INSTRUCTIONS QUALIFYING EVENTS

EMPLOYER For a qualifying event, subscribers must provide notice within 30 days of the Complete Section A - Employer and enrollment/change information event. Examples include: Check box(es) indicating reason(s) for submitting enrollment/change request.  Marriage  Loss of other insurance coverage  Birth of a child Complete Section E - in the lower right hand corner of the Form  Adoption/ Legal Guardianship  Death Employer must sign and date the Form after reviewing all information in order for  It to be processed. Divorce/ Legal Separation (Subscriber or Spouse notification within 60 days) EMPLOYEE – Complete Sections B - E Section B - Employee and Covered Dependent Information CIGNA HEALTHCARE PROVISIONS Complete all information in order for your enrollment/change request to be processed. Applicant Acknowledgments and Agreements  Provide LEGAL NAME AND MIDDLE INITIAL for all enrollees. On behalf of myself and the dependents listed on the reverse side, I agree to or  Federal regulations require social security numbers for all enrollees. with the following:  Provide valid email address(es) to be sure you receive information regarding wellness cash incentives. 1. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Section C - Plan Option Corporation. Products and services provided by these subsidiaries and not by Check one SCHOOLCARE medical plan option box that you are selecting as offered Cigna Corporation. These subsidiaries include Cigna Healthcare, Cigna Health by your employer. and Life Insurance Company, Cigna Home Delivery Program and its affiliates, Cigna Behavioral Health, Inc., Intracorp, and HMO or service company SCHOOLCARE Check one dental plan option box, if applicable, and insert plan code. subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. If declining coverage, initial accordingly. 2. I agree, for myself and my dependents, that, in the event any health services Section D - Other Health Care Coverage provided are the primary responsibility of any other party by way of other Only complete for covered dependents on the plan who will maintain other group health coverage or by the act or omission of another person to fully insurance while on SCHOOLCARE. inform the healthplan and will execute such assignments, liens or other documents which may be necessary to enable the healthplan to recover the Section E - Employee Verification value of the services provided. I further agree that in the event I or any of Employee must sign and date the Form after completing and reviewing all my dependents collect benefits or damages from any other party who has information in order for it to be processed. primary responsibility for services provided by SCHOOLCARE, I will immediately reimburse SCHOOLCARE to the extent of services provided and to the extent permitted by state law. SPECIAL PROVISIONS FOR EMPLOYERS WITH SECTION 125 PLANS 3. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of By allowing an individual to enroll in the Insurance Plan other than during the claim containing any materially false information or conceals for the purpose open enrollment period, SCHOOLCARE, Cigna HealthCare or Cigna Health and of misleading, information concerning any fact material thereto commits a Life Insurance Company do not waive any terms of its contracts. Further, by fraudulent insurance act, which is a crime and subject such person to criminal allowing an individual to enroll in the Insurance Plan other than during the and civil penalties. open enrollment period, SCHOOLCARE, Cigna HealthCare or Cigna Health and Life Insurance Company do not thereby express any opinion regarding the 4. I authorize deductions from my earnings or the required contributions, if any, appropriateness of the change under Section 125 of the Internal Revenue Code toward the cost of the coverage. This authorization applies only if employee or the terms of the employer's Section 125 plan. contributions are required. Back to contents SCHOOLCARE Yellow Open Access Choice Fund

SUMMARY OF BENEFITS Benefits outlined below are intended as a general summary and are covered only when using a CIGNA Open Access Plus Network participating provider. All benefits are subject to the terms and conditions of your Health Benefits Booklet. In the event of any inconsistency between this Summary and the Health Benefits Booklet, the provisions as defined in the Health Benefits Booklet and Endorsements will govern. Covered benefits are subject to review for medical necessity. The plan year is defined from July 1 through June 30.

BENEFITS YELLOW OPEN ACCESS (In‐Network Benefits Only) DEDUCTIBLES, MAXIMUMS* Plan Year Deductible Individual: $1,250; Family: $2,500 Coinsurance Medical 20%; Pharmacy 10% ($75 cap per prescription) Out‐of‐Pocket Maximum/Plan Year Individual: $2,000; Family: $4,000 Maximum Lifetime Benefit Unlimited *All family members contribute towards family deductible/out‐of‐pocket max. CHOICE FUND (if activated) SCHOOLCARE PAYS Embedded Choice Fund (health reimbursement account) pays for eligible out‐of‐ pocket Individual: $1,000; Family: $2,000 expenses during the plan year. Subscriber must take the online Health Assessment to activate Choice Fund. NET COST AFTER CHOICE FUND (if activated) PLAN MEMBER PAYS Out‐of‐Pocket Cost (including deductible) Individual: $1,000; Family: $2,000 The Employer may not fund any additional portion of the out‐of‐pocket costs under SCHOOLCARE policy. PREVENTIVE CARE (Includes Naturopath Services, Routine Laboratory & Diagnostic Testing) Routine Physical Examination $0 Routine Immunizations $0 Well Child Preventive Care $0 Well Woman Preventive Care $0 Adult Preventive Care $0 Additional services such as urinalysis and EKG $0 Routine Eye Exam (one every 12 months for all ages) Discounts Available for Eyewear $0

OTHER PHYSICIAN SERVICES (Includes Naturopath Services) Office Visits and/or Office Surgery Deductible, then 20% to the Out of Pocket Maximum Maternity Care Deductible, then 20% to the Out of Pocket Maximum Cigna Telehealth Connection (see details on myCigna.com) Deductible, then 20% to the Out of Pocket Maximum OUTPATIENT DIAGNOSTIC TESTING Deductible, then 20% to the Out of Pocket Maximum Radiology and Laboratory Services (Prior authorization required for some tests) HOSPITAL CARE Deductible, then 20% to the Out of Pocket Maximum Inpatient Services including Newborn Care Same Day or Outpatient Surgery (Inpatient admissions and some outpatient procedures require prior authorization) Radiation and Chemotherapy Physician Visits and Services Anesthesiologist Services Operating Room X‐ray and Laboratory Services Medications and Supplies OVER www.schoolcare.org 7/1/18 Back to contents SCHOOLCARE Yellow Open Access Choice Fund

BENEFITS YELLOW OPEN ACCESS (In‐Network Benefits Only) HEARING TESTS Deductible, then 20% to the Out of Pocket Maximum

EMERGENCY & URGENT CARE (Medically Necessary and Worldwide) Hospital Emergency Room Deductible, then 20% to the Out of Pocket Maximum Urgent Care Facility Deductible, then 20% to the Out of Pocket Maximum

MENTAL HEALTH/SUBSTANCE USE DISORDER OUTPATIENT (Physician’s office) Deductible, then 20% to the Out of Pocket Maximum INPATIENT HOSPITALIZATION AND OUTPATIENT FACILITY Deductible, then 20% to the Out of Pocket Maximum (Prior authorization required)

PRESCRIPTION DRUGS Retail ‐ up to 90‐day supply: Deductible, then 10% to the Out of Pocket Maximum‡ Cigna Participating Pharmacies Mail Order – up to 90‐day supply: Deductible, then 10% to the Out of Pocket Go to Cigna.com/Rx90network for listing of 90‐day network retail pharmacies Maximum‡ available only through Cigna Home Delivery mail order Certain Preventive Generic Drugs including oral contraceptives (generic): $0 Specialty Drugs: 30‐day supply only, filled through Cigna Home Delivery mail order (Prior authorization and step therapy are required for some drugs) ‡$75 cap per prescription after deductible

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPIES OUTPATIENT: short‐term rehab, up to 60 days per person/per plan year, includes PT, OT, Deductible, then 20% to the Out of Pocket Maximum ST and cardiac rehab (Combined maximum). INPATIENT (Prior authorization required) Deductible, then 20% to the Out of Pocket Maximum CHIROPRACTIC CARE Deductible, then 20% to the Out of Pocket Maximum 20 days per person/per plan year

ACUPUNCTURE† (In or Out of Network) Deductible, then 20% to the Out of Pocket Maximum 12 days per person/per plan year †Coverage based on Cigna medical guidelines.

