Summary Of Benefits And Coverage: Coverage Period: 01/01 .

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCigna HealthCare of Arizona, Inc.: Cigna Connect 7000Coverage Period: 01/01/2020 – 12/31/2020Coverage for: Individual&Family Plan Type: HMOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866-494-2111 or visit us y For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-866-494-2111to request a copy.Important QuestionsAnswersWhat is the overalldeductible? 7,000 person/ 14,000 familyWhy This Matters:Generally, you must pay all of the costs from providers up to the deductible amount before thisplan begins to pay. If you have other family members on the plan, each family member must meettheir own individual deductible until the total amount of deductible expenses paid by all familymembers meets the overall family deductible.Are there servicescovered before you meetyour deductible?Yes. Preventive care, eyeexam/glasses for children andHome health care are coveredbefore you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. Buta copayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at e-benefits/.Are there otherdeductibles for specificservices?No.You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan? 8,150 person/ 16,300 familyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have otherfamily members in this plan, they have to meet their own out-of-pocket limits until the overallfamily out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Will you pay less if youuse a network provider?Premiums, balance-billingcharges, penalties for failure toobtain preauthorization forservices and health care this plandoesn’t cover.Yes. See www.cigna.com/ifpproviders or call 1-866-494-2111for a list of network providers.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.This plan uses a provider network. You will pay less if you use a provider in the plan’s network.You will pay the most if you use an out-of-network provider, and you might receive a bill from aprovider for the difference between the provider’s charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.1 of 6

Do you need a referral tosee a specialist?Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if youhave a referral before you see the specialist.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedPrimary care visit to treat aninjury or illnessIf you visit a healthcare provider’s officeor clinicSpecialist visitWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)50% coinsurance.Includes Virtual visitNot Coveredwith a Cigna TelehealthConnection Physician.50% coinsuranceLimitations, Exceptions, & Other ImportantInformationRefer to the policy for more information aboutVirtual Telehealth Visits.Not CoveredNone.Preventive care/screening/immunizationNo chargeNot CoveredYou may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for.Diagnostic test (x-ray, bloodwork)50% coinsuranceNot CoveredNone.Imaging (CT/PET scans, MRIs)50% coinsuranceNot CoveredNone.If you have a test2 of 6

CommonMedical EventServices You May NeedPreferred generic drugsIf you need drugs totreat your illness orGeneric drugsconditionMore information aboutprescription drugPreferred brand drugscoverage is available atwww.cigna.com/ifpdrug-listNon-preferred drugsIf you need immediatemedical attention10% coinsurance(retail/home delivery)Not Covered50% coinsurance(retail/home delivery)Not Covered40% coinsurance(retail/home delivery)Not Covered50% coinsurance(retail/home delivery)Not Covered50% coinsurance(retail); 40%coinsurance (homedelivery)Limitations, Exceptions, & Other ImportantInformationLimited to a 30 day supply at any participatingpharmacy or up to a 90 day supply at adesignated 90 day retail pharmacy/homedelivery.Not CoveredLimited to a 30 day supply at any participatingpharmacy or up to a 30 day supply at adesignated 90 day retail pharmacy/homedelivery.50% coinsuranceNot CoveredNone.50% coinsuranceNot CoveredNone.Emergency room care50% coinsurance50% coinsuranceEmergency medicaltransportation50% coinsurance50% coinsuranceUrgent care50% coinsurance50% coinsuranceSpecialty drugs and other highcost drugsIf you have outpatientsurgeryWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Facility fee (e.g., ambulatorysurgery center)Physician/surgeon feesYou pay the same level as In-network if it is anemergency as defined in your plan, otherwiseNot Covered.3 of 6

CommonMedical EventIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesIf you are pregnantIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careServices You May NeedWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Limitations, Exceptions, & Other ImportantInformationFacility fee (e.g., hospital room) 50% coinsuranceNot CoveredNone.Physician/surgeon fees50% coinsuranceNot CoveredNone.Outpatient services50% coinsuranceNot CoveredNone.Inpatient services50% coinsuranceNot CoveredNone.Office visitsChildbirth/delivery professionalservicesChildbirth/delivery facilityservicesHome health careRehabilitation servicesHabilitation servicesSkilled nursing careDurable medical equipmentHospice services50% coinsuranceNot Covered50% coinsuranceNot Covered50% coinsuranceNot CoveredNo charge35% coinsurance35% coinsurance50% coinsurance35% coinsurance50% coinsuranceNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredChildren’s eye examNo chargeNot CoveredChildren’s glassesNo chargeNot CoveredChildren’s dental check-upNot coveredNot CoveredCost sharing does not apply for preventiveservices. Depending on the type of services,coinsurance may apply. Maternity care mayinclude tests and services describedelsewhere in the SBC (i.e. ultrasound).Coverage is limited to 42 visits annual max.Coverage is limited to 60 visits annual max.Coverage is limited to 60 visits annual max.None.None.None.Children up to age 19. Coverage limited to oneexam/year.Children up to age 19. Coverage limited to onepair of glasses/year.Coverage is available through a stand-alonedental policy.Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Non-emergency care when traveling outside the Cosmetic SurgeryU.S. Elective Abortion Dental Care (Adult) Routine eye care (Adult) Infertility Treatment Dental Care (Child) (coverage available through Routine Foot Care Long Term Carea stand-alone dental policy) Weight Loss Programs4 of 6

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric Surgery (Benefit depends on type of Private-duty nursing (If determined to be Hearing Aids (Maximum of 1 hearing aid per ear,service provided)medically necessary; as part of inpatient hospitalper calendar year)care coverage.) Chiropractic CareYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: Arizona Department of Insurance at 1-602-364-2499. Other coverage options may be available to you too, including buying individual insurancecoverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. For moreinformation on your rights to continue coverage, contact the insurer at 1-866-494-2111.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: Arizona Department of Insurance at 1-602-364-2499.Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month.Does this plan meet Minimum Value Standards? N/A.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-866-494-2111.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-494-2111.Chinese (中文): �1-866-494-2111.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' �––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next ––––––––5 of 6