the western union company - cigna · western union medical plans have no pre-existing condition...

1

The Western Union Company

Health and Life Plans Summary Plan Description

Effective January 1, 2017

2

IntroductionThis Summary Plan Description (SPD) describes the main features of the following plans:

Cigna Choice Fund Health Savings Account® / Cigna Open Access Plus®

Prescription Drug

Employee Assistance Program

Cigna Dental PPO

Cigna Dental DHMO

Flexible Spending Accounts

Cigna Global Health Benefits

Cigna Medical Benefits Abroad

Vision Service Plan

Life and Accidental Death and Dismemberment

Business Travel Accident

Short Term and Long Term Disability

Legal Assistance

This booklet provides information about what each plan covers and does not cover, how benefits are paid, special programs and services available to you and your family and certain rules and

provisions that apply to your coverage and benefits under the plan.

This SPD is based on official plan documents. In the unlikely event that there is a discrepancy between the SPD and the official plan documents, the official plan documents will control. Western Union reserves the right to amend, suspend or terminate plans or programs at any time. This SPD is not, nor is it intended to be, a contract between Western Union and any employee or contractor,

or a guarantee of employment.

If you have questions or need help with any aspect of the plan, turn to the Benefits Assistance and Resources information in the Overview section, go to the Cigna customized Western Union Website

at cigna.com/westernunion, or call the Cigna Member Service number on your ID card.

Western Union also offers the Cigna Dental Health Maintenance Organization (DHMO) coverage to employees living within a DHMO service area. For specific information on services covered by

the DHMO, go to the Cigna customized Western Union Website at cigna.com/westernunion or contact Cigna directly at 1-800-244-6224.

The plans limit the time in which an action at law or equity can be brought to recover under the plans. In general, no action at law or equity can be brought to recover on benefits under any of the plans after the expiration of three years after the deadline for a claim to be filed under the

applicable plan; however, a shorter deadline for such action may be provided under the applicable plan document(s).

http://cigna.com/westernunion


3

Table of ContentsOverview..........................................................................................................................................5

Benefits Assistance and Resources .....................................................................................5Eligibility...........................................................................................................................................6

Employees ............................................................................................................................6Rehired Employees ..............................................................................................................6Dependents ..........................................................................................................................7Same-sex Couples and Pre-tax Contributions......................................................................7Dependent Eligibility Rules ...................................................................................................7Handicapped Children ..........................................................................................................8Additional Important Health Plan Information .......................................................................8

Enrollment .......................................................................................................................................9Initial Enrollment ...................................................................................................................9Open Enrollment ...................................................................................................................9Late Enrollment.....................................................................................................................9New Dependents ..................................................................................................................9Special Enrollment Rights under the Health Insurance Portability and Accountability Act (HIPAA) ...............................................................................................................................10Qualified Status Changes – Mid-year Enrollment Changes ...............................................11Qualified Status Changes – Domestic Partners .................................................................11Coverage for Maternity Hospital Stay .................................................................................12Group Plan Coverage Instead of Medicaid .........................................................................12Qualified Medical Child Support Order (QMCSO) ..............................................................12ID Cards ..............................................................................................................................12Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) ...............13Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) .....13

Important Plan Terms ....................................................................................................................14The Cigna Open Access Plus Network..........................................................................................22The Cigna Choice Fund Health Savings Account (HSA) Plan ......................................................23What You Should Know About Cigna Choice Fund® – Health Savings Account ...........................25The Cigna Choice Fund Health Savings Account (HSA) Plan Prescription Drug Benefits ............36The Cigna Open Access Plus (OAP) Plan.....................................................................................40The Cigna Open Access Plus (OAP) Plan Prescription Drug Benefits ..........................................50Medical Benefits Provisions for Open Access Plus and Choice Fund plans .................................54Medical Plan – Covered Expenses................................................................................................55Prescription Drug Benefits and Exclusions ...................................................................................64Medical Plan Exclusions, Expenses Not Covered and General Limitations ..................................67Coordination of Benefits ................................................................................................................70Medicare Eligible ...........................................................................................................................73DPPO – Cigna Dental Preferred Provider Organization Plan........................................................74

4

DHMO – Cigna Dental Health Maintenance Organization Plan ....................................................79Filing Medical and Dental Claims ..................................................................................................80Payment of Benefits ......................................................................................................................82Medical Benefits Extension ...........................................................................................................83Employee Assistance Program......................................................................................................87Cigna Global Health Benefits Plan ................................................................................................88Cigna Global Health Benefits Plan Preferred Provider Medical Benefits ......................................99Cigna Global Health Benefits Plan Prescription Drug Benefits ...................................................110Emergency Evacuation................................................................................................................113Cigna Global Health Benefits Plan Vision Benefits .....................................................................115Cigna Global Health Benefits Plan Dental Preferred Provider Insurance ...................................117Exclusions, Expenses Not Covered and General Limitations .....................................................121Cigna Global Health Benefits – Coordination of Benefits ............................................................124Cigna Medical Benefits Abroad Traveler Insurance Plan ............................................................125Vision Coverage ..........................................................................................................................127Flexible Spending Accounts ........................................................................................................131Filing Flexible Spending Account Claims.....................................................................................137How to Appeal a Denied Claim ....................................................................................................139Life and Accident Coverage.........................................................................................................140Business Travel Accident Coverage ............................................................................................148Short Term Disability Coverage ...................................................................................................154Long Term Disability Coverage ....................................................................................................156ARAG Legal Plan ........................................................................................................................161When Coverage Ends .................................................................................................................165COBRA Continuation Rights Under Federal Law ........................................................................167Important Plan Provisions............................................................................................................172

5

Overview 5

OverviewThe plans described in this booklet are designed to provide you and your family with quality employee benefits. This booklet describes the main features of the various plans offered by Western Union – including who is eligible for coverage, what to do if you need care, how benefits are paid and when coverage ends. In addition, you’ll find information about certain rights and responsibilities you have as a covered person.

To take full advantage of all that the plan offers, it’s important to read this book carefully and make it available to other covered family members.

Benefits Assistance and ResourcesWhen you need help, answers or information, here are some resources available to you.

Resource Telephone Website

OneSource Virtual

■ Western Union Benefits Service Center

1-844-449-8236 7:00 a.m. - 7:00 p.m. CT (M-F)

[email protected]

■ COBRA/HIPAA Notice Administrator

1-866-634-9784 [email protected]

Cigna Plans

■ Medical, Dental, Pharmacy and Flexible Spending Account (FSA)

1-800-244-6224 myCigna.com

■ Cigna Global Health Benefits 1-800-441-2668 302-797-3100 collect

cignaenvoy.com

■ Cigna Medical Benefits Abroad 1-800-243-1348 302-797-3535 collect

cignaenvoy.com

■ Cigna Leave Solutions (Disability and Leave Management)

1-888-842-4462 myCigna.com

■ MDLIVE 1-888-726-3171 MDLIVE.com/westernunion

■ Cigna Life Insurance Claim Center 1-800-238-2125

■ Cigna Employee Assistance Program

1-877-622-4327 cignabehavioral.com employer ID: westernunion

Other Partners

■ Vision Service Plan (VSP) 1-800-877-7195 vsp.com

■ ARAG® Legal Assistance 1-800-247-4184 araggroup.com

■ AIG Benefits Travel Assist Accident Insurance

US / Canada: 1-877-244-6871International Operator:

1-715-346-0859Group:

The Western Union CompanyAssistance Number: 3473

Policy Number: 0009111243

mailto:[email protected]


http://myCigna.com

http://www.cignaenvoy.com


http://myCigna.com

http://MDLIVE.com/westernunion

http://cignabehavioral.com

http://vsp.com

http://araggroup.com

6

Eligibility 6

EligibilityEmployeesEffective January 1, 2017, you are eligible for benefits if you are on the U.S. domestic payroll as a regular full-time employee or a regular part-time employee, subject to the exclusions and limitations described below. Full-time employees are eligible to participate in the Plan and will become a Participant on the first day of the month coincident with or next following the date the individual becomes an Employee.

Medical Long Term Disability Insurance*Dental Legal Service PlanVision Health Care Flexible Spending AccountBasic Life Insurance* Dependent Care Flexible Spending AccountVoluntary Life Insurance* Voluntary Accidental Death and Dismemberment Insurance*Basic Accidental Death and Dismemberment Insurance* Short Term Disability (on your 91st day of employment)*Dependent Life Insurance (spouse and child)** Only part-time employees regularly scheduled to work 20 or more hours per week are eligible.

Your coverage in the Employee Assistance Program, the Business Travel Accident Insurance Plan and the Cigna Medical Benefits Abroad Program begins on your first day at work.

Western Union Medical plans have no pre-existing condition exclusions or limitations for medical coverage that would prevent or limit your eligibility. Under the Cigna Long Term Disability Insurance Plan, no benefit is payable for any disability that is caused by or contributed to by a pre-existing condition and starts before the end of the first 12 months following your effective date of coverage.

The following employees are not eligible to participate in benefits:

● any individual classified by the Employer as serving in a non-common law employee capacity with the Employer (whether or not such individual is later determined by a governmental agency or a court of competent jurisdiction to be a common-law employee of the Employer), including, but not limited to:o an independent contractor, leased employee, contract worker, temporary employee, on-call or seasonal employee; ando any self-employed individual (within the meaning of Code Section 401(c));o any employee covered by a collective bargaining agreement that does not require participation in this Plan; and

● an intern.The Business Travel Accident Insurance Plan includes eligible guests and eligible interns on authorized Western Union business travel. The Employee Assistance Program includes employees, their covered Dependents and household members.

During any period in which you are on a company-approved leave, you and your eligible Dependents, if any, may continue any medical, dental or vision group health coverage (“Group Health Coverage”), provided: (1) you were already enrolled in such coverage or you subsequently elect Group Health Coverage during the Company’s annual open enrollment period, (2) you make all required employee contributions for such coverage, and (3) your employment during such leave period is not terminated by either you or the Company. You are responsible for your share of the cost of any Group Health Coverage and failure to submit payment in a timely manner may result in termination of Group Health Coverage. Employees returning from disability leave OR LTD will be required to obtain and provide medical documentation authorizing a return to work. A failure to provide some documentation may result in the termination of your employment and any Group Health Coverage.