DURABLE MEDICAL EQUIPMENT Deductible, then 20% to the Out of Pocket Maximum

EXTERNAL PROSTHETIC APPLIANCES Deductible, then 20% to the Out of Pocket Maximum

OTHER BENEFITS All other covered services subject to plan year deductible and 20% coinsurance to the ORAL SURGERY (accidents only) out‐of‐pocket maximum for the plan year. REMOVAL OF BONEY IMPACTED WISDOM TEETH SKILLED NURSING CARE (100 days per person/per plan year maximum) AMBULANCE (if not a true emergency, services are not covered) BLOOD TRANSFUSIONS HOME HEALTH SERVICES

GOOD FOR YOU! by SCHOOLCARE HEALTH AND WELLNESS INCENTIVES, EMPLOYEE ASSISTANCE PROGRAM Included – up to $800 for subscriber and $400 for spouse

OVER www.schoolcare.org 7/1/18 SCHOOLCARE Yellow Open Access Back to contents

PREVENTIVE CARE (Includes Naturopath Services, Routine Laboratory & Diagnostic Testing) Routine Physical Examination $0 Routine Immunizations $0 Well Child Preventive Care $0 Well Woman Preventive Care $0 Adult Preventive Care $0 Additional services such as urinalysis and EKG $0 Routine Eye Exam (one every 12 months for all ages) Discounts Available for Eyewear $0

OUTPATIENT DIAGNOSTIC TESTING Deductible, then 20% to the Out of Pocket Maximum Radiology and Laboratory Services (Prior authorization required for some tests) HOSPITAL CARE Deductible, then 20% to the Out of Pocket Maximum Inpatient Services including Newborn Care Same Day or Outpatient Surgery (Inpatient admissions and some outpatient procedures require prior authorization) Radiation and Chemotherapy Physician Visits and Services Anesthesiologist Services Operating Room X‐ray and Laboratory Services Medications and Supplies

OVER www.schoolcare.org 7/1/18 SCHOOLCARE Yellow Open Access Back to contents

BENEFITS YELLOW OPEN ACCESS (In‐Network Benefits Only) HEARING TESTS Deductible, then 20% to the Out of Pocket Maximum

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPIES OUTPATIENT: short‐term rehab, up to 60 days per person/per plan year, includes PT, OT, ST Deductible, then 20% to the Out of Pocket Maximum and cardiac rehab (Combined maximum). INPATIENT (Prior authorization required) Deductible, then 20% to the Out of Pocket Maximum CHIROPRACTIC CARE Deductible, then 20% to the Out of Pocket Maximum 20 days per person/per plan year

ACUPUNCTURE† (In or Out of Network) Deductible, then 20% to the Out of Pocket Maximum 12 days per person/per plan year †Coverage based on Cigna medical guidelines.

DURABLE MEDICAL EQUIPMENT Deductible, then 20% to the Out of Pocket Maximum

EXTERNAL PROSTHETIC APPLIANCES Deductible, then 20% to the Out of Pocket Maximum

GOOD FOR YOU! by SCHOOLCARE HEALTH AND WELLNESS INCENTIVES, EMPLOYEE ASSISTANCE PROGRAM Included – up to $800 for subscriber and $400 for spouse

OVER www.schoolcare.org 7/1/18 SCHOOLCARE Orange Open Access Back to contents

BENEFITS ORANGE OPEN ACCESS (In‐Network Benefits Only) DEDUCTIBLES, MAXIMUMS* Plan Year Deductible Individual: $2,000; Family: $4,000 Coinsurance Medical 20%; Pharmacy 10% (or $75 cap per prescription) Out‐of‐Pocket Maximum/Plan Year Individual: $4,000; Family: $8,000 (Individual in a Family: $6,550) Maximum Lifetime Benefit Unlimited *All family members contribute towards family deductible/out‐of‐pocket max. EMPLOYER FUNDING Optional subject to collective bargaining or governance policy, the employer may contribute Individual: $1,000; Family: $2,000 up to 50% of the deductible through an HSA, HRA, FSA or other legally permissible method. This is the maximum amount allowed annually under SCHOOLCARE policy.

OVER www.schoolcare.org 7/1/18 SCHOOLCARE Orange Open Access Back to contents

BENEFITS ORANGE OPEN ACCESS (In‐Network Benefits Only) HEARING TESTS Deductible, then 20% to the Out of Pocket Maximum

ACUPUNCTURE† (In or Out of Network) Deductible, then 20% to the Out of Pocket Maximum 12 days per person/per plan year †Coverage based on Cigna medical guidelines.

DURABLE MEDICAL EQUIPMENT Deductible, then 20% to the Out of Pocket Maximum

EXTERNAL PROSTHETIC APPLIANCES Deductible, then 20% to the Out of Pocket Maximum OTHER BENEFITS All other covered services subject to plan year deductible and 20% coinsurance to the ORAL SURGERY (accidents only) out‐of‐pocket maximum for the plan year. REMOVAL OF BONEY IMPACTED WISDOM TEETH SKILLED NURSING CARE (100 days per person/per plan year maximum) AMBULANCE (if not a true emergency, services are not covered) BLOOD TRANSFUSIONS HOME HEALTH SERVICES HOSPICE

GOOD FOR YOU! by SCHOOLCARE HEALTH AND WELLNESS INCENTIVES, EMPLOYEE ASSISTANCE PROGRAM Included – up to $800 for subscriber and $400 for spouse

OVER www.schoolcare.org 7/1/18 SCHOOLCARE DENTAL DP4A (SAU 17 PLAN 1 – TEACHERS & UNION SUPPORT) SUMMARY OF BENEFITS Benefits outlined below are intended only as a general summary. All benefits are subject to the terms and conditions of your Dental Summary Plan Document. In the event of any inconsistency between this summary and the actual provisions of the plan, the provisions as defined in the Summary Plan Document, Amendments, and Riders will govern. All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network. Plan maximum refreshes on a calendar year – every January 1.

BENEFITS Total Cigna DPPO Out-of-Network* (In Network)

CALENDAR YEAR MAXIMUM (refreshes January 1) (Class I, II and III Expenses) $1,000 $1,000

CALENDAR YEAR DEDUCTIBLE Per Individual $25 $25 Per Family $75 $75

CLASS I EXPENSES – PREVENTIVE & DIAGNOSTIC CARE 100%, No Deductible 100%, No Deductible

Oral Exams Cleanings Routine X-Rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Non-Routine X-Rays Emergency Care to Relieve Pain

CLASS II EXPENSES – BASIC RESTORATIVE CARE 80%, After Deductible 80%, After Deductible Fillings – Amalgam and Composite

Oral Surgery – Simple Extractions Oral Surgery – All Except Simple Extractions Surgical Extraction of Impacted Teeth Anesthetics Major Periodontics Minor Periodontics Root Canal Therapy/Endodontics Relines, Rebases, and Adjustments Repairs – Bridges, Crowns, and Inlays Repairs – Dentures

CLASS III EXPENSES – MAJOR RESTORATIVE CARE 50%, After Deductible 50%, After Deductible

Crowns/ Inlays/Onlays

Dentures Bridges Implants Occlusal Night Guards

CLASS IV EXPENSES – ORTHODONTIA (Children Only) 50%, No Ortho Deductible 50%, No Ortho Deductible

$1,000 $1,000 Lifetime Maximum

Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. Dental Oral Health Integration Program (OHIP) – All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP) is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The Program provides:  100% coverage for certain procedures (provided the maximum has not been depleted during the calendar year)  Guidance on behavioral issues related to oral health  Discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. * For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will pay as billed. www.schoolcare.org SCHOOLCARE DENTAL DP4A (SAU 17 PLAN 1 – TEACHERS & UNION SUPPORT)

