socorro independent school district...socorro independent school district open access plus medical...

Socorro Independent SchoolDistrict

OPEN ACCESS PLUS MEDICALBENEFITS

HRA Plan

EFFECTIVE DATE: September 1, 2009

ASO8

3325396

This document printed in January, 2010 takes the place of any documents previously issued to you whichdescribed your benefits.

Printed in U.S.A.

Table of Contents

Important Information..................................................................................................................5

Special Plan Provisions..................................................................................................................7

Case Management ..................................................................................................................................................7

How To File Your Claim ...............................................................................................................9

Accident and Health Provisions....................................................................................................9

Eligibility — Effective Date.........................................................................................................10

Waiting Period......................................................................................................................................................10

Employee Insurance .............................................................................................................................................10

Dependent Insurance ............................................................................................................................................10

Open Access Plus Medical Benefits ............................................................................................11

The Schedule ........................................................................................................................................................11

Certification Requirements - Out-of-Network......................................................................................................24

Prior Authorization/Pre-Authorized .....................................................................................................................24

Covered Expenses ................................................................................................................................................24

Exclusions, Expenses Not Covered and General Limitations..................................................34

Coordination of Benefits..............................................................................................................37

Medicare Eligibles........................................................................................................................39

Expenses For Which A Third Party May Be Responsible .......................................................40

Payment of Benefits .....................................................................................................................41

Termination of Insurance............................................................................................................42

Employees ............................................................................................................................................................42

Dependents ...........................................................................................................................................................42

Medical Benefits Extension .........................................................................................................43

Federal Requirements .................................................................................................................43

Notice of Provider Directory/Networks................................................................................................................43

Qualified Medical Child Support Order (QMCSO) .............................................................................................44

Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) ..................44

Effect of Section 125 Tax Regulations on This Plan............................................................................................46

Eligibility for Coverage for Adopted Children.....................................................................................................46

Federal Tax Implications for Dependent Coverage ..............................................................................................46

Coverage for Maternity Hospital Stay..................................................................................................................47

Women’s Health and Cancer Rights Act (WHCRA) ...........................................................................................47

Group Plan Coverage Instead of Medicaid...........................................................................................................47

Pre-Existing Conditions Under the Health Insurance Portability & Accountability Act (HIPAA) ......................47

Requirements of Medical Leave Act of 1993 (as amended) (FMLA)..................................................................48

Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)....................................48

When You Have a Complaint or an Adverse Determination Appeal .....................................49

COBRA Continuation Rights Under Federal Law ...............................................................................................51

Definitions.....................................................................................................................................55

What You Should Know about CIGNA Choice Fund® – Health ReimbursementArrangement ................................................................................................................................63

Important InformationTHIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET ORANY RIDER ATTACHED HERETO ARE SELF-INSURED BY SOCORRO INDEPENDENT SCHOOLDISTRICT WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CONNECTICUT GENERAL PROVIDESCLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CONNECTICUT GENERAL DOES NOTINSURE THE BENEFITS DESCRIBED.

THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CONNECTICUTGENERAL. BECAUSE THE PLAN IS NOT INSURED BY CONNECTICUT GENERAL, ALLREFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED.FOR EXAMPLE, REFERENCES TO "CG," "INSURANCE COMPANY," AND "POLICYHOLDER" SHALLBE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TOMEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."

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For Employees who reside in Canada, this plan is available to the extent that services are not coveredunder a Provincial government health insurance plan.

Explanation of Terms

You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these termsare defined in the Definitions section of your certificate.

The Schedule

The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full descriptionof each benefit, refer to the appropriate section listed in the Table of Contents.

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Special Plan ProvisionsWhen you select a Participating Provider, this Plan pays agreater share of the costs than if you select a non-ParticipatingProvider. Participating Providers include Physicians, Hospitalsand Other Health Care Professionals and Other Health CareFacilities. Consult your Physician Guide for a list ofParticipating Providers in your area. Participating Providersare committed to providing you and your Dependentsappropriate care while lowering medical costs.

Services Available in Conjunction With Your MedicalPlan

The following pages describe helpful services available inconjunction with your medical plan. You can access theseservices by calling the toll-free number shown on the back ofyour ID card.

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CIGNA'S Toll-Free Care Line

CIGNA's toll-free care line allows you to talk to a health careprofessional during normal business hours, Monday throughFriday, simply by calling the toll-free number shown on yourID card.

CIGNA's toll-free care line personnel can provide you with thenames of Participating Providers. If you or your Dependentsneed medical care, you may consult your Physician Guidewhich lists the Participating Providers in your area or callCIGNA's toll-free number for assistance. If you or yourDependents need medical care while away from home, youmay have access to a national network of ParticipatingProviders through CIGNA's Away-From-Home Care feature.Call CIGNA's toll-free care line for the names of ParticipatingProviders in other network areas. Whether you obtain thename of a Participating Provider from your Physician Guide orthrough the care line, it is recommended that prior to makingan appointment you call the provider to confirm that he or sheis a current participant in the Open Access Plus Program.

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Case Management

Case Management is a service provided through a ReviewOrganization, which assists individuals with treatment needsthat extend beyond the acute care setting. The goal of CaseManagement is to ensure that patients receive appropriate care

in the most effective setting possible whether at home, as anoutpatient, or an inpatient in a Hospital or specialized facility.Should the need for Case Management arise, a CaseManagement professional will work closely with the patient,his or her family and the attending Physician to determineappropriate treatment options which will best meet thepatient's needs and keep costs manageable. The Case Managerwill help coordinate the treatment program and arrange fornecessary resources. Case Managers are also available toanswer questions and provide ongoing support for the familyin times of medical crisis.

Case Managers are Registered Nurses (RNs) and othercredentialed health care professionals, each trained in aclinical specialty area such as trauma, high risk pregnancy andneonates, oncology, mental health, rehabilitation or generalmedicine and surgery. A Case Manager trained in theappropriate clinical specialty area will be assigned to you oryour Dependent. In addition, Case Managers are supported bya panel of Physician advisors who offer guidance on up-to-date treatment programs and medical technology. While theCase Manager recommends alternate treatment programs andhelps coordinate needed resources, the patient's attendingPhysician remains responsible for the actual medical care.

1. You, your dependent or an attending Physician canrequest Case Management services by calling the toll-freenumber shown on your ID card during normal businesshours, Monday through Friday. In addition, youremployer, a claim office or a utilization review program(see the PAC/CSR section of your certificate) may referan individual for Case Management.

2. The Review Organization assesses each case to determinewhether Case Management is appropriate.

3. You or your Dependent is contacted by an assigned CaseManager who explains in detail how the program works.Participation in the program is voluntary - no penalty orbenefit reduction is imposed if you do not wish toparticipate in Case Management.

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4. Following an initial assessment, the Case Manager workswith you, your family and Physician to determine theneeds of the patient and to identify what alternatetreatment programs are available (for example, in-homemedical care in lieu of an extended Hospitalconvalescence). You are not penalized if the alternatetreatment program is not followed.

5. The Case Manager arranges for alternate treatmentservices and supplies, as needed (for example, nursing

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services or a Hospital bed and other Durable MedicalEquipment for the home).

6. The Case Manager also acts as a liaison between theinsurer, the patient, his or her family and Physician asneeded (for example, by helping you to understand acomplex medical diagnosis or treatment plan).

7. Once the alternate treatment program is in place, the CaseManager continues to manage the case to ensure thetreatment program remains appropriate to the patient'sneeds.

While participation in Case Management is strictly voluntary,Case Management professionals can offer quality, cost-effective treatment alternatives, as well as provide assistancein obtaining needed medical resources and ongoing familysupport in a time of need.

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Additional Programs

We may, from time to time, offer or arrange for variousentities to offer discounts, benefits, or other consideration toour members for the purpose of promoting the general healthand well being of our members. We may also arrange for thereimbursement of all or a portion of the cost of servicesprovided by other parties to the Policyholder. Contact us fordetails regarding any such arrangements.

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Important Information About Your MedicalPlan

Details of your medical benefits are described on thefollowing pages.

Opportunity to Select a Primary Care Physician

Choice of Primary Care Physician:

This medical plan does not require that you select a PrimaryCare Physician or obtain a referral from a Primary CarePhysician in order to receive all benefits available to youunder this medical plan. Notwithstanding, a Primary CarePhysician may serve an important role in meeting your healthcare needs by providing or arranging for medical care for youand your Dependents. For this reason, we encourage the use ofPrimary Care Physicians and provide you with the opportunityto select a Primary Care Physician from a list provided by CGfor yourself and your Dependents. If you choose to select aPrimary Care Physician, the Primary Care Physician youselect for yourself may be different from the Primary CarePhysician you select for each of your Dependents.

Changing Primary Care Physicians:

You may request a transfer from one Primary Care Physicianto another by contacting us at the member services number onyour ID card. Any such transfer will be effective on the firstday of the month following the month in which the processingof the change request is completed.

In addition, if at any time a Primary Care Physician ceases tobe a Participating Provider, you or your Dependent will benotified for the purpose of selecting a new Primary CarePhysician, if you choose.

NOT123 V1

Notice of Coverage for Acquired Brain Injury

Your health benefit plan coverage for an acquired brain injuryincludes the following services:

cognitive rehabilitation therapy;

cognitive communication therapy;

neurocognitive therapy and rehabilitation;

neurobehavioral, neurophysiological, neuropsychologicaland psychophysiological testing and treatment;

neurofeedback therapy and remediation;

post-acute transition services and community reintegrationservices, including outpatient day treatment services orother post-acute care treatment services; and

reasonable expenses related to periodic reevaluation of thecare of an individual covered under the plan who hasincurred an acquired brain injury, has been unresponsive totreatment, and becomes responsive to treatment at a laterdate, at which time the cognitive rehabilitation serviceswould be a covered benefit.

The fact that an acquired brain injury does not result inhospitalization or acute care treatment does not affect the rightof the insured or the enrollee to receive the precedingtreatments or services commensurate with their condition.Post-acute care treatment or services may be obtained in anyfacility where such services may legally be provided,including acute or post-acute rehabilitation hospitals andassisted living facilities regulated under the Health and SafetyCode.

GM6000 NOT207

Notice of Certain Mandatory Benefits

This notice is to advise you of certain coverage and/or benefitsprovided by your contract with Connecticut General LifeInsurance Company.

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Examinations for Detection of Cervical Cancer

Benefits are provided for each covered female age 18 and overfor an annual medically recognized diagnostic examination forthe early detection of cervical cancer. Benefits include at aminimum:

(a) a conventional Pap smear screening; or

(b) a screening using liquid-based cytology methods, asapproved by the United States Food and DrugAdministration, alone or in combination with a testapproved by the United States Food and DrugAdministration for the detection of the humanpapillomavirus.

If any person covered by this plan has questions concerningthe above, please call Connecticut General Life InsuranceCompany at 1-800-244-6224, or write us at the address on theback of your ID card.

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How To File Your ClaimThe prompt filing of any required claim form will result infaster payment of your claim.

You may get the required claim forms from your Benefit PlanAdministrator. All fully completed claim forms and billsshould be sent directly to your servicing CG Claim Office.

Depending on your Group Insurance Plan benefits, file yourclaim forms as described below.

Hospital Confinement

If possible, get your Group Medical Insurance claim formbefore you are admitted to the Hospital. This form will makeyour admission easier and any cash deposit usually requiredwill be waived.

If you have a Benefit Identification Card, present it at theadmission office at the time of your admission. The card tellsthe Hospital to send its bills directly to CG.

Doctor's Bills and Other Medical Expenses

The first Medical Claim should be filed as soon as you haveincurred covered expenses. Itemized copies of your billsshould be sent with the claim form. If you have any additionalbills after the first treatment, file them periodically.

CLAIM REMINDERS

BE SURE TO USE YOUR MEMBER ID ANDACCOUNT NUMBER WHEN YOU FILE CG'S CLAIMFORMS, OR WHEN YOU CALL YOUR CG CLAIMOFFICE.

YOUR MEMBER ID IS THE ID SHOWN ON YOURBENEFIT IDENTIFICATION CARD.

YOUR ACCOUNT NUMBER IS THE 7-DIGIT POLICYNUMBER SHOWN ON YOUR BENEFITIDENTIFICATION CARD.

PROMPT FILING OF ANY REQUIRED CLAIM FORMSRESULTS IN FASTER PAYMENT OF YOUR CLAIMS.

WARNING: Any person who knowingly presents a false orfraudulent claim for payment of a loss or benefit is guilty of acrime and may be subject to fines and confinement in prison.

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Accident and Health ProvisionsNotice of Claim

Written notice of claim must be given to CG within 30 daysafter the occurrence or start of the loss on which claim isbased. If notice is not given in that time, the claim will not beinvalidated or reduced if it is shown that written notice wasgiven as soon as was reasonably possible.

Claim Forms

When CG receives the notice of claim, it will give to theclaimant, or to the Employer for the claimant, the claim formswhich it uses for filing proof of loss. If the claimant does notreceive these claim forms within 15 days after CG receivesnotice of claim, he will be considered to meet the proof of lossrequirements if he submits written proof of loss within 90 daysafter the date of loss. This proof must describe the occurrence,character and extent of the loss for which claim is made.

Proof of Loss

Written proof of loss must be given to CG within 90 days afterthe date of the loss for which claim is made. If written proof ofloss is not given in that time, the claim will not be invalidatedor reduced if it is shown that written proof of loss was given assoon as was reasonably possible.

Physical Examination

The Employer, at its own expense, will have the right toexamine any person for whom claim is pending as often as itmay reasonably require.

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Eligibility — Effective DateEligibility for Employee Insurance

You will become eligible for insurance on the day youcomplete the waiting period if:

you are in a Class of Eligible Employees; and

you are an eligible, full-time Employee and you normallywork at least 37.5 hours a week; or

you are an eligible food service Employee, bus driver or busmonitor and you normally work at least 20 hours a week.

If you were previously insured and your insurance ceased, youmust satisfy the New Employee Group Waiting Period tobecome insured again. If your insurance ceased because youwere no longer employed in a Class of Eligible Employees,you are not required to satisfy any waiting period if you againbecome a member of a Class of Eligible Employees withinone year after your insurance ceased.

Initial Employee Group: You are in the Initial EmployeeGroup if you are employed in a class of employees on the datethat class of employees becomes a Class of EligibleEmployees as determined by your Employer.

New Employee Group: You are in the New Employee Groupif you are not in the Initial Employee Group.

Eligibility for Dependent Insurance

You will become eligible for Dependent insurance on the laterof:

the day you become eligible for yourself; or

the day you acquire your first Dependent.

Waiting Period

Initial Employee Group: The first day of the month following30 days from date of hire.

New Employee Group: The first day of the month following30 days from date of hire.

Classes of Eligible Employees

Each Employee as reported to the insurance company by yourEmployer.

Employee Insurance

This Plan is offered to you as an Employee.

Effective Date of Your Insurance

You will become insured on the date you become eligible ifyou are in Active Service on that date or, if you are not inActive Service due to your health status, on that date.However, you will not be insured for any loss of life,

dismemberment or loss of income coverage until you are inActive Service.

You will not be enrolled for Medical Insurance if you do notenroll within 30 days of the date you become eligible, unlessyou qualify under the section of this certificate entitled"Special Enrollment Rights Under the Health InsurancePortability & Accountability Act (HIPAA)".

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Dependent Insurance

For your Dependents to be insured, you will have to pay partof the cost of Dependent Insurance.

Effective Date of Dependent Insurance

Insurance for your Dependents will become effective on thedate you elect it by signing an approved payroll deductionform, but no earlier than the day you become eligible forDependent Insurance. All of your Dependents as defined willbe included.

Your Dependent will not be denied enrollment for MedicalInsurance due to health status.

Your Dependents will be insured only if you are insured.

You will not be eligible to enroll your Dependents if you donot enroll them within 30 days of the date you becomeeligible, unless you qualify under the section of this certificateentitled "Special Enrollment Rights Under the HealthInsurance Portability & Accountability Act (HIPAA)".

Exception for Newborns

Any Dependent child born while you are insured for MedicalInsurance will become insured for Medical Insurance on thedate of his birth if you elect Dependent Medical Insurance nolater than 31 days after his birth. If you do not elect to insureyour newborn child within such 31 days, coverage for thatchild will end on the 31st day. No benefits for expensesincurred beyond the 31st day will be payable.

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OPEN ACCESS PLUS MEDICAL BENEFITS

The Schedule

For You and Your Dependents

Open Access Plus Medical Benefits provide coverage for care In-Network and Out-of-Network. To receive Open AccessPlus Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for servicesand supplies. That portion is the Copayment, Deductible or Coinsurance.

If you are unable to locate an In-Network Provider in your area who can provide you with a service or supply that iscovered under this plan, you must call the number on the back of your I.D. card to obtain authorization for Out-of-Network Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, benefits forthose services will be covered at the In-Network benefit level.

Coinsurance

The term Coinsurance means the percentage of charges for Covered Expenses that an insured person is required to payunder the plan.

Deductibles

Deductibles are also expenses to be paid by you or your Dependent. Deductibles are in addition to any Coinsurance.Once the Deductible maximum in The Schedule has been reached, you and your family need not satisfy any furthermedical deductible for the rest of that year.

Out-of-Pocket Expenses

Out-of-Pocket Expenses are Covered Expenses incurred for In-Network and Out-of-Network charges that are not paid bythe benefit plan because of any:

Coinsurance.

In-Network Plan Deductibles.

Charges will not accumulate toward the Out-of-Pocket Maximum for Covered Expenses incurred for:

Mental Health (other than Biologically Based Mental Illness) treatment.

non-compliance penalties.

provider charges in excess of the Maximum Reimbursable Charge.

When the Out-of-Pocket Maximum shown in The Schedule is reached, Injury and Sickness benefits are payable at 100%except for:

Mental Health (other than Biologically Based Mental Illness) treatment.

non-compliance penalties.

provider charges in excess of the Maximum Reimbursable Charge.

Accumulation of Plan Deductibles and Out-of-Pocket Maximums

Deductibles and Out-of-Pocket Maximums will not cross accumulate between In and Out-of-Network. All other planmaximums and service-specific maximums (dollar and occurrence) cross-accumulate between In- and Out-of-Networkunless otherwise noted.

Note:Refer to your CIGNA Choice Fund Member Handbook for information about your health fund benefit and how it can helpyou pay for expenses that may not be covered under this plan.

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OPEN ACCESS PLUS MEDICAL BENEFITS

The Schedule

Contract Year

Contract Year means a twelve month period beginning on each 09/01.

Multiple Surgical Reduction

Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lessercharge. The most expensive procedure is paid as any other surgery.

Assistant Surgeon and Co-Surgeon Charges

Assistant Surgeon

The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed 20 percent ofthe surgeon's allowable charge. (For purposes of this limitation, allowable charge means the amount payable to thesurgeon prior to any reductions due to coinsurance or deductible amounts.)

Co-Surgeon

The maximum amount payable will be limited to charges made by co-surgeons that do not exceed 20 percent of thesurgeon's allowable charge plus 20 percent. (For purposes of this limitation, allowable charge means the amount payableto the surgeons prior to any reductions due to coinsurance or deductible amounts.)

BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK

Lifetime Maximum $1,000,000

Coinsurance Levels 80% 60% of the Maximum ReimbursableCharge

Maximum Reimbursable Charge

Maximum Reimbursable Charge isdetermined based on the lesser of theprovider's normal charge for a similarservice or supply; or

A percentile of charges made byproviders of such service or supply inthe geographic area where the service isreceived. These charges are compiledin a database we have selected.

Not Applicable 90th Percentile

Note:The provider may bill you for thedifference between the provider'snormal charge and the MaximumReimbursable Charge, in addition toapplicable deductibles, copayments andcoinsurance.

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Contract Year Deductible

Individual $2,000 per person $4,000 per person

Family Maximum $4,000 per family $8,000 per family

Family Maximum Calculation

Collective Deductible:

All family members contributetowards the family deductible. Anindividual cannot have claimscovered under the plan coinsuranceuntil the total family deductible hasbeen satisfied.

Out-of-Pocket Maximum

Individual $4,000 per person $8,000 per person

Family Maximum $8,000 per family $16,000 per family

Family Maximum Calculation

Collective Out-of-PocketMaximum:

All family members contributetowards the family Out-of-Pocket.An individual cannot have claimscovered at 100% until the totalfamily Out-of-Pocket has beensatisfied.

Physician's Services

Primary Care Physician's Office visit 80% after plan deductible 60% after plan deductible

Specialty Care Physician's OfficeVisits

Consultant and ReferralPhysician's Services

Note:OB/GYN providers will beconsidered either as a PCP orSpecialist, depending on howthe provider contracts with CG.

80% after plan deductible 60% after plan deductible

Surgery Performed In the Physician'sOffice


Second Opinion Consultations(provided on a voluntary basis)


Allergy Treatment/Injections 80% after plan deductible 60% after plan deductible

Allergy Serum (dispensed by thePhysician in the office)


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Preventive Care

Contract Year Maximum through age 6 (including immunizations): Unlimited

Contract Year Maximum for age 7 years and above (including immunizations): 1 visit

Note:

Well-woman OB/GYN visits will be considered either a PCP or Specialist depending on how the provider contractswith CG.