Rehired EmployeesWhen you return to work, your eligibility and benefits depend on the amount of time you were away.

● Within 31 days – If you return to work within 31 days, you will have the same coverages and elections for which you were eligible prior to your termination (i.e., if you had satisfied any waiting periods such as medical coverage the first of the month coincident or following hire, or the 90-day waiting period for Short Term Disability, you will not have to satisfy these again). If you return in a different plan year, you have an opportunity to enroll for new coverage.

● After 31 days – If you return to work after 31 days, the same eligibility rules that apply to new hires will apply to you.

When Coverage Ends – For detailed information, please see the When Coverage Ends section.

7

Eligibility 7

DependentsYou may cover the following Dependents under the plan:● Your legal spouse;● Your same- or opposite-gender domestic partner; and● Your Dependent children up to the end of the year in which the child attains age 26 (this is referred to as the plan’s “limiting

age” throughout this SPD) for medical, dental and vision coverage without regard to tax dependency, student status, residency, financial dependency, marriage, employment or if the adult child is eligible for other employer-based health plan coverage. See the section titled “Handicapped Children” below for an eligibility exception to plan’s limiting age for handicapped children.

The term child includes biological children, legally adopted children and children placed with the employee for adoption. The term child can also include stepchildren, foster children, grandchildren and children for whom the employee is the legal guardian, if the child qualifies as a Dependent under IRS guidelines.A legal spouse includes a common-law spouse in states that recognize common law marriage. You may be able to enroll your same- or opposite-gender domestic partner and his or her children for medical, dental and vision coverage.A Dependent does not include anyone who is also enrolled as an employee. No one can be enrolled as a Dependent of more than one employee.When you and your spouse are both employees at Western Union, special rules apply under the group life insurance plans● You can both enroll in Voluntary Life Insurance with no Spouse Life Insurance enrollment for either of you; or● One of you can enroll in Voluntary Life Insurance and Spouse Life Insurance with the other electing no coverage in Voluntary

and Spouse Life Insurance.● Either you or your spouse can elect Child Life Insurance coverage – but not both.Western Union has the right to require proof of Dependent eligibility, which includes but is not limited to, requesting Dependent eligibility documentation. It is the company’s fiduciary responsibility to ensure that covered Dependents are valid under the plan eligibility rules. Dependents recently enrolled in the WU Health & Life Benefits plan during annual enrollment, due to a qualifying life event or as a new hire, may from time to time be required to submit to the Western Union Benefits Service Center documentation to support their relationship with the added Dependent(s). In addition, Western Union has an ongoing right to require that you submit dependent verification information at any time. If you fail to provide any requested verification documentation, Western Union may terminate your group health plan coverage and/or your Dependent group health plan coverage prospectively or retroactively, as determined by Western Union in its sole discretion.

Same-sex Couples and Pre-tax ContributionsEffective September 16, 2013, employees who are same-sex couples, legally married in states that recognize their marriage, will be treated as married for federal tax purposes and qualify for pre-tax health plan contributions under the Western Union Health and Life Benefits program (regardless of whether the couple currently lives in a state that recognizes same-sex marriage). This change is in compliance with a recent IRS determination resulting from a Supreme Court decision regarding the Defense of Marriage Act (DOMA). If you consider your enrolled domestic partner to be qualified for pre-tax health plan contributions, please send an email to [email protected] so additional information can be collected from you.The ruling does not apply to registered domestic partnerships, civil unions, or similar formal relationships recognized under state law. As a reminder, spouses and domestic partners continue to be eligible Dependents under the Health and Life Benefit program, regardless of the tax treatment of benefits.

Dependent Eligibility RulesA Dependent does not include anyone who is also enrolled as an employee. No one can be enrolled as a Dependent of more than one employee.When you and your spouse are both employees at Western Union, special rules apply under the group life insurance plans● You can both enroll in Voluntary Life Insurance with no Spouse Life Insurance enrollment for either of you; or● One of you can enroll in Voluntary Life Insurance and Spouse Life Insurance with the other electing no coverage in Voluntary



8

Eligibility 8

Handicapped ChildrenIf you have a handicapped child, the child’s coverage may be continued past the plan’s limiting age for Dependents.Your child is considered to be handicapped if he or she:● Became disabled before age 19 (or age 26 if a full-time student);● Is unable to earn a living because of a mental or physical handicap that starts before he or she reaches the age limit for

Dependents; and● Depends mainly on you for support and maintenance.You must provide Cigna with proof of your child’s handicap no later than 31 days after your child reaches the Dependent age limit. The child’s coverage will end on the first to occur of the following:● Your child is no longer handicapped;● You fail to provide proof that the handicap continues;● You fail to have any required exam performed; or● Your child’s coverage ends for a reason other than reaching the age limit.Cigna has the right to require proof that the handicap continues. Cigna also has the right to examine your child as often as needed while the handicap continues. Once the child is two years beyond the plan’s Dependent age limit, these exams will not be required more than once a year. Cigna will pay for the exams.

Additional Important Health Plan InformationThe following are notifications Western Union is required to provide to you to comply with health care reform legislation and other federal laws governing group health plans.

Collection of Social Security NumbersThe Medicare, Medicaid & SCHIP (State Children’s Health Insurance Program) Extension Act requires plan sponsors and plan administrators to submit Social Security numbers of covered employees and their Dependents to the Centers of Medicare & Medicaid Services (CMS). CMS will use this information for coordination of benefits with Medicare. The law requires the company to obtain Social Security numbers for you or your covered Dependents age 45 and older. Although employees and Dependents below age 45 are not part of the requirement, Western Union may request this information in the future to be prepared for when you and your Dependents age into this requirement.

Notice Regarding Provider/Pharmacy Directories and Provider/Pharmacy NetworksIf your Plan uses a network of Providers, a separate listing of Participating Providers/Pharmacies who participate in the network is available to you without charge by visiting Cigna.com; myCigna.com or by calling the toll-free telephone number on your ID card.Your Participating Provider/Pharmacy networks consist of a group of local medical or dental practitioners, and Hospitals, of varied specialties as well as general practice or a group of local Pharmacies who are employed by or contracted with Cigna Healthcare.

Children’s Health Insurance Program (CHIP)If you are eligible for coverage under the Western Union medical plans but are unable to afford the required premium contributions, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or Children’s Health Insurance Program (CHIP) programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their share of health premiums. If you or your Dependents are already enrolled in Medicaid or CHIP, you can contact your State’s Medicaid or CHIP office to find out if premium assistance is available. If you or your Dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your Dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDSNOW (1-877-543-7669) or visit insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay your required premium contributions for an employer-sponsored health plan.Once it is determined that you or your Dependents are eligible for premium assistance under Medicaid or CHIP, you and your Dependents can enroll in the plan – as long as you and your Dependents are eligible, but not already enrolled in the plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.For more information on special enrollment rights and eligibility for premium assistance from Medicaid and CHIP, you can contact the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services at 1-877-267-2323, extension 61565 or visit cms.hhs.gov. The CHIP Notice is located on WU Life.

Women’s Health and Cancer Rights Act (WHCRA)The Women’s Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. Call Cigna Member Services at the toll-free number listed on your ID card for more information.

http://Cigna.com

http://myCigna.com

http://insurekidsnow.gov

http://cms.hhs.gov

9

Enrollment 9

EnrollmentInitial Enrollment

Coverage You Receive Automatically Coverage You ElectBasic Life Insurance MedicalBasic Accidental Death & Dismemberment Insurance Dental

Business Travel Accident Insurance VisionShort Term Disability Insurance Voluntary Life Insurance Long Term Disability Insurance Dependent Life Insurance (spouse and child)

Employee Assistance Program Voluntary Accidental Death & Dismemberment Insurance

Cigna Medical Benefits Abroad Legal Service PlanHealth Savings AccountHealth Care Flexible Spending AccountDependent Care Flexible Spending AccountCare$ Benefit

You must elect coverage by completing the enrollment process within 31 days of becoming eligible. The enrollment process allows you to choose or decline coverage. If you elect coverage, the amount of your contributions is determined by Western Union and may change. If you have any questions about enrollment or contributions, you should contact the Western Union Benefits Service Center at 1-844-449-8236.

Note: The plan will pay benefits for covered expenses incurred by a newborn child during the first 31 days of life, whether or not the child is or becomes enrolled in the plan. If the child does not become enrolled in the plan, his or her coverage will end once the 31-day period has ended. You have 90 days from the date of birth to enroll the child, whereby medical coverage is retroactive to the date of birth. You must add a newly eligible child to your health plan even if you already have employee + child(ren) or employee + family coverage.

Open EnrollmentAnnual open enrollment is your opportunity to review your benefit needs for the upcoming year and change your benefit elections, if necessary. Open enrollment is typically held in the fourth quarter each year and the elections you make will be in effect the following plan year beginning January 1.

Late EnrollmentIf you do not enroll yourself or a Dependent for coverage when first eligible, you will not be able to do so until the next annual open enrollment period.

There are some exceptions, however, as described below.

New DependentsYou may be able to elect coverage for yourself or your Dependents at the time you acquire a new Dependent in the following circumstances:

● You acquire a new Dependent through marriage and elect coverage for yourself and the new Dependent within 31 days of acquiring the Dependent. Coverage will take effect on the day of your status change (date of qualifying event).

● You (or you and your spouse) acquire a new Dependent through birth, adoption or placement for adoption and elect coverage for yourself (or yourself and your spouse) and the new Dependent within 90 days of acquiring the Dependent. Coverage will take effect on the child’s birth date, the date of adoption or placement for adoption, as applicable. You must add the newborn to your health benefits even if you have employee + child(ren) or employee + family coverage.

● You must request coverage under the group medical plan within 60 days of the date you or a Dependent loses Medicaid or State Child Health Insurance Plan.