Cigna Dental PPO / Indemnity Exclusions and Limitations: ______Procedures Exclusions & Limitations Exams 2 per Calendar year Prophylaxis (Cleanings) 4 per Calendar year (routine or periodontal) Fillings Covered for both amalgam and composite fillings. No alternate benefit is applied. Fluoride 2 per Calendar year for people under 19 Histopathologic Exams Various limits per Calendar year depending on specific test X-Rays (routine) Bitewings: 2 per Calendar year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months. Panorex: 1 every 36 consecutive months Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment Model Payable only when in conjunction with Ortho workup and extensive Perio treatment Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Relines, Rebases & Adjustments Covered if more than 6 months after installation Repairs – Bridges Reviewed if more than once Repairs – Dentures Reviewed if more than once Prosthesis Over Implants 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. ______Benefit Exclusions:  Services performed primarily for cosmetic reasons  Replacement of a lost or stolen appliance  Replacement of a bridge or denture within five years following the date of its original installation  Replacement of a bridge or denture which can be made useable according to accepted dental standards  Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion  Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars  Bite registrations; precision or semi-precision attachments; splinting  Instruction for plaque control, oral hygiene and diet  Dental services that do not meet common dental standards  Services that are deemed to be medical services  Services and supplies received from a hospital  Charges which the person is not legally required to pay  Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service  Experimental or investigational procedures and treatments  Any injury resulting from, or in the course of, any employment for wage or profit  Any sickness covered under any worker’s compensation or similar law  Charges in excess of the reasonable and customary allowances  To the extent that payment is unlawful where the person resides when the expenses are incurred;  Procedures performed by a Dentist who is a member of the covered person's family (covered person's family is limited to a spouse, siblings, parents, children, grandparents, and the spouse's siblings and parents);  For charges which would not have been made if the person had no insurance;  For charges for unnecessary care, treatment or surgery;  To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;  To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a "no-fault" insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.  In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer. This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Cigna HealthCare.

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FINDING A DOCTOR OR DENTIST IN OUR DIRECTORY IS EASY

Is your doctor, dentist or hospital in the Cigna network? Cigna’s online directory makes it easy to find who (or what) you’re looking for. SEARCH OUR NETWORK IN FOUR SIMPLE STEPS

Step 1 Step 2 Step 3 Step 4 Go to Cigna.com, and click on “Find a Doctor” at the Enter the Optional – Select Type in who or top of the screen. Then, under “Not a Cigna Customer location in one of the plans what you are Yet?” select “Plans through your employer or school.” which you offered by your looking for. want to employer during Or browse the (If you’re already a Cigna customer, log in to search. open enrollment. A-to-Z glossary myCigna.com or the myCigna® app to search your of providers and current network. To search other networks, use the procedures or Cigna.com directory.) keywords option.

That’s it! You can also refine your search results by distance, years in practice, specialty, languages spoken and more. Search first. Then choose Cigna. There are so many things to love about Cigna. Our directory search is just the beginning. After you enroll, you’ll have access to myCigna.com – your one-stop source for managing your health plan, anytime, just about anyplace. On myCigna.com, you can estimate your health care costs, manage and track claims, learn how to live a healthier life and more. Questions? Call

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. Providers and facilities that participate in the Cigna network are independent practitioners solely responsible for the treatment provided to their patients. They are not agents of Cigna. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, see your plan documents. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc., including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), Cigna HealthCare of Texas, Inc., Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc., Cigna Dental Health of Kentucky, Inc., Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. Policy forms: Medical: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). Dental (CHLIC): OK – Indemnity/DPPO: HP-POL99, DHMO: POL115; OR - Indemnity/DPPO/DEPO: HP-POL68, DHMO: HP-POL121 04-10; TN – Indemnity/DPPO/DEPO: HP-POL69/HC-CER2V1 et al., DHMO: HP-POL134/HC-CER17V1 et al. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 878133 f 04/18 © 2018 Cigna. Some content provided under license. Back to contents

PPACA NO COST-SHARE PREVENTIVE MEDICATIONS

by drug category

At Cigna, your health and well-being is important to us. We want you to live life to the fullest. Taking your preventive medications regularly can help you get – and stay – healthy.

Health care reform requires coverage Religious exemptions to the coverage of certain preventive medications at no of contraceptives cost-share to you PPACA allows certain employers to exclude Health care reform under the Patient Protection and contraceptives from coverage due to religious beliefs. If Affordable Care Act (PPACA) requires plans to cover you’re a woman with medical coverage though one of certain preventive medications and products at 100%, these employers, Cigna will let you know that your plan or no cost-share ($0) to you.* The U.S. Preventive doesn’t cover these medications. Where required by law, Services Task Force and the Institute of Medicine Cigna will offer to pay for your contraceptives and/or provides guidance on which drug classes should be certain medications at no extra cost to you (if you covered. These recommendations are meant to help choose). This coverage is private and confidential and prevent disease, as well as meet women’s unique isn’t administered, funded by or connected in any way health care needs. to your employer’s health coverage.

Preventive medication coverage Choosing the right preventive medication This drug list shows the prescription medications There are many preventive medications covered at 100% and over-the-counter medicines (available without (or no cost-share to you) under PPACA’s preventive a prescription) and products available to you at no coverage requirement. You should talk with your doctor cost-share (copay, coinsurance and/or deductible). to find out which medication or product may be right for This list is updated as the U.S. Preventive Services you. If your doctor feels a certain contraceptive Task Force makes new recommendations. medication or smoking cessation medication on this list isn’t right for you, ask your doctor to call us. Together, You should log into the myCigna® website or app or we’ll look for other medications and products not on check your plan materials to learn more about how your this list that may be available to you at no cost-share. plan covers preventive medications. You can also use Please be sure to get a prescription from your doctor the Drug Cost tool to estimate how much your for your preventive medication or over-the-counter medications may cost. product. Your pharmacy will need a prescription for the medication to process correctly in the claims system at no cost ($0) to you.

* This is a list of the medications and other products covered at 100% under the plan’s pharmacy benefit at this time, based on existing legal requirements, and is subject to plan terms like limitations and exclusions. For example, if legal requirements for preventive coverage changes, then this list may change.

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 855125 r 10/18 Back to contents

This drug list shows the prescription medications and over-the-counter medicines and products available to you at no cost-share under PPACA. This list is updated as the U.S. Preventive Services Task Force makes new recommendations. Aspirin Products Natura-Lax Hormonal Contraception^* Nulytely With Flavor Packs Aspir 81 Altavera OsmoPrep aspirin Alyacen PEG 3350-Electrolyte aspirin EC Amethia PEG 3350 Aspir-Low Amethia Lo PEG-Prep Bayer Chewable Aspirin Amethyst Powderlax Bufferin Apri Prepopik Ecotrin Aranelle Purelax EcPirin Ashlyna Smoothlax Low Dose Aspirin EC Aubra Suprep Tri-Buffered Aspirin Aviane Trilyte With Flavor Packets Azurette Breast Cancer Prevention Cholesterol Medications Balziva raloxifene Bekyree Available to adults tamoxifen Blisovi 24 FE 40-75 years of age Blisovi FE Barrier Contraception atorvastatin 10mg, 20mg Briellyn Caya Contoured fluvastatin 20mg, 40mg Camila FC2 Female Condom fluvastatin ER 80mg Camrese FemCap lovastatin 20mg, 40mg Camrese Lo Today Contraceptive Sponge pravastatin 10mg, 20mg, 40mg, Caziant VCF 80mg Chateal Wide Seal Diaphragm rosuvastatin 5mg, 10mg Cryselle simvastatin 10mg, 20mg, 40 mg Cyclafem Bowel Prep Products for Cyred Colorectal Cancer Emergency Contraception Dasetta Screenings Aftera Daysee Available to adults Econtra EZ Deblitane 50–75 years of age Econtra One-Step Delyla Ella desogestrel-ethinyl estradiol Alophen Pills My Choice drospirenone-ethinyl estradiol bisacodyl tablet My Way Elinest Bisa-Lax Opcicon One-Step Emoquette Clearlax Option 2 Enpresse CoLyte With Flavor Packets Enskyce Correctol Folic Acid Supplementation Errin Ducodyl Only includes products containing Estarylla Dulcolax tablet 0.4 mg–0.8 mg of folic acid ethynodiol-ethinyl estradiol Gavilax Falmina Gavilyte-C Fa-8 Fayosim Gavilyte-G folic acid Femynor Gavilyte-N KPN Gianvi GentleLax Perry Prenatal Heather Gialax Prenatal Introvale Glycolax Prenatal Multi + DHA Isibloom GoLytely Prenatal Multivitamin Jencycla Healthylax Prenatal Vitamin Jolessa LaxaClear Right Step Prenatal Vitamins Jolivette Miralax Urosex Juleber MoviPrep Junel Brand name medications are capitalized and generic medications are lowercase Back to contents

