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Cigna Health and Life Insurance Co.: Open Access Plus Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016 - 09/30/2016 Coverage for: Individual/Individual + Family | Plan Type: OAP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cigna.com/sp/ or by calling 1-800-Cigna24 What is the overall deductible? Important Questions Answers For in-network providers $500 person / $1,000 family For out-of-network providers $1,000 person / $2,000 family Does not apply to in-network preventive care & immunizations, in-network office visits, prescription drugs Co-payments don't count toward the deductible. Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? Yes, $100 per admission for out-of-network hospital stay There are no other specific deductibles. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Is there an out-of-pocket limit on my expenses? Yes. For in-network providers $5,000 person / $10,000 family For out-of-network providers $10,000 person / $20,000 family The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out-of-pocket limit? Premium, balance-billed charges, penalties for no pre- authorization, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of- pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. For a list of participating providers, see www.myCigna.com or call 1-800-Cigna24 If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in- network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do | need a referral to see a specialist? No. You don't need a referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn't cover? Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 1 of 8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? e Costs don't include premiums. e Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. e The patient's condition was not an excluded or pre existing condition. e Allservices and treatments started and ended in the same coverage period. e There are no other medical expenses for any member covered under this plan. e Out-of-pocket expenses are based only on treating the condition in the example. e The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? x No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can | use Coverage Examples to compare plans? v Yes, When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs | should consider when comparing plans? v Yes, An important cost is the premium you pay. Generally, the lower your_premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Plan ID: 5176678 BenefitVersion: 5 Plan Name: 5176678 OAP HP-POL/HP-APP 9/23/12 Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. 8 of 8