10

Enrollment 10

Special Enrollment Rights under the Health Insurance Portability and Accountability Act (HIPAA)If you or your eligible Dependent(s) experience a special enrollment event as described below, you or your eligible Dependent(s) may be entitled to enroll in the Plan outside of a designated enrollment period upon the occurrence of one of the special enrollment events listed below. If you are already enrolled in the Plan, you may request enrollment for you and your eligible Dependent(s) under a different option offered by the Employer for which you are currently eligible. If you are not already enrolled in the Plan, you must request special enrollment for yourself in addition to your eligible Dependent(s). You and all of your eligible Dependent(s) must be covered under the same option. The special enrollment events include:

● Acquiring a new Dependent. If you acquire a new Dependent(s) through marriage, birth, adoption or placement for adoption, you may request special enrollment for any of the following combinations of individuals if not already enrolled in the Plan: Employee only; Spouse only; Employee and Spouse; Dependent Children only; Employee and Dependent Children; Employee, Spouse and Dependent Children. Enrollment of Dependent Children is limited to the newborn or adopted children or children who became Dependent Children of the Employee due to marriage. Dependent Children who were already Dependents of the Employee but not currently enrolled in the Plan are not entitled to special enrollment. Exception: The birth, adoption or placement of a child within 90 days.

● Loss of eligibility for state Medicaid or Children’s Health Insurance Program (CHIP). If you and/or your Dependent(s) were covered under a state Medicaid or CHIP Plan and the coverage is terminated due to a loss of eligibility, you may request special enrollment for yourself and any affected Dependent(s) who are not already enrolled in the Plan. You must request enrollment within 60 days after termination of Medicaid or CHIP coverage.

● Loss of eligibility for other coverage (excluding continuation coverage). If coverage was declined under this Plan due to coverage under another Plan, and eligibility for the other coverage is lost, you and all of your eligible Dependent(s) may request special enrollment in this Plan. If required by the Plan, when enrollment in this Plan was previously declined, it must have been declined in writing with a statement that the reason for declining enrollment was due to other health coverage. This provision applies to loss of eligibility as a result of any of the following:o divorce or legal separation;o cessation of Dependent status (such as reaching the limiting age);o death of the Employee;o termination of employment;o you or your Dependent(s) no longer reside, live or work in the other Plan’s network service area and no other coverage is

available under the other Plan;o you or your Dependent(s) incur a claim that meets or exceeds the lifetime maximum limit that is applicable to all benefits

offered under the other Plan; oro the other Plan no longer offers any benefits to a class of similarly situated individuals.

● Termination of Employer contributions (excluding continuation coverage). If a current or former Employer ceases all contributions toward the Employee’s or Dependent’s other coverage, special enrollment may be requested in this Plan for you and all of your eligible Dependent(s).

● Exhaustion of COBRA or other continuation coverage. Special enrollment may be requested in this Plan for you and all of your eligible Dependent(s) upon exhaustion of COBRA or other continuation coverage. If you or your Dependent(s) elect COBRA or other continuation coverage following loss of coverage under another Plan, the COBRA or other continuation coverage must be exhausted before any special enrollment rights exist under this Plan. An individual is considered to have exhausted COBRA or other continuation coverage only if such coverage ceases: (a) due to failure of the Employer or other responsible entity to remit premiums on a timely basis; (b) when the person no longer resides or works in the other Plan’s service area and there is no other COBRA or continuation coverage available under the Plan; or (c) when the individual incurs a claim that would meet or exceed a lifetime maximum limit on all benefits and there is no other COBRA or other continuation coverage available to the individual. This does not include termination of an Employer’s limited period of contributions toward COBRA or other continuation coverage as provided under any severance or other agreement.

● Eligibility for employment assistance under state Medicaid or Children’s Health Insurance Program (CHIP). If you and/or your Dependent(s) become eligible for assistance with group health Plan premium payments under a state Medicaid or CHIP Plan, you may request special enrollment for yourself and any affected Dependent(s) who are not already enrolled in the Plan. You must request enrollment within 60 days after the date you are determined to be eligible for assistance.

Except as stated above, special enrollment must be requested within 31 days after the occurrence of the special enrollment event. If the special enrollment event is the birth or adoption of a Dependent Child, coverage will be effective immediately on the date of birth, adoption or placement for adoption. Coverage with regard to any other special enrollment event will be effective on the first day of the calendar month following receipt of the request for special enrollment.

11

Enrollment 11

Qualified Status Changes – Mid-year Enrollment ChangesYour Employer has chosen to administer this Plan in accordance with Section 125 regulations of the Internal Revenue Code. Per this regulation, you may agree to a pre-tax salary 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 to enroll for or change coverage only before each annual benefit period. However, exceptions are allowed if your Employer agrees and you enroll for or change coverage within the number of days listed above (generally, 31 days) of the following:

● the date you meet the Special Enrollment criteria described above; or● the date you meet the criteria shown in the following Sections (B through F).

B. Change of Status

A change in status is defined as:

● change in legal marital status due to marriage, death of a Spouse, divorce, annulment or legal separation;● change in number of Dependents due to birth, adoption, placement for adoption, or death of a Dependent;● change in employment status of Employee, Spouse or Dependent due to termination or start of employment, strike, lockout,

beginning or end of an approved unpaid leave of absence, including under the Family and Medical Leave Act (FMLA), or change in worksite;

● changes in employment status of Employee, Spouse or Dependent resulting in eligibility or ineligibility for coverage;● change in residence of Employee, Spouse or Dependent to a location outside of the Employer’s network service area; and● changes that cause a Dependent to become eligible or ineligible for coverage.

C. Court Order

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

D. Medicare or Medicaid Eligibility/Entitlement

The Employee, Spouse or Dependent cancels or reduces coverage due to entitlement to Medicare or Medicaid, or enrolls or increases coverage due to loss of Medicare or Medicaid eligibility.

E. Change in Cost of Coverage

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

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

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

You may make a coverage election change if the Plan of your Spouse or Dependent:

● incurs a change such as adding or deleting a benefit option;● allows election changes due to Special Enrollment, Change in Status, Court Order or Medicare or Medicaid Eligibility/

Entitlement; or● this Plan and the other Plan have different periods of coverage or open enrollment periods.

Qualified Status Changes – Domestic PartnersWhen a domestic partner is removed from coverage after initially being covered as a dependent, the employee’s ability to add this domestic partner back to coverage is limited to one time, unless the employee takes this action during the annual enrollment period.

You must report a change in status by accessing Your Benefits in Workday or calling the Western Union Benefits Service Center at 1-844-449-8236 within 31 days of the change in status. Otherwise, you must wait until the next annual open enrollment period to enroll for coverage. You can make changes during the year consistent with qualified status change except with regard to the Legal Plan.

12

Enrollment 12

Coverage for Maternity Hospital StayGroup health Plans and health insurance issuers offering group health insurance coverage generally may not, under a federal law known as the Newborns’ and Mothers’ Health Protection Act: restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section; or require that a provider obtain authorization from the Plan or insurance issuer for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.

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

Group Plan Coverage Instead of MedicaidIf your income and liquid resources do not exceed certain limits established by law, the state may decide to pay premiums for this coverage instead of for Medicaid, if it is cost effective. This includes premiums for continuation coverage required by federal law.

Qualified Medical Child Support Order (QMCSO)

Eligibility for Coverage under a QMCSO

If a Qualified Medical Child Support Order (QMCSO) is issued for your child, that child will be eligible for coverage as required by the order and you will not be considered a Late Entrant for Dependent Insurance.

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

QualifiedMedicalChildSupportOrderDefined

A Qualified Medical Child Support Order (QMCSO) is a judgment, decree or order (including approval of a settlement agreement) or administrative notice that is issued pursuant to a state domestic relations law (including a community property law), or to an administrative process, which provides for child support or provides for health benefit coverage to such child and relates to benefits under the group health Plan, and satisfies all of the following:

● the order recognizes or creates a child’s right to receive group health benefits for which a participant or beneficiary is eligible;● the order specifies your name and last known address, and the child’s name and last known address, except that the name and

address of an official of a state or political subdivision may be substituted for the child’s mailing address;● the order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be

determined;● the order states the period to which it applies; and● if the order is a National Medical Support Notice completed in accordance with the Child Support Performance and Incentive

Act of 1998, such Notice meets the requirements above.

If you are not enrolled, you and your dependent will be enrolled in the OAP Plan. In these situations, your company can deduct from your paycheck your share of the premium for your and the child’s coverage.

The QMCSO may not require the health insurance Policy to provide coverage for any type or form of benefit or option not otherwise provided under the Policy, except that an order may require a Plan to comply with state laws regarding health care coverage.

PaymentofBenefits

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

ID CardsWhen you enroll in the Cigna medical plan or the Cigna Dental Health Maintenance Organization (DHMO) plan, you will receive an ID card from Cigna. The ID card shows:

● Your name and identification number;● Whether you have dependent coverage;● The Member Services telephone number and address; and● Information about the plan’s pre-certification requirement, including the telephone number to call.

13

Enrollment 13

Keep your ID card handy and show it whenever you receive care.

You will use your Cigna medical member ID card for medical and pharmacy services. Cigna DOES NOT issue a member ID card for the Cigna Dental Preferred Provider Organization (DPPO). Your dental provider should call Cigna Member Services at 1-800-244-6224 to confirm eligibility and DPPO plan provisions.

Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA)Any provisions of the Policy that provide for: (a) continuation of insurance during a leave of absence; and (b) reinstatement of insurance following a return to Active Service; are modified by the following provisions of the federal Family and Medical Leave Act of 1993, as amended, where applicable:

Continuation of Health Insurance During Leave

Your health insurance will be continued during a leave of absence if:

● that leave qualifies as a leave of absence under the Family and 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 be paid, whether entirely by your Employer or in part by you and your Employer.

Reinstatement of Canceled Insurance Following Leave

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

You will not be required to re-satisfy any eligibility or benefit waiting period or the requirements of any Pre-existing Condition Limitation to the extent that they had been satisfied prior to the start of such leave of absence.

Your Employer and/or Cigna will give you detailed information about the Family and Medical Leave Act of 1993, as amended.

Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)The Uniformed Services Employment and Re-employment Rights Act of 1994 (USERRA) sets requirements for continuation of health coverage and re-employment in regard to an Employee’s military leave of absence. These requirements apply to medical and dental coverage for you and your Dependents.

Continuation of Coverage

For leaves of less than 31 days, coverage will continue as described in the Termination section regarding Leave of Absence.

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

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

● 24 months from the last day of employment with the Employer;● the day after you fail to return to work; and● the date the Policy cancels.