Hormonal Contraception^* Pimtrea Pediatric Multivitamins (continued) Pirmella Containing Fluoride and Portia Junel FE Fluoride Supplements Previfem Junel FE 24 Available to children Quasense Kaitlib FE six months – sixteen years of age Rajani Kariva Reclipsen Escavite Kelnor 1-35 Rivelsa Escavite D Kelnor 1-50 Setlakin Floriva Kurvelo Sharobel Fluorabon Larin Sprintec fluoride Larin 24 FE Sronyx Fluoritab Larin FE Syeda Flura-Drops Larissia Tarina FE Ludent Fluoride Leena Tilia FE multi-vitamin with fluoride-iron Lessina Tri Femynor multivitamin with fluoride Levonest Tri-Estarylla MVC-fluoride levonorgestrel-ethinyl estradiol Tri-Legest FE Poly-Vi-Flor levonorgestrel-ethinyl estradiol- Tri-Linyah Poly-Vi-Flor With Iron ethinyl estradiol Tri-Lo-Estarylla Polyvitamins with Fluoride Levora-28 Tri-lo-Marzia Quflora Lillow Tri-Lo-Sprintec Sodium Fluoride Loryna Tri-Mili Tri-Vi-flor Low-Ogestrel Trinessa Tri-Vitamin with fluoride Lutera Trinessa Lo Lyza Smoking Cessation^* Tri-Previfem Marlissa Tri-Sprintec Quantity limits apply Melodetta 24 FE Trivora-28 Mibelas 24 FE bupropion SR 150mg tablet Tri-Vylibra Microgestin Nicoderm CQ Tulana Microgestin FE Nicorelief Tydemy Mili Nicorette Velivet Mono-Linyah nicotine gum Vienva Mononessa nicotine lozenge Viorele Myzilra nicotine patch Vyfemla Necon Quit 2 Vylibra Nikki Quit 4 Wera Nora-Be Wymzya FE ^ If your doctor feels these medications norethindrone aren’t right for you, ask him/her to call Xulane us. There may be other brands available norethindrone-ethinyl estradiol Zarah at no cost-share to you norethindrone-ethinyl estradiol-FE Zenchent * Generic nicotine replacement therapy norgestimate-ethinyl estradiol Zovia 1-35e (known as “store-brands” are available at Norlyda no cost-share to you, even though they Norlyroc ^ If your doctor feels these medications may not be listed here) Nortrel aren’t right for you, ask him/her to call us. There may be other brands available Nuvaring at no cost-share to you Ocella * Generic hormonal contraceptives are Orsythia available at no cost-share to you, even Philith though they may not be listed here

Brand name medications are capitalized and generic medications are lowercase Back to contents

Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms: OK - HP-APP-1 et al (CHLIC), OR - HP-POL38 02-13 (CHLIC), TN - HP-POL43/HC-CER1V1 et al (CHLIC), GSA-COVER, et al (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 855125 r 10/18 © 2018 Cigna. Some content provided under license. Back to contents DISCRIMINATION IS AGAINST THE LAW

Medical coverage

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Cigna: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to [email protected] or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to [email protected]. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). 896375a 05/17 © 2017 Cigna. Back to contents Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711). Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711). Arabic – برجاء االنتباه خدمات الترجمة المجانية متاحة لكم. لعمالء Cigna الحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. او اتصل ب TTY) 1.800.244.6224: اتصل ب 711). French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711). French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711). Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711). Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711). Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）まで、お電話にてご連絡ください。 Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711). (Persian (Farsi – توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه می شود. برای مشتريان فعلی ٬Cigna لطفاً با شماره ای که در پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره 1.800.244.6224 تماس بگيريد (شماره تلفن ويژه ناشنوايان: شماره 711 را شماره گيری کنيد). 896375a 05/17 2019 PREVENTIVE GENERICS DRUG LIST

As of January 1, 2019

Preventive medications are used to prevent conditions like high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack, stroke and prenatal nutrient deficiency.

This document shows the most commonly prescribed Some plans have specific coverage requirements for preventive generic medications your plan covers as of preventive medications. January 1, 2019.* Medications are listed alphabetically For example, some plans may: by the condition they prevent. The Preventive Generics Drug List is regularly updated so it’s important to know › Require you to pay a copay, coinsurance (the that this is not a complete list of covered medications, percentage you pay after you meet your deductible) and not all of the medications listed here may be and/or deductible (the amount you pay before your covered by your specific plan. plan starts to pay) to receive coverage for a preventive generic medication. Or, › Cover preventive generic medications at 100%, or no cost ($0) to you. You should log into the myCigna® website or app or check your plan materials to learn more about how your plan covers preventive medications. You can also use the Drug Cost tool to estimate how much your medication may cost.**

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 825433 v Generics With Diabetic Supplies 10/18 Preventive Generics Drug List

Asthma related chlorthalidone nimodipine clonidine nisoldipine albuterol diltiazem olmesartan budesonide diltiazem 12hr ER olmesartan-amlodipine-HCTZ caffeine citrate diltiazem 24hr CD olmesartan-HCTZ cromolyn diltiazem 24hr ER perindopril fluticasone-salmeterol diltiazem ER phenoxybenzamine ipratropium Dilt-XR pindolol ipratropium-albuterol doxazosin prazosin levalbuterol enalapril propranolol levalbuterol concentrate enalapril-HCTZ propranolol ER levalbuterol HFA eplerenone propranolol-HCTZ metaproterenol eprosartan quinapril montelukast felodipine ER quinapril-HCTZ terbutaline fosinopril ramipril Theochron fosinopril-HCTZ Sorine theophylline furosemide sotalol zafirlukast guanfacine sotalol AF zileuton ER hydralazine spironolactone Blood pressure related hydrochlorothiazide spironolactone-HCTZ indapamide Taztia XT acebutolol irbesartan telmisartan acetazolamide irbesartan-HCTZ telmisartan-amlodipine Afeditab CR isradipine telmisartan-HCTZ amiloride labetalol terazosin amiloride-HCTZ lisinopril timolol amlodipine lisinopril-HCTZ torsemide amlodipine-benazepril losartan trandolapril amlodipine-olmesartan losartan-HCTZ trandolapril-verapamil ER amlodipine-valsartan Matzim LA triamterene-HCTZ amlodipine-valsartan-HCTZ methazolamide valsartan atenolol methyclothiazide valsartan-HCTZ atenolol-chlorthalidone methyldopa tablet Vecamyl benazepril methyldopa-HCTZ verapamil benazepril-HCTZ metolazone verapamil ER betaxolol metoprolol verapamil ER PM bisoprolol metoprolol ER-HCTZ verapamil SR bisoprolol-HCTZ metoprolol-HCTZ bumetanide minoxidil Blood thinner related candesartan moexipril aspirin-dipyridamole ER candesartan-HCTZ moexipril-HCTZ cilostazol captopril nadolol clopidogrel captopril-HCTZ nadolol-bendroflumethiazide dipyridamole Cartia XT nicardipine Jantoven carvedilol nifedipine prasugrel carvedilol ER nifedipine ER warfarin chlorothiazide