Preventive Care

Routine Preventive Care for Childrenthrough age 6 (includingimmunizations)

No charge 60% after plan deductible

Immunizations No charge No charge

Routine Preventive Care for age 7years and over (includingimmunizations)


Immunizations No charge 60% after plan deductible

Early Cancer Detection Colon/Rectal

Contract Year Maximum:1 visit


Colorectal Exam

Contract Year Maximum:1 colonoscopy


Mammograms, PSA, PAP Smear

Preventive Care Related Services(i.e. "routine" services)



Diagnostic Related Services (i.e."non-routine" services)


Inpatient Hospital - Facility Services 80% after plan deductible 60% after plan deductible

Semi-Private Room and Board Limited to the semi-private roomnegotiated rate

Limited to the semi-private room rate

Private Room Limited to the semi-private roomnegotiated rate

Limited to the semi-private room rate

Special Care Units (ICU/CCU) Limited to the negotiated rate Limited to the ICU/CCU daily roomrate

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Outpatient Facility Services

Operating Room, Recovery Room,Procedures Room, Treatment Roomand Observation Room


Inpatient Hospital Physician'sVisits/Consultations


Inpatient Hospital ProfessionalServices


Surgeon

Radiologist

Pathologist

Anesthesiologist

Outpatient Professional Services 80% after plan deductible 60% after plan deductible

Surgeon

Radiologist

Pathologist

Anesthesiologist

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Emergency and Urgent CareServices

Physician’s Office Visit 80% after plan deductible 80% after plan deductible (except ifnot a true emergency, then 60% afterplan deductible)

Hospital Emergency Room 80% after plan deductible 80% after plan deductible (except ifnot a true emergency, then 60% afterplan deductible)

Outpatient Professional services(radiology, pathology and ERPhysician)

80% after plan deductible 80% after plan deductible (except ifnot a true emergency, then 60% afterplan deductible)

Urgent Care Facility or OutpatientFacility


X-ray and/or Lab performed at theEmergency Room/Urgent CareFacility (billed by the facility as partof the ER/UC visit)


Independent x-ray and/or LabFacility in conjunction with an ERvisit


Advanced Radiological Imaging (i.e.MRIs, MRAs, CAT Scans, PETScans etc.)


Ambulance 80% after plan deductible 80% after plan deductible (except ifnot a true emergency, then 60% afterplan deductible)

Inpatient Services at Other HealthCare Facilities

Includes Skilled Nursing Facility,Rehabilitation Hospital and Sub-Acute Facilities

Contract Year Maximum:$10,000


Laboratory and Radiology Services(includes pre-admission testing)

Physician’s Office Visit 80% after plan deductible 60% after plan deductible

Outpatient Hospital Facility 80% after plan deductible 60% after plan deductible

Independent X-ray and/or LabFacility


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Advanced Radiological Imaging (i.e.MRIs, MRAs, CAT Scans and PETScans)


Inpatient Facility 80% after plan deductible 60% after plan deductible

Outpatient Facility 80% after plan deductible 60% after plan deductible

Outpatient Short-TermRehabilitative Therapy

Contract Year Maximum:Unlimited

Includes:Cardiac RehabPhysical TherapySpeech TherapyOccupational TherapyPulmonary RehabCognitive Therapy


Chiropractic Services

Contract Year Maximum:$1,500

Physician's Office Visit 80% after plan deductible 60% after plan deductible

Home Health Care

Contract Year Maximum:$10,000 (includes outpatient privatenursing when approved as medicallynecessary)


Hospice

Inpatient Services

Lifetime Maximum:$20,000


Outpatient Services

(same coinsurance level as HomeHealth Care)


Bereavement Counseling

Services provided as part of HospiceCare

Inpatient 80% after plan deductible 60% after plan deductible

Outpatient 80% after plan deductible 60% after plan deductible

Services provided by Mental HealthProfessional

Covered under Mental Health Benefit Covered under Mental Health Benefit

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Maternity Care Services

Initial Visit to Confirm Pregnancy

Note:OB/GYN providers will beconsidered either a PCP or Specialistdepending on how the providercontracts with CG.


All subsequent Prenatal Visits,Postnatal Visits and Physician'sDelivery Charges (i.e. globalmaternity fee)


Physician's Office Visits in additionto the global maternity fee whenperformed by an OB/GYN orSpecialist


Delivery - Facility(Inpatient Hospital, Birthing Center)


Abortion

Includes elective and non-electiveprocedures




Physician's Services 80% after plan deductible 60% after plan deductible

Family Planning Services

Office Visits, Lab and RadiologyTests and Counseling


Note:The standard benefit will includecoverage for contraceptive devices(e.g. Depo-Provera and IntrauterineDevices (IUDs). Diaphragms willalso be covered when services areprovided in the physician's office.

Surgical Sterilization Procedures forVasectomy/Tubal Ligation (excludesreversals)





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Infertility Treatment

Services Not Covered include:

Testing performed specifically todetermine the cause of infertility.

Treatment and/or proceduresperformed specifically to restorefertility (e.g. procedures to correctan infertility condition).

Artificial means of becomingpregnant (e.g. ArtificialInsemination, In-vitro, GIFT,ZIFT, etc).

Note:Coverage will be provided for thetreatment of an underlying medicalcondition up to the point an infertilitycondition is diagnosed. Services will becovered as any other illness.

Not Covered Not Covered

Organ Transplants

Includes all medically appropriate, non-experimental transplants


Inpatient Facility 100% at Lifesource center after plandeductible, otherwise 80% after plandeductible

60% after plan deductible

Physician’s Services 100% at Lifesource center after plandeductible, otherwise 80% after plandeductible

60% after plan deductible

Lifetime Travel Maximum:$10,000 per transplant

No charge (only available whenusing Lifesource facility)

In-Network coverage only

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Durable Medical Equipment



Diabetes Equipment



External Prosthetic Appliances



Diabetes Equipment & Custom FootOrthotics



Nutritional Evaluation

Contract Year Maximum:3 visits per person, however the threevisit limit will not apply to treatmentof diabetes





Dental Care

Limited to charges made for acontinuous course of dental treatmentstarted within six months of an injury tosound, natural teeth.





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Bariatric Surgery

Note:Subject to any limitations shown in the“Exclusions, Expenses Not Coveredand General Limitations” section of thiscertificate.





Oral Surgery(Impacted Wisdom Teeth)

Note:Any service related to extraction ofImpacted Wisdom Teeth is covered andpayable under per place of servicebenefits.





Biologically Based Mental Illness



Outpatient Group Therapy (Onegroup therapy session equals oneindividual therapy session)


Intensive Outpatient

Lifetime Maximum:Up to 3 per programBased on a ratio of 1:1


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Eye Care Services Not covered 100%

Note:Allow 1 Routine Eye Exam (includingrefraction) and 1 Routine Contact Lensfitting exam every contract year.

Hearing Services

Includes Routine Hearing screening,testing and exam.

100% 60% after plan deductible


Routine Foot Disorders Not covered except for servicesassociated with foot care for diabetesand peripheral vascular disease.

Not covered except for servicesassociated with foot care for diabetesand peripheral vascular disease.

Treatment Resulting From Life Threatening Emergencies

Medical treatment required as a result of an emergency, such as a suicide attempt, will be considered a medical expenseuntil the medical condition is stabilized and will not count toward any plan limits that are shown in the Schedule formental health and substance abuse services including in-hospital services. Once the medical condition is stabilized,whether the treatment will be characterized as either a medical expense or a mental health/substance abuse expense will bedetermined by the utilization review Physician in accordance with the applicable mixed services claim guidelines.

Mental Health (other thanBiologically Based Mental Illness)

Inpatient

Contract Year Maximum: 30 days

Acute: based on a ratio of 1:1Partial: based on a ratio of 2:1Residential: based on a ratio of 2:1


Outpatient

Contract Year Maximum:30 visits


Outpatient Group Therapy (Onegroup therapy session equals oneindividual therapy session)


Intensive Outpatient



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Chemical Dependency

Note: Lifetime maximum of 3 series oftreatments is covered. A series oftreatment can be a combination ofinpatient and outpatient treatments.

Inpatient


Acute detox: requires 24 hournursing; based on a ratio of 1:1Acute Inpatient Rehab: requires 24hour nursing; based on a ratio of 1:1Partial: based on a ratio of 2:1Residential: based on a ratio of 2:1


Outpatient



Intensive Outpatient(Chemical Dependency)



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Open Access Plus Medical Benefits

Certification Requirements - Out-of-Network


Pre-Admission Certification/Continued Stay Review forHospital Confinement

Pre-Admission Certification (PAC) and Continued StayReview (CSR) refer to the process used to certify the MedicalNecessity and length of a Hospital Confinement when you oryour Dependent require treatment in a Hospital:

as a registered bed patient;

for a Partial Hospitalization for the treatment of MentalHealth or Substance Abuse;

for Mental Health or Substance Abuse ResidentialTreatment Services.

You or your Dependent should request PAC prior to any non-emergency treatment in a Hospital described above. In thecase of an emergency admission, you should contact theReview Organization within 48 hours after the admission. Foran admission due to pregnancy, you should call the ReviewOrganization by the end of the third month of pregnancy. CSRshould be requested, prior to the end of the certified length ofstay, for continued Hospital Confinement.

Covered Expenses incurred will not include the first $250 ofHospital charges made for each separate admission to theHospital:

unless PAC is received: (a) prior to the date of admission; or(b) in the case of an emergency admission, within 48 hoursafter the date of admission.

Covered Expenses incurred for which benefits wouldotherwise be payable under this plan for the charges listedbelow will not include:

Hospital charges for Bed and Board, for treatment listedabove for which PAC was performed, which are made forany day in excess of the number of days certified throughPAC or CSR; and

any Hospital charges for treatment listed above for whichPAC was requested, but which was not certified asMedically Necessary.

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PAC and CSR are performed through a utilization reviewprogram by a Review Organization with which CG hascontracted.

In any case, those expenses incurred for which payment isexcluded by the terms set forth above will not be considered asexpenses incurred for the purpose of any other part of thisplan, except for the "Coordination of Benefits" section.

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Prior Authorization/Pre-Authorized

The term Prior Authorization means the approval that aParticipating Provider must receive from the ReviewOrganization, prior to services being rendered, in order forcertain services and benefits to be covered under this policy.

Services that require Prior Authorization include, but are notlimited to:

inpatient Hospital services;

inpatient services at any participating Other Health CareFacility;

residential treatment;

intensive outpatient programs;

nonemergency ambulance; or

transplant services.

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Covered Expenses

The term Covered Expenses means the expenses incurred byor on behalf of a person for the charges listed below if they areincurred after he becomes insured for these benefits. Expensesincurred for such charges are considered Covered Expenses tothe extent that the services or supplies provided arerecommended by a Physician, and are Medically Necessaryfor the care and treatment of an Injury or a Sickness, asdetermined by CG. Any applicable Copayments,Deductibles or limits are shown in The Schedule.

Covered Expenses

charges made by a Hospital, on its own behalf, for Bed andBoard and other Necessary Services and Supplies; exceptthat for any day of Hospital Confinement, CoveredExpenses will not include that portion of charges for Bedand Board which is more than the Bed and Board Limitshown in The Schedule.

charges for licensed ambulance service to or from thenearest Hospital where the needed medical care andtreatment can be provided.

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charges made by a Hospital, on its own behalf, for medicalcare and treatment received as an outpatient.

charges made by a Free-Standing Surgical Facility, on itsown behalf for medical care and treatment.

charges made on its own behalf, by an Other Health CareFacility, including a Skilled Nursing Facility, aRehabilitation Hospital or a subacute facility for medicalcare and treatment; except that for any day of Other HealthCare Facility confinement, Covered Expenses will notinclude that portion of charges which are in excess of theOther Health Care Facility Daily Limit shown in TheSchedule.

charges made for Emergency Services and Urgent Care.

charges made by a Physician or a Psychologist forprofessional services.

charges made by a Nurse, other than a member of yourfamily or your Dependent's family, for professional nursingservice.

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charges made for anesthetics and their administration;diagnostic x-ray and laboratory examinations; x-ray,radium, and radioactive isotope treatment; chemotherapy;blood transfusions; oxygen and other gases and theiradministration.

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charges made for a mammogram for women ages 35 to 69,every one to two years, or at any age for women at risk,when recommended by a Physician.

charges made for an annual Papanicolaou laboratoryscreening test.

charges for appropriate counseling, medical servicesconnected with surgical therapies, including vasectomy andtubal ligation.

charges made for laboratory services, radiation therapy andother diagnostic and therapeutic radiological procedures.

charges made for Family Planning, including medicalhistory, physical exam, related laboratory tests, medicalsupervision in accordance with generally accepted medicalpractices, other medical services, information andcounseling on contraception, implanted/injectedcontraceptives.

office visits, tests and counseling for Family Planningservices are subject to the Preventive Care Maximum shownin the Schedule.

charges made for Routine Preventive Care from age 3including immunizations, not to exceed the maximumshown in the Schedule. Routine Preventive Care meanshealth care assessments, wellness visits and any relatedservices.

charges made for visits for routine preventive care of aDependent child during the first two years of thatDependent child’s life, excluding immunizations.

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charges made for or in connection with annual diagnosticexaminations for the detection of prostate cancer, regardlessof medical necessity; and a prostate-specific antigen (PSA)test for a man who is: (a) at least 50 years of age andasymptomatic; or (b) at least 40 years of age with a familyhistory of prostate cancer, or another prostate risk factor.

charges for a minimum of 48 hours of inpatient carefollowing a mastectomy and a minimum 24 hours followinga lymph node dissection for the treatment of breast cancer.A shorter period of inpatient care may be deemedacceptable if the insured consults with the Physician andboth agree it is appropriate.

charges for immunizations for Dependent children frombirth through age 6. These immunizations will include: (a)diphtheria; (b) Haemophilus influenzae type b; (c) hepatitisB; (d) measles; (e) mumps; (f) pertussis; (g) polio; (h)rubella; (i) tetanus; (j) varicella (chicken pox); (k) rotavirus;and (l) any other children's immunizations required by theState Board of Health. A deductible, copayment, orcoinsurance is not required for immunizations.

GM6000 CM65 INDEM160V3

charges for a service provided through Telemedicine fordiagnosis, consultation, treatment, transfer of medical data,and medical education.

These benefits may not be subject to a greater deductible,copayment, or coinsurance than for the same service underthis plan provided through a face-to-face consultation.

The term Telemedicine means the practice of health caredelivery, diagnosis, consultation, treatment, transfer ofmedical data, and medical education through the use ofinteractive audio, video, or other electronic media. It doesnot include the use of telephone or fax.

charges for Hospital Confinement of a mother and hernewborn child for 48 hours following a vaginal delivery, orfor 96 hours following a cesarean delivery. After consultingwith her attending Physician the mother may request an

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earlier discharge if it is determined that less time is neededfor recovery. If medical necessity requires the mother and/ornewborn to remain confined for longer than 48 hours, theadditional confinement will be covered. If the mother isdischarged prior to the 48 or 96 hours, the additionalconfinement will be covered. If the mother is dischargedprior to the 48 or 96 hours described above, a postpartumhome care visit will be covered. Postpartum home careservices include parent education; assistance and training inbreast feeding and bottle feeding; and the performance ofany necessary and appropriate clinical tests.

charges for diagnostic and surgical treatment for conditionseffecting temporomandibular joint and craniomandibulardisorders which are a result of: (a) an accident; (b) trauma;(c) a congenital defect; (d) a developmental defect; or (e) apathology.


charges for a screening test for hearing loss from birththrough the date the child is 30 days old, and necessarydiagnostic follow-up care related to the screening test frombirth through the date the child is 24 months old withoutapplication of a deductible.

GM6000 CM65 INDEM160V9 M

The following benefits will apply to insulin and non-insulindependent diabetics as well as covered individuals who haveelevated blood sugar levels due to pregnancy or other medicalconditions:

charges for Durable Medical Equipment, including podiatricappliances, related to diabetes. A special maximum will notapply.

charges for insulin; syringes; prefilled insulin cartridges forthe blind; oral blood sugar control agents; glucose teststrips; visual reading ketone strips; urine test strips; lancets;and alcohol swabs.

charges for training by a Physician, including a podiatristwith recent education in diabetes management, but limitedto the following:

medically necessary visits when diabetes is diagnosed;

visits following a diagnosis of a significant change in thesymptoms or conditions that warrant change in self-management;

visits when reeducation or refresher training is prescribedby the Physician; and

medical nutrition therapy related to diabetes management.


charges made for an acquired brain injury including: a)cognitive rehabilitation therapy; b) cognitivecommunication therapy; c) neurocognitive therapy andrehabilitation; d) neurobehavioral, neurophysiological,neuropsychological and psychophysiological testing andtreatment; e) neurofeedback therapy and remediation; f)post-acute transition services and community reintegrationservices, including outpatient day treatment services orother post-acute care treatment services; and g) reasonableexpenses related to periodic reevaluation of the care of anindividual covered under the plan who has incurred anacquired brain injury, has been unresponsive to treatment,and becomes responsive to treatment at a later date, atwhich time the cognitive rehabilitation services would be acovered benefit

charges made for an annual medically recognized diagnosticexamination for the early detection of cervical cancer foreach covered female age 18 and over. Such coverage shallinclude at a minimum: (a) a conventional Pap smearscreening; or (b) a screening using liquid-based cytologymethods, as approved by the United States Food and DrugAdministration, alone or in combination with a testapproved by the United States Food and DrugAdministration for the detection of the humanpapillomavirus.

charges for treatment of Biologically-Based Mental Illnessat the same rate as for other illnesses. A Biologically-BasedMental Illness is defined as: schizophrenia, paranoid andother psychotic disorders, bipolar disorders (hypomanic,manic, depressive, and mixed), major depressive disorder,schizoaffective disorders (bipolar or depressive), obsessive-compulsive disorders, and depression in childhood oradolescence.

GM6000 INDEM262

charges made for special formula treatment forphenylketonuria and other inherited diseases.

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charges made for reconstructive surgery of craniofacialabnormalities for covered Dependents age 18 or younger toimprove the function of, or to attempt to create a normalappearance for an abnormal structure caused by congenitaldefects, developmental deformities, trauma, tumors,infection or disease.

GM6000 CM65

GM6000 INDEM62

GM6000 CM5 05BPT90V3

orthognathic surgery to repair or correct a severe facialdeformity or disfigurement that orthodontics alone can notcorrect, provided:

the deformity or disfigurement is accompanied by adocumented clinically significant functional impairment,and there is a reasonable expectation that the procedurewill result in meaningful functional improvement; or

the orthognathic surgery is Medically Necessary as aresult of tumor, trauma, disease or;

the orthognathic surgery is performed prior to age 19 andis required as a result of severe congenital facialdeformity or congenital condition.

Repeat or subsequent orthognathic surgeries for the samecondition are covered only when the previous orthognathicsurgery met the above requirements, and there is a highprobability of significant additional improvement asdetermined by the utilization review Physician.

GM6000 06BNR10

Clinical Trials

charges made for routine patient services associated withcancer clinical trials approved and sponsored by the federalgovernment. In addition the following criteria must be met:

the cancer clinical trial is listed on the NIH web sitewww.clinicaltrials.gov as being sponsored by the federalgovernment;

the trial investigates a treatment for terminal cancer and:(1) the person has failed standard therapies for thedisease; (2) cannot tolerate standard therapies for thedisease; or (3) no effective nonexperimental treatment forthe disease exists;

the person meets all inclusion criteria for the clinical trialand is not treated “off-protocol”;

the trial is approved by the Institutional Review Board ofthe institution administering the treatment; and

coverage will not be extended to clinical trials conductedat nonparticipating facilities if a person is eligible toparticipate in a covered clinical trial from a ParticipatingProvider.

Routine patient services do not include, and reimbursementwill not be provided for:

the investigational service or supply itself;

services or supplies listed herein as Exclusions;

services or supplies related to data collection for the clinicaltrial (i.e., protocol-induced costs);

services or supplies which, in the absence of private healthcare coverage, are provided by a clinical trial sponsor orother party (e.g., device, drug, item or service supplied bymanufacturer and not yet FDA approved) without charge tothe trial participant.

Genetic Testing

charges made for genetic testing that uses a proven testingmethod for the identification of genetically-linkedinheritable disease. Genetic testing is covered only if:

a person has symptoms or signs of a genetically-linkedinheritable disease;

it has been determined that a person is at risk for carrierstatus as supported by existing peer-reviewed, evidence-based, scientific literature for the development of agenetically-linked inheritable disease when the resultswill impact clinical outcome; or

GM6000 05BPT1

the therapeutic purpose is to identify specific geneticmutation that has been demonstrated in the existing peer-reviewed, evidence-based, scientific literature to directlyimpact treatment options.

Pre-implantation genetic testing, genetic diagnosis prior toembryo transfer, is covered when either parent has aninherited disease or is a documented carrier of a genetically-linked inheritable disease.

Genetic counseling is covered if a person is undergoingapproved genetic testing, or if a person has an inheriteddisease and is a potential candidate for genetic testing. Geneticcounseling is limited to 3 visits per contract year for both pre-and postgenetic testing.