Your Employer may charge you and your Dependents up to 102 percent of the total premium.

Following continuation of health coverage per USERRA requirements, you may convert to a Plan of individual coverage according to any Conversion Privilege shown in your certificate.

ReinstatementofBenefits(applicabletoallcoverage)

If your coverage ends during the leave of absence because you do not elect USERRA or an available conversion Plan at the expiration of USERRA and you are re-employed by your current Employer, coverage for you and your Dependents may be reinstated if:

● you gave your Employer advance written or verbal notice of your military service leave; and● the duration of all military leaves while you are employed with your current Employer does not exceed five years.Any 63-day break-in-coverage rule regarding credit for time accrued toward a PCL waiting period will be waived.

If your coverage under this Plan terminates as a result of your eligibility for military medical and dental coverage and your order to active duty is canceled before your active duty service commences, these reinstatement rights will continue to apply.

14

Important Plan Terms 14

Important Plan TermsWhen you select a Participating Provider, this Plan pays a greater share of the costs than if you select a non-Participating Provider. Participating Providers include Physicians, Hospitals and Other Health Care Professionals and Other Health Care Facilities. Consult myCigna.com for Participating Providers in your area. Participating Providers are committed to providing you and your Dependents appropriate care while lowering medical costs.

Services Available in Conjunction with Your Medical Plan

The following pages describe helpful services available in conjunction with your medical Plan. You can access these services by calling the toll-free number shown on the back of your ID card.

Cigna’s Toll-Free Care Line 1-800-244-6224

Cigna’s toll-free care line allows you to talk to a health care professional 24 hours each day, 7 days a week – including all holidays.

Cigna’s toll-free care line personnel can provide you with the names of Participating Providers. If you or your Dependents need medical care, you may review your online provider directory at myCigna.com, which lists the Participating Providers in your area and nationwide, or call Cigna’s toll-free number for assistance. If you or your Dependents need medical care while away from home, you may have access to a national network of Participating Providers through Cigna’s Away-From-Home Care feature. Call Cigna’s toll-free care line for the names of Participating Providers in other network areas. Whether you obtain the name of a Participating Provider from your online provider directory at myCigna.com, or through the care line, it is recommended that prior to making an appointment you call the provider to confirm that he or she is a current participant in the Cigna network.

Active ServiceYou will be considered in Active Service on any of your Employer’s scheduled workdays if you are performing the regular duties of your work on that day either at your Employer’s place of business or at some location to which you are required to travel for your Employer’s business on a day that is not one of your Employer’s scheduled workdays if you were in Active Service on the preceding scheduled workday.

Bed and BoardThe term Bed and Board includes all charges made by a Hospital on its own behalf for room and meals and for all general services and activities needed for the care of registered bed patients.

Case ManagementCase Management is a service provided through a Review Organization, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a Hospital or specialized facility. Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending Physician to determine appropriate treatment options that will best meet the patient’s needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis.

Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, each trained in a clinical specialty area such as trauma, high-risk pregnancy and neonates, oncology, mental health, rehabilitation or general medicine and surgery. A Case Manager trained in the appropriate clinical specialty area will be assigned to you or your Dependent. In addition, Case Managers are supported by a panel of Physician advisors who offer guidance on up-to-date treatment programs and medical technology. While the Case Manager recommends alternate treatment programs and helps coordinate needed resources, the patient’s attending Physician remains responsible for the actual medical care.

(1) You, your Dependent or an attending Physician can request Case Management services by calling the toll-free number shown on your ID card during normal business hours, Monday through Friday.

(2) The Review Organization assesses each case to determine whether Case Management is appropriate.

(3) You or your Dependent is contacted by an assigned Case Manager who explains in detail how the program works. Participation in the program is voluntary – no penalty or benefit reduction is imposed if you do not wish to participate in Case Management.

(4) Following an initial assessment, the Case Manager works with you, your family and Physician to determine the needs of the patient and to identify what alternative treatment programs are available (for example, in-home medical care in lieu of an extended Hospital convalescence). You are not penalized if the alternative treatment program is not followed.

http://myCigna.com

http://myCigna.com

http://myCigna.com

15


(5) The Case Manager arranges for alternate treatment services and supplies, as needed (for example, nursing services or a Hospital bed and other Durable Medical Equipment for the home).

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

(7) Once the alternative treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient’s needs.

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

This medical Plan does not require that you select a Primary Care Physician or obtain a referral from a Primary Care Physician in order to receive all benefits available to you under this medical Plan. Notwithstanding, a Primary Care Physician may serve an important role in meeting your health care needs by providing or arranging for medical care for you and your Dependents.

ChargesThe term Charges means the actual billed charges; except when the provider has contracted directly or indirectly with Cigna for a different amount.

Chiropractic CareThe term Chiropractic Care means the conservative management of neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to specific joints to restore motion, reduce pain and improve function.

Cigna Dental Health (herein referred to as CDH)CDH is a wholly owned subsidiary of Cigna Corporation that, on behalf of Cigna, contracts with Participating General Dentists for the provision of dental care. CDH also provides management and information services to Policyholders and Participating Dental Facilities.

Civil Union PartnerCivil Union Partners are two adults of the same sex who have entered into a civil union partnership in a state that recognizes civil union partnerships.

CoinsuranceThe term Coinsurance means the percentage of charges for Covered Expenses that an insured person is required to pay under the Plan.

Contracted Fee – Cigna Dental Preferred ProviderThe term Contracted Fee refers to the total compensation level that a provider has agreed to accept as payment for dental procedures and services performed on an Employee or Dependent, according to the Employee’s dental benefit Plan.

Custodial ServicesAny services that are of a sheltering, protective or safeguarding nature. Such services may include a stay in an institutional setting, at-home care or nursing services to care for 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 mainly to maintain the person’s current state of health. These services cannot be intended to greatly improve a medical condition; they are intended to provide care while the patient cannot care for himself or herself. Custodial Services include, but are not limited to:

● Services related to watching or protecting a person;● Services related to performing or assisting a person in performing any activities of daily living, such as: (a) walking; (b)

grooming; (c) bathing; (d) dressing; (e) getting in 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 skilled medical or paramedical personnel.

16


DentistThe term Dentist means a person practicing dentistry or oral surgery within the scope of his or her license. It will also include a Physician operating within the scope of his or her license when he or she performs any of the Dental Services described in the Policy.

DependentYou may cover the following Dependents under the plan:● Your legal spouse;● Your same- or opposite-gender domestic partner; and● Your Dependent children up to the end of the year in which the child attains age 26 (this is referred to as the plan’s “limiting

age” throughout this SPD) for medical, dental and vision coverage without regard to tax dependency, student status, residency, financial dependency, marriage, employment or if the adult child is eligible for other employer-based health plan coverage. See the section titled “Handicapped Children” below for an eligibility exception to plan’s limiting age for handicapped children.

The term child includes biological children, legally adopted children and children placed with the employee for adoption. The term child can also include stepchildren, foster children, grandchildren and children for whom the employee is the legal guardian, if the child qualifies as a Dependent under IRS guidelines.A legal spouse includes a common-law spouse in states that recognize common law marriage. You may be able to enroll your same- or opposite-gender domestic partner and his or her children for medical, dental and vision coverage.A Dependent does not include anyone who is also enrolled as an employee. No one can be enrolled as a Dependent of more than one employee.When you and your spouse are both employees at Western Union, special rules apply under the group life insurance plans● You can both enroll in Voluntary Life Insurance with no Spouse Life Insurance enrollment for either of you; or● One of you can enroll in Voluntary Life Insurance and Spouse Life Insurance with the other electing no coverage in Voluntary


Domestic PartnerA Domestic Partner is defined as a person of the same or opposite sex who:

● shares your permanent residence;● has resided with you for no less than six months; (Provision applicable for Cigna Life Insurance Plan.)● is no less than 18 years of age;● is not a blood relative any closer than would prohibit legal marriage; and● has signed jointly with you, a notarized affidavit that can be made available to Cigna upon request.

In addition, you and your Domestic Partner will be considered to have met the terms of this definition as long as neither you nor your Domestic Partner:

● has signed a Domestic Partner affidavit or declaration with any other person within twelve months prior to designating each other as Domestic Partners hereunder;

● is currently legally married to another person; or● has any other Domestic Partner, Spouse or Spouse equivalent of the same or opposite sex.

You and your Domestic Partner must have registered as Domestic Partners, if you reside in a state that provides for such registration.

The section of this certificate entitled COBRA Continuation Rights under Federal Law will not apply to your Domestic Partner and his or her Dependents.

17


Same-sex Couples – Federal Tax Purposes

Effective September 16, 2013, employees who are same-sex couples, legally married in states that recognize their marriage, will be treated as married for federal tax purposes and qualify for pre-tax health plan contributions under the WU Health and Life Benefits program (regardless of whether the couple currently lives in a state that recognizes same-sex marriage). This change is in compliance with a recent IRS determination resulting from a Supreme Court decision regarding the Defense of Marriage Act (DOMA). If you consider your enrolled domestic partner to be qualified for pre-tax health plan contributions, please send an email to [email protected], so additional information can be collected from you.

The ruling does not apply to registered domestic partnerships, civil unions, or similar formal relationships recognized under state law. As a reminder, spouses and domestic partners continue to be eligible dependents under the Health & Life Benefit program, regardless of the tax treatment of benefits.

Emergency Medical ConditionEmergency Medical Condition means a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Emergency ServicesEmergency Services means, with respect to an emergency medical condition, a medical screening examination that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate the emergency medical condition; and such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital, to stabilize the patient.

EmployeeThe term Employee means a full-time or part-time Employee of the Employer who is currently in Active Service.

EmployerThe term Employer means the Plan Sponsor self-insuring the benefits described in this booklet, on whose behalf Cigna is providing claim administration services.

Expense IncurredAn Expense is incurred when the service or the supply for which it is incurred is provided.

Freestanding Surgical FacilityThe term Freestanding Surgical Facility means an institution that meets all of the following requirements:

● it has a medical staff of Physicians, Nurses and licensed anesthesiologists;● it maintains at least two operating rooms and one recovery 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 immediate acceptance of patients who need Hospital Confinement on an inpatient basis;

and● it is licensed in accordance with the laws of the appropriate legally authorized agency.