Brand name medications are capitalized and generic medications are lowercase

2 Cholesterol related Diabetes related miglitol nateglinide amlodipine-atorvastatin Please log in to the myCigna OneTouch test strips and meters atorvastatin website or app, or check your plan pioglitazone cholestyramine materials, to learn more about pioglitazone-glimepiride cholestyramine light how your plan covers diabetes- pioglitazone-metformin colesevelam related preventive medications. repaglinide colestipol acarbose repaglinide-metformin ezetimibe alogliptin tolazamide ezetimibe-simvastatin alogliptin-metformin tolbutamide fenofibrate alogliptin-pioglitazone fenofibric acid chlorpropamide Osteoporosis related fluvastatin ER Diabetic Supplies (i.e. lancets, alendronate fluvastatin syringes, urine test, alcohol pads) calcitonin-salmon gemfibrozil glimepiride etidronate lovastatin glipizide ibandronate niacin ER glipizide ER raloxifene Niacor glipizide XL risedronate omega-3 ethyl esters glipizide-metformin risedronate DR pravastatin glyburide Prevalite glyburide micronized Prenatal vitamins rosuvastatin glyburide-metformin Your plan considers all prescription simvastatin metformin strength prenatal vitamins to be Triklo metformin ER “preventive.”

Brand name medications are capitalized and generic medications are lowercase

3 * State laws in Texas and Louisiana may require your plan to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, these changes may not begin until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card. ** Prices are not guaranteed, and even though a price is displayed in the Drug Cost tool, it’s not a guarantee of coverage. Your costs and coverage may change by the time you fill your prescription at the pharmacy, and medication costs at individual pharmacies can vary. For example, your pharmacy’s retail cash price for a specific medication may be less than the price shown in the Drug Cost tool. Coverage and pricing may change. Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), 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, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms: OK - HP-APP-1 et al (CHLIC), OR - HP-POL38 02-13 (CHLIC), TN - HP-POL43/HC-CER1V1 et al (CHLIC), GSA-COVER, et al (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 825433 v Generics With Diabetic Supplies 10/18 © 2018 Cigna. Some content provided under license. DISCRIMINATION IS AGAINST THE LAW

Medical coverage

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). 896375a 05/17 © 2017 Cigna. Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

NOTICE REGARDING WELLNESS PROGRAMS

SCHOOLCARE’s Good For You! Wellness Programs are voluntary incentive programs available to all subscribers and covered spouses of SCHOOLCARE/Cigna medical plans. The annual incentive program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in this incentive program as a participant of SCHOOLCARE, you will have the opportunity to complete a voluntary Health Assessment or "HA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, heart disease, etc.). You will also be offered the opportunity to complete a biometric screening, which will include a blood test to determine glucose, cholesterol and triglycerides, in addition to blood pressure, height, weight and waist circumference. You are required to complete the HA to earn incentives.

Participants who receive their medical insurance through SCHOOLCARE and who choose to participate in the incentive program will receive an incentive of $150 cash for completing their biometric screening. Although you are not required to complete the biometric screening, only participants who do so will receive the cash incentive.

Additional incentives of up to $650 for subscribers and $250 for covered spouses may be available for participants who complete certain health-related activities including working with a health coach, completing preventive care, participating in healthy events, etc. If you are unable to participate in any of the health-related activities to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting SCHOOLCARE’s health management provider, Cigna at 800-244-6224.

The information from your HA and the results from your biometric screening will be used by Cigna to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the Wellness Programs, such as Health Coaching. You also are encouraged to share your results or concerns with your own doctor.

Page 1 of 2 Back to contents Protections from Disclosure of Medical Information

We are required by law to maintain the privacy and security of your personally identifiable health information. Although SCHOOLCARE and Cigna may use aggregate information collected to design a program based on identified health risks in the workplace, the Good For You! Wellness Programs will never disclose any of your personal information either publicly or to the employer, except as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Wellness Programs, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Wellness Programs or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the Wellness Programs will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are SCHOOLCARE’s Health Management Provider, Cigna in order to provide you with services under the Wellness Programs.

In addition, all medical information obtained through the Wellness Programs will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the Wellness Programs will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the Wellness Programs, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the Wellness Programs, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Lisa Duquette, Executive Director, SCHOOLCARE at 800-562-5254 ext. 305.

Page 2 of 2 Back to contents Effective July 1, 2019

SCHOOLCARE’s 3 Pillars of Wellness; Understand YOU, Take Action & Stay Active help EMPOWER you to make healthy lifestyle choices, take small steps toward changing behaviors, and ADVOCATE for yourself and the well-being of others.

Understand YOU SCHOOLCARE 's Philosophy Is to focus on the subscriber and spouse. We designed the program to help educate adults on their health and wellness in hopes that the habits Build Awareness of your own would then be passed on to their dependents. personal health and wellness Take Action What does well-being mean to you? Choose activities best suited for your own personal health & wellness goals. We are each uniquely motivated. The 3 Pillars of Wellness offer Awareness, Education, and Physical Educate yourself on your own Activity. personal health and well-being Stay Active SCHOOLCARE’s commitment Good For You! is our commitment to your health and well- being. SCHOOLCARE is partnered with Cigna, to provide best practice, evidence-based, achievable and engaging Make Physical Activity wellness programs. part of your lifestyle

SCHOOLCARE/Cigna medical participants can annually earn up to: Subscriber = $800 Covered Spouses & 65+ Retirees = $400 Incentives earned are paid on a quarterly basis

For all questions, please contact SCHOOLCARE’S wellness partner, Cigna 24/7/365: Program Questions: 1-800-244-6224 myCigna Technical Assistance: 1-800-284-8346 Back to contents Effective July 1, 2019

Incentive Summary

The SCHOOLCARE Good For You! wellness programs empowers you to become an advocate for your health. Incentives available beginning July 1 except as indicated below.

Health Assessment To receive cash incentives for participating in the wellness programs the Cigna Health Assessment must be completed annually. Upon completion all incentives earned will become available. Biometrics - $150 Understand YOU Use a Quest or LapCorp facility, attend an on-site screening, or complete a Physician Lab Form. Online Health Coaching - earn up to $250 Earn $50 for each online program completed. Telephonic Health Coaching - earn up to $350 Engage with a Health Professional to support YOU in achieving health goals. Incentive available beginning October 1

Preventive Care Compliance - earn up to $225 Earn $75 for your physician recommended annual age and gender specific preventive services. Incentive available beginning January 1

Omada Program - $250 Meet your weight loss goal of 5% through the Omada Program (look-back to 1/1/2019). Take Action Healthy Pregnancy, Healthy Baby - earn up to $250 Enroll and complete program beginning in the first trimester and earn $250 Enroll and complete program beginning in the second trimester and earn $125

Case Management - earn up to $350 Work with a Cigna Case Manager to coordinate care and/or make progress toward a goal.

Self-Reported Healthy Events - earn up to $300 Stay Active Earn up to $75 for completing activities during the quarter for your total health ($25ea). Incentive available beginning July 1, October 1, January 1, April 1

Apps & Activities - earn up to $400 Earn $50 for each challenge/goal you complete with or without a device/app.

Start earning your SCHOOLCARE Good For You! incentives today using myCigna For easy-to-follow program instructions, videos, and more… visit SchoolCare.org

Note: Cash incentives, payments, and rewards paid to wellness program participants are taxable income. Please review with your tax consultant for more information.

SchoolCare.org ● myCigna.com ● myCigna App Back to contents PREVENTIVE HEALTH CARE

Your guide to understanding what it is and what’s covered

Why Do You Need Preventive Care? What’s Not Preventive Care? Your health care plan covers specific preventive care When your doctor determines that you have a health services. Even when you’re in the best shape of your issue, the additional screenings and tests after this life, a serious condition with no symptoms may put diagnosis are no longer considered preventive. These your health at risk. Using these services at the right services are covered under your plan’s medical time can help you stay healthier by: benefits, not your preventive care benefits.