Nutritional Evaluation

charges made for nutritional evaluation and counselingwhen diet is a part of the medical management of adocumented organic disease.

http://www.clinicaltrials.gov/

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Internal Prosthetic/Medical Appliances

charges made for internal prosthetic/medical appliances thatprovide permanent or temporary internal functional supportsfor nonfunctional body parts are covered. MedicallyNecessary repair, maintenance or replacement of a coveredappliance is also covered.

GM6000 05BPT2 V1

Home Health Care Services

charges made for Home Health Care Services when you:

require skilled care;

are unable to obtain the required care as an ambulatoryoutpatient; and

do not require confinement in a Hospital or Other HealthCare Facility.

Home Health Care Services are provided under the terms of aHome Health Care plan for the person named in that plan.

If you are a minor or an adult who is dependent upon othersfor nonskilled care (e.g. bathing, eating, toileting), HomeHealth Care Services will only be provided for you duringtimes when there is a family member or care giver present inthe home to meet your nonskilled care needs.

Home Health Care Services are those skilled health careservices that can be provided during intermittent visits of twohours or less by Other Health Care Professionals. Necessaryconsumable medical supplies, home infusion therapy, andDurable Medical Equipment administered or used by OtherHealth Care Professionals in providing Home Health CareServices are covered. Home Health Care Services do notinclude services of a person who is a member of your familyor your Dependent's family or who normally resides in yourhouse or your Dependent's house. Physical, occupational, andspeech therapy provided in the home are subject to the benefitlimitations described under "Short-Term RehabilitativeTherapy."

GM6000 INDEM2 V16

Hospice Care Services

charges made for a person who has been diagnosed ashaving six months or fewer to live, due to Terminal Illness,for the following Hospice Care Services provided under aHospice Care Program:

by a Hospice Facility for Bed and Board and Services andSupplies;

by a Hospice Facility for services provided on anoutpatient basis;

by a Physician for professional services;

by a Psychologist, social worker, family counselor orordained minister for individual and family counseling;

for pain relief treatment, including drugs, medicines andmedical supplies;

by an Other Health Care Facility for:

part-time or intermittent nursing care by or under thesupervision of a Nurse;

part-time or intermittent services of an Other HealthCare Professional;

GM6000 CM34 FLX124V38

physical, occupational and speech therapy;

medical supplies; drugs and medicines lawfullydispensed only on the written prescription of aPhysician; and laboratory services; but only to theextent such charges would have been payable under thepolicy if the person had remained or been Confined in aHospital or Hospice Facility.

The following charges for Hospice Care Services are notincluded as Covered Expenses:

for the services of a person who is a member of your familyor your Dependent's family or who normally resides in yourhouse or your Dependent's house;

for any period when you or your Dependent is not under thecare of a Physician;

for services or supplies not listed in the Hospice CareProgram;

for any curative or life-prolonging procedures;

to the extent that any other benefits are payable for thoseexpenses under the policy;

for services or supplies that are primarily to aid you or yourDependent in daily living;

GM6000 CM35 FLX124V27

Mental Health and Chemical Dependency Services

Mental Health Services are services that are required to treata disorder that impairs the behavior, emotional reaction orthought processes. In determining benefits payable, chargesmade for the treatment of any physiological conditions relatedto Mental Health will not be considered to be charges madefor treatment of Mental Health.

Chemical Dependency is defined as the abuse of orpsychological or physical dependence on or addiction to

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alcohol or a controlled substance that requires diagnosis, care,and treatment. In determining benefits payable, charges madefor the treatment of any physiological conditions related torehabilitation services for Chemical Dependency will not beconsidered to be charges made for treatment of ChemicalDependency.

A Controlled Substance means a Toxic Inhalant or asubstance designated as a controlled substance in Chapter 481,Health and Safety code.

A Toxic Inhalant means a volatile chemical under Chapter484, Health and Safety code, or usable glue or aerosol paintunder Section 485.001, Health and Safety code.

Inpatient Mental Health Services

Services that are provided by an In-Network Hospital whileyou or your Dependents are Confined in a Hospital for thetreatment and evaluation of Mental Health. Inpatient MentalHealth Services include Mental Health treatment in aResidential Treatment Center for Children and Adolescents,Crisis Stabilization Unit, Partial Hospitalization and MentalHealth Residential Treatment Services.

Inpatient Mental Health benefits are exchangeable withPartial Hospitalization sessions when benefits are providedfor not less than 4 hours and not more than 12 hours in any 24-hour period. The benefit exchange will be two partialhospitalization sessions are equal to one day of inpatient care.

GM6000 INDEM9 V59

Mental Health Residential Treatment Services are servicesprovided by a Hospital for the evaluation and treatment of thepsychological and social functional disturbances that are aresult of subacute Mental Health conditions.

Mental Health Residential Treatment benefits are exchangedwith Inpatient Mental Health benefits at a rate of two days ofMental Health Residential Treatment being equal to one dayof Inpatient Mental Health Treatment.

Mental Health Residential Treatment Center means aninstitution which (a) specializes in the treatment ofpsychological and social disturbances that are the result ofMental Health conditions; (b) provides a subacute, structured,psychotherapeutic treatment program, under the supervision ofPhysicians; (c) provides 24-hour care, in which a person livesin an open setting; and (d) is licensed in accordance with thelaws of the appropriate legally authorized agency as aresidential treatment center.

A person is considered Confined in a Mental HealthResidential Treatment Center when she/he is a registered bedpatient in a Mental Health Residential Treatment Center uponthe recommendation of a Physician.

Residential Treatment Center for Children andAdolescents means a child care institution that providesresidential care and treatment for emotionally disturbedchildren and adolescents, and that is accredited as aResidential Treatment Center by the Council on Accreditation,the Joint Commission on Accreditation of Hospitals, or theAmerican Association of Psychiatric Services for Children.

GM6000 INDEM10 V53

A Crisis Stabilization Unit means a 24-hour residentialprogram that is usually short term in nature and that providesintensive supervision and highly structured activities toindividuals who are demonstrating an acute demonstrablepsychiatric crisis of moderate to severe proportions.

Mental Health Residential Treatment services in a MentalHealth Residential Treatment Center for Children andAdolescents, or a Crisis Stabilization Unit are exchanged withInpatient Mental Health Benefits at a rate of:

2 days of Mental Health Residential Treatment at a Centerfor Children and Adolescents being equal to 1 day ofInpatient Mental Health Treatment.

2 days of Mental Health Services provided through CrisisStabilization Units being equal to 1 day of Inpatient MentalHealth Treatment.

Outpatient Mental Health Services

Services of Providers who are qualified to treat Mental Healthwhen treatment is provided on an outpatient basis, while youor your Dependent is not Confined in a Hospital, and isprovided in an individual, group or Mental Health IntensiveOutpatient Therapy Program. Covered services include, butare not limited to, outpatient treatment of conditions such as:anxiety or depression which interfere with daily functioning;emotional adjustment or concerns related to chronicconditions, such as psychosis or depression; emotionalreactions associated with marital problems or divorce;child/adolescent problems of conduct or poor impulse control;affective disorders; suicidal or homicidal threats or acts; eatingdisorders; or acute exacerbation of chronic Mental Healthconditions (crisis intervention and relapse prevention) andoutpatient testing and assessment.

A Mental Health Intensive Outpatient Therapy Programconsists of distinct levels or phases of treatment that areprovided by a certified/licensed Mental Health program.Intensive Outpatient Therapy Programs provide a combinationof individual, family and/or group therapy in a day, totaling 9or more hours in a week. Mental Health Intensive OutpatientTherapy Program services are exchanged with OutpatientMental Health services at a rate of 1 visit of Mental Health

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Intensive Outpatient Therapy being equal to 1 visit ofOutpatient Mental Health Services.

GM6000 INDEM17 V4

Inpatient Chemical Dependency Rehabilitation Services

Services provided for rehabilitation, while you or yourDependent is Confined in a Hospital, when required for thediagnosis and treatment of Chemical Dependency.

Inpatient Chemical Dependency services are exchangeablewith Partial Hospitalization sessions when services areprovided for not less than 4 hours and not more than 12 hoursin any 24-hour period. The exchange for services will be 2partial hospitalization sessions are equal to 1 day of inpatientcare.

Chemical Dependency Outpatient Therapy Programconsists of distinct levels or phases of treatment that areprovided by a certified/licensed Chemical Dependencyprogram. Intensive outpatient structured therapy programsprovide a combination of individual, family and/or grouptherapy in a day, totaling 9 or more hours in a week.

Chemical Dependency Outpatient Therapy Program benefitsare exchanged with Inpatient Chemical Dependency benefitsat a rate of 3 days of Chemical Dependency OutpatientStructured Therapy being equal to 1 day of Inpatient ChemicalDependency Rehabilitation Services.

Chemical Dependency Residential Treatment Services areservices provided by a Hospital for the evaluation andtreatment of the psychological and social functionaldisturbances that are a result of subacute Substance Abuseconditions.

Chemical Dependency Residential Treatment benefits areexchanged with Inpatient Chemical Dependency benefits at arate of 2 days of Chemical Dependency Residential Treatmentbeing equal to 1 day of Inpatient Chemical DependencyTreatment.

Chemical Dependency Residential Treatment Centermeans an institution which (a) specializes in the treatment ofpsychological and social disturbances that are the result ofChemical Dependency conditions; (b) provides a subacute,structured, psychotherapeutic treatment program, under thesupervision of Physicians; (c) provided 24-hour care, in whicha person lives in an open setting; and (d) is licensed inaccordance with the laws of the appropriate legally authorizedagency as a residential treatment center.

A person is considered Confined in a Chemical DependencyResidential Treatment Center when she/he is a registered bedpatient in a Chemical Dependency Residential TreatmentCenter upon the recommendation of a Physician.

GM6000 INDEM11 V65

Outpatient Chemical Dependency Rehabilitation Services

Services provided for the diagnosis and treatment of ChemicalDependency, while you or your Dependent is not Confined ina Hospital, including outpatient rehabilitation in an individual,group or Chemical Dependency intensive OutpatientStructured Therapy Program.

A Chemical Dependency Outpatient Structured TherapyProgram consists of distinct levels or phases of treatment thatare provided by a certified/licensed Chemical Dependencyprogram. Intensive Outpatient Therapy Programs provide acombination of individual, family and/or group therapy in aday, totaling 9 or more hours in a week. ChemicalDependency Intensive Outpatient Therapy Program servicesare exchanged with Outpatient Chemical Dependency servicesat a rate of 1 visit of Chemical Dependency IntensiveOutpatient Therapy being equal to 1 visit of OutpatientChemical Dependency Rehabilitation Services.

Lifetime Maximum

Chemical Dependency Benefits will be limited to a lifetimemaximum of three separate Series of Treatments per person.

A Series of Treatments is a planned, structured andorganized program to promote chemical free status which mayor may not include different facilities or modalities, and iscomplete when you are discharged on medical advice frominpatient detoxification, inpatient rehabilitation, partialhospitalization or intensive outpatient, or a series of theselevels of treatment without a lapse in treatment, or when youfail to materially comply with the treatment program for aperiod of 30 days.

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Chemical Dependency Detoxification Services

Detoxification and related medical ancillary services providedwhen required for the diagnosis and treatment of addiction toalcohol and/or drugs. CG will decide, based on the MedicalNecessity of each situation, whether such services will beprovided in an inpatient or outpatient setting.

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Exclusions

The following are specifically excluded from Mental Healthand Chemical Dependency Services:

any court ordered treatment or therapy, or any treatment ortherapy ordered as a condition of parole, probation orcustody or visitation evaluations unless MedicallyNecessary and otherwise covered under this policy oragreement;

treatment of medical disorders which have been diagnosedas organic mental disorders associated with permanentdysfunction of the brain;

developmental disorders, including but not limited to,developmental reading disorders, developmental arithmeticdisorders, developmental language disorders ordevelopmental articulation disorders;

counseling for activities of an educational nature;

counseling for borderline intellectual functioning;

counseling for occupational problems;

counseling related to consciousness raising;

vocational or religious counseling;

I.Q. testing;

custodial care, including but not limited to geriatric daycare;

psychological testing on children requested by or for aschool system;

occupational/recreational therapy programs even ifcombined with supportive therapy for age-related cognitivedecline;

GM6000 INDEM12 V56

Durable Medical Equipment

charges made for purchase or rental of Durable MedicalEquipment that is ordered or prescribed by a Physician andprovided by a vendor approved by CG for use outside aHospital or Other Health Care Facility. Coverage for repair,replacement or duplicate equipment is provided only whenrequired due to anatomical change and/or reasonable wearand tear. All maintenance and repairs that result from aperson’s misuse are the person’s responsibility. Coveragefor Durable Medical Equipment is limited to the lowest-costalternative as determined by the utilization reviewPhysician.

Durable Medical Equipment is defined as items which aredesigned for and able to withstand repeated use by more thanone person; customarily serve a medical purpose; generallyare not useful in the absence of Injury or Sickness; areappropriate for use in the home; and are not disposable. Such

equipment includes, but is not limited to, crutches, hospitalbeds, respirators, wheel chairs, and dialysis machines.

Durable Medical Equipment items that are not covered includebut are not limited to those that are listed below:

Bed Related Items: bed trays, over the bed tables, bedwedges, pillows, custom bedroom equipment, mattresses,including nonpower mattresses, custom mattresses andposturepedic mattresses.

Bath Related Items: bath lifts, nonportable whirlpools,bathtub rails, toilet rails, raised toilet seats, bath benches,bath stools, hand held showers, paraffin baths, bath mats,and spas.

Chairs, Lifts and Standing Devices: computerized orgyroscopic mobility systems, roll about chairs, geriatricchairs, hip chairs, seat lifts (mechanical or motorized),patient lifts (mechanical or motorized – manual hydrauliclifts are covered if patient is two-person transfer), and autotilt chairs.

Fixtures to Real Property: ceiling lifts and wheelchairramps.

Car/Van Modifications.

Air Quality Items: room humidifiers, vaporizers, airpurifiers and electrostatic machines.

Blood/Injection Related Items: blood pressure cuffs,centrifuges, nova pens and needleless injectors.

Other Equipment: heat lamps, heating pads, cryounits,cryotherapy machines, electronic-controlled therapy units,ultraviolet cabinets, sheepskin pads and boots, posturaldrainage board, AC/DC adaptors, enuresis alarms, magneticequipment, scales (baby and adult), stair gliders, elevators,saunas, any exercise equipment and diathermy machines.

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External Prosthetic Appliances and Devices

charges made or ordered by a Physician for: the initialpurchase and fitting of external prosthetic appliances anddevices available only by prescription which are necessaryfor the alleviation or correction of Injury, Sickness orcongenital defect. Coverage for External ProstheticAppliances is limited to the most appropriate and costeffective alternative as determined by the utilization reviewPhysician.

External prosthetic appliances and devices shall includeprostheses/prosthetic appliances and devices, orthoses andorthotic devices; braces; and splints.

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Prostheses/Prosthetic Appliances and Devices

Prostheses/prosthetic appliances and devices are defined asfabricated replacements for missing body parts.Prostheses/prosthetic appliances and devices include, but arenot limited to:

basic limb prostheses;

terminal devices such as hands or hooks; and

speech prostheses.

Orthoses and Orthotic Devices

Orthoses and orthotic devices are defined as orthopedicappliances or apparatuses used to support, align, prevent orcorrect deformities. Coverage is provided for custom footorthoses and other orthoses as follows:

Nonfoot orthoses – only the following nonfoot orthoses arecovered:

rigid and semirigid custom fabricated orthoses,

semirigid prefabricated and flexible orthoses; and

rigid prefabricated orthoses including preparation, fittingand basic additions, such as bars and joints.

Custom foot orthoses – custom foot orthoses are onlycovered as follows:

for persons with impaired peripheral sensation and/oraltered peripheral circulation (e.g. diabetic neuropathyand peripheral vascular disease);

when the foot orthosis is an integral part of a leg braceand is necessary for the proper functioning of the brace;

when the foot orthosis is for use as a replacement orsubstitute for missing parts of the foot (e.g. amputatedtoes) and is necessary for the alleviation or correction ofInjury, Sickness or congenital defect; and

for persons with neurologic or neuromuscular condition(e.g. cerebral palsy, hemiplegia, spina bifida) producingspasticity, malalignment, or pathological positioning ofthe foot and there is reasonable expectation ofimprovement.

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The following are specifically excluded orthoses and orthoticdevices:

prefabricated foot orthoses;

cranial banding and/or cranial orthoses. Other similardevices are excluded except when used postoperatively forsynostotic plagiocephaly. When used for this indication, thecranial orthosis will be subject to the limitations andmaximums of the External Prosthetic Appliances andDevices benefit;

orthosis shoes, shoe additions, procedures for footorthopedic shoes, shoe modifications and transfers;

orthoses primarily used for cosmetic rather than functionalreasons; and

orthoses primarily for improved athletic performance orsports participation.

Braces

A Brace is defined as an orthosis or orthopedic appliance thatsupports or holds in correct position any movable part of thebody and that allows for motion of that part.

The following braces are specifically excluded: Copesscoliosis braces.

Splints

A Splint is defined as an appliance for preventing movementof a joint or for the fixation of displaced or movable parts.

Coverage for replacement of external prosthetic appliancesand devices is limited to the following:

Replacement due to regular wear. Replacement for damagedue to abuse or misuse by the person will not be covered.

Replacement will be provided when anatomic change hasrendered the external prosthetic appliance or deviceineffective. Anatomic change includes significant weightgain or loss, atrophy and/or growth.

Coverage for replacement is limited as follows:

No more than once every 24 months for persons 19 yearsof age and older and

No more than once every 12 months for persons 18 yearsof age and under.

Replacement due to a surgical alteration or revision of thesite.

The following are specifically excluded external prostheticappliances and devices:

External and internal power enhancements or powercontrols for prosthetic limbs and terminal devices; and

Myoelectric prostheses peripheral nerve stimulators.

GM6000 05BPT5

Short-Term Rehabilitative Therapy

Short-term Rehabilitative Therapy that is part of arehabilitation program, including physical, speech,occupational, cognitive, osteopathic manipulative, cardiacrehabilitation and pulmonary rehabilitation therapy, whenprovided in the most medically appropriate setting.

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The following limitation applies to Short-term RehabilitativeTherapy:

Occupational therapy is provided only for purposes ofenabling persons to perform the activities of daily livingafter an Illness or Injury or Sickness.

Short-term Rehabilitative Therapy services that are notcovered include but are not limited to:

Sensory integration therapy, group therapy; treatment ofdyslexia; behavior modification or myofunctional therapyfor dysfluency, such as stuttering or other involuntarilyacted conditions without evidence of an underlying medicalcondition or neurological disorder;

Treatment for functional articulation disorder such ascorrection of tongue thrust, lisp, verbal apraxia orswallowing dysfunction that is not based on an underlyingdiagnosed medical condition or Injury; and

Maintenance or preventive treatment consisting of routine,long-term or non-Medically Necessary care provided toprevent recurrence or to maintain the patient’s currentstatus;

Services that are provided by a chiropractic Physician are notcovered.

These services include the conservative management of acuteneuromusculoskeletal conditions through manipulation andancillary physiological treatment rendered to restore motion,reduce pain and improve function.

GM6000 07BNR3

Chiropractic Care Services

Charges made for diagnostic and treatment services utilized inan office setting by chiropractic Physicians. Chiropractictreatment includes the conservative management of acuteneuromusculoskeletal conditions through manipulation andancillary physiological treatment rendered to specific joints torestore motion, reduce pain, and improve function. For theseservices you have direct access to qualified chiropracticPhysicians.

The following limitation applies to Chiropractic CareServices:

Occupational therapy is provided only for purposes ofenabling persons to perform the activities of daily livingafter an Injury or Sickness;

Chiropractic Care services that are not covered include but arenot limited to:

services of a chiropractor which are not within his scope ofpractice, as defined by state law;

charges for care not provided in an office setting;

maintenance or preventive treatment consisting of routine,longterm or non-Medically Necessary care provided toprevent recurrence or to maintain the patient’s currentstatus; and

vitamin therapy.

GM6000 07BNR4

Transplant Services

charges made for human organ and tissue Transplantservices which include solid organ and bone marrow/stemcell procedures at designated facilities throughout theUnited States or its territories. This coverage is subject tothe following conditions and limitations.

Transplant services include the recipient’s medical, surgicaland Hospital services; inpatient immunosuppressivemedications; and costs for organ or bone marrow/stem cellprocurement. Transplant services are covered only if they arerequired to perform any of the following human to humanorgan or tissue transplants: allogeneic bone marrow/stem cell,autologous bone marrow/stem cell, cornea, heart, heart/lung,kidney, kidney/pancreas, liver, lung, pancreas or intestinewhich includes small bowel-liver or multi-visceral.