Hospice Care ProgramThe term Hospice Care Program means:

● a program for persons who have a Terminal Illness and for the families of those persons;● a coordinated, interdisciplinary program to meet the physical, psychological, spiritual and social needs of dying persons and

their families;● a program that provides palliative and supportive medical, nursing and other health services through home or inpatient care

during the illness.


18


Hospice Care ServicesThe term Hospice Care Services means any services provided by: (a) a Hospital; (b) a Skilled Nursing Facility or a similar institution; (c) a Home Health Care Agency; (d) a Hospice Facility; or (e) any other licensed facility or agency under a Hospice Care Program.

Hospice FacilityThe term Hospice Facility means an institution or part of it that:

● primarily provides care for Terminally Ill patients;● is accredited by the National Hospice Organization;● meets standards established by Cigna; and● fulfills any licensing requirements of the state or locality in which it operates.

HospitalThe term Hospital means:

● an institution licensed as a Hospital, which: (a) maintains, on the premises, all facilities necessary for medical and surgical treatment; (b) provides such treatment on an inpatient basis, for compensation, under the supervision of Physicians; and (c) provides 24-hour service by Registered Graduate Nurses;

● an institution that qualifies as a Hospital, a psychiatric Hospital or a tuberculosis Hospital, and a provider of services under Medicare, if such institution is accredited as a Hospital by the Joint Commission on the Accreditation of Health care Organizations; or

● an institution that: (a) specializes in treatment of Mental Health and Substance Abuse or other related illness; (b) provides residential treatment programs; and (c) is licensed in accordance with the laws of the appropriate legally authorized agency.

The term Hospital will not include an institution that is primarily a place for rest, a place for the aged or a nursing home.

Hospital Confinement or Confined in a HospitalA person will be considered Confined in a Hospital if he or she is:

● a registered bed patient in a Hospital upon the recommendation of a Physician;● receiving treatment for Mental Health and Substance Abuse Services in a Partial Hospitalization program;● receiving treatment for Mental Health and Substance Abuse Services in a Mental Health or Substance Abuse residential

Treatment Center.

InjuryThe term Injury means an accidental bodily injury.

Maintenance TreatmentThe term Maintenance Treatment means treatment rendered to keep or maintain the patient’s current health status.

Maximum Reimbursable Charge – MedicalThe Maximum Reimbursable Charge for covered services is determined based on the lesser of:

● the provider’s normal charge for a similar service or supply; or● a Policyholder-selected percentile of charges made by providers of such service or supply in the geographic area where it is

received as compiled in a database selected by Cigna.

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

The Maximum Reimbursable Charge is subject to all other benefit limitations and applicable coding and payment methodologies determined by Cigna. Additional information about how Cigna determines the Maximum Reimbursable Charge is available upon request.

Maximum Reimbursable Charge – DentalThe Maximum Reimbursable Charge is the lesser of:

● the provider’s normal charge for a similar service or supply; or● the Policyholder-selected percentile of all charges made by providers of such service or supply in the geographic area where

it is received.

19


To determine whether a charge exceeds the Maximum Reimbursable Charge, the nature and severity of the injury or Sickness may be considered. Cigna uses the Ingénue Prevailing Health Care System database to determine the charges made by providers in an area. The database is updated semiannually. The percentile used to determine the Maximum Reimbursable Charge is listed in The Schedule. Additional information about the Maximum Reimbursable Charge is available upon request.

MedicaidThe term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.

Medically Necessary/Medical NecessityMedically Necessary Covered Services and Supplies are those determined by the Medical Director to be:

● required to diagnose or treat an illness, injury, disease or its symptoms;● in accordance with generally accepted standards of medical practice;● clinically appropriate in terms of type, frequency, extent, site and duration;● not primarily for the convenience of the patient, Physician or other health care provider; and● rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. Where applicable, the

Medical Director may compare the cost-effectiveness of alternative services, settings or supplies when determining least intensive setting.

MedicareThe term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965, as amended.

Necessary Services and SuppliesThe term Necessary Services and Supplies includes:

● any charges, except charges for Bed and Board, made by a Hospital on its own behalf for medical services and supplies actually used during Hospital Confinement;

● any charges, by whomever made, for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided; and

● any charges, by whomever made, for the administration of anesthetics during Hospital Confinement.

The term Necessary Services and Supplies will not include any charges for special nursing fees, dental fees or medical fees.

NurseThe term Nurse means a Registered Graduate Nurse, a Licensed Practical Nurse or a Licensed Vocational Nurse who has the right to use the abbreviation “R. N.,” “L. P. N.,” or “L.V. N.”

Other Health Care FacilityThe term Other Health Care Facility means a facility other than a Hospital or Hospice Facility. Examples of Other Health Care Facilities include, but are not limited to, licensed skilled nursing facilities, rehabilitation Hospitals and sub-acute facilities.

Other Health ProfessionalThe term Other Health Professional means an individual other than a Physician who is licensed or otherwise authorized under the applicable state law to deliver medical services and supplies. Other Health Professionals include, but are not limited to physical therapists, registered Nurses and licensed practical Nurses.

Participating PharmacyThe term Participating Pharmacy means a retail pharmacy with which Cigna Health and Life Insurance Company has contracted to provide prescription services to insureds, or a designated mail-order pharmacy with which Cigna has contracted to provide mail-order prescription services to insureds.

Participating ProviderThe term Participating Provider means a Hospital, a Physician or any other health care practitioner or entity that has a direct or indirect contractual arrangement with Cigna to provide covered services with regard to a particular Plan under which the participant is covered.

20


Participating Provider – Cigna Dental Preferred ProviderThe term Participating Provider means: a Dentist, or a professional corporation, professional association, partnership or other entity that is entered into a contract with Cigna to provide dental services at predetermined fees.

The providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers can be obtained by visiting myCigna.com.

Patient Protection and Affordable Care Act of 2010 (PPACA)Patient Protection and Affordable Care Act of 2010 means the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148) as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).

PharmacyThe term Pharmacy means a retail pharmacy or a mail-order pharmacy.

Pharmacy and Therapeutics (P&T) CommitteeA committee of Cigna Participating Providers, Medical Directors and Pharmacy Directors that regularly reviews Prescription Drugs and Related Supplies for safety and efficacy. The P&T Committee evaluates Prescription Drugs and Related Supplies for potential addition to or deletion from the Prescription Drug List and may also set dosage and/or dispensing limits on Prescription Drugs and Related Supplies.

PhysicianThe term Physician means a licensed medical practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer drugs or to perform surgery. It will also include any other licensed medical practitioner whose services are required to be covered by law in the locality where the Policy is issued if he or she is:

● operating within the scope of his license; and● performing a service for which benefits are provided under this Plan when performed by a Physician.

Prescription DrugPrescription Drug means: (a) a drug that has been approved by the Food and Drug Administration for safety and efficacy; (b) certain drugs approved under the Drug Efficacy Study Implementation review; or (c) drugs marketed prior to 1938 and not subject to review, and that can, under federal or state law, be dispensed only pursuant to a Prescription Order.

Prescription Drug ListPrescription Drug List means a listing of approved Prescription Drugs and Related Supplies. The Prescription Drugs and Related Supplies included in the Prescription Drug List have been approved in accordance with parameters established by the P&T Committee. The Prescription Drug List is regularly reviewed and updated.

Prescription OrderPrescription Order means the lawful authorization for a Prescription Drug or Related Supply by a Physician who is duly licensed to make such authorization within the course of such Physician’s professional practice or each authorized refill thereof.

Preventive TreatmentThe term Preventive Treatment means treatment rendered to prevent disease or its recurrence.

Primary Care PhysicianThe term Primary Care Physician means a Physician: (a) who qualifies as a Participating Provider in general practice, internal medicine, family practice or pediatrics; and (b) who has been selected by you, as authorized by the Provider Organization, to provide or arrange for medical care for you or any of your insured Dependents.

http://myCigna.com

21


PsychologistThe term Psychologist means a person who is licensed or certified as a clinical psychologist. Where no licensure or certification exists, the term Psychologist means a person who is considered qualified as a clinical psychologist by a recognized psychological association. It will also include any other licensed counseling practitioner whose services are required to be covered by law in the locality where the Policy is issued if he or she is:

● operating within the scope of his or her license; and● performing a service for which benefits are provided under this Plan when performed by a Psychologist.

Related SuppliesRelated Supplies means diabetic supplies (insulin needles and syringes, lancets and glucose test strips), needles and syringes for injectables covered under the Pharmacy Plan, and spacers for use with oral inhalers.

Review OrganizationThe term Review Organization refers to an affiliate of Cigna or another entity to which Cigna has delegated responsibility for performing utilization review services. The Review Organization is an organization with a staff of clinicians that may include Physicians, Registered Graduate Nurses, licensed mental health and substance abuse professionals, and other trained staff members who perform utilization review services.

Sickness – For Medical InsuranceThe term Sickness means a physical or mental illness. It also includes pregnancy. Expenses incurred for routine Hospital and pediatric care of a newborn child prior to discharge from the Hospital Nursery will be considered to be incurred as a result of Sickness.

Skilled Nursing FacilityThe term Skilled Nursing Facility means a licensed institution (other than a Hospital, as defined) that 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 all facilities necessary for medical treatment; (b) provides such treatment, for compensation, under the supervision of Physicians; and (c) provides Nurses’ services.

StabilizeStabilize means, with respect to an emergency medical condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.

Terminal IllnessA Terminal Illness will be considered to exist if a person becomes Terminally Ill with a prognosis of six months or less to live, as diagnosed by a Physician.

Urgent CareUrgent Care is medical, surgical, Hospital or related health care services and testing that are not Emergency Services, but are determined by Cigna, in accordance with generally accepted medical standards, to have been necessary to treat a condition requiring prompt medical attention. This does not include care that could have been foreseen before leaving the immediate area where you ordinarily receive and/or were scheduled to receive services. Such care includes, but is not limited to, dialysis, scheduled medical treatments or therapy, or care received after a Physician’s recommendation that the insured should not travel due to any medical condition.