› Preventing certain illnesses and health conditions What’s Your Share of the Cost? from happening Many plans cover preventive care services at 100% – no Detecting health problems at early stages, when › additional cost to you – when you go to a health care they may be easier to treat professional in your plan’s network. Check your plan To make sure you get the care you need – without any materials for details about your specific medical plan’s unexpected costs – it’s important for you to know: coverage and the provider directory for a list of health › What is preventive care care professionals and facilities in your plan’s network. › Preventive care services your plan covers Even when your appointment is for preventive care, you may receive other services during that exam that What’s Preventive Care? are not preventive. These other services are generally covered under your plan’s medical benefits, not your Preventive care services are provided when you don’t preventive care benefits. This means you may be have any symptoms and haven’t been diagnosed with responsible for paying a portion or all of the cost, a health issue connected with the preventive service. depending on your plan’s deductible, copay, and They typically are provided during a wellness exam. coinsurance amounts. You and your doctor will determine what tests and health screenings are right for you based on your: The charts on the following pages list the services › Age and supplies that are considered preventive care under your plan. › Gender › Personal health history › Current health Questions? Talk with your doctor or call Cigna at the toll-free number on the back of your ID card.

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 855050 g 12/17 Back to contents Wellness exams

SERVICE GROUP AGE, FREQUENCY

Well-baby/well-child/well-person exams, including annual • Birth, 1, 2, 4, 6, 9, 12, 15, 18, 24 and 30 months well-woman exam (includes height, weight, head circumference, BMI, blood • Additional visit at 2–4 days for infants discharged less than 48 hours after delivery pressure, history, anticipatory guidance, education regarding risk reduction, • Ages 3 to 21, once a year psychosocial/behavioral assessment) • Ages 22 and older, periodic visits as doctor advises

The following routine immunizations are currently designated preventive services

SERVICE SERVICE Diphtheria, Tetanus Toxoids and Acellular Pertussis (DTaP, Tdap, Td) Meningococcal (MCV) Haemophilus influenzae type b conjugate (Hib) Pneumococcal (pneumonia) Hepatitis A (Hep A) Poliovirus (IPV) Hepatitis B (Hep B) Rotavirus (RV) Human papillomavirus (HPV) (age criteria apply depending on vaccine brand) Varicella (chickenpox) Influenza vaccine Zoster (shingles) Measles, mumps and rubella (MMR) You may view the immunization schedules on the CDC website: cdc.gov/vaccines/schedules/.

Health screenings and interventions

SERVICE GROUP AGE, FREQUENCY

Abnormal blood glucose and type 2 diabetes screening/counseling Adults ages 40–70 who are overweight or obese Alcohol misuse/substance abuse screening All adults; adolescents age 11–21 Aspirin to prevent cardiovascular disease and colorectal cancer; Adults ages 50–59 with risk factors; or to reduce risk for preeclampsia1 Pregnant women at risk for preeclampsia Autism screening 18, 24 months Bacteriuria screening Pregnant women Bilirubin screening (effective on or after 1/1/18 as plans renew) Newborns before discharge from hospital Breast cancer screening (mammogram) Women ages 40 and older, every 1–2 years Breast-feeding support/counseling, supplies2 During pregnancy and after birth Cervical cancer screening (Pap test) Women ages 21–65, every 3 years HPV DNA test with Pap test Women ages 30–65, every 5 years Chlamydia screening Sexually active women ages 24 and under and older women at risk Cholesterol/lipid disorders screening1 • Screening of children and adolescents ages 9–11 years and 17–21 years; children and adolescents with risk factors ages 2–8 and 12–16 years • All adults ages 40-75 Colon cancer screening1 The following tests will be covered for colorectal cancer screening, ages 50 and older: • Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually • Flexible sigmoidoscopy every 5 years • Double-contrast barium enema (DCBE) every 5 years • Colonoscopy every 10 years • Computed tomographic colonography (CTC)/virtual colonoscopy every 5 years - Requires precertification • Stool-based deoxyribonucleic acid (DNA) test (i.e., Cologuard) every 3 years Congenital hypothyroidism screening Newborns Critical congenital heart disease screening Newborns before discharge from hospital

= Men = Women = Children/adolescents Health screenings and interventions Back to contents

SERVICE GROUP AGE, FREQUENCY

Contraception counseling/education. Women with reproductive capacity Contraceptive products and services1,3, 4 Depression screening Ages 12–21, All adults, including pregnant and postpartum women Developmental screening 9, 18, 30 months Developmental surveillance Newborn, 1, 2, 4, 6, 12, 15, 24 months. At each visit ages 3 to 21 Discussion about potential benefits/risk Women at risk of breast cancer preventive medication1 Dental caries prevention Evaluate water source for sufficient fluoride; if deficient prescribe oral fluoride1 Children older than 6 months Application of fluoride varnish to primary teeth at time of eruption (in primary care setting) Children to age 6 years Domestic and interpersonal violence screening All women (adolescent/adult)

Fall prevention in older adults (physical therapy, vitamin D Community-dwelling adults ages 65 and older with risk factors supplementation1) Folic acid supplementation1 Women planning or capable of pregnancy Genetic counseling/evaluation and BRCA1/BRCA2 testing Women at risk • Genetic counseling must be provided by an independent board-certified genetic specialist prior to BRCA1/BRCA2 genetic testing • BRCA1/BRCA2 testing requires precertification Gestational diabetes screening Pregnant women Gonorrhea screening Sexually active women age 24 years and younger and older women at risk

Hearing screening (not complete hearing examination) All newborns by 2 months. Ages 4, 5, 6, 8, 10. Adolescents once between ages 11-14, 15-17 and 18-21 (effective on or after 2/1/18 as plans renew) Healthy diet and physical activity counseling Ages 6 and older - to promote improvement in weight status; Overweight or obese adults with risk factors for cardiovascular disease Hemoglobin or hematocrit 12 months Hepatitis B screening Pregnant women; adolescents and adults at risk Hepatitis C screening Adults at risk; one-time screening for adults born between 1945 and 1965 High blood pressure screening (outside clinical setting)2 Adults ages 18 and older without known high blood pressure HIV screening and counseling Pregnant women; adolescents and adults 15 to 65 years; younger adolescents and older adults at risk; sexually active women (adolescent/adult), annually Iron supplementation1 6–12 months for children at risk Lead screening 12, 24 months

Lung cancer screening (low-dose computed tomography) Adults ages 55 to 80 with 30 pack-year smoking history, and currently smoke, or have quit within the past 15 years. Computed tomography requires precertification. Metabolic/hemoglobinopathies (according to state law) Newborns Obesity screening/counseling Ages 6 and older, all adults Oral health evaluation/assess for dental referral 6, 9 months. Ages 12 months, 18 months-6 years for children at risk Osteoporosis screening Age 65 or older (or under age 65 for women with fracture risk as determined by Fracture Risk Assessment Score). Computed tomographic bone density study requires precertification PKU screening Newborns

= Men = Women = Children/adolescents Health screenings and interventions Back to contents

SERVICE GROUP AGE, FREQUENCY

Ocular (eye) medication to prevent blindness Newborns Prostate cancer screening (PSA) Men ages 50 and older or age 40 with risk factors Rh incompatibility test Pregnant women Sexually transmitted infections (STI) counseling Sexually active women, annually; sexually active adolescents; and men at increased risk Sexually transmitted infections (STI) screening Adolescents ages 11–21 Sickle cell disease screening Newborns Skin cancer prevention counseling to minimize exposure to Ages 10–24 ultraviolet radiation Syphilis screening Individuals at risk; pregnant women Tobacco use cessation: counseling/interventions1 All adults1; pregnant women Tobacco use prevention (counseling to prevent initiation) School-age children and adolescents Tuberculosis screening Children, adolescents and adults at risk Ultrasound aortic abdominal aneurysm screening Men ages 65–75 who have ever smoked Vision screening (not complete eye examination) Ages 3, 4, 5, 6, 8, 10, 12, and 15 or as doctor advises