All Transplant services, other than cornea, are covered at100% when received at CIGNA LIFESOURCE TransplantNetwork® facilities. Cornea transplants are not covered atCIGNA LIFESOURCE Transplant Network® facilities.Transplant services, including cornea, received at participatingfacilities specifically contracted with CIGNA for thoseTransplant services, other than CIGNA LIFESOURCETransplant Network® facilities, are payable at the In-Networklevel. Transplant services received at any other facilities,including Non-Participating Providers and ParticipatingProviders not specifically contracted with CIGNA forTransplant services, are covered at the Out-of-Network level.

Coverage for organ procurement costs are limited to costsdirectly related to the procurement of an organ, from a cadaveror a live donor. Organ procurement costs shall consist ofsurgery necessary for organ removal, organ transportation andthe transportation, hospitalization and surgery of a live donor.Compatibility testing undertaken prior to procurement iscovered if Medically Necessary. Costs related to the searchfor, and identification of a bone marrow or stem cell donor foran allogeneic transplant are also covered.

Transplant Travel Services

Charges made for reasonable travel expenses incurred by youin connection with a preapproved organ/tissue transplant arecovered subject to the following conditions and limitations.Transplant travel benefits are not available for corneatransplants. Benefits for transportation, lodging and food are

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available to you only if you are the recipient of a preapprovedorgan/tissue transplant from a designated CIGNALIFESOURCE Transplant Network® facility. The termrecipient is defined to include a person receiving authorizedtransplant related services during any of the following: (a)evaluation, (b) candidacy, (c) transplant event, or (d) post-transplant care. Travel expenses for the person receiving thetransplant will include charges for: transportation to and fromthe transplant site (including charges for a rental car usedduring a period of care at the transplant facility); lodgingwhile at, or traveling to and from the transplant site; and foodwhile at, or traveling to and from the transplant site.

In addition to your coverage for the charges associated withthe items above, such charges will also be considered coveredtravel expenses for one companion to accompany you. Theterm companion includes your spouse, a member of yourfamily, your legal guardian, or any person not related to you,but actively involved as your caregiver. The following arespecifically excluded travel expenses:

travel costs incurred due to travel within 60 miles of yourhome; laundry bills; telephone bills; alcohol or tobaccoproducts; and charges for transportation that exceed coachclass rates.

These benefits are only available when the covered person isthe recipient of an organ transplant. No benefits are availablewhen the covered person is a donor.

GM6000 05BPT7 V11

Breast Reconstruction and Breast Prostheses

charges made for reconstructive surgery following amastectomy; benefits include: (a) surgical services forreconstruction of the breast on which surgery wasperformed; (b) surgical services for reconstruction of thenondiseased breast to produce symmetrical appearance; (c)postoperative breast prostheses; and (d) mastectomy brasand external prosthetics, limited to the lowest costalternative available that meets external prostheticplacement needs. During all stages of mastectomy,treatment of physical complications, including lymphedematherapy, are covered.

Reconstructive Surgery

charges made for reconstructive surgery or therapy to repairor correct a severe physical deformity or disfigurementwhich is accompanied by functional deficit; (other thanabnormalities of the jaw or conditions related to TMJdisorder) provided that: (a) the surgery or therapy restoresor improves function; (b) reconstruction is required as aresult of Medically Necessary, noncosmetic surgery; or (c)the surgery or therapy is performed prior to age 19 and isrequired as a result of the congenital absence or agenesis

(lack of formation or development) of a body part. Repeator subsequent surgeries for the same condition are coveredonly when there is the probability of significant additionalimprovement as determined by the utilization reviewPhysician.

GM6000 05BPT2 V2

Exclusions, Expenses Not Covered andGeneral LimitationsAdditional coverage limitations determined by plan orprovider type are shown in the Schedule. Payment for thefollowing is specifically excluded from this plan:

expenses for supplies, care, treatment, or surgery that arenot Medically Necessary.

to the extent that you or any one of your Dependents is inany way paid or entitled to payment for those expenses byor through a public program, other than Medicaid.

to the extent that payment is unlawful where the personresides when the expenses are incurred.

charges made by a Hospital owned or operated by or whichprovides care or performs services for, the United StatesGovernment, if such charges are directly related to amilitary-service-connected Injury or Sickness.

for or in connection with an Injury or Sickness which is dueto war, declared or undeclared.

charges which you are not obligated to pay or for which youare not billed or for which you would not have been billedexcept that they were covered under this plan.

assistance in the activities of daily living, including but notlimited to eating, bathing, dressing or other CustodialServices or self-care activities, homemaker services andservices primarily for rest, domiciliary or convalescent care.

for or in connection with experimental, investigational orunproven services.

Experimental, investigational and unproven services aremedical, surgical, diagnostic, psychiatric, substance abuseor other health care technologies, supplies, treatments,procedures, drug therapies or devices that are determined bythe utilization review Physician to be:

not demonstrated, through existing peer-reviewed,evidence-based, scientific literature to be safe andeffective for treating or diagnosing the condition orsickness for which its use is proposed;

not approved by the U.S. Food and Drug Administration(FDA) or other appropriate regulatory agency to belawfully marketed for the proposed use;

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the subject of review or approval by an InstitutionalReview Board for the proposed use except as provided inthe “Clinical Trials” section of this plan; or

the subject of an ongoing phase I, II or III clinical trial,except as provided in the “Clinical Trials” section of thisplan.

cosmetic surgery and therapies. Cosmetic surgery or therapyis defined as surgery or therapy performed to improve oralter appearance or self-esteem or to treat psychologicalsymptomatology or psychosocial complaints related toone’s appearance.

regardless of clinical indication for macromastia orgynecomastia surgeries; blepharoplasty; redundant skinsurgery; removal of skin tags; acupressure;craniosacral/cranial therapy; dance therapy; movementtherapy; applied kinesiology; rolfing; prolotherapy; andextracorporeal shock wave lithotripsy (ESWL) formusculoskeletal and orthopedic conditions.

for or in connection with treatment of the teeth orperiodontium unless such expenses are incurred for: (a)charges made for a continuous course of dental treatmentstarted within six months of an Injury to sound natural teeth;(b) charges made by a Hospital for Bed and Board orNecessary Services and Supplies; (c) charges made by aFree-Standing Surgical Facility or the outpatient departmentof a Hospital in connection with surgery; or (d) chargesmade by a Physician for any of the following SurgicalProcedures: excision of epulis; excision of uneruptedimpacted tooth, including removal of alveolar bone andsectioning of tooth; removal of residual root (whenperformed by a Dentist other than the one who extracted thetooth); intraoral drainage of acute alveolar abscess withcellulitis; alveolectomy; gingivectomy, for gingivitis orperiodontitis.

for medical and surgical services intended primarily for thetreatment or control of obesity. However, treatment ofclinically severe obesity, as defined by the body mass index(BMI) classifications of the National Heart, Lung, andBlood Institute (NHLBI) guideline is covered only atapproved centers if the services are demonstrated, throughexisting peer-reviewed, evidence-based, scientific literatureand scientifically based guidelines, to be safe and effectivefor treatment of the condition. Clinically severe obesity isdefined by the NHLBI as a BMI of 40 or greater withoutcomorbidities, or 35-39 with comorbidities. The followingare specifically excluded:

medical and surgical services to alter appearances orphysical changes that are the result of any surgeryperformed for the management of obesity or clinicallysevere (morbid) obesity; and

weight loss programs or treatments, whether prescribed orrecommended by a Physician or under medicalsupervision.

unless otherwise covered in this plan, for reports,evaluations, physical examinations, or hospitalization notrequired for health reasons including, but not limited to,employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations.

court-ordered treatment or hospitalization, unless suchtreatment is prescribed by a Physician and listed as coveredin this plan.

infertility services including infertility drugs, surgical ormedical treatment programs for infertility, including in vitrofertilization, gamete intrafallopian transfer (GIFT), zygoteintrafallopian transfer (ZIFT), variations of theseprocedures, and any costs associated with the collection,washing, preparation or storage of sperm for artificialinsemination (including donor fees). Cryopreservation ofdonor sperm and eggs are also excluded from coverage.

reversal of male and female voluntary sterilizationprocedures.

transsexual surgery including medical or psychologicalcounseling and hormonal therapy in preparation for, orsubsequent to, any such surgery.

any services or supplies for the treatment of male or femalesexual dysfunction such as, but not limited to, treatment oferectile dysfunction (including penile implants), anorgasmy,and premature ejaculation.

medical and Hospital care and costs for the infant child of aDependent, unless this infant child is otherwise eligibleunder this plan.

nonmedical counseling or ancillary services, including butnot limited to Custodial Services, education, training,vocational rehabilitation, behavioral training, biofeedback,neurofeedback, hypnosis, sleep therapy, employmentcounseling, back school, return to work services, workhardening programs, driving safety, and services, training,educational therapy or other nonmedical ancillary servicesfor learning disabilities, developmental delays, autism ormental retardation.

therapy or treatment intended primarily to improve ormaintain general physical condition or for the purpose ofenhancing job, school, athletic or recreational performance,including but not limited to routine, long term, ormaintenance care which is provided after the resolution ofthe acute medical problem and when significant therapeuticimprovement is not expected.

consumable medical supplies other than ostomy suppliesand urinary catheters. Excluded supplies include, but are notlimited to bandages and other disposable medical supplies,

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skin preparations and test strips, except as specified in the“Home Health Services” or “Breast Reconstruction andBreast Prostheses” sections of this plan.

private Hospital rooms and/or private duty nursing except asprovided under the Home Health Services provision.

personal or comfort items such as personal care kitsprovided on admission to a Hospital, television, telephone,newborn infant photographs, complimentary meals, birthannouncements, and other articles which are not for thespecific treatment of an Injury or Sickness.

hearing aids, including but not limited to semi-implantablehearing devices, audiant bone conductors and BoneAnchored Hearing Aids (BAHAs). A hearing aid is anydevice that amplifies sound.

artificial aids including, but not limited to, correctiveorthopedic shoes, arch supports, elastic stockings, garterbelts, corsets, dentures and wigs.

aids or devices that assist with nonverbal communications,including but not limited to communication boards,prerecorded speech devices, laptop computers, desktopcomputers, Personal Digital Assistants (PDAs), Brailletypewriters, visual alert systems for the deaf and memorybooks.

medical benefits for eyeglasses, contact lenses orexaminations for prescription or fitting thereof, except thatCovered Expenses will include the purchase of the first pairof eyeglasses, lenses, frames or contact lenses that followskeratoconus or cataract surgery.

charges made for eye exercises and for surgical treatmentfor the correction of a refractive error, including radialkeratotomy, when eyeglasses or contact lenses may beworn.

treatment by acupuncture.

all noninjectable prescription drugs, injectable prescriptiondrugs that do not require Physician supervision and aretypically considered self-administered drugs,nonprescription drugs, and investigational and experimentaldrugs, except as provided in this plan.

routine foot care, including the paring and removing ofcorns and calluses or trimming of nails. However, servicesassociated with foot care for diabetes and peripheralvascular disease are covered when Medically Necessary.

membership costs or fees associated with health clubs,weight loss programs and smoking cessation programs.

genetic screening or pre-implantations genetic screening.General population-based genetic screening is a testingmethod performed in the absence of any symptoms or anysignificant, proven risk factors for genetically linkedinheritable disease.

dental implants for any condition.

fees associated with the collection or donation of blood orblood products, except for autologous donation inanticipation of scheduled services where in the utilizationreview Physician’s opinion the likelihood of excess bloodloss is such that transfusion is an expected adjunct tosurgery.

blood administration for the purpose of generalimprovement in physical condition.

cost of biologicals that are immunizations or medicationsfor the purpose of travel, or to protect against occupationalhazards and risks.

cosmetics, dietary supplements and health and beauty aids.

medical treatment for a person age 65 or older, who iscovered under this plan as a retiree, or their Dependent,when payment is denied by the Medicare plan becausetreatment was received from a nonparticipating provider.

medical treatment when payment is denied by a PrimaryPlan because treatment was received from anonparticipating provider.

for or in connection with an Injury or Sickness arising outof, or in the course of, any employment for wage or profit.

telephone, e-mail, and Internet consultations.

massage therapy.

for charges which would not have been made if the personhad no insurance.

to the extent that they are more than MaximumReimbursable Charges.

expenses incurred outside the United States or Canada,unless you or your Dependent is a U.S. or Canadian residentand the charges are incurred while traveling on business orfor pleasure.

charges made by any covered provider who is a member ofyour family or your Dependent’s family.

to the extent of the exclusions imposed by any certificationrequirement shown in this plan.

rhinoplasty when solely for the purpose of changingappearance.

rhinoplasty when as a primary treatment for an obstructivesleep disorder when criteria for approval have not been met.

GM6000 05BPT14 V143

GM6000 05BPT105

GM6000 06BNR2V2

GM6000 06BNR2 V88 M

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Pre-existing Condition Limitations

No payment will be made for Covered Expenses for or inconnection with an Injury or a Sickness which is a Pre-existing Condition, unless those expenses are incurred after acontinuous one-year period during which a person is satisfyinga waiting period and/or is insured for these benefits.

This limitation will not apply to any person who is a memberof the Initial Employee Group.

Pre-existing Condition

A Pre-existing Condition is an Injury or a Sickness for which aperson receives treatment, incurs expenses or receives adiagnosis from a Physician during the 90 days before theearlier of the date a person begins an eligibility waiting period,or becomes insured for these benefits.

Exceptions to Pre-existing Condition Limitation

Pregnancy, and genetic information with no related treatment,will not be considered Pre-existing Conditions.

A newborn child, an adopted child, or a child placed foradoption before age 18 will not be subject to any Pre-existingCondition limitation if such child was covered within 31 daysof birth, adoption or placement for adoption. Such waiver willnot apply if 63 days elapse between coverage during a priorperiod of Creditable Coverage and coverage under this plan.

Credit for Coverage Under Prior Plan

If a person was previously covered under a plan whichqualifies as Creditable Coverage, the following will apply,provided he notifies the Employer of such prior coverage, andfewer than 63 days elapse between coverage under the priorplan and coverage under this plan, exclusive of any waitingperiod.

CG will reduce any Pre-existing Condition limitation periodunder this policy by the number of days of prior CreditableCoverage you had under a creditable health plan or policy.

GM6000 CM10 INDEM82 V3 M

Coordination of BenefitsThis section applies if you or any one of your Dependents iscovered under more than one Plan and determines howbenefits payable from all such Plans will be coordinated. Youshould file all claims with each Plan.

Definitions

For the purposes of this section, the following terms have themeanings set forth below:

Plan

Any of the following that provides benefits or services formedical care or treatment:

(1) Group insurance and/or group-type coverage, whetherinsured or self-insured which neither can be purchased bythe general public, nor is individually underwritten,including closed panel coverage.

(2) Coverage under Medicare and other governmental benefitsas permitted by law, excepting Medicaid and Medicaresupplement policies.

(3) Medical benefits coverage of group, group-type, andindividual automobile contracts.

Each Plan or part of a Plan which has the right to coordinatebenefits will be considered a separate Plan.

Closed Panel Plan

A Plan that provides medical or dental benefits primarily inthe form of services through a panel of employed orcontracted providers, and that limits or excludes benefitsprovided by providers outside of the panel, except in the caseof emergency or if referred by a provider within the panel.

Primary Plan

The Plan that determines and provides or pays benefitswithout taking into consideration the existence of any otherPlan.

Secondary Plan

A Plan that determines, and may reduce its benefits aftertaking into consideration, the benefits provided or paid by thePrimary Plan. A Secondary Plan may also recover from thePrimary Plan the Reasonable Cash Value of any services itprovided to you.

GM6000 COB11

Allowable Expense

A necessary, reasonable and customary service or expense,including deductibles, coinsurance or copayments, that iscovered in full or in part by any Plan covering you. When aPlan provides benefits in the form of services, the ReasonableCash Value of each service is the Allowable Expense and is apaid benefit.

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Examples of expenses or services that are not AllowableExpenses include, but are not limited to the following:

(1) An expense or service or a portion of an expense orservice that is not covered by any of the Plans is not anAllowable Expense.

(2) If you are confined to a private Hospital room and no Planprovides coverage for more than a semiprivate room, thedifference in cost between a private and semiprivate roomis not an Allowable Expense.

(3) If you are covered by two or more Plans that provideservices or supplies on the basis of reasonable andcustomary fees, any amount in excess of the highestreasonable and customary fee is not an AllowableExpense.

(4) If you are covered by one Plan that provides services orsupplies on the basis of reasonable and customary feesand one Plan that provides services and supplies on thebasis of negotiated fees, the Primary Plan's feearrangement shall be the Allowable Expense.

(5) If your benefits are reduced under the Primary Plan(through the imposition of a higher copayment amount,higher coinsurance percentage, a deductible and/or apenalty) because you did not comply with Plan provisionsor because you did not use a preferred provider, theamount of the reduction is not an Allowable Expense.Such Plan provisions include second surgical opinionsand precertification of admissions or services.

Claim Determination Period

A calendar year, but does not include any part of a year duringwhich you are not covered under this policy or any date beforethis section or any similar provision takes effect.

GM6000 COB12

Reasonable Cash Value

An amount which a duly licensed provider of health careservices usually charges patients and which is within the rangeof fees usually charged for the same service by other healthcare providers located within the immediate geographic areawhere the health care service is rendered under similar orcomparable circumstances.

Order of Benefit Determination Rules

A Plan that does not have a coordination of benefits ruleconsistent with this section shall always be the Primary Plan.If the Plan does have a coordination of benefits rule consistentwith this section, the first of the following rules that applies tothe situation is the one to use:

(1) The Plan that covers you as an enrollee or an employeeshall be the Primary Plan and the Plan that covers you as aDependent shall be the Secondary Plan;

(2) If you are a Dependent child whose parents are notdivorced or legally separated, the Primary Plan shall bethe Plan which covers the parent whose birthday falls firstin the calendar year as an enrollee or employee;

(3) If you are the Dependent of divorced or separated parents,benefits for the Dependent shall be determined in thefollowing order:

(a) first, if a court decree states that one parent isresponsible for the child's healthcare expenses orhealth coverage and the Plan for that parent has actualknowledge of the terms of the order, but only fromthe time of actual knowledge;

(b) then, the Plan of the parent with custody of the child;

(c) then, the Plan of the spouse of the parent with custodyof the child;

(d) then, the Plan of the parent not having custody of thechild, and

(e) finally, the Plan of the spouse of the parent not havingcustody of the child.

GM6000 COB13

(4) The Plan that covers you as an active employee (or as thatemployee's Dependent) shall be the Primary Plan and thePlan that covers you as laid-off or retired employee (or asthat employee's Dependent) shall be the secondary Plan.If the other Plan does not have a similar provision and, asa result, the Plans cannot agree on the order of benefitdetermination, this paragraph shall not apply.

(5) The Plan that covers you under a right of continuationwhich is provided by federal or state law shall be theSecondary Plan and the Plan that covers you as an activeemployee or retiree (or as that employee's Dependent)shall be the Primary Plan. If the other Plan does not havea similar provision and, as a result, the Plans cannot agreeon the order of benefit determination, this paragraph shallnot apply.

(6) If one of the Plans that covers you is issued out of thestate whose laws govern this Policy, and determines theorder of benefits based upon the gender of a parent, and as

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a result, the Plans do not agree on the order of benefitdetermination, the Plan with the gender rules shalldetermine the order of benefits.

If none of the above rules determines the order of benefits, thePlan that has covered you for the longer period of time shallbe primary.

When coordinating benefits with Medicare, this Plan will bethe Secondary Plan and determine benefits after Medicare,where permitted by the Social Security Act of 1965, asamended. However, when more than one Plan is secondary toMedicare, the benefit determination rules identified above,will be used to determine how benefits will be coordinated.

Effect on the Benefits of This Plan

If this Plan is the Secondary Plan, this Plan may reducebenefits so that the total benefits paid by all Plans during aClaim Determination Period are not more than 100% of thetotal of all Allowable Expenses.

The difference between the amount that this Plan would havepaid if this Plan had been the Primary Plan, and the benefitpayments that this Plan had actually paid as the SecondaryPlan, will be recorded as a benefit reserve for you. CG will usethis benefit reserve to pay any Allowable Expense nototherwise paid during the Claim Determination Period.

GM6000 COB14

As each claim is submitted, CG will determine the following:

(1) CG's obligation to provide services and supplies underthis policy;

(2) whether a benefit reserve has been recorded for you; and

(3) whether there are any unpaid Allowable Expenses duringthe Claims Determination Period.

If there is a benefit reserve, CG will use the benefit reserverecorded for you to pay up to 100% of the total of allAllowable Expenses. At the end of the Claim DeterminationPeriod, your benefit reserve will return to zero and a newbenefit reserve will be calculated for each new ClaimDetermination Period.

Recovery of Excess Benefits

If CG pays charges for benefits that should have been paid bythe Primary Plan, or if CG pays charges in excess of those forwhich we are obligated to provide under the Policy, CG willhave the right to recover the actual payment made or theReasonable Cash Value of any services.

CG will have sole discretion to seek such recovery from anyperson to, or for whom, or with respect to whom, suchservices were provided or such payments made by anyinsurance company, healthcare plan or other organization. Ifwe request, you must execute and deliver to us such

instruments and documents as we determine are necessary tosecure the right of recovery.