22

The Cigna Open Access Plus Network 22

The Cigna Open Access Plus NetworkRegardless of the medical plan option you select, doctors, hospitals and other health care providers who belong to the Cigna Open Access Plus network are “in-network” providers. To be selected for the network, a doctor or other health care provider must meet certain standards in a process called credentialing. The credentialing process looks at factors such as education, residency, board certification and licensing, and admitting privileges to determine whether or not a provider may participate in the network. When they join the network, they agree to provide services or supplies at negotiated charges. The providers in Cigna’s network represent a wide range of services, from basic, routine care (such as general practitioners, pediatricians, internists), to specialty care (such as OB/GYNs, cardiologists, urologists), to radiology and lab services.

You can find in-network providers by visiting myCigna.com. You can also call the Cigna Member Services number on your ID card (1-800-244-6224) for help in finding in-network providers in your area.

View your Cigna Choice Fund Open Access Plus Schedule of Benefits at the Western Union website, cigna.com/westernunion, for additional details on the benefits available.

http://myCigna.com


23

The Cigna Choice Fund Health Savings Account (HSA) Plan 23

The Cigna Choice Fund Health Savings Account (HSA) PlanThe Cigna Choice Fund with a Health Savings Account (HSA) is comprised of two parts: the Medical and Prescription Drug Plan, and a Health Savings Account (HSA) that you will open with HSA Bank.

How the plan works: Cigna Choice Fund with HSA is a consumer-driven health plan that combines traditional health coverage with a Health Savings Account that Western Union contributes to in order to help you pay for your eligible medical expenses.

The Health Savings Account (HSA)If you choose Cigna Choice Fund with HSA as your medical plan, you will need to open an HSA with HSA Bank. Western Union will make an initial contribution of $500 individual/ $1,000 family into your HSA as long as you have opened your account. You will also be able to make pre-tax* contributions from your paycheck to the HSA.

You must enroll in the Cigna Choice Fund with HSA in order to qualify to open an HSA and receive a contribution from Western Union. If you participate in the Cigna Choice Fund with HSA, you cannot contribute to a Health Care FSA.

As you incur covered medical expenses, you may use the money in your HSA to cover these costs. Any money left in your HSA at the end of the year will remain in your account. With careful spending and decision-making you can accumulate funds for future health care expenses – and the money in your HSA is yours to keep, whether or not you continue your employment with Western Union.

The DeductibleThe deductible is a set amount of eligible expenses you pay each year before the medical and prescription drug plans start to pay benefits. You pay the full cost of your medical and prescription drug expenses until your deductible has been met. If you enroll as Employee Only (no dependents), you will be subject to the Individual Deductible. However, if you enroll dependents under the plan you will be subject to the overall Family Deductible. All family members’ charges will apply towards the Family Deductible.

The Medical PlanOnce your deductible is met, the medical and prescription drug plans start to pay benefits. You may receive care from any licensed provider. However, when you visit a network provider, the plan pays more and you pay less. All out-of network providers are subject to reasonable and customary limits.

Annual Out-Of-pocket MaximumWhen you reach the annual out-of-pocket maximum, the plan pays 100 percent of your remaining eligible medical and pharmacy expenses for the rest of the plan year.

Preventive CarePreventive care (e.g., routine care, annual screenings and certain preventive services) for Cigna Choice Fund with HSA plan participants who use network providers is covered at 100%. When you use out-of-network providers, preventive care is covered at 100%, up to reasonable and customary limits.

*Contact your tax advisor for complete details about the tax advantages of your HSA.

HSA – Cigna Choice Fund Health Savings Account 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 Access Plus Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services and supplies. That portion is the Deductible or Coinsurance.

When you receive services from an In-Network Provider, remind your provider to utilize In-Network Providers for X-rays, lab tests and other services to ensure the cost may be considered at the In-Network level.

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

24


Coinsurance

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

Deductibles

Deductibles are 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 further medical deductible for the rest of that year.

Out-of-Pocket Expenses – For In-Network Charges Only

Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan because of any Deductibles or Coinsurance. Such Covered Expenses accumulate toward the Out-of-Pocket Maximum shown in The Schedule. When the Out-of-Pocket Maximum is reached, all Covered Expenses, except charges for non-compliance penalties, are payable by the benefit plan at 100%.

Out-of-Pocket Expenses – For Out-of-Network Charges Only

Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan. The following Expenses contribute toward the Out-of-Pocket Maximum, and when the Out-of-Pocket Maximum shown in The Schedule is reached, they are payable by the benefit plan at 100%:

● Coinsurance● Plan Deductible

The following Out-of-Pocket Expenses and charges do not contribute to the Out-of-Pocket Maximum, and they are not payable by the benefit plan at 100% when the Out-of-Pocket Maximum shown in The Schedule is reached:

● Non-compliance penalties● Any benefit deductibles● 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 cross-accumulate (that is, In-Network will accumulate to Out-of-Network and Out-of-Network will accumulate to In-Network). All other Plan maximums and service-specific maximums (dollar and occurrence) also cross-accumulate between In- and Out-of-Network, unless otherwise noted.

Note: For information about your Health Savings Account benefit and how it can help you pay for expenses that may not be covered under this plan, refer to What You Should Know about Cigna Choice Fund – Health Savings Account.

Multiple Surgical Reduction

Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. 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 a percentage of the surgeon’s allowable charge as specified in Cigna Reimbursement Policies. (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.)

Co-Surgeon

The maximum amount payable for charges made by co-surgeons will be limited to the amount specified in Cigna Reimbursement Policies.

25

What You Should Know About Cigna Choice Fund® – Health Savings Account 25

What You Should Know About Cigna Choice Fund® – Health Savings AccountCigna Choice Fund is designed to give you:

● Control: You decide how much you’d like to contribute (up to federal limits) to your Health Savings Account. You decide how and when to access your account. And the money in the account is yours until you spend it. Unused dollars remain in your account from year to year and earn interest.

● Choice: You have the freedom to choose any licensed doctor, even those who do not participate with Cigna. Your costs are lower for services from Cigna-contracted health care professionals and facilities because they have agreed to accept discounted payments to help you make the most of your health care dollars.

● Easy access to your HSA dollars: You can draw money directly from your health savings account using the HSA Bank/MasterCard® debit card, checkbook or online bill pay. Or, you may choose automatic claim forwarding, which allows Cigna to pay your qualified medical claims directly from your account to your doctor or hospital.

● Flexibility and tax savings: You can also choose to pay for medical expenses out of your pocket until you reach the deductible, allowing you to save for qualified medical expenses in future years or retirement. You are not taxed on your HSA unless you use the money to pay for nonqualified expenses.

● Health information and education: Call the toll-free number on your ID card to reach Cigna’s 24-Hour Health Information LineSM, giving you access to trained nurses and an audio library of health topics 24 hours a day.

● Cigna Healthy Pregnancies, Healthy Babies®: This program for expectant mothers gives you 24/7 access to live support when you call the number on the back of your Cigna ID card. You can earn $150 when you enroll in your first trimester, or $75 in your second, after you complete the program, paid in a gift card.

● Tools and support: We help you keep track of your health and coverage with online benefits information, transactions, and account activity; medical and drug cost comparisons; monthly statements; and more. You also have toll-free access to dedicated Customer Service team, specially trained to answer your questions and address your needs.

● Savings on health and wellness products and services: Through Cigna Healthy Rewards®, you can save money on a variety of health-related products and services. Offerings include laser vision correction, acupuncture, chiropractic care, Weight Watchers® and more.

The Basics

Who is eligible?

You are eligible to open a Health Savings Account only if you are covered under a federally qualified high deductible health plan, such as the one described in this booklet. You cannot be covered by Medicare or any other individual or group health plan that is not a federally qualified high deductible health plan. You can no longer contribute to the HSA once you become entitled to Medicare due to age, or are no longer covered under a high deductible health plan. However, you will still be able to use the HSA funds for qualified medical expenses.

How does it work?

The Health Savings Account combines a health care plan with a tax-free savings account.

● You, your employer or both may contribute to your account. Contributions are tax-free up to federal limits.● You choose how to pay for qualified medical expenses:

o You may pay for qualified expenses on your own using a debit card, checkbook (if requested) or online bill pay that draws from your health savings account.

o You may choose the Automatic Claim Forwarding option, allowing qualifying expenses to be paid directly to your doctor, hospital, or other facility from your HSA. You can change your election at any time during the year.

o You may choose to cover your expenses using other personal funds.● You are able to save the money in your HSA for qualified medical expenses in future years or at retirement. The balance

in your savings account will earn interest. The amount used from your account for services covered under your health plan counts toward the deductible.

● Once you meet your deductible, you and your plan share the costs. Depending on your plan, you pay pre-determined coinsurance or copayments for certain services. Your employer determines the maximum amount of out-of-pocket expenses you pay each year. Once you meet the maximum, the plan pays covered expenses at 100%.

● Your HSA can be a tax-sheltered savings tool. Because your HSA rolls over year after year, and unused money accumulates tax-free interest, you have the option to pay for current qualified medical expenses out of your pocket and use the account to save for future qualified medical expenses.

26

What You Should Know About Cigna Choice Fund® – Health Savings Account 26

Please note: Your HSA contributions are not taxable under federal and most state laws. However, your contributions to your HSA may be taxable as income in the following states: Alabama, California, New Hampshire, New Jersey and Wisconsin. If you live or work in one of these states, please consult your tax advisor.

Which out-of-pocket services can be reimbursed by my Cigna Choice Fund Health Savings Account?

Money in your HSA can be used only to cover qualified medical expenses for you and your dependents as allowed under federal tax law. In addition, your HSA may be used to cover COBRA continuation premiums, qualified long-term care insurance premiums, health plan premiums when you are receiving unemployment compensation, or Medicare or retiree health plan premiums (excluding Medicare Supplement or Medigap premiums) once you reach age 65. If you use your HSA funds for expenses that are not allowed under federal tax law, the contributions to your HSA fund and any accrued interest and earnings will be subject to tax, and you will incur a 20 percent tax penalty. The 20 percent penalty is not applicable once you reach age 65. A list of qualified medical expenses is available on Cigna.com/expenses.

Which services are covered by my medical Plan, and which will I have to pay out of my own pocket?