= Men = Women = Children/adolescents

1. Subject to the terms of your plan’s pharmacy coverage, certain drugs and products may be covered at 100%. Your doctor is required to give you a prescription, including for those that are available over-the-counter, for them to be covered under your Pharmacy benefit. Cost sharing may be applied for brand-name products where generic alternatives are available. Please refer to Cigna’s “No Cost Preventive Medications by Drug Category” Guide for information on drugs and products with no out-of-pocket cost. 2. Subject to the terms of your plan’s medical coverage, home blood pressure monitoring supplies, breast-feeding equipment rental and supplies may be covered at the preventive level. Your doctor is required to provide a prescription, and the equipment and supplies must be ordered through CareCentrix, Cigna’s national durable medical equipment vendor. Precertification is required for some types of breast pump equipment. To obtain home blood pressure monitoring equipment, breast pump and breast pump supplies, contact CareCentrix at 844.457.9810. 3. Examples include oral contraceptives; diaphragms; hormonal injections and contraceptive supplies (spermicide, female condoms); emergency contraception. 4. Subject to the terms of your plan’s medical coverage, contraceptive products and services such as some types of IUD’s, implants and sterilization procedures may be covered at the preventive level. Check your plan materials for details about your specific medical plan. These preventive health services are based on recommendations from the U.S. Preventive Services Task Force (A and B recommendations), the Advisory Committee on Immunization Practices (ACIP) for immunizations, the American Academy of Pediatrics’ Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care, the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children and, with respect to women, evidence-informed preventive care and screening guidelines supported by the Health Resources and Services Administration. For additional information on immunizations, visit the immunization schedule section of www.cdc.gov. This document is a general guide. Always discuss your particular preventive care needs with your doctor. Some plans choose to supplement the preventive care services listed above with a few additional services, such as other common laboratory panel tests. When delivered during a preventive care visit, these services also may be covered at the preventive level. Exclusions This document provides highlights of preventive care coverage generally. Some preventive services may not be covered under your plan. For example, immunizations for travel are generally not covered. Other non-covered services/supplies may include any service or device that is not medically necessary or services/supplies that are unproven (experimental or investigational). For the specific coverage terms of your plan, refer to the Evidence of Coverage, Summary Plan Description or Insurance Certificate. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms: OK - HP-APP-1 et al (CHLIC); TN - HP-POL43/HC-CER1V1 et al (CHLIC), GSA-COVER, et al (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 855050 g 12/17 © 2017 Cigna. Some content provided under license. Back to contents 90 -DAY PRESCRIPTION FILLS

Filling your maintenance medications just got easier with Cigna 90 NowSM

You have a lot going on. Taking your medication every day and remembering to pick up your refill every month isn’t always easy. We have a program that can help – it’s called Cigna 90 Now. More choice Your plan includes a new maintenance medication program called Cigna 90 Now. Maintenance medications are taken regularly, over time, to treat an ongoing health condition. Cigna 90 Now offers you more choice in Why fill a 90-day supply? how, and where, you can fill your prescription. Filling your prescriptions in a 90-day supply may Choose what works best for you help you stay healthy because having a 90-day › If you choose to fill your prescription in a90-day supply of your medication on-hand typically supply, you have to use a 90-day retail pharmacy means you’re less likely to miss a dose.** It also in your plan’s new network, or Cigna Home means you can make fewer visits to the pharmacy Delivery PharmacySM.* to refill your medication, and depending on your plan, you may be able to save money by filling If you choose to fill your prescription in a30-day › your prescriptions 90-days at a time. supply, you can use any retail pharmacy in your plan’s new network.

Here are some of the 90-day retail pharmacies in your network:*** You choose! 90-day or 30-day supply. › CVS (including Target and Navarro) › Walmart Kroger (including Harris Teeter Pharmacy, Pick N Where you can fill a 90-day prescription › Save Pharmacy, Fred Meyer Pharmacy, Fry’s Food With Cigna 90 Now, your plan offers a new retail and Drug) pharmacy network that gives you more choice in › Access Health (including Benzer Pharmacy, where you can fill your 90-day prescriptions. Marcs, Big Y Pharmacy, Marsh Drugs, LLC, Snyder There are thousands of retail pharmacies in your Drug Emporium) new network. They include local pharmacies, › Good Neighbor Pharmacies (including Big Y grocery stores, retail chains and wholesale warehouse Pharmacy, Super RX Pharmacy, Medical Center stores – all places where you may already shop! If you Pharmacy, Family Pharmacy, King Kullen Pharmacy) prefer the convenience of having your medications › Cardinal Health (including Freds Pharmacy, delivered to your home, you can also use Cigna Home Medicine Shoppe Pharmacy, Harris Teeter Pharmacy, Delivery Pharmacy to fill your prescriptions.* Medicap Pharmacy) For more information about your new pharmacy network, you can go to Cigna.com/Rx90network.

893345 f VoluntaryCigna90Now 11/18 Back to contents

Prefer to have your medications delivered to your door? Questions? Then Cigna Home Delivery Pharmacy may be right Please call Customer Service for you! We’ll deliver your maintenance medication using the number on the back to you at the location of your choice. And standard of your Cigna ID card. shipping is always free. No more waiting in line at We’re here to help. the pharmacy! For more information, please call Customer Service at 800.835.3784, #3, or visit Cigna.com/home-delivery-pharmacy.

90-Day Fills

Get a 90-day prescription Take your prescription to a 90-day Receive your medication for your medication retail pharmacy in your network, in a 90-day supply for or mail to Cigna Home convenience Delivery Pharmacy 30-Day Fills

Get a 30-day prescription for Take your prescription to any Receive your medication your maintenance medication retail pharmacy in your network

* Plans vary, so some plans may not include Cigna Home Delivery Pharmacy. Please check your plan materials for more information on what pharmacies are covered under your plan. ** Internal Cigna analysis performed March 2016, utilizing 2015 Cigna national book of business average medication adherence (customer adherent > 80% PDC), 90-day supply vs. those who received a 30-day supply taking antidiabetics, RAS antagonist and statins. *** Participating 90-day network pharmacies as of April 2016. Subject to change. Para obtener ayuda en español llame al número en su tarjeta de Cigna. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage. 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 Health Management, Inc., Tel-Drug, Inc., and Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 893345 f VoluntaryCigna90Now 11/18 © 2018 Cigna. Some content provided under license. Back to contents KNOW BEFORE YOU GO

Your guide for where to go when you need medical care.

Lower Cost and time Greater

Cigna Telehealth Convenience Doctor’s office Urgent care center Emergency room Connection Care clinic Access telehealth services to Treats minor medical concerns. The best place to go for routine For conditions that aren’t life For immediate treatment of treat minor medical conditions. Staffed by nurse practitioners or preventive care, to keep track threatening. Staffed by nurses critical injuries or illness. Open Connect with a board-certified and physician assistants. of medications, or for a referral and doctors and usually have 24/7. If a situation seems doctor via video or phone when Located in retail stores and to see a specialist. extended hours. life‑threatening, call 911 or go where and how it works best for pharmacies. Often open nights to the nearest emergency room. you. Visit the website or call and weekends. “Freestanding” emergency room (ER) to register.1 locations are becoming more common AmwellforCigna.com in many areas. Because these ERs 855-667-9722 are not inside hospitals, they may look like urgent care centers. When you MDLIVEforCigna.com receive care at an ER, you’re billed at 888-726-3171 a much higher cost than at other health care facilities. › Colds and flu › Colds and flu › General health issues › Fever and flu symptoms › Sudden numbness, weakness 2 › Rashes › Rashes or skin conditions › Preventive care › Minor cuts, sprains, › Uncontrolled bleeding › Sore throats › Sore throats, earaches, › Routine checkups burns, rashes › Seizure or loss of consciousness › Headaches sinus pain › Immunizations and › Headaches › Shortness of breath › Stomachaches › Minor cuts or burns screenings › Lower back pain › Chest pain › Fever › Pregnancy testing › Joint pain › Head injury/major trauma › Allergies › Vaccines › Minor respiratory symptoms › Blurry or loss of vision

Conditions treated Conditions › Acne › Urinary tract infections › Severe cuts or burns › UTIs and more › Overdose

3 › Costs the same or less than › Same or lower than › May charge copay/ › Costs lower than ER › Highest cost a visit with your primary doctor’s office coinsurance and/ › No appointment needed › No appointment needed care provider › No appointment needed or deductible › Wait times vary › Wait times may be long › Appointments typically in › Usually need appointment an hour or less › Short wait times › No need to leave home Your cost and time cost Your or work

Cigna Health Information Line A telephone service staffed by nurses that helps you understand and make informed decisions about health issues you are experiencing, at no extra cost. It can help you choose the right care in the right setting at the right time, whether it’s reviewing home treatment options, following up on a doctor’s appointment, or finding the nearest urgent care center. Just call the number on your Cigna ID card. Open 24/7.

To find a specific health care facility or doctor, go to myCigna.com or use the myCigna Mobile App.

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 900766 a 04/17 Back to contents

1. Amwell/MDLIVE are independent companies/entities and are not affiliated with Cigna. The services, websites and mobile apps are provided exclusively by Amwell/MDLIVE and not by Cigna. Not all providers have video chat capabilities. Video chat is not available in all areas. Amwell/MDLIVE services are separate from your health plan’s provider network. Telehealth services may not be available in all areas or under all plan types. A Primary Care Provider referral is not required for Amwell/MDLIVE services. 2. This list is not all inclusive and is for informational purposes only. This list is NOT a description of coverage or a guarantee that these or any other services provided by the health care professional or facility are covered under your employer’s specific group health plan or insurance policy. Check your employer’s official plan documents for information about the services covered under your plan benefits. 3. Check your employer’s official plan documents for information about the costs you are responsible for under your employer’s specific medical plan, including any deductible, copayment and/ or coinsurance or other requirements. The information provided here is intended to be general information on how you can get the most out of your plan and your health care dollars. It is not intended as medical advice. You should consider all relevant factors and to consult with your treating doctor when selecting a provider for care. During a medical emergency, go to the nearest hospital or call 911. Providers that participate in the Cigna network and the AmWell/MDLIVE programs are independent contractors solely responsible for the care and services delivered to their patients. They are not agents of Cigna. Exclusions and limitations: All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and complete details of coverage, see your plan documents. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company (CGLIC), Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms: OK - HP-APP-1 et al. (CHLIC), GM6000 C1 et al. (CGLIC); TN - HP-POL43/HC-CER1V1 et al. (CHLIC), GSA- COVER, et al. (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 900766 a 04/17 © 2017 Cigna. Some content provided under license. Back to contents

MAKE MYCIGNA YOUR PERSONAL HEALTH PLACE

Enjoy a simple way to personalize, organize and access your important plan information.

Register on myCigna. Once you do, you can log in anytime, anywhere to: › Manage and track claims › View ID card information › Find doctors and compare cost and quality ratings › Review your coverage › Track your account balances and deductibles › Compare prescription drug prices at thousands of pharmacies in our network

Go to myCigna.com to go paperless! After you register, you can set up paperless communications. Just log in to myCigna.com and select "Go Paperless".

Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. | Android and Google Play are trademarks of Google Inc. *The downloading and use of the myCigna Mobile App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and data usage charges apply. “Cigna” and the “Tree of Life” logo are registered service marks, and “Together, all the way.” is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company (CGLIC), and HMO subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc. (IL & IN), Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc. (MO, KS & IL), Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (TN & MS), and Cigna HealthCare of Texas, Inc. OK Policy Forms: GM6000 C1 et al (CGLIC); HP-APP-1 et al (CHLIC). 881825 12/14 © 2014 Cigna Some content provided under license. SR 35796423-79908788 Back to contents

Have questions? Don’t see what you’re looking for? Contact us to get the assistance you need.

Call 1.877.622.4327 Log in to CignaBehavioral.com and enter your Employer ID: schoolcare

Employee Assistance & Work/Life Support Program WE CAN HELP 24/7 YOU WITH THAT

Explore the programs and services available to you.

Employee Assistance & Work/Life Support Program 24/7 **Legal consultations related to employment matters are not available under this program. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Behavioral Health, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Base Catalog 818480 c 12/15 © 2015 Cigna. Some content provided under license. 818480 c 12/15 SR # Back to contents Employee TAKE A DEEP BREATH. A well-balanced offering to help you Assistance & live a well-balanced life. WE'RE HERE TO HELP. Work/Life Give us a call or go online to locate referrals for support Support Program services, such as: The enclosed listing is just a small sampling of the support available to you at no additional 24/7 Child Care: Whether you need care all cost with your Employee Assistance & day, before/after school, during the Work/Life Support Program. summer or just want a back-up plan for If you can’t seem to find exactly what you’re unplanned events, we’ll help you find a looking for, remember: we’re always just a call place, program or person that’s right for or click away. your family. Call us anytime, any day. Financial Services & Referral: Take advantage of a free 30-minute financial We’re here to listen to your needs, get you the consultation by phone and 25% off on information you need and guide you toward tax preparation. the right solution. Identity Theft: Learn how to protect yourself from and respond correctly to Get in touch. Call We can also direct you to a variety of helpful identity theft with a free 60-minute resources in your community. 1.877.622.4327 or visit expert consultation by phone. CignaBehavioral.com Get the support you need conveniently online. Legal Consulting**: Get a free 30-minute and enter your consultation and up to 25% off select › Read educational materials on work or fees. Employer ID: life topics. Pet Care: From vets to dog walkers, we’ll schoolcare › Access various interactive tools related to help connect you with the right people health and wellness. and places to ensure your pets are well › Explore our stress toolkit, which includes taken care of. assessment tools, articles and stress Senior Care: Learn about challenges and management techniques. solutions related to caring for an aging Visit an Employee Assistance Program loved one. (EAP) provider.

1-3 sessions are available to you and your household members. Call us or go online, search the provider directory and request an authorization.

Get in touch. Call 1.877.622.4327 or visit CignaBehavioral.com and enter your Employer ID: schoolcare Back to contents

Identity Fraud Expense Reimbursement

COVERAGE HIGHLIGHTS

Identity fraud is the fastest-growing white-collar crime in America, Each year, the number of identity fraud cases impacting one in every 20 consumers.* rises; most recently 12.6 million adults in the United States were victims. On average, it Why you need protection takes an individual more than 37 hours and Becoming a victim of identity fraud is a frightening, frustrating $535 in out-of-pocket expenses* to clean up experience. It can happen to anyone at any time in a variety of ways, ranging from a stolen wallet or home burglary to online the mess caused by an identity thief. theft of your personal information.

Recovering from identity fraud means more than just canceling In addition to expense reimbursement, Travelers also offers credit cards. Not only can it be a complicated and stressful Identity Fraud Resolution Service through Identity Theft 911, experience, but it can cost your employee or member of your which includes: organization hours of time and out-of-pocket expenses to • Exclusive online education resources providing tips and re-establish their credit and clear their name. The hard reality information to help avoid becoming a victim is that victims must painstakingly prove, often to disbelieving creditors, that the debts are not their own. Purchasing identity • 24/7 personal access to an expert fraud specialist fraud expense reimbursement coverage for your employees or • Document replacement help (i.e., Social Security card, members can be an affordable and compelling addition to your birth certificate, passport, etc.) benefits suite. In the event of an actual identity fraud, services include: Coverage highlights • Step-by-step guidance through the resolution process, Travelers Identity Fraud Expense Reimbursement coverage pays including unlimited assistance to restore a victim’s identity for expenses associated with resolving an identity fraud event and • 3-in-1 credit reporting perhaps most importantly, gives people tools and information to reduce their risk of future additional fraud. • One year of free credit, cyber and fraud monitoring

*Javelin Strategy & Research, February 2013 Report