Right to Receive and Release Information

CG, without consent or notice to you, may obtain informationfrom and release information to any other Plan with respect toyou in order to coordinate your benefits pursuant to thissection. You must provide us with any information we requestin order to coordinate your benefits pursuant to this section.This request may occur in connection with a submitted claim;if so, you will be advised that the "other coverage"information, (including an Explanation of Benefits paid underthe Primary Plan) is required before the claim will beprocessed for payment. If no response is received within 90days of the request, the claim will be denied. If the requestedinformation is subsequently received, the claim will beprocessed.

GM6000 COB15

Medicare Eligibles

CG will pay as the Secondary Plan as permittedby the Social Security Act of 1965 as amendedfor the following:

(a) a former Employee who is eligible forMedicare and whose insurance is continuedfor any reason as provided in this plan;

(b)a former Employee's Dependent, or a formerDependent Spouse, who is eligible forMedicare and whose insurance is continuedfor any reason as provided in this plan;

(c) an Employee whose Employer and eachother Employer participating in theEmployer's plan have fewer than 100Employees and that Employee is eligible forMedicare due to disability;

(d) the Dependent of an Employee whoseEmployer and each other Employerparticipating in the Employer's plan havefewer than 100 Employees and thatDependent is eligible for Medicare due todisability;

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(e) an Employee or a Dependent of anEmployee of an Employer who has fewerthan 20 Employees, if that person is eligiblefor Medicare due to age;

(f) an Employee, retired Employee, Employee'sDependent or retired Employee's Dependentwho is eligible for Medicare due to EndStage Renal Disease after that person hasbeen eligible for Medicare for 30 months;

GM6000 MEL23 V4

CG will assume the amount payable under:

Part A of Medicare for a person who iseligible for that Part without premiumpayment, but has not applied, to be theamount he would receive if he had applied.

Part B of Medicare for a person who isentitled to be enrolled in that Part, but is not,to be the amount he would receive if he wereenrolled.

Part B of Medicare for a person who hasentered into a private contract with a provider,to be the amount he would receive in theabsence of such private contract.

A person is considered eligible for Medicare onthe earliest date any coverage under Medicarecould become effective for him.

This reduction will not apply to any Employeeand his Dependent or any former Employee andhis Dependent unless he is listed under (a)through (f) above.

Domestic Partners

Under federal law, the Medicare SecondaryPayer Rules do not apply to Domestic Partnerscovered under a group health plan. Therefore,Medicare is always the Primary Plan for aperson covered as a Domestic Partner, andCIGNA is the Secondary Plan.

GM6000 MEL45 V3

Expenses For Which A Third Party MayBe ResponsibleThis plan does not cover:

1. Expenses incurred by you or your Dependent (hereinafterindividually and collectively referred to as a "Participant,")for which another party may be responsible as a result ofhaving caused or contributed to an Injury or Sickness.

2. Expenses incurred by a Participant to the extent anypayment is received for them either directly or indirectlyfrom a third party tortfeasor or as a result of a settlement,judgment or arbitration award in connection with anyautomobile medical, automobile no-fault, uninsured orunderinsured motorist, homeowners, workers'compensation, government insurance (other than Medicaid),or similar type of insurance or coverage.

Subrogation/Right of Reimbursement

If a Participant incurs a Covered Expense for which, in theopinion of the plan or its claim administrator, another partymay be responsible or for which the Participant may receivepayment as described above:

1. Subrogation: The plan shall, to the extent permitted by law,be subrogated to all rights, claims or interests that aParticipant may have against such party and shallautomatically have a lien upon the proceeds of any recoveryby a Participant from such party to the extent of any benefitspaid under the plan. A Participant or his/her representativeshall execute such documents as may be required to securethe plan’s subrogation rights.

2. Right of Reimbursement: The plan is also granted a right ofreimbursement from the proceeds of any recovery whetherby settlement, judgment, or otherwise. This right ofreimbursement is cumulative with and not exclusive of thesubrogation right granted in paragraph 1, but only to theextent of the benefits provided by the plan.

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Lien of the Plan

By accepting benefits under this plan, a Participant:

grants a lien and assigns to the plan an amount equal to thebenefits paid under the plan against any recovery made byor on behalf of the Participant which is binding on anyattorney or other party who represents the Participantwhether or not an agent of the Participant or of anyinsurance company or other financially responsible partyagainst whom a Participant may have a claim provided saidattorney, insurance carrier or other party has been notifiedby the plan or its agents;

agrees that this lien shall constitute a charge against theproceeds of any recovery and the plan shall be entitled toassert a security interest thereon;

agrees to hold the proceeds of any recovery in trust for thebenefit of the plan to the extent of any payment made by theplan.

Additional Terms

No adult Participant hereunder may assign any rights that itmay have to recover medical expenses from any third partyor other person or entity to any minor Dependent of saidadult Participant without the prior express written consentof the plan. The plan’s right to recover shall apply todecedents’, minors’, and incompetent or disabled persons’settlements or recoveries.

No Participant shall make any settlement, which specificallyreduces or excludes, or attempts to reduce or exclude, thebenefits provided by the plan.

The plan’s right of recovery shall be a prior lien against anyproceeds recovered by the Participant. This right ofrecovery shall not be defeated nor reduced by theapplication of any so-called “Made-Whole Doctrine”,“Rimes Doctrine”, or any other such doctrine purporting todefeat the plan’s recovery rights by allocating the proceedsexclusively to non-medical expense damages.

No Participant hereunder shall incur any expenses on behalfof the plan in pursuit of the plan’s rights hereunder,specifically; no court costs, attorneys' fees or otherrepresentatives' fees may be deducted from the plan’srecovery without the prior express written consent of theplan. This right shall not be defeated by any so-called“Fund Doctrine”, “Common Fund Doctrine”, or “Attorney’sFund Doctrine”.

The plan shall recover the full amount of benefits providedhereunder without regard to any claim of fault on the part ofany Participant, whether under comparative negligence orotherwise.

In the event that a Participant shall fail or refuse to honor itsobligations hereunder, then the plan shall be entitled torecover any costs incurred in enforcing the terms hereof

including, but not limited to, attorney’s fees, litigation, courtcosts, and other expenses. The plan shall also be entitled tooffset the reimbursement obligation against any entitlementto future medical benefits hereunder until the Participant hasfully complied with his reimbursement obligationshereunder, regardless of how those future medical benefitsare incurred.

Any reference to state law in any other provision of thisplan shall not be applicable to this provision, if the plan isgoverned by ERISA. By acceptance of benefits under theplan, the Participant agrees that a breach hereof would causeirreparable and substantial harm and that no adequateremedy at law would exist. Further, the Plan shall beentitled to invoke such equitable remedies as may benecessary to enforce the terms of the plan, including, but notlimited to, specific performance, restitution, the impositionof an equitable lien and/or constructive trust, as well asinjunctive relief.

GM6000 CCP7 CCL1V24

Payment of BenefitsTo Whom Payable

All Medical Benefits are payable to you. However, at theoption of CG, all or any part of them may be paid directly tothe person or institution on whose charge claim is based.

Medical Benefits are not assignable unless agreed to by CG.CG may, at its option, make payment to you for the cost ofany Covered Expenses received by you or your Dependentfrom a Non-Participating Provider even if benefits have beenassigned. When benefits are paid to you or your Dependent,you or your Dependent is responsible for reimbursing theProvider. If any person to whom benefits are payable is aminor or, in the opinion of CG, is not able to give a validreceipt for any payment due him, such payment will be madeto his legal guardian. If no request for payment has been madeby his legal guardian, CG may, at its option, make payment tothe person or institution appearing to have assumed hiscustody and support.

If you die while any of these benefits remain unpaid, CG maychoose to make direct payment to any of your following livingrelatives: spouse, mother, father, child or children, brothers orsisters; or to the executors or administrators of your estate.

Payment as described above will release CG from all liabilityto the extent of any payment made.

Time of Payment

Benefits will be paid by CG when it receives due proof of loss.

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Recovery of Overpayment

When an overpayment has been made by CG, CG will havethe right at any time to: (a) recover that overpayment from theperson to whom or on whose behalf it was made; or (b) offsetthe amount of that overpayment from a future claim payment.

Calculation of Covered Expenses

CG, in its discretion, will calculate Covered Expensesfollowing evaluation and validation of all provider billings inaccordance with:

the methodologies in the most recent edition of the CurrentProcedural terminology.

the methodologies as reported by generally recognizedprofessionals or publications.

GM6000 TRM366

Termination of Insurance

Employees

Your insurance will cease on the earliest date below:

the date you cease to be in a Class of Eligible Employees orcease to qualify for the insurance.

the last day for which you have made any requiredcontribution for the insurance.

the date the policy is canceled.

the last day of the calendar month in which your ActiveService ends except as described below.

Any continuation of insurance must be based on a plan whichprecludes individual selection.

Temporary Layoff or Leave of Absence

If your Active Service ends due to temporary layoff or leaveof absence, your insurance will be continued until the dateyour Employer cancels your insurance. However, yourinsurance will not be continued for more than 60 days past thedate your Active Service ends.

Injury or Sickness

If your Active Service ends due to an Injury or Sickness, yourinsurance will be continued while you remain totally andcontinuously disabled as a result of the Injury or Sickness.However, the insurance will not continue past the date yourEmployer cancels the insurance.

Retirement

If your Active Service ends because you retire, your insurancewill be continued until the date on which your Employer stopspaying premium for you or otherwise cancels the insurance.

GM6000 TRM15V44

Dependents

Your insurance for all of your Dependents will cease on theearliest date below:

the date your insurance ceases.

the date you cease to be eligible for Dependent Insurance.

the last day for which you have made any requiredcontribution for the insurance.

the date Dependent Insurance is canceled.

The insurance for any one of your Dependents will cease onthe date that Dependent no longer qualifies as a Dependent.

GM6000 TRM62

Special Continuation of Medical Insurance

If Medical Insurance for you or your Dependent wouldotherwise cease for any reason except due to involuntarytermination for cause or due to discontinuance in entirety ofthe policy or an insured class, coverage may be continued if:

the person was covered by this policy and/or a prior policyfor the three months immediately prior to the date coveragewould otherwise cease, and

the person elects continuation coverage and pays the firstmonthly premium within 31 days of the later of either thedate coverage would otherwise cease or the date requirednotice is provided.

Coverage will continue until the earliest of the following:

6 months after continuation coverage is elected;

the end of the period for which premium is paid;

the date the policy is discontinued and not replaced;

the date the person becomes eligible for Medicare; and

the date the person becomes insured under another similarpolicy or becomes eligible for coverage under a group planor a state or federal plan.

GM6000 TRM353

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Texas – Special Continuation of Dependent MedicalInsurance

If your Dependent's Medical Insurance would otherwise ceasebecause of your death or retirement, or because of divorce orannulment, his insurance will be continued upon payment ofrequired premium, if: (a) he has been insured under the policy,or a previous policy sponsored by your Employer, for at leastone year prior to the date the insurance would cease; or (b) heis a Dependent child less than one year old. The insurance willbe continued until the earliest of:

three years from the date the insurance would otherwisehave ceased;

the last day for which the required premium has been paid;

with respect to any one Dependent, the earlier of the datesthat Dependent: (a) becomes eligible for similar groupcoverage; or (b) no longer qualifies as a Dependent for anyreason other than your death or retirement or divorce orannulment; or

the date the policy cancels.

If, on the day before the Effective Date of the policy, medicalinsurance was being continued for a Dependent under a groupmedical policy: (a) sponsored by your Employer; and (b)replaced by the policy, his insurance will be continued for theremaining portion of his period of continuation under thepolicy, as set forth above.

Your Dependent must provide your Employer with writtennotice of retirement, death, divorce or annulment within 15days of such event. Your Employer will, upon receiving noticeof the death, retirement, divorce or annulment, notify yourDependent of his right to elect continuation as set forth above.Your Dependent may elect in writing such continuation within45 days after the date the insurance would otherwise cease, bypaying the required premium to your Employer.

GM6000 TER34

TRM136V3

Medical Benefits ExtensionUpon Policy Cancellation

If the Medical Benefits under this plan cease for you or yourDependent due to cancellation of the policy, and you or yourDependent is Totally Disabled on that date due to an Injury orSickness, Medical Benefits will be paid for Covered Expensesincurred in connection with that Injury or Sickness. However,no benefits will be paid after the earliest of:

the date you exceed the Maximum Benefit, if any, shown inthe Schedule;

the date you are covered for medical benefits under anothergroup policy;

the date you are no longer Totally Disabled;

90 days from the date your Medical Benefits cease; or

90 days from the date the policy is canceled.

Totally Disabled

You will be considered Totally Disabled if, because of anInjury or a Sickness:

you are unable to perform the basic duties of youroccupation; and

you are not performing any other work or engaging in anyother occupation for wage or profit.

Your Dependent will be considered Totally Disabled if,because of an Injury or a Sickness:

he is unable to engage in the normal activities of a person ofthe same age, sex and ability; or

in the case of a Dependent who normally works for wage orprofit, he is not performing such work.

The terms of this Medical Benefits Extension will not apply toa child born as a result of a pregnancy which exists when youor your Dependent's Medical Benefits cease.

GM6000 BEX183 V11

Federal RequirementsThe following pages explain your rights and responsibilitiesunder federal laws and regulations. Some states may havesimilar requirements. If a similar provision appears elsewherein this booklet, the provision which provides the better benefitwill apply.

FDRL1 V2

Notice of Provider Directory/Networks

Notice Regarding Provider Directories and ProviderNetworks

If your Plan utilizes a network of Providers, you willautomatically and without charge, receive a separate listing ofParticipating Providers.

You may also have access to a list of Providers whoparticipate in the network by visiting www.cigna.com;mycigna.com or by calling the toll-free telephone number onyour ID card.

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Your Participating Provider network consists of a group oflocal medical practitioners, including Hospitals, of variedspecialties as well as general practice, who are employed by orcontracted with CIGNA HealthCare.

FDRL32

Qualified Medical Child Support Order(QMCSO)

A. Eligibility for Coverage Under a QMCSO

If a Qualified Medical Child Support Order (QMCSO) isissued for your child, that child will be eligible for coverage asrequired by the order and you will not be considered a LateEntrant for Dependent Insurance.

You must notify your Employer and elect coverage for thatchild and yourself, if you are not already enrolled, within 31days of the QMCSO being issued.

B. Qualified Medical Child Support Order Defined

A Qualified Medical Child Support Order is a judgment,decree or order (including approval of a settlement agreement)or administrative notice, which is issued pursuant to a statedomestic relations law (including a community property law),or to an administrative process, which provides for childsupport or provides for health benefit coverage to such childand relates to benefits under the group health plan, andsatisfies all of the following:

1. the order recognizes or creates a child’s right to receivegroup health benefits for which a participant or beneficiaryis eligible;

2. the order specifies your name and last known address, andthe child’s name and last known address, except that thename and address of an official of a state or politicalsubdivision may be substituted for the child’s mailingaddress;

3. the order provides a description of the coverage to beprovided, or the manner in which the type of coverage is tobe determined;

4. the order states the period to which it applies; and

5. if the order is a National Medical Support Noticecompleted in accordance with the Child SupportPerformance and Incentive Act of 1998, such Notice meetsthe requirements above.

The QMCSO may not require the health insurance policy toprovide coverage for any type or form of benefit or option nototherwise provided under the policy, except that an order mayrequire a plan to comply with State laws regarding health carecoverage.

C. Payment of Benefits

Any payment of benefits in reimbursement for CoveredExpenses paid by the child, or the child’s custodial parent orlegal guardian, shall be made to the child, the child’s custodialparent or legal guardian, or a state official whose name andaddress have been substituted for the name and address of thechild.

FDRL2 V1

Special Enrollment Rights Under the HealthInsurance Portability & Accountability Act(HIPAA)

If you or your eligible Dependent(s) experience a specialenrollment event as described below, you or your eligibleDependent(s) may be entitled to enroll in the Plan outside of adesignated enrollment period upon the occurrence of one ofthe special enrollment events listed below. If you are alreadyenrolled in the Plan, you may request enrollment for you andyour eligible Dependent(s) under a different option offered bythe Employer for which you are currently eligible. If you arenot already enrolled in the Plan, you must request specialenrollment for yourself in addition to your eligibleDependent(s). You and all of your eligible Dependent(s) mustbe covered under the same option. The special enrollmentevents include:

Acquiring a new Dependent. If you acquire a newDependent(s) through marriage, birth, adoption orplacement for adoption, you may request special enrollmentfor any of the following combinations of individuals if notalready enrolled in the Plan: Employee only; spouse only;Employee and spouse; Dependent child(ren) only;Employee and Dependent child(ren); Employee, spouse andDependent child(ren). Enrollment of Dependent children islimited to the newborn or adopted children or children whobecame Dependent children of the Employee due tomarriage. Dependent children who were already Dependentsof the Employee but not currently enrolled in the Plan arenot entitled to special enrollment.

Loss of eligibility for State Medicaid or Children’sHealth Insurance Program (CHIP). If you and/or yourDependent(s) were covered under a state Medicaid or CHIPplan and the coverage is terminated due to a loss ofeligibility, you may request special enrollment for yourselfand any affected Dependent(s) who are not already enrolledin the Plan. You must request enrollment within 60 daysafter termination of Medicaid or CHIP coverage.

Loss of eligibility for other coverage (excludingcontinuation coverage). If coverage was declined under

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this Plan due to coverage under another plan, and eligibilityfor the other coverage is lost, you and all of your eligibleDependent(s) may request special enrollment in this Plan. Ifrequired by the Plan, when enrollment in this Plan waspreviously declined, it must have been declined in writingwith a statement that the reason for declining enrollmentwas due to other health coverage. This provision applies toloss of eligibility as a result of any of the following:

divorce or legal separation;

cessation of Dependent status (such as reaching thelimiting age);

death of the Employee;

termination of employment;

reduction in work hours to below the minimum requiredfor eligibility;

you or your Dependent(s) no longer reside, live or workin the other plan’s network service area and no othercoverage is available under the other plan;

you or your Dependent(s) incur a claim which meets orexceeds the lifetime maximum limit that is applicable toall benefits offered under the other plan; or

the other plan no longer offers any benefits to a class ofsimilarly situated individuals.

Termination of employer contributions (excludingcontinuation coverage). If a current or former employerceases all contributions toward the Employee’s orDependent’s other coverage, special enrollment may berequested in this Plan for you and all of your eligibleDependent(s).

Exhaustion of COBRA or other continuation coverage.Special enrollment may be requested in this Plan for youand all of your eligible Dependent(s) upon exhaustion ofCOBRA or other continuation coverage. If you or yourDependent(s) elect COBRA or other continuation coveragefollowing loss of coverage under another plan, the COBRAor other continuation coverage must be exhausted beforeany special enrollment rights exist under this Plan. Anindividual is considered to have exhausted COBRA or othercontinuation coverage only if such coverage ceases: (a) dueto failure of the employer or other responsible entity toremit premiums on a timely basis; (b) when the person nolonger resides or works in the other plan’s service area andthere is no other COBRA or continuation coverage availableunder the plan; or (c) when the individual incurs a claim thatwould meet or exceed a lifetime maximum limit on allbenefits and there is no other COBRA or other continuationcoverage available to the individual. This does not includetermination of an employer’s limited period of contributionstoward COBRA or other continuation coverage as providedunder any severance or other agreement.

FDRL3 V4

Eligibility for employment assistance under StateMedicaid or Children’s Health Insurance Program(CHIP). If you and/or your Dependent(s) become eligiblefor assistance with group health plan premium paymentsunder a state Medicaid or CHIP plan, you may requestspecial enrollment for yourself and any affectedDependent(s) who are not already enrolled in the Plan. Youmust request enrollment within 60 days after the date youare determined to be eligible for assistance.

Except as stated above, special enrollment must be requestedwithin 30 days after the occurrence of the special enrollmentevent. If the special enrollment event is the birth or adoptionof a Dependent child, coverage will be effective immediatelyon the date of birth, adoption or placement for adoption.Coverage with regard to any other special enrollment eventwill be effective on the first day of the calendar monthfollowing receipt of the request for special enrollment.

Individuals who enroll in the Plan due to a special enrollmentevent will not be denied enrollment. You will not be enrolledin this Plan if you do not enroll within 30 days of the date youbecome eligible, unless you are eligible for special enrollment.

Domestic Partners and their children (if not legal children ofthe Employee) are not eligible for special enrollment.

FDRL4 V3 M

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Effect of Section 125 Tax Regulations on ThisPlan

Your Employer has chosen to administer this Plan inaccordance with Section 125 regulations of the InternalRevenue Code. Per this regulation, you may agree to a pretaxsalary reduction put toward the cost of your benefits.Otherwise, you will receive your taxable earnings as cash(salary).

A. Coverage Elections

Per Section 125 regulations, you are generally allowed toenroll for or change coverage only before each annual benefitperiod. However, exceptions are allowed if your Employeragrees and you enroll for or change coverage within 30 daysof the following:

the date you meet the Special Enrollment criteria describedabove; or

the date you meet the criteria shown in the followingSections B through F.

B. Change of Status

A change in status is defined as:

1. change in legal marital status due to marriage, death of aspouse, divorce, annulment or legal separation;

2. change in number of Dependents due to birth, adoption,placement for adoption, or death of a Dependent;

3. change in employment status of Employee, spouse orDependent due to termination or start of employment,strike, lockout, beginning or end of unpaid leave ofabsence, including under the Family and Medical LeaveAct (FMLA), or change in worksite;

4. changes in employment status of Employee, spouse orDependent resulting in eligibility or ineligibility forcoverage;

5. change in residence of Employee, spouse or Dependent toa location outside of the Employer’s network servicearea; and

6. changes which cause a Dependent to become eligible orineligible for coverage.

C. Court Order

A change in coverage due to and consistent with a court orderof the Employee or other person to cover a Dependent.

D. Medicare or Medicaid Eligibility/Entitlement

The Employee, spouse or Dependent cancels or reducescoverage due to entitlement to Medicare or Medicaid, orenrolls or increases coverage due to loss of Medicare orMedicaid eligibility.

E. Change in Cost of Coverage

If the cost of benefits increases or decreases during a benefitperiod, your Employer may, in accordance with plan terms,automatically change your elective contribution.

When the change in cost is significant, you may eitherincrease your contribution or elect less-costly coverage. Whena significant overall reduction is made to the benefit optionyou have elected, you may elect another available benefitoption. When a new benefit option is added, you may changeyour election to the new benefit option.

F. Changes in Coverage of Spouse or Dependent UnderAnother Employer’s Plan

You may make a coverage election change if the plan of yourspouse or Dependent: (a) incurs a change such as adding ordeleting a benefit option; (b) allows election changes due toSpecial Enrollment, Change in Status, Court Order orMedicare or Medicaid Eligibility/Entitlement; or (c) this Planand the other plan have different periods of coverage or openenrollment periods.

FDRL70

Eligibility for Coverage for Adopted Children

Any child under the age of 18 who is adopted by you,including a child who is placed with you for adoption, will beeligible for Dependent Insurance upon the date of placementwith you. A child will be considered placed for adoption whenyou become legally obligated to support that child, totally orpartially, prior to that child’s adoption.

If a child placed for adoption is not adopted, all healthcoverage ceases when the placement ends, and will not becontinued.

The provisions in the “Exception for Newborns” section ofthis document that describe requirements for enrollment andeffective date of insurance will also apply to an adopted childor a child placed with you for adoption.

FDRL6

Federal Tax Implications for DependentCoverage

Premium payments for Dependent health insurance are usuallyexempt from federal income tax. Generally, if you can claiman individual as a Dependent for purposes of federal incometax, then the premium for that Dependent’s health insurancecoverage will not be taxable to you as income. However, inthe rare instance that you cover an individual under your

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health insurance who does not meet the federal definition of aDependent, the premium may be taxable to you as income. Ifyou have questions concerning your specific situation, youshould consult your own tax consultant or attorney.

FDRL7

Coverage for Maternity Hospital Stay

Group health plans and health insurance issuers offering grouphealth insurance coverage generally may not, under a federallaw known as the “Newborns’ and Mothers’ Health ProtectionAct”: restrict benefits for any Hospital length of stay inconnection with childbirth for the mother or newborn child toless than 48 hours following a vaginal delivery, or less than 96hours following a cesarean section; or require that a providerobtain authorization from the plan or insurance issuer forprescribing a length of stay not in excess of the above periods.The law generally does not prohibit an attending provider ofthe mother or newborn, in consultation with the mother, fromdischarging the mother or newborn earlier than 48 or 96 hours,as applicable.

Please review this Plan for further details on the specificcoverage available to you and your Dependents.

FDRL8

Women’s Health and Cancer Rights Act(WHCRA)

Do you know that your plan, as required by the Women’sHealth and Cancer Rights Act of 1998, provides benefits formastectomy-related services including all stages ofreconstruction and surgery to achieve symmetry between thebreasts, prostheses, and complications resulting from amastectomy, including lymphedema? Call Member Services atthe toll free number listed on your ID card for moreinformation.

FDRL51

Group Plan Coverage Instead of Medicaid

If your income and liquid resources do not exceed certainlimits established by law, the state may decide to paypremiums for this coverage instead of for Medicaid, if it iscost effective. This includes premiums for continuationcoverage required by federal law.

FDRL75

Pre-Existing Conditions Under the HealthInsurance Portability & Accountability Act(HIPAA)

A federal law known as the Health Insurance Portability &Accountability Act (HIPAA) establishes requirements for Pre-existing Condition limitation provisions in health plans.Following is an explanation of the requirements andlimitations under this law.

A. Pre-Existing Condition Limitation

Under HIPAA, a Pre-existing Condition limitation is alimitation or exclusion of benefits relating to a condition basedon the fact that the condition was present before the effectivedate of coverage under the plan, whether or not any medicaladvice, diagnosis, care, or treatment was recommended orreceived before that date. A Pre-existing Condition limitationis permitted under group health plans, provided it is appliedonly to a physical or mental condition for which medicaladvice, diagnosis, care, or treatment was recommended orreceived within the 6-month period (or a shorter period asapplies under the plan) ending on the enrollment date. Planprovisions may vary. Please refer to the section entitled“Exclusions, Expenses Not Covered and General Limitations”for the specific Pre-existing Condition limitation provisionwhich applies under this Plan, if any.

B. Exceptions to Pre-existing Condition Limitation

Pregnancy, and genetic information with no related treatment,will not be considered Pre-existing Conditions.

A newborn child, an adopted child, or a child placed foradoption before age 18 will not be subject to any Pre-existingCondition limitation if such child was covered under anycreditable coverage within 30 days of birth, adoption orplacement for adoption. Such waiver will not apply if 63 daysor more elapse between coverage under the prior creditablecoverage and coverage under this Plan.

C. Credit for Coverage Under Prior Plan

If you and/or your Dependent(s) were previously coveredunder a plan which qualifies as Creditable Coverage, CG willreduce any Pre-existing Condition limitation period under thispolicy by the number of days of prior Creditable Coverage

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you had under the prior plan(s). However, credit is availableonly if you notify the Employer of such prior coverage, andfewer than 63 days elapse between coverage under the priorplan and coverage under this Plan, exclusive of any waitingperiod. Credit will be given for coverage under all priorCreditable Coverage, provided fewer than 63 days elapsedbetween coverage under any two plans.

If you and/or your Dependent enrolled or re-enrolled inCOBRA continuation coverage or state continuation coverageunder the extended election period allowed in the AmericanRecovery and Reinvestment Act of 2009 (“ARRA”), this lapsein coverage will be disregarded for the purposes ofdetermining Creditable Coverage.

D. Certificate of Prior Creditable Coverage

You must provide proof of your prior Creditable Coverage inorder to reduce a Pre-Existing Condition limitation period.You should submit proof of prior coverage with yourenrollment material. A certificate of prior CreditableCoverage, or other proofs of coverage which need to besubmitted outside the standard enrollment form process forany reason, may be sent directly to: Eligibility ProductionServices, 900 Cottage Grove Road, Routing C2ECC, Hartford,CT 06152. You should contact the Plan Administrator or aCIGNA Customer Service Representative if assistance isneeded to obtain proof of prior Creditable Coverage. Onceyour prior coverage records are reviewed and credit iscalculated, you will receive a notice of any remaining Pre-existing Condition limitation period.

E. Creditable Coverage

Creditable Coverage will include coverage under any of thefollowing: A self-insured employer group health plan;Individual or group health insurance indemnity or HMO plans;Part A or Part B of Medicare; Medicaid, except coveragesolely for pediatric vaccines; A health plan for certainmembers of the uniformed armed services and theirdependents, including the Commissioned Corps of theNational Oceanic and Atmospheric Administration and of thePublic Health Service; A medical care program of the IndianHealth Service or of a tribal organization; A state healthbenefits risk pool; The Federal Employees Health BenefitsProgram; A public health plan established by a State, the U.S.government, or a foreign country; the Peace Corps Act; Or aState Children’s Health Insurance Program.

F. Obtaining a Certificate of Creditable Coverage UnderThis Plan

Upon loss of coverage under this Plan, a Certificate ofCreditable Coverage will be mailed to each terminatingindividual at the last address on file. You or your dependentmay also request a Certificate of Creditable Coverage, withoutcharge, at any time while enrolled in the Plan and for 24months following termination of coverage. You may need this

document as evidence of your prior coverage to reduce anypre-existing condition limitation period under another plan, tohelp you get special enrollment in another plan, or to obtaincertain types of individual health coverage even if you havehealth problems. To obtain a Certificate of CreditableCoverage, contact the Plan Administrator or call the toll-freecustomer service number on the back of your ID card.

FDRL73

Requirements of Medical Leave Act of 1993 (asamended) (FMLA)

Any provisions of the policy that provide for: (a) continuationof insurance during a leave of absence; and (b) reinstatementof insurance following a return to Active Service; are modifiedby the following provisions of the federal Family and MedicalLeave Act of 1993, as amended, where applicable:

A. Continuation of Health Insurance During Leave

Your health insurance will be continued during a leave ofabsence if:

that leave qualifies as a leave of absence under the Familyand Medical Leave Act of 1993, as amended; and

you are an eligible Employee under the terms of that Act.

The cost of your health insurance during such leave must bepaid, whether entirely by your Employer or in part by you andyour Employer.

B. Reinstatement of Canceled Insurance Following Leave

Upon your return to Active Service following a leave ofabsence that qualifies under the Family and Medical LeaveAct of 1993, as amended, any canceled insurance (health, lifeor disability) will be reinstated as of the date of your return.

You will not be required to satisfy any eligibility or benefitwaiting period or the requirements of any Pre-existingCondition limitation to the extent that they had been satisfiedprior to the start of such leave of absence.

Your Employer will give you detailed information about theFamily and Medical Leave Act of 1993, as amended.

FDRL74

Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)

The Uniformed Services Employment and Re-employmentRights Act of 1994 (USERRA) sets requirements forcontinuation of health coverage and re-employment in regard

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to an Employee’s military leave of absence. Theserequirements apply to medical and dental coverage for youand your Dependents. They do not apply to any Life, Short-term or Long-term Disability or Accidental Death &Dismemberment coverage you may have.

A. Continuation of Coverage

For leaves of less than 31 days, coverage will continue asdescribed in the Termination section regarding Leave ofAbsence.

For leaves of 31 days or more, you may continue coverage foryourself and your Dependents as follows:

You may continue benefits by paying the required premium toyour Employer, until the earliest of the following:

24 months from the last day of employment with theEmployer;

the day after you fail to return to work; and

the date the policy cancels.

Your Employer may charge you and your Dependents up to102% of the total premium.

Following continuation of health coverage per USERRArequirements, you may convert to a plan of individualcoverage according to any “Conversion Privilege” shown inyour certificate.

B. Reinstatement of Benefits (applicable to all coverages)

If your coverage ends during the leave of absence because youdo not elect USERRA or an available conversion plan at theexpiration of USERRA and you are reemployed by yourcurrent Employer, coverage for you and your Dependents maybe reinstated if (a) you gave your Employer advance written orverbal notice of your military service leave, and (b) theduration of all military leaves while you are employed withyour current Employer does not exceed 5 years.

You and your Dependents will be subject to only the balanceof a Pre-Existing Condition Limitation (PCL) or waitingperiod that was not yet satisfied before the leave began.However, if an Injury or Sickness occurs or is aggravatedduring the military leave, full Plan limitations will apply.

Any 63-day break in coverage rule regarding credit for timeaccrued toward a PCL waiting period will be waived.

If your coverage under this plan terminates as a result of youreligibility for military medical and dental coverage and yourorder to active duty is canceled before your active duty servicecommences, these reinstatement rights will continue to apply.

FDRL58

The Following Will Apply to Residents ofTexas

When You Have a Complaint or anAdverse Determination AppealFor the purposes of this section, any reference to "you," "your"or "Member" also refers to a representative or providerdesignated by you to act on your behalf, unless otherwisenoted.

We want you to be completely satisfied with the care youreceive. That is why we have established a process foraddressing your concerns and solving your problems.

When You Have a Complaint

We are here to listen and help. If you have a complaintregarding a person, a service, the quality of care, orcontractual benefits not related to Medical Necessity, you cancall our toll-free number and explain your concern to one ofour Customer Service representatives. A complaint does notinclude: (a) a misunderstanding or problem of misinformationthat can be promptly resolved by CG by clearing up themisunderstanding or supplying the correct information to yoursatisfaction; or (b) you or your provider's dissatisfaction ordisagreement with an adverse determination. You can alsoexpress that complaint in writing. Please call or write to us atthe following:

Customer Services Toll-Free Number or address thatappears on your Benefit Identification card, explanation ofbenefits or claim form.

We will do our best to resolve the matter on your initialcontact. If we need more time to review or investigate yourcomplaint, we will send you a letter acknowledging the dateon which we received your complaint no later than the fifthworking day after we receive your complaint. We will respondin writing with a decision 30 calendar days after we receive acomplaint for a postservice coverage determination. If moretime or information is needed to make the determination, wewill notify you in writing to request an extension of up to 15calendar days and to specify any additional informationneeded to complete the review.

GM6000 APL484 V1

You may request that the appeal process be expedited if, (a)the time frames under this process would seriously jeopardizeyour life, health or ability to regain maximum function or inthe opinion of your Physician would cause you severe painwhich cannot be managed without the requested services; or(b) your appeal involves nonauthorization of an admission orcontinuing inpatient Hospital stay. CG's Physician reviewer, in

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consultation with the treating Physician, will decide if anexpedited appeal is necessary. When a complaint is expedited,we will respond orally with a decision within the earlier of: (a)72 hours; or (b) one working day, followed up in writingwithin 3 calendar days.

If you are not satisfied with the results of a coverage decision,you can start the complaint appeals procedure.

Complaint Appeals Procedure

To initiate an appeal of a complaint resolution decision, youmust submit a request for an appeal in writing. You shouldstate the reason why you feel your appeal should be approvedand include any information supporting your appeal. If you areunable or choose not to write, you may ask to register yourappeal by telephone. Call or write to us at the toll-free numberor address on your Benefit Identification card, explanation ofbenefits or claim form.

GM6000 APL485

Your complaint appeal request will be conducted by theComplaint Appeals Committee, which consists of at least threepeople. Anyone involved in the prior decision may not vote onthe Committee. You may present your situation to theCommittee in person or by conference call.

We will acknowledge in writing that we have received yourrequest within five working days after the date we receiveyour request for a Committee review and schedule aCommittee review. The Committee review will be completedwithin 30 calendar days. If more time or information is neededto make the determination, we will notify you in writing torequest an extension of up to 15 calendar days and to specifyany additional information needed by the Committee tocomplete the review. You will be notified in writing of theCommittee's decision within five working days after theCommittee meeting, and within the Committee review timeframes above if the Committee does not approve the requestedcoverage.

You may request that the appeal process be expedited if, (a)the time frames under this process would seriously jeopardizeyour life, health or ability to regain maximum function or inthe opinion of your Physician would cause you severe painwhich cannot be managed without the requested services; or(b) your appeal involves nonauthorization of an admission orcontinuing inpatient Hospital stay. CG's Physician reviewer, inconsultation with the treating Physician will decide if anexpedited appeal is necessary. When an appeal is expedited,we will respond orally with a decision within the earlier of: (1)72 hours; or (2) one working day, followed up in writingwithin three calendar days.

GM6000 APL486

When You have an Adverse Determination Appeal

An Adverse Determination is a decision made by CG that thehealth care service(s) furnished or proposed to be furnished toyou is (are) not Medically Necessary or clinically appropriate.An Adverse Determination also includes a denial by CG of arequest to cover a specific prescription drug prescribed byyour Physician. If you are not satisfied with the AdverseDetermination, you may appeal the Adverse Determinationorally or in writing. You should state the reason why you feelyour appeal should be approved and include any informationsupporting your appeal. We will acknowledge the appeal inwriting within five working days after we receive the AdverseDetermination Appeal request.

Your appeal of an Adverse Determination will be reviewedand the decision made by a health care professional notinvolved in the initial decision. We will respond in writingwith a decision within 30 calendar days after receiving theAdverse Determination appeal request.

You may request that the appeal process be expedited if, (a)the time frames under this process would seriously jeopardizeyour life, health or ability to regain maximum function or inthe opinion of your Physician would cause you severe painwhich cannot be managed without the requested services; or(b) your appeal involves nonauthorization of an admission orcontinuing inpatient Hospital stay. CG's Physician reviewer, inconsultation with the treating Physician will decide if anexpedited appeal is necessary. When an appeal is expedited,we will respond orally with a decision within the earlier of: (a)72 hours; or (b) one working day, followed up in writingwithin three calendar days.

In addition, your treating Physician may request in writing aspecialty review within 10 working days of our writtendecision. The specialty review will be conducted by aPhysician in the same or similar specialty as the care underconsideration. The specialty review will be completed and aresponse sent within 15 working days of the request. Specialty

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review is voluntary. If the specialty reviewer upholds theinitial adverse determination and you remain dissatisfied, youare still eligible to request a review by an Independent ReviewOrganization.

GM6000 APL487 V1

Independent Review Procedure

If you are not fully satisfied with the decision of CG's AdverseDetermination appeal process or if you feel your condition islife-threatening, you may request that your appeal be referredto an Independent Review Organization. In addition, yourtreating Physician may request in writing that CG conduct aspecialty review. The specialty review request must be madewithin 10 days of receipt of the Adverse Determination appealdecision letter. CG must complete the specialist review andsend a written response within 15 days of its receipt of therequest for specialty review. If the specialist upholds the initialAdverse Determination, you are still eligible to request areview by an Independent Review Organization. TheIndependent Review Organization is composed of personswho are not employed by CG or any of its affiliates. Adecision to use the voluntary level of appeal will not affect theclaimant's rights to any other benefits under the plan.

There is no charge for you to initiate this independent reviewprocess and the decision to use the process is voluntary. CGwill abide by the decision of the Independent ReviewOrganization.

In order to request a referral to an Independent ReviewOrganization, certain conditions apply. The reason for thedenial must be based on a Medical Necessity or clinicalappropriateness determination by CG. Administrative,eligibility or benefit coverage limits or exclusions are noteligible for appeal under this process. To initiate a leveltwo appeal, follow the same process required for a level oneappeal except send this appeal to Socorro IndependentSchool District who will administer the Level Two AppealProcess.

Socorro Independent School District

Attn: Health Insurance Representative

12440 Rojas Drive

El Paso, Tx. 79928

915.937.0214

You will be notified in writing of the Committee’s decisionafter the Appeal Committee meeting. The Appeal Committeerefers to the Socorro Independent School District MedicalAppeals Committee doing the second level nonurgent carereview.

For submitting urgent care appeals at this level, follow theprocess in Level One Appeal. You may request that theappeal process be expedited if (a) the time frames under thisprocess would seriously jeopardize your life, health or abilityto regain maximum functionality or in the opinion of yourphysician, would cause you severe pain which cannot bemanaged without the requested services; or (b) your appealinvolves nonauthorization of an admission or continuinginpatient hospital stay. The Claim Adminstrator’s Physicianreviewer, in consultation with the treating physician, willdecide if an expedited appeal is necessary. When an appeal isexpedited, CG will respond orally with a decision within 72hours, followed up in writing.

GM6000 APL488 V1

Notice of Benefit Determination on Appeal

Every notice of an appeal decision will be provided in writingor electronically and, if an adverse determination, will include:(1) the specific reason or reasons for the denial decision; (2)reference to the specific plan provisions on which the decisionis based.

Relevant Information

Relevant Information is any document, record, or otherinformation which (a) was relied upon in making the benefitdetermination; (b) was submitted, considered, or generated inthe course of making the benefit determination, without regardto whether such document, record, or other information wasrelied upon in making the benefit determination; (c)demonstrates compliance with the administrative processesand safeguards required by federal law in making the benefitdetermination; or (d) constitutes a statement of policy orguidance with respect to the plan concerning the deniedtreatment option or benefit or the claimant's diagnosis, withoutregard to whether such advice or statement was relied upon inmaking the benefit determination.

GM6000 APL489

COBRA Continuation Rights Under FederalLaw


What is COBRA Continuation Coverage?

Under federal law, you and/or your Dependents must be giventhe opportunity to continue health insurance when there is a“qualifying event” that would result in loss of coverage under

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the Plan. You and/or your Dependents will be permitted tocontinue the same coverage under which you or yourDependents were covered on the day before the qualifyingevent occurred, unless you move out of that plan’s coveragearea or the plan is no longer available. You and/or yourDependents cannot change coverage options until the nextopen enrollment period.

When is COBRA Continuation Available?

For you and your Dependents, COBRA continuation isavailable for up to 18 months from the date of the followingqualifying events if the event would result in a loss ofcoverage under the Plan:

your termination of employment for any reason, other thangross misconduct, or

your reduction in work hours.

For your Dependents, COBRA continuation coverage isavailable for up to 36 months from the date of the followingqualifying events if the event would result in a loss ofcoverage under the Plan:

your death;

your divorce or legal separation; or

for a Dependent child, failure to continue to qualify as aDependent under the Plan.

Who is Entitled to COBRA Continuation?

Only a “qualified beneficiary” (as defined by federal law) mayelect to continue health insurance coverage. A qualifiedbeneficiary may include the following individuals who werecovered by the Plan on the day the qualifying event occurred:you, your spouse, and your Dependent children. Eachqualified beneficiary has their own right to elect or declineCOBRA continuation coverage even if you decline or are noteligible for COBRA continuation.

The following individuals are not qualified beneficiaries forpurposes of COBRA continuation: domestic partners, samesex spouses, grandchildren (unless adopted by you),stepchildren (unless adopted by you). Although theseindividuals do not have an independent right to elect COBRAcontinuation coverage, if you elect COBRA continuationcoverage for yourself, you may also cover your Dependentseven if they are not considered qualified beneficiaries underCOBRA. However, such individuals’ coverage will terminatewhen your COBRA continuation coverage terminates. Thesections titled “Secondary Qualifying Events” and “MedicareExtension For Your Dependents” are not applicable to theseindividuals.

FDRL67

Secondary Qualifying Events

If, as a result of your termination of employment or reductionin work hours, your Dependent(s) have elected COBRAcontinuation coverage and one or more Dependents experienceanother COBRA qualifying event, the affected Dependent(s)may elect to extend their COBRA continuation coverage foran additional 18 months (7 months if the secondary eventoccurs within the disability extension period) for a maximumof 36 months from the initial qualifying event. The secondqualifying event must occur before the end of the initial 18months of COBRA continuation coverage or within thedisability extension period discussed below. Under nocircumstances will COBRA continuation coverage beavailable for more than 36 months from the initial qualifyingevent. Secondary qualifying events are: your death; yourdivorce or legal separation; or, for a Dependent child, failureto continue to qualify as a Dependent under the Plan.

Disability Extension

If, after electing COBRA continuation coverage due to yourtermination of employment or reduction in work hours, you orone of your Dependents is determined by the Social SecurityAdministration (SSA) to be totally disabled under title II orXVI of the SSA, you and all of your Dependents who haveelected COBRA continuation coverage may extend suchcontinuation for an additional 11 months, for a maximum of29 months from the initial qualifying event.

To qualify for the disability extension, all of the followingrequirements must be satisfied:

1. SSA must determine that the disability occurred prior to orwithin 60 days after the disabled individual elected COBRAcontinuation coverage; and

2. A copy of the written SSA determination must be providedto the Plan Administrator within 60 calendar days after thedate the SSA determination is made AND before the end ofthe initial 18-month continuation period.

If the SSA later determines that the individual is no longerdisabled, you must notify the Plan Administrator within 30days after the date the final determination is made by SSA.The 11-month disability extension will terminate for allcovered persons on the first day of the month that is more than30 days after the date the SSA makes a final determinationthat the disabled individual is no longer disabled.

All causes for “Termination of COBRA Continuation” listedbelow will also apply to the period of disability extension.

Medicare Extension for Your Dependents

When the qualifying event is your termination of employmentor reduction in work hours and you became enrolled inMedicare (Part A, Part B or both) within the 18 months beforethe qualifying event, COBRA continuation coverage for yourDependents will last for up to 36 months after the date you

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became enrolled in Medicare. Your COBRA continuationcoverage will last for up to 18 months from the date of yourtermination of employment or reduction in work hours.

FDRL21

Termination of COBRA Continuation

COBRA continuation coverage will be terminated upon theoccurrence of any of the following:

the end of the COBRA continuation period of 18, 29 or 36months, as applicable;

failure to pay the required premium within 30 calendar daysafter the due date;

cancellation of the Employer’s policy with CIGNA;

after electing COBRA continuation coverage, a qualifiedbeneficiary enrolls in Medicare (Part A, Part B, or both);

after electing COBRA continuation coverage, a qualifiedbeneficiary becomes covered under another group healthplan, unless the qualified beneficiary has a condition forwhich the new plan limits or excludes coverage under a pre-existing condition provision. In such case coverage willcontinue until the earliest of: (a) the end of the applicablemaximum period; (b) the date the pre-existing conditionprovision is no longer applicable; or (c) the occurrence of anevent described in one of the first three bullets above; or

any reason the Plan would terminate coverage of aparticipant or beneficiary who is not receiving continuationcoverage (e.g., fraud).

Moving Out of Employer’s Service Area or Elimination ofa Service Area

If you and/or your Dependents move out of the Employer’sservice area or the Employer eliminates a service area in yourlocation, your COBRA continuation coverage under the planwill be limited to out-of-network coverage only. In-networkcoverage is not available outside of the Employer’s servicearea. If the Employer offers another benefit option throughCIGNA or another carrier which can provide coverage in yourlocation, you may elect COBRA continuation coverage underthat option.

FDRL22 V1

Employer’s Notification Requirements

Your Employer is required to provide you and/or yourDependents with the following notices:

An initial notification of COBRA continuation rights mustbe provided within 90 days after your (or your spouse’s)coverage under the Plan begins (or the Plan first becomes

subject to COBRA continuation requirements, if later). Ifyou and/or your Dependents experience a qualifying eventbefore the end of that 90-day period, the initial notice mustbe provided within the time frame required for the COBRAcontinuation coverage election notice as explained below.

A COBRA continuation coverage election notice must beprovided to you and/or your Dependents within thefollowing timeframes:

(a) if the Plan provides that COBRA continuation coverageand the period within which an Employer must notifythe Plan Administrator of a qualifying event starts uponthe loss of coverage, 44 days after loss of coverageunder the Plan;

(b) if the Plan provides that COBRA continuation coverageand the period within which an Employer must notifythe Plan Administrator of a qualifying event starts uponthe occurrence of a qualifying event, 44 days after thequalifying event occurs; or

(c) in the case of a multi-employer plan, no later than 14days after the end of the period in which Employersmust provide notice of a qualifying event to the PlanAdministrator.

How to Elect COBRA Continuation Coverage

The COBRA coverage election notice will list the individualswho are eligible for COBRA continuation coverage andinform you of the applicable premium. The notice will alsoinclude instructions for electing COBRA continuationcoverage. You must notify the Plan Administrator of yourelection no later than the due date stated on the COBRAelection notice. If a written election notice is required, it mustbe post-marked no later than the due date stated on theCOBRA election notice. If you do not make propernotification by the due date shown on the notice, you and yourDependents will lose the right to elect COBRA continuationcoverage. If you reject COBRA continuation coverage beforethe due date, you may change your mind as long as youfurnish a completed election form before the due date.

Each qualified beneficiary has an independent right to electCOBRA continuation coverage. Continuation coverage maybe elected for only one, several, or for all Dependents who arequalified beneficiaries. Parents may elect to continue coverageon behalf of their Dependent children. You or your spousemay elect continuation coverage on behalf of all the qualifiedbeneficiaries. You are not required to elect COBRAcontinuation coverage in order for your Dependents to electCOBRA continuation.

FDRL23

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How Much Does COBRA Continuation Coverage Cost?

Each qualified beneficiary may be required to pay the entirecost of continuation coverage. The amount may not exceed102% of the cost to the group health plan (including bothEmployer and Employee contributions) for coverage of asimilarly situated active Employee or family member. Thepremium during the 11-month disability extension may notexceed 150% of the cost to the group health plan (includingboth employer and employee contributions) for coverage of asimilarly situated active Employee or family member. Forexample:

If the Employee alone elects COBRA continuation coverage,the Employee will be charged 102% (or 150%) of the activeEmployee premium. If the spouse or one Dependent childalone elects COBRA continuation coverage, they will becharged 102% (or 150%) of the active Employee premium. Ifmore than one qualified beneficiary elects COBRAcontinuation coverage, they will be charged 102% (or 150%)of the applicable family premium.

When and How to Pay COBRA Premiums

First payment for COBRA continuation

If you elect COBRA continuation coverage, you do not haveto send any payment with the election form. However, youmust make your first payment no later than 45 calendar daysafter the date of your election. (This is the date the ElectionNotice is postmarked, if mailed.) If you do not make your firstpayment within that 45 days, you will lose all COBRAcontinuation rights under the Plan.

Subsequent payments

After you make your first payment for COBRA continuationcoverage, you will be required to make subsequent paymentsof the required premium for each additional month ofcoverage. Payment is due on the first day of each month. Ifyou make a payment on or before its due date, your coverageunder the Plan will continue for that coverage period withoutany break.

Grace periods for subsequent payments

Although subsequent payments are due by the first day of themonth, you will be given a grace period of 30 days after thefirst day of the coverage period to make each monthlypayment. Your COBRA continuation coverage will beprovided for each coverage period as long as payment for thatcoverage period is made before the end of the grace period forthat payment. However, if your payment is received after thedue date, your coverage under the Plan may be suspendedduring this time. Any providers who contact the Plan toconfirm coverage during this time may be informed thatcoverage has been suspended. If payment is received beforethe end of the grace period, your coverage will be reinstatedback to the beginning of the coverage period. This means thatany claim you submit for benefits while your coverage is

suspended may be denied and may have to be resubmittedonce your coverage is reinstated. If you fail to make apayment before the end of the grace period for that coverageperiod, you will lose all rights to COBRA continuationcoverage under the Plan.

FDRL24 V2

You Must Give Notice of Certain Qualifying Events

If you or your Dependent(s) experience one of the followingqualifying events, you must notify the Plan Administratorwithin 60 calendar days after the later of the date thequalifying event occurs or the date coverage would cease as aresult of the qualifying event:

Your divorce or legal separation;

Your child ceases to qualify as a Dependent under the Plan;or

The occurrence of a secondary qualifying event as discussedunder “Secondary Qualifying Events” above (this noticemust be received prior to the end of the initial 18- or 29-month COBRA period).

(Also refer to the section titled “Disability Extension” foradditional notice requirements.)

Notice must be made in writing and must include: the name ofthe Plan, name and address of the Employee covered under thePlan, name and address(es) of the qualified beneficiariesaffected by the qualifying event; the qualifying event; the datethe qualifying event occurred; and supporting documentation(e.g., divorce decree, birth certificate, disability determination,etc.).

Newly Acquired Dependents

If you acquire a new Dependent through marriage, birth,adoption or placement for adoption while your coverage isbeing continued, you may cover such Dependent under yourCOBRA continuation coverage. However, only your newbornor adopted Dependent child is a qualified beneficiary and maycontinue COBRA continuation coverage for the remainder ofthe coverage period following your early termination ofCOBRA coverage or due to a secondary qualifying event.COBRA coverage for your Dependent spouse and anyDependent children who are not your children (e.g.,stepchildren or grandchildren) will cease on the date yourCOBRA coverage ceases and they are not eligible for asecondary qualifying event.

COBRA Continuation for Retirees Following Employer’sBankruptcy

If you are covered as a retiree, and a proceeding in bankruptcyis filed with respect to the Employer under Title 11 of theUnited States Code, you may be entitled to COBRA

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continuation coverage. If the bankruptcy results in a loss ofcoverage for you, your Dependents or your surviving spousewithin one year before or after such proceeding, you and yourcovered Dependents will become COBRA qualifiedbeneficiaries with respect to the bankruptcy. You will beentitled to COBRA continuation coverage until your death.Your surviving spouse and covered Dependent children willbe entitled to COBRA continuation coverage for up to 36months following your death. However, COBRA continuationcoverage will cease upon the occurrence of any of the eventslisted under “Termination of COBRA Continuation” above.

FDRL25 V1

Trade Act of 2002

The Trade Act of 2002 created a new tax credit for certainindividuals who become eligible for trade adjustmentassistance and for certain retired Employees who are receivingpension payments from the Pension Benefit GuarantyCorporation (PBGC) (eligible individuals). Under the new taxprovisions, eligible individuals can either take a tax credit orget advance payment of 65% of premiums paid for qualifiedhealth insurance, including continuation coverage. If you havequestions about these new tax provisions, you may call theHealth Coverage Tax Credit Customer Contact Center toll-freeat 1-866-628-4282. TDD/TYY callers may call toll-free at 1-866-626-4282. More information about the Trade Act is alsoavailable at www.doleta.gov/tradeact/2002act_index.asp.

In addition, if you initially declined COBRA continuationcoverage and, within 60 days after your loss of coverage underthe Plan, you are deemed eligible by the U.S. Department ofLabor or a state labor agency for trade adjustment assistance(TAA) benefits and the tax credit, you may be eligible for aspecial 60 day COBRA election period. The special electionperiod begins on the first day of the month that you becomeTAA-eligible. If you elect COBRA coverage during thisspecial election period, COBRA coverage will be effective onthe first day of the special election period and will continue for18 months, unless you experience one of the events discussedunder “Termination of COBRA Continuation” above.Coverage will not be retroactive to the initial loss of coverage.If you receive a determination that you are TAA-eligible, youmust notify the Plan Administrator immediately.

Interaction With Other Continuation Benefits

You may be eligible for other continuation benefits under statelaw. Refer to the Termination section for any othercontinuation benefits.

FDRL26

DefinitionsActive Service

You will be considered in Active Service:

on any of your Employer's scheduled work days if you areperforming the regular duties of your work on a full-timebasis on that day either at your Employer's place of businessor at some location to which you are required to travel foryour Employer's business.

on a day which is not one of your Employer's scheduledwork days if you were in Active Service on the precedingscheduled work day.

DFS1

Bed and Board

The term Bed and Board includes all charges made by aHospital on its own behalf for room and meals and for allgeneral services and activities needed for the care of registeredbed patients.

DFS14

Charges

The term "charges" means the actual billed charges; exceptwhen the provider has contracted directly or indirectly withCG for a different amount.

DFS940

Chiropractic Care

The term Chiropractic Care means the conservativemanagement of neuromusculoskeletal conditions throughmanipulation and ancillary physiological treatment rendered tospecific joints to restore motion, reduce pain and improvefunction.

DFS1689

Custodial Services

Any services that are of a sheltering, protective, orsafeguarding nature. Such services may include a stay in aninstitutional setting, at-home care, or nursing services to carefor someone because of age or mental or physical condition.This service primarily helps the person in daily living.Custodial care also can provide medical services, given mainlyto maintain the person’s current state of health. These services

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cannot be intended to greatly improve a medical condition;they are intended to provide care while the patient cannot carefor himself or herself. Custodial Services include but are notlimited to:

Services related to watching or protecting a person;

Services related to performing or assisting a person inperforming any activities of daily living, such as: (a)walking, (b) grooming, (c) bathing, (d) dressing, (e) gettingin or out of bed, (f) toileting, (g) eating, (h) preparing foods,or (i) taking medications that can be self administered, and

Services not required to be performed by trained or skilledmedical or paramedical personnel.

DFS1812

Dependent

Dependents are:

your lawful spouse; and

any unmarried child of yours who is

less than 25 years old;

25 or more years old and primarily supported by you andincapable of self-sustaining employment by reason ofmental or physical handicap. Proof of the child's conditionand dependence must be submitted to CG within 31 daysafter the date the child ceases to qualify above. During thenext two years CG may, from time to time, require proofof the continuation of such condition and dependence.After that, CG may require proof no more than once ayear.

A child includes your natural child, stepchild, or legallyadopted child, or the child for whom you are the legalguardian, or the child who is the subject of a lawsuit foradoption by you, or the child who is supported pursuant to acourt order imposed on you (including a qualified medicalchild support order) or your grandchild who is your Dependentfor federal income tax purposes at the time of application.

Benefits for a Dependent child will continue until the last dayof the calendar month in which the limiting age is reached.

Anyone who is eligible as an Employee will not be consideredas a Dependent.

No one may be considered as a Dependent of more than oneEmployee.

DFS1877

Emergency Services/Emergency Medical Condition

Emergency Services are a health care item or service furnishedor required to evaluate and treat an Emergency MedicalCondition, which may include, but shall not be limited tohealth care services that are provided in a licensed Hospital'semergency facility by an appropriate provider. An EmergencyMedical Condition is the sudden and, at the time, unexpectedonset of a health condition that manifests itself by symptomsof sufficient severity that would lead a prudent layperson,possessing an average knowledge of medicine and health, tobelieve that immediate medical care is required, which mayinclude, but shall not be limited to:

(1) Placing the person's health in significant jeopardy;

(2) Serious impairment to a bodily function;

(3) Serious dysfunction of any bodily organ or part;

(4) Inadequately controlled pain; or

(5) With respect to a pregnant woman who is havingcontractions:

(a) That there is inadequate time to effect a safe transferto another hospital before delivery; or

(b) That transfer to another hospital may pose a threat tothe health or safety of the woman or unborn child.

DFS1540

Employee

The term Employee means a full-time employee of theEmployer who is currently in Active Service. The term doesnot include employees who are part-time or temporary or whonormally work less than 20 hours a week for the Employer.

DFS1427 M

Employer

The term Employer means the plan sponsor self-insuring thebenefits described in this booklet, on whose behalf CG isproviding claim administration services.

DFS1595

Expense Incurred

An expense is incurred when the service or the supply forwhich it is incurred is provided.

DFS60

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Free-Standing Surgical Facility

The term Free-standing Surgical Facility means an institutionwhich meets all of the following requirements:

it has a medical staff of Physicians, Nurses and licensedanesthesiologists;

it maintains at least two operating rooms and onerecovery room;

it maintains diagnostic laboratory and x-ray facilities;

it has equipment for emergency care;

it has a blood supply;

it maintains medical records;

it has agreements with Hospitals for immediateacceptance of patients who need Hospital Confinementon an inpatient basis; and

it is licensed in accordance with the laws of theappropriate legally authorized agency.

DFS682

Hospice Care Program

The term Hospice Care Program means:

a coordinated, interdisciplinary program to meet thephysical, psychological, spiritual and social needs of dyingpersons and their families;

a program that provides palliative and supportivemedical, nursing and other health services through homeor inpatient care during the illness;

a program for persons who have a Terminal Illness andfor the families of those persons.

DFS70

Hospice Care Services

The term Hospice Care Services means any services providedby: (a) a Hospital, (b) a Skilled Nursing Facility or a similarinstitution, (c) a Home Health Care Agency, (d) a HospiceFacility, or (e) any other licensed facility or agency under aHospice Care Program.

DFS599

Hospice Facility

The term Hospice Facility means an institution or part of itwhich:

primarily provides care for Terminally Ill patients;

is accredited by the National Hospice Organization;

meets standards established by CG; and

fulfills any licensing requirements of the state or localityin which it operates.

DFS72

Hospital

The term Hospital means:

an institution licensed as a hospital, which: (a) maintains, onthe premises, all facilities necessary for medical andsurgical treatment; (b) provides such treatment on aninpatient basis, for compensation, under the supervision ofPhysicians; and (c) provides 24-hour service by RegisteredGraduate Nurses;

an institution which qualifies as a hospital, a psychiatrichospital or a tuberculosis hospital, and a provider ofservices under Medicare, if such institution is accredited asa hospital by the Joint Commission on the Accreditation ofHealthcare Organizations;

an institution which: (a) specializes in treatment of MentalHealth and Substance Abuse or other related illness; (b)provides residential treatment programs; and (c) is licensedor certified in accordance with the laws of the appropriatelegally authorized agency;

a Free-standing Surgical Facility; or

a Psychiatric Day Treatment Facility.

The term Hospital will not include an institution which isprimarily a place for rest, a place for the aged, or a nursinghome.

DFS1746

Hospital Confinement or Confined in a Hospital

A person will be considered Confined in a Hospital if he is:

a registered bed patient in a Hospital upon therecommendation of a Physician;

receiving treatment for Mental Health and Substance AbuseServices in a Partial Hospitalization program;

receiving treatment for Mental Health and Substance AbuseServices in a Mental Health or Substance Abuse ResidentialTreatment Center.

DFS1815

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Injury

The term Injury means an accidental bodily injury.

DFS147

Inpatient Mental Illness Benefits

Benefits that are provided while you or your Dependents areConfined in a Hospital for the treatment and evaluation ofMental Illness. Inpatient Mental Illness Services includeMental Illness treatment in a Residential Treatment Center forChildren and Adolescents, and from a Crisis StabilizationUnit, Partial Hospitalization, and Mental Illness ResidentialTreatment Services.

Inpatient mental illness benefits are exchangeable with PartialHospitalization sessions when benefits are provided for notless than four (4) hours and not more than twelve (12) hours inany twenty-four (24) hour period. The benefit exchange willbe two (2) partial hospitalization sessions are equal to one (1)day of inpatient care.

DFS1593

Maintenance Treatment

The term Maintenance Treatment means:

treatment rendered to keep or maintain the patient's currentstatus.

DFS1650

Maximum Reimbursable Charge - Medical

The Maximum Reimbursable Charge for covered services isdetermined based on the lesser of:

the provider’s normal charge for a similar service or supply;or

a policyholder-selected percentile of charges made byproviders of such service or supply in the geographic areawhere it is received as compiled in a database selected byCG.

The percentile used to determine the Maximum ReimbursableCharge is listed in The Schedule.

The Maximum Reimbursable Charge is subject to all otherbenefit limitations and applicable coding and paymentmethodologies determined by CG. Additional informationabout how CG determines the Maximum ReimbursableCharge is available upon request.

GM6000 DFS1997 V14

Medicaid

The term Medicaid means a state program of medical aid forneedy persons established under Title XIX of the SocialSecurity Act of 1965 as amended.

DFS192

Medically Necessary/Medical Necessity

Medically Necessary Covered Services and Supplies are thosedetermined by the Medical Director to be:

required to diagnose or treat an illness, injury, disease or itssymptoms;

in accordance with generally accepted standards of medicalpractice;

clinically appropriate in terms of type, frequency, extent,site and duration;

not primarily for the convenience of the patient, Physicianor other health care provider; and

rendered in the least intensive setting that is appropriate forthe delivery of the services and supplies. Where applicable,the Medical Director may compare the cost-effectiveness ofalternative services, settings or supplies when determiningleast intensive setting.

DFS1813

Medicare

The term Medicare means the program of medical carebenefits provided under Title XVIII of the Social Security Actof 1965 as amended.

DFS149

Mental Illness Residential Treatment Services

The Mental Illness Residential Treatment Services are servicesprovided by a Hospital that is designated by CG for theevaluation and treatment of the psychological and social

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functional disturbances that are a result of subacute mentalillness conditions.

Mental Illness Residential Treatment benefits are exchangedwith Inpatient Mental Illness benefits at a rate of two (2) daysof Mental Illness Residential Treatment being equal to one (1)day of Inpatient Mental Illness Treatment.

Mental Illness Residential Treatment Center means aninstitution which (a) specializes in the treatment ofpsychological and social disturbances that are the result ofmental illness conditions; (b) provides a subacute, structured,psychotherapeutic treatment program, under the supervision ofPhysicians; (c) provides 24-hour care, in which a person livesin an open setting; and (d) is licensed in accordance with thelaws of the appropriate legally authorized agency as aResidential Treatment Center.

A person is considered Confined in a Residential TreatmentCenter when she/he is a registered bed patient in a ResidentialTreatment Center upon the recommendation of a Physician.

DFS1584

Necessary Services and Supplies

The term Necessary Services and Supplies includes:

any charges, except charges for Bed and Board, made by aHospital on its own behalf for medical services and suppliesactually used during Hospital Confinement;

any charges, by whomever made, for licensed ambulanceservice to or from the nearest Hospital where the neededmedical care and treatment can be provided; and

any charges, by whomever made, for the administration ofanesthetics during Hospital Confinement.

The term Necessary Services and Supplies will not includeany charges for special nursing fees, dental fees or medicalfees.

DFS151

Nurse

The term Nurse means a Registered Graduate Nurse, aLicensed Practical Nurse or a Licensed Vocational Nurse whohas the right to use the abbreviation "R.N.," "L.P.N." or"L.V.N."

DFS155

Other Health Care Facility

The term Other Health Care Facility means a facility otherthan a Hospital or hospice facility. Examples of Other HealthCare Facilities include, but are not limited to, licensed skillednursing facilities, rehabilitation Hospitals and subacutefacilities.

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Other Health Professional

The term Other Health Professional means an individual otherthan a Physician who is licensed or otherwise authorized underthe applicable state law to deliver medical services andsupplies. Other Health Professionals include, but are notlimited to physical therapists, registered nurses and licensedpractical nurses.

DFS1685

Outpatient Chemical Dependency Rehabilitation Services

Outpatient Chemical Dependency Rehabilitation Services areservices provided for the diagnosis and treatment of ChemicalDependency, while you or your Dependent are not Confinedin a Hospital, including outpatient rehabilitation in anindividual, group, structured group or in a ChemicalDependency Outpatient Structured Therapy Program.

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Outpatient Mental Illness Services

Outpatient Mental Illness Services are services of providerswho are qualified to treat mental illness when treatment isprovided on an outpatient basis, while you or your Dependentis not Confined in a Hospital, in an individual, group orstructured group therapy program. Covered services include,but are not limited to, outpatient treatment of conditions suchas: anxiety or depression which interferes with dailyfunctioning; emotional adjustment or concerns related tochronic conditions, such as psychosis or depression; emotionalreactions associated with marital problems or divorce;child/adolescent problems of conduct or poor impulse control;affective disorders; suicidal or homicidal threats or acts; eatingdisorders; or acute exacerbation of chronic mental illnessconditions (crisis intervention and relapse prevention) andoutpatient testing and assessment.

DFS1594

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Participating Provider

The term Participating Provider means a hospital, aPhysician or any other health care practitioner or entity thathas a direct or indirect contractual arrangement with CIGNAto provide covered services with regard to a particular planunder which the participant is covered.

DFS1910

Physician

The term Physician means a licensed medical practitioner whois practicing within the scope of his license and who islicensed to prescribe and administer drugs or to performsurgery. It will also include any other licensed medicalpractitioner whose services are required to be covered by lawin the locality where the policy is issued if he is:

operating within the scope of his license; and

performing a service for which benefits are provided underthis plan when performed by a Physician.

DFS164

Preventive Treatment

The term Preventive Treatment means:

treatment rendered to prevent disease or its recurrence.

DFS1652

Primary Care Physician

The term Primary Care Physician means a Physician: (a) whoqualifies as a Participating Provider in general practice,internal medicine, family practice or pediatrics; and (b) whohas been selected by you, as authorized by the ProviderOrganization, to provide or arrange for medical care for you orany of your insured Dependents.

DFS622

Psychologist

The term Psychologist means a person who is licensed orcertified as a clinical psychologist. Where no licensure orcertification exists, the term Psychologist means a person whois considered qualified as a clinical psychologist by arecognized psychological association. It will also include anyother licensed counseling practitioner whose services are

required to be covered by law in the locality where the policyis issued if he is:

operating within the scope of his license; and

performing a service for which benefits are provided underthis plan when performed by a Psychologist.

DFS170

Residential Treatment for Children and Adolescents

The Residential Treatment for Children and Adolescentsmeans a child care institution that provides residential care andtreatment for emotionally disturbed children and adolescents,and that is accredited as a Residential Treatment Center by theCouncil on Accreditation, the Joint Commission onAccreditation of Hospitals, or the American Association ofPsychiatric Services for Children.

DFS1583

Review Organization

The term Review Organization refers to an affiliate of CG oranother entity to which CG has delegated responsibility forperforming utilization review services. The ReviewOrganization is an organization with a staff of clinicians whichmay include Physicians, Registered Graduate Nurses, licensedmental health and substance abuse professionals, and othertrained staff members who perform utilization review services.

DFS1688

Series of Treatments

A Series of Treatments is a planned, structured and organizedprogram to promote chemical free status which may or maynot include different facilities or modalities, and is completewhen you are discharged on medical advice from inpatientdetoxification, inpatient rehabilitation, partial hospitalizationor intensive outpatient care, or a series of these levels oftreatment without a lapse in treatment, or when you fail tomaterially comply with the treatment program for a period ofthirty (30) days.

DFS1589

Sickness – For Medical Insurance

The term Sickness means a physical or mental illness. It alsoincludes pregnancy. Expenses incurred for routine Hospitaland pediatric care of a newborn child prior to discharge from

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the Hospital nursery will be considered to be incurred as aresult of Sickness.

DFS531

Skilled Nursing Facility

The term Skilled Nursing Facility means a licensed institution(other than a Hospital, as defined) which specializes in:

physical rehabilitation on an inpatient basis; or

skilled nursing and medical care on an inpatient basis;

but only if that institution: (a) maintains on the premises allfacilities necessary for medical treatment; (b) provides suchtreatment, for compensation, under the supervision ofPhysicians; and (c) provides Nurses' services.

DFS193

Terminal Illness

A Terminal Illness will be considered to exist if a personbecomes terminally ill with a prognosis of six months or lessto live, as diagnosed by a Physician.

DFS197

Toxic Inhalant

A Toxic Inhalant means a volatile chemical under Chapter484, Health and Safety Code, or usable glue or aerosol paintunder Section 485.001, Health and Safety Code.

DFS1592

Urgent Care

Urgent Care is medical, surgical, Hospital and related healthcare service and testing which is provided to treat a conditionthat is: (1) less severe than an Emergency Medical Condition;(2) requires immediate medical attention; and (3) isunforeseen. Care which could have been foreseen as neededbefore leaving the provider network area where the insuredordinarily receives and/or was scheduled to receive servicesdoes not meet the definition of Urgent Care. Such foreseeablecare includes, but is not limited to, delivery beyond the 35thweek of pregnancy, dialysis, scheduled medical treatments ortherapy, or care received after a Physician's recommendationthat the insured should not travel due to any medicalcondition.

DFS1541

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The following pages describe the features of your CIGNA Choice Fund - Health ReimbursementArrangement. Please read them carefully.

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What You Should Know about CIGNAChoice Fund® – Health ReimbursementArrangementCIGNA Choice Fund is designed to give you more of whatyou want:

Options to help you manage your health and your healthcare

Simple ways to predict and track cost

A better understanding of your options

What’s in it for you?

Control

The services you get and where you get them are up to you.

Choice

You have the freedom to choose any licensed doctor. Yourcosts are lower for services from CIGNA contracted providers.

Flexibility

Your employer’s annual contribution to your HRA helpsoffset the cost of your deductible. You can use your HRA topay for qualified expenses, and your employer may permit youto carry over some or the entire unused amount, which will beadded to your account for the following year, as long as youstay in the plan. Ask your employer if this option is availableto you. Please visit myCIGNA.com for a list of qualifiedexpenses.

Quality

Your plan covers medical care when you’re sick, but alsoincludes coverage for preventive care services.

Tools

Easy-to-use resources help you make informed decisions.

Health Information and Education

Just call the toll-free number on your ID card to reach theCIGNA HealthCare 24-Hour Health Information LineSM,giving you access to registered nurses and an audio library ofhealth topics 24 hours a day. In addition, the CIGNAHealthCare Healthy Babies® program provides prenataleducation and support for mothers-to-be.

Support

We help you keep track with online benefits information,transactions, and account activity; medical and drug costcomparisons; monthly statements; and more. You also havetoll-free access to dedicated Member Service teams, speciallytrained to answer your questions and address your needs.

Savings on Health and Wellness Products and Services

Through CIGNA Healthy Rewards®, you can save money onproducts and services not often covered by many traditionalplans. Offerings include laser vision correction, acupuncture,chiropractic care, Weight Watchers®, and more.

Opportunity to earn funds for future use

If your employer offers the CIGNA Healthy Future Account®,you can earn funds to cover qualified expenses for future use,such as retirement. All or a portion of unused HRA funds atthe end of each plan year will transfer to this account until youmeet the eligibility requirements (such as retirement, reachingage 65, or accumulating a certain number of years of servicewith your employer). Once you reach your qualifying event,you may then use the Healthy Future Account to pay yourselfback for certain expenses defined by your employer. See yourbenefits administrator for more details.

The Basics

How does it work?

The Health Reimbursement Arrangement combines traditionalmedical coverage with a fund that includes contributions onlyfrom your employer.

1. Employer contribution — Your employer establishes ahealth fund that can be used to pay for qualified healthcare expenses during that year. The services you receiveand where you get them are up to you. Amounts paid bythe fund for covered services count toward the annualdeductible. For a list of qualified expenses, please visitCIGNA.com, subject to limits set by your employer.

2. Your contribution — Once you’ve used the dollars inyour health fund, you pay your expenses up to thedeductible.

3. Your employer and you — After your deductible is met,you use a traditional medical plan for covered services.Depending on your plan, you pay pre-determinedcoinsurance or copayments for certain services.

Which services are covered by my Health ReimbursementArrangement?

According to federal law, HRA funds can be used to coveronly qualified medical expenses for you and your dependents.However, your employer may choose not to allow coveragefor certain qualified expenses. Please refer to myCIGNA.comfor information on the services for which you may use yourHRA funds. If you use your HRA for expenses not allowedunder federal tax law, your contributions will be subject totaxes.

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Which services are covered by my medical plan, and whichwill I have to pay out of my own pocket?

Covered services vary depending on your plan, so visitmyCIGNA.com or check your plan materials in this bookletfor specific information. In addition to your premiumsdeducted from your paycheck, you’ll be responsible forpaying:

Costs for any services needed after you’ve spent your healthfund, if you haven’t met your deductible.

Your coinsurance or copayments after you meet thedeductible and your medical plan coverage begins.

If all of your medical expenses are covered services and thetotal cost doesn’t exceed the amount in your health fund, youmay not have additional out-of-pocket costs.

Your plan may also include a Flexible Spending Account(FSA). If you are eligible to enroll in this account, you cancontribute pre-tax dollars from each paycheck — then use thefunds to reimburse yourself for eligible health care expenses,such as certain vision, hearing, or orthodontic care, even ifthey’re not covered by your CIGNA medical plan. Youremployer determines which health care expenses are eligiblefor reimbursement. Your employer also decides whethermoney for expenses is deducted first from your HRA or FSA.In addition, your employer may allow you to use FSA fundsremaining at the end of the plan year to pay for claimsincurred during the 2½ months after your plan year ends.Please check with your employer to determine if this option isavailable to you.

Limited Purpose HRA (if offered by your employer)

Your plan may include a Limited Purpose HRA. If youremployer chooses this option, and you decide to enroll in aHealth Savings Account (HSA) in the future, you will haveaccess to unused HRA funds through the Limited PurposeHRA. When you enroll in the HSA, you keep your HRAfunds, but you may use them only for specific expenses. If youdecide at a later point to re-enroll in the CIGNA Choice FundHRA, Limited Purpose HRA funds move back into your HRAand can be used for any qualified expenses under the HRA.For more information, please visit myCIGNA.com or talk withyour benefits administrator.

Are services covered if I use out-of-network doctors?

You can use the dollars in your HRA to visit any licenseddoctor or facility. However, if you choose a provider whoparticipates with CIGNA HealthCare, your costs will belower.

Key Terms

For the specific amounts in your plan, please see the medicalplan section of this booklet.

Deductible

The amount that you must pay for covered health expensesbefore the underlying health plan covers expenses.

Out-of-Pocket Maximum

The maximum amount you pay out of your pocket for eligibleexpenses each year.

HRA amount

The amount your employer contributes to your HRA eachyear.

Plan coinsurance

The percentage of charges you pay for expenses covered byyour medical plan.

Tools and Resources at Your Fingertips

To help you understand your benefits, we’ve created a suite ofinformation and tools that you can access confidentiallythrough our member website, myCIGNA.com.

You have a right to know the cost of services you receive. Youhave the power to make a difference in the type and quality ofthose services. You have unique health care needs.

And that’s why you have myCIGNA.com – to find value inyour health plan. myCIGNA.com includes helpful resourcesspecifically for members who have CIGNA Choice Fund.

Online access to your current fund balance, past transactionsand claim status, as well as your Explanation of Benefits.

Your own savings account calculator, with account balancetracking and transaction worksheets to estimate your out-of-pocket expenses.

Medical cost and drug cost information, including averagecosts for your state.

Explanations of other CIGNA HealthCare products andservices – what they are and how you can use them.

Frequently asked questions – about health care in generaland CIGNA HealthCare specifically.

A number of convenient, helpful tools that let you:

Compare costs

Use tools to compare costs and help you decide where to getcare. You can get average price ranges for certainambulatory surgical procedures and radiology services. Youcan also find estimated costs in your region for commonmedical services and conditions.

Find out more about your local hospitals

Learn how hospitals rank by number of proceduresperformed, patients’ average length of stay, and cost. Go toour online provider directory for estimated average costranges for certain procedures, including total charges andyour out-of-pocket expense, based on a CIGNA HealthCarebenefit plan. You can also find hospitals that earn the

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“Centers of Excellence” designation based on effectivenessin treating selected procedures/conditions and cost.

Get the facts about your medication, cost, treatmentoptions and side effects

Use the pharmacy tools to: check your prescription drugcosts, listed by specific pharmacy and location (includingCIGNA Tel-Drug); and review your claims history for thepast 16 months. Click “WebMD Drug Comparison Tool”under Related Health Resources to look at condition-specific drug treatments and compare characteristics ofmore than 200 common medications. Evaluate up to 10medications at once to better understand side effects, druginteractions and alternatives.

Take control of your health

Take the health risk assessment, an online questionnaire thatcan help you identify and monitor your health status. Youalso can find out how your family history may affect you,learn about preventive care and check your progress towardhealthy goals. And if your results show that you may benefitfrom other services, you can learn about related CIGNAHealthCare programs on the same site.

Explore topics on medicine, health and wellness

Get information on more than 5,000 health conditions,health and wellness, first aid and medical exams throughHealthwise®, an interactive library. Research articles onclinical findings through Condition Centers®.

Keep track of your personal health information

Health Record is your central, secure location for yourmedical conditions, medications, allergies, surgeries,immunizations, and emergency contacts. You can add yourhealth risk assessment results to Health Record, so you caneasily print and share the information with your doctor.Your lab results from certain facilities can be automaticallyentered into your Personal Health Record.

Chart progress of important health indicators

Input key data such as blood pressure, blood sugar,cholesterol (Total/LDL/HDL), height and weight, andexercise regimen. Health Tracker makes it easy to chartthe results and share them with your doctor.

On the Phone

Call the toll-free number on your CIGNA HealthCare ID cardto reach the CIGNA HealthCare 24-Hour Health InformationLineSM. You can speak to a trained nurse for guidance onappropriate care or directions to the nearest facility. You alsocan listen to audio tapes on a variety of health topics. It’s easy,reassuring, convenient and confidential.

CIGNA Health Advisor®/Personal Health Team

You now have access to health specialists – includingindividuals trained as nurses, coaches, nutritionists and

clinicians – who will listen, understand your needs and helpyou find solutions, even when you’re not sure where to begin.Partner with a health coach and get help to maintain goodeating and exercise habits; support and encouragement to setand reach health improvement goals; and guidance to bettermanage conditions, including coronary artery disease, lowback pain, osteoarthritis, high blood pressure, high cholesteroland more. From quick answers to health questions toassistance with managing more serious health needs, call thetoll-free number on your CIGNA ID card or visitmycigna.com. See your benefits administrator for more detailsabout all of the services you have access to through your plan.

Getting the Most from Your HRA

As a consumer, you make decisions every day – from buyingthe family car to choosing the breakfast cereal. Make yourselfa more educated health care consumer and you’ll find thatyou, too, can make a difference in the health care services youreceive and what you ultimately pay.

Fast Facts

If you choose to see a CIGNA HealthCare participatingprovider, the cost is based on discounted rates, so yourcosts will be lower. If you visit a provider not in the network,you may still use CIGNA Choice Fund to pay for the cost ofthose services, but you will pay a higher rate, and you mayhave to file claims.

If you need hospital care, there are several tools to helpyou make informed decisions about quality and cost.

With the Select Quality CareTM hospital comparison tool onmyCIGNA.com, you can learn how hospitals rank bynumber of procedures performed, patients’ average lengthof stay, and cost.

Visit our provider directory for CIGNA “Centers ofExcellence,” providing hospital scores for specificprocedures/conditions, such as cardiac care, hip and kneereplacement, and bariatric surgery. Scores are based on costand effectiveness in treating the procedure/condition, basedon publicly available data.

www.cigna.com also includes a Provider ExcellenceRecognition Directory. This directory includes informationon:

Participating physicians who have achieved recognitionfrom the National Committee for Quality Assurance(NCQA) for diabetes and/or heart and stroke care.

Hospitals that fully meet The Leapfrog Group patientsafety standards.

Wherever you go in the U.S., you take the CIGNAHealthCare 24-Hour Health Information LineSM with you.

Whether it’s late at night, and your child has a fever, or you’retraveling and you’re not sure where to get care, or you don’tfeel well and you’re unsure about the symptoms, you can call

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the CIGNA HealthCare 24-Hour Health Information Linewhenever you have a question. Call the toll-free number onyour CIGNA HealthCare ID card and you will speak to anurse who will help direct you to the appropriate care.

A little knowledge goes a long way.

Getting the facts about your care, such as treatment optionsand health risks is important to your health and well-being —and your pocketbook. For instance:

Getting appropriate preventive care is key to stayinghealthy. Your CIGNA HealthCare participating doctor canprovide a wide variety of tests and exams that are coveredby your CIGNA HealthCare plan. Visit myCIGNA.com tolearn more about proper preventive care and what’s coveredunder your plan. You can also find ways to stay healthy bycalling the CIGNA HealthCare 24-Hour Health InformationLine, which includes audio tapes on preventive health,exercise and fitness, nutrition and weight control, and more.

When it comes to medications, talk to your doctor aboutwhether generic drugs are right for you. The brand namedrugs you are prescribed may have generic alternatives thatcould lower your costs. If a generic version of your brandname drug is not available, other generic drugs with thesame treatment effect may meet your needs.

The health care cost estimator tool on myCIGNA.com canhelp you use the plan effectively. When planning andbudgeting, consider:

Your medical and prescription drug expenses from lastyear.

Any expected changes in your medical spending in thecoming year.

Your anticipated benefit expenses and out-of-pocket costsfor the coming year.

The amount in your CIGNA Choice Fund compared withyour expected out-of-pocket costs. Keep in mind thecopayment and/or coinsurance you will pay once the fundis spent.

Additional tools on myCIGNA.com can help you takecontrol of your health, learn more about medical topics andwellness, and keep track of your personal healthinformation. You can print personalized reports to discusswith your doctor.

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