Covered services vary depending on your plan, so visit myCigna.com or check your plan materials. In addition to your monthly premiums deducted from your paycheck, you’ll be responsible for paying:

● Any health care services not covered by your plan● Costs for any services you receive until you meet your deductible, if you choose not to use your Health Savings Account, or

after you spend all the money in your account● Your share of the cost for your covered health care expenses (coinsurance or copayments) after you meet the deductible and

your medical plan coverage begins

http://Cigna.com/expenses

http://myCigna.com

27


BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK

Lifetime Maximum Unlimited Unlimited

Pre-Existing Condition Limitation (PCL) Not Applicable Not Applicable

The Percentage of Covered Expenses the Plan Pays

Note: “No charge” means an insured person is not required to pay Coinsurance.

80% 60% of the Maximum Reimbursable Charge

Maximum Reimbursable Charge

Maximum Reimbursable Charge is determined based on the lesser of the provider’s normal charge for a similar service or supply; or

A percentage of a schedule that Cigna has developed that is based upon a methodology similar to a methodology utilized by Medicare to determine the allowable fee for similar services within the geographic market. In some cases, a Medicare-based schedule will not be used and the Maximum Reimbursable Charge for covered services is determined based on the lesser of:

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

● the 80th percentile of charges made by providers of such service or supply in the geographic area where it is received, as compiled in a database selected by the Insurance Company.

Notes:

● The provider may bill you for the difference between the provider’s normal charge and the Maximum Reimbursable Charge, in addition to applicable Deductibles, Copayments and Coinsurance.

● Some providers forgive or waive the cost share obligation (e.g., your deductible and/or coinsurance) that this plan requires you to pay. Waiver of your required cost share obligation can jeopardize your coverage under this plan. For more details, see the Exclusions section.

Not Applicable 150%

Calendar Year Deductible

Individual Family Maximum

Family Maximum Calculation

Collective Deductible: All family members contribute towards the family deductible. An individual cannot have claims covered under the plan coinsurance until the total family deductible has been satisfied.

$2,000 per person $4,000 per family


28



Combined Medical/Pharmacy Calendar Year Deductible

Combined Medical/Pharmacy Deductible includes retail and mail order drugs

Home Delivery Pharmacy costs contribute to the Combined Medical/Pharmacy Deductible

Yes

Yes

In-Network coverage only

Yes

Combined Medical/Pharmacy Out-of-Pocket Maximum

Combined Medical/Pharmacy Out of-Pocket includes retail and home delivery prescription drugs

Home Delivery Pharmacy costs contribute to the Combined Medical/Pharmacy Out-of-Pocket Maximum

Yes

Yes


Yes

Combined Out-of-Pocket Maximum for Pharmacy


Family Maximum Calculation

Individual Calculation: Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%.

$4,000 per person* $8,000 per family*


Physician’s Services

Primary Care Physician’s Office Visit Specialty Care Physician’s Office Visits Consultant and Referral Physician’s Services

Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company.

Surgery Performed In the Physician’s Office

Second Opinion Consultations (provided on a voluntary basis)

Allergy Treatment/Injections/Allergy Serum (dispensed by the Physician in the office)

80% after Plan Deductible 80% after Plan Deductible 80% after Plan Deductible

80% after Plan Deductible







Preventive Care

Note: Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit.

Routine Preventive Care – all ages

Immunizations – all ages

Travel Immunizations

No Charge

No Charge

No Charge

No Charge



* Beginning in 2017, if a family member spends over $7,150 on health expenses, your plan will cover 100% of that person’s in-network services for the rest of the calendar year. However, the rest of the family will not receive 100% coverage until your family reaches the family out-of-pocket maximum.

29



Mammograms, PSA, PAP Smear, ColonoscopyPreventive Care-Related Services

Diagnostic-Related Services

No charge

Subject to the plan’s X-ray & lab benefit; based on place of service


Subject to the plan’s X-ray & lab benefit; based on place of service

Inpatient Hospital-Facility ServicesSemi-Private Room and Board

Private Room

Special Care Units (ICU/CCU)


Limited to the semi-private room negotiated rate


Limited to the negotiated rate


Limited to the semi-private room rate


Limited to the ICU/CCU daily room rate

Outpatient Facility ServicesOperating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room

80% after Plan Deductible 60% after Plan Deductible

Inpatient Hospital Physician’s Visits/Consultations 80% after Plan Deductible 60% after Plan Deductible

Inpatient Hospital Professional Services● Surgeon● Radiologist● Pathologist● Anesthesiologist


Urgent Care ServicesPhysician’s Office Visit Urgent Care Facility or Outpatient Facility Outpatient Professional Services (radiology, pathology and Physician)

X-ray and/or Lab performed at the Urgent Care Facility (billed by the facility as part of the UC visit) or Outpatient Facility

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







Emergency ServicesPhysician’s Office Visit

Hospital Emergency Room

Outpatient Professional Services (radiology, pathology, ER physician)

X-ray and/or Lab performed at the Emergency Room Facility (billed by the facility as part of the ER visit)

Independent X-ray and/or Lab Facility in conjunction with an ER visit

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

Ambulance















30



Inpatient Services at Other Health Care Facilities

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

Calendar Year Maximum: 120 days combined


Laboratory and Radiology Services (includes preadmission testing)

Physician’s Office Visit Outpatient Hospital Facility Independent X-ray and/or Lab Facility



Laboratory Services

Cigna is contracted with two of the largest national laboratories, Laboratory Corporation of America (LabCorp) and Quest Diagnostics, Inc. (Quest), as well as several regional and local laboratories. Using these nationally contracted laboratories can help Cigna customers obtain the services they need at in-network benefit levels.Want to spend your medical dollars wisely? Here’s how …when you need lab work done, be sure you and your provider use an in-network facility. Using out-of-network facilities will cost you more money for the same service. To make sure your lab is in network, check on myCigna.com.By participating with two of the largest national laboratories and other regional and local laboratories, Cigna helps its customers obtain the services they need while receiving the greatest value from their Cigna medical benefits.Non-Participating LaboratoriesCigna reimburses covered laboratory and pathology services from non-participating laboratories and health care professionals at the applicable out-of-network benefit level (if available).Covered Services from a non-participating laboratory or non-participating health care professional may be reimbursed at the customer’s in-network benefit plan level in limited circumstances if:● Laboratory and pathology services are associated with a true emergency service visit.● Federal or state law requires that laboratory and pathology services are to be paid at the in-network benefit level.● Laboratory and pathology services are not available from a participating laboratory and the services are Covered

Services (medically necessary and a covered benefit). Services will be reviewed to determine if Cigna’s Network Adequacy Policy applies.

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

Physician’s Office Visit Inpatient Facility Outpatient Facility



http://myCigna.com

31



Outpatient Short Term Rehabilitative Therapy

Calendar Year Maximum: 60 days for in-network and out-of-network for all therapies combined

Includes:

● Physical Therapy● Speech Therapy● Occupational Therapy● Pulmonary Rehab● Cognitive Therapy

Note: Speech therapy is covered for children who failed to achieve complete speech articulation due to hearing loss, corrective surgery for congenital defects, cerebral palsy, spina bifida, multiple sclerosis, autism, neurological disorders or Down Syndrome. Physical, and occupational therapy for the treatment of Autism Spectrum Disorder is unlimited.


Note: Outpatient Short-Term Rehab copay applies, regardless of place of service, including the home.


Outpatient Cardiac Rehabilitation

Calendar Year Maximum: 36 days


Chiropractic Care


Physician’s Office Visit 80% after Plan Deductible 60% after Plan Deductible

Home Health Care

Maximum of 16 hours per day

Calendar Year Maximum: 120 days (includes outpatient private nursing when approved as Medically Necessary)


Hospice

Inpatient Services Outpatient Services



Bereavement Counseling Services provided as part of Hospice Care

Inpatient Outpatient

Services provided by Mental Health Professional


Covered under Mental Health Benefit



32



Maternity Care Services

Initial Visit to Confirm Pregnancy

Note: OB/GYN providers will be considered either a PCP or Specialist, depending on how the provider contracts with the Insurance Company

All subsequent Prenatal Visits, Postnatal Visits and Physician’s Delivery Charges (i.e., global maternity fee)

Physician’s Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist

Delivery Facility (Inpatient Hospital, Birthing Center)









Abortion

Includes elective and non-elective procedures

Physician’s Office Visit Inpatient Facility Outpatient Facility Physician’s Services

80% after Plan Deductible 80% after Plan Deductible 80%after Plan Deductible 80% after Plan Deductible

60% after Plan Deductible 60% after Plan Deductible 60% after Plan Deductible 60% after Plan Deductible

Women’s Family Planning Services

Office Visits, Lab and Radiology Tests and Counseling

Note: Includes coverage for contraceptive devices (e.g., Depo-Provera and Intrauterine Devices (IUDs) as ordered or prescribed by a physician). Diaphragms also are covered when services are provided in the Physician’s office.

Surgical Sterilization Procedure for Tubal Ligation (excludes reversals)


No Charge

No Charge No Charge No Charge No Charge



Men’s Family Planning Services


Surgical Sterilization Procedure for Vasectomy (excludes reversals)






Infertility Treatment

Coverage will be provided for the following services:

● Testing and treatment services performed in connection with an underlying medical condition.● Testing performed specifically to determine the cause of infertility.● Treatment and/or procedures performed specifically to restore fertility (e.g., procedures to correct an infertility condition).● Artificial insemination, In-vitro, GIFT, ZIFT, etc.● Lifetime Maximum: $5,000 per member

33



Physician’sOfficeVisit (Lab and Radiology Tests, Counseling)

Inpatient Facility Outpatient Facility Physician’s Services

Lifetime Maximum: $5,000 per member

Includes all related services billed with an infertility diagnosis (i.e., X-ray or lab services billed by an independent facility)





Organ Transplants Includes all medically appropriate, non-experimental transplants

Physician’s Office Visit

Inpatient Facility


Lifetime Travel Maximum: $10,000 per transplant


100% at Cigna LifeSOURCE Center after Plan Deductible; otherwise, 80% after Plan Deductible

100% at Cigna LifeSOURCE Center after Plan Deductible; otherwise, 80% after Plan Deductible

No charge (only available when using Cigna LifeSOURCE facility)





Durable Medical Equipment

Calendar Year Maximum: Unlimited


Breast Feeding Equipment and Supplies

● Limited to the rental or purchase of one breast pump per birth as ordered or prescribed by a physician when coordinated by Cigna’s Care Centrix

● Includes related supplies

No Charge 60% after Plan Deductible

External Prosthetic Appliances



Acupuncture



Consumable Medical Supplies 80% after Plan Deductible 60% after Plan Deductible

Wigs

(Covered with medical necessity)


34



Nutritional Evaluation

Calendar Year Maximum: Three visits per person for in-network and out-of-network combined (however, the three visit limit will not apply to treatment of mental health and substance use disorder conditions)




Dental Care

Limited to charges made for a continuous course of dental treatment started within six months of an injury to sound, natural teeth.




Hearing Services

Note: Specific to Hearing Exam

Maximum: One visit per Calendar Year


TMJ Surgical and Non-Surgical

Always excludes appliances and orthodontic treatment. Subject to Medical Necessity.

Physician’s Office Visit Inpatient Facility Outpatient Facility Inpatient Professional Services Outpatient Professional Services

80% after Plan Deductible 80% after Plan Deductible 80% after Plan Deductible 80% after Plan Deductible 80% after Plan Deductible

60% after Plan Deductible 60% after Plan Deductible 60% after Plan Deductible 60% after Plan Deductible 60% after Plan Deductible

Routine Foot Disorders Not covered, except for services associated with foot care for diabetes and peripheral vascular disease.

Not covered, except for services associated with foot care for diabetes and peripheral vascular disease.

Treatment Resulting From Life-Threatening EmergenciesMedical treatment required as a result of an emergency, such as a suicide attempt, will be considered a medical expense until the medical condition is stabilized. Once the medical condition is stabilized, whether the treatment will be characterized as either a medical expense or a mental health/substance use disorder expense will be determined by the utilization review Physician in accordance with the applicable mixed services claim guidelines.

35



Mental Health Inpatient (includes acute inpatient and residential treatment) Calendar Year Maximum: Unlimited

Outpatient

Outpatient Physician’s Office Visit (includes individual, family and group psychotherapy, medication management, etc.) Calendar Year Maximum: Unlimited

Outpatient All Other Services (includes partial hospitalization, intensive outpatient services, etc.) Calendar Year Maximum: Unlimited







Substance Use Disorder Inpatient (includes acute inpatient detoxification, acute inpatient rehabilitation and residential treatment) Calendar Year Maximum: Unlimited

Outpatient

Outpatient Office Visits (includes individual, family and group psychotherapy, medication management, etc.) Calendar Year Maximum: Unlimited

Outpatient All Other Services (includes partial hospitalization, intensive outpatient services, etc.) Calendar Year Maximum: Unlimited







36

The Cigna Choice Fund Health Savings Account (HSA) Plan Prescription Drug Benefits 36

The Cigna Choice Fund Health Savings Account (HSA) Plan Prescription Drug BenefitsWhen you enroll in a Cigna medical plan, you automatically receive prescription drug benefits. The amount you pay depends on: which medical plan you choose, where you purchase the prescription (retail drug store or home delivery) and whether your prescription drug is a generic, brand name formulary, or brand name non-formulary.

With the Cigna Choice Fund with HSA, you must pay for your prescription drugs out of pocket, until you reach your deductible. Once you’ve reached your deductible, the plan will pay 80% of the cost of your prescription medications.

You have three options for filling your prescriptions:

1. Retail Pharmacy: Fill short-term prescriptions (up to a 30-day supply) at a participating retail pharmacy.

2. Mail Order: Fill long-term prescriptions (31 to 90-day supply) using Cigna Home Delivery Pharmacy, Cigna’s mail order service.

3. Cigna 90 NowSM: For Maintenance Medications, after you’ve received fills of your 30-day prescriptions, you must switch to a 90-day supply, but you’ll have more choice on where you can get your medication: either at one of the 90-day retail pharmacies in your plan’s new network or through Cigna Home Delivery PharmacySM.

Cigna Rx Savings Program

Cigna Rx Savings Program provides reduced copayments (almost 50% of standard copayments) for certain generic and brand medications to treat the following conditions: Asthma, Diabetes, Hyperlipidemia, and Hypertension and Heart Disease.

The purpose of this program is to make these drugs more affordable so you do not need more costly treatment later as a result of skipping your medications. Eligible medications are determined based on various factors, including the cost impact to the company. If your medication is eligible, you will be charged the appropriate copay at the time of purchase.

Cigna Home Delivery Specialty Pharmacy

If you or a covered family member needs an injectable or specialty medication that requires storage under special conditions such as refrigeration, or is not normally found at your retail pharmacy, you may need to fill your prescription through Cigna Specialty Pharmacy. A 30-day supply of your medication will be mailed to your home at the cost of a retail copayment. A 90-day supply through Cigna Home Delivery will cost the mail order copayment.

Your doctor should request your first prescription, but you may also have your new prescriptions filled by calling 1-800-244-6224. Medications will be sent to you within 24 to 48 hours of receipt of your prescription. After filling your first prescription, a patient care coordinator will call as a reminder a week before it is time for your next refill. Cigna Specialty Pharmacy gives extra help to patients who need specialty medication, including support from nurses and pharmacists on call 24 hours a day, 7 days a week. For more information, call 1-800-244-6224 or visit myCigna.com.

Dispense As Written

You and your doctor usually have a choice between a brand-name versus generic drug, and in most cases your prescription is filled with the generic drug unless your doctor tells the pharmacy “Dispense as Written.” However, the active ingredient(s) in generic drugs are exactly the same as in brand name drugs. In order to contain prescription drug costs, Cigna will impose tighter controls on all drugs when generics are available. If your doctor prescribes a brand name medication, you would need to pay the generic copay and difference in cost.

http://myCigna.com

37


HSA – Cigna Choice Fund Health Savings Account Prescription Drug Benefits – The Schedule

For You and Your DependentsThis Plan provides Prescription Drug benefits for Prescription Drug Products provided by Pharmacies as shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for Prescription Drug Products. That portion includes any applicable Copayment, Deductible and/or Coinsurance. As applicable, your Deductible or Coinsurance Payment will be based on the Prescription Drug charge when the Pharmacy is a Network Pharmacy.

CopaymentThe term Copayment is a set dollar amount you or your Dependent are required to pay for covered Prescription Drug Products under this plan.

DeductibleThe term Deductible is a set amount of eligible expenses you pay each year before the medical and prescription drug plans start to pay benefits.

CoinsuranceThe term Coinsurance means the percentage of Charges for covered Prescription Drug Products that you or your Dependent are required to pay under this plan.

ChargesThe term Charges means the Prescription Drug Charge when the Pharmacy is a Network Pharmacy.

Cigna Pharmacy Three-Tier Coinsurance Plan● Patient is responsible for the applicable coinsurance based upon the tier of the dispensed medication● Self-administered injectable and optional injectable drugs – includes infertility drugs● Includes oral contraceptives – with specific products covered 100%● Lifestyle drugs included – limited to sexual dysfunction● Prescription diet drugs included● Prescription smoking cessation drugs included● Oral fertility drugs included● Insulin, glucose test strips, lancets, insulin needles and syringes, insulin pens and cartridges included

BENEFIT HIGHLIGHTS NETWORK PHARMACY NON-NETWORK PHARMACY

Lifetime MaximumCalendar Year DeductibleIndividualFamily

Refer to the Medical Benefits Schedule

Refer to the Medical Benefits ScheduleRefer to the Medical Benefits Schedule



Out-of-Pocket MaximumIndividualFamily



Maintenance Drug Products

Maintenance Drug Products must be filled in an amount equal to a consecutive 90-day supply per Prescription Order or Refill at a retail Designated Pharmacy or home delivery Pharmacy, after three 30-day supply fills at a retail Pharmacy or home delivery Pharmacy. If you do not fill your Maintenance Drug Products in a 90-day supply at a retail Designated Pharmacy or home delivery Pharmacy after the specified 30-day supply fill limit, the Plan will not cover the Maintenance Drug Product.

Certain Preventive Care Medications covered under this plan and required as part of preventive care services (detailed information is available at www.healthcare.gov) are payable at 100% with no Copayment or Deductible, when purchased from a Network Pharmacy. A written prescription is required.

Note: Contraceptive devices and oral contraceptives are payable as shown in The Schedule.

http://www.healthcare.gov

38



Prescription Drug Products at Retail Pharmacies

The amount you pay for up to a consecutive 30-day supply at a Network Pharmacy

The amount you pay for up to a consecutive 30-day supply at a Non-Network Pharmacy

Certain Specialty Prescription Drug Products are only covered when dispensed by a home delivery Pharmacy, after 1 fill of the Specialty Prescription Drug Product at a retail Pharmacy.

Tier 1: Generic Drugs on the Prescription Drug List

Non-Maintenance Drug Products


Asthma, Diabetes, Hyperlipidemia, Hypertension and Heart Disease




20% after plan Deductible for the first 3 fills, then no coverage for a 30-day supply

No charge after $4 copay after plan Deductible

$4 after plan Deductible for the first 3 fills, then no coverage for a 30-day supply





Tier 2: Brand Drugs designated as preferred on the Prescription Drug List








15% subject to a maximum of $40, then the plan pays 100% after plan Deductible

15% subject to a maximum of $40, then the plan pays 100% after plan Deductible for the first 3 fills, then no coverage for a 30-day supply





Tier 3: Brand Drugs designated as non-preferred on the Prescription Drug List






20% after plan Deductible



25% subject to a maximum of $55, then the plan pays 100% after plan Deductible for the first 3 fills, then no coverage for a 30-day supply





39



Prescription Drug Products at Retail Designated Pharmacies


The amount you pay for up to a consecutive 90-day supply at a Non-Network Pharmacy


Specialty Prescription Drug Products are limited to up to a consecutive 30-day supply per Prescription Order or Refill.

Note: in this context, a Designated Pharmacy is a retail Network Pharmacy that has contracted with Cigna for dispensing of covered Prescription Drug Products, including Maintenance Drug Products, in 90-day supplies.

Tier 1: Generic Drugs on the Prescription Drug ListAsthma, Diabetes, Hyperlipidemia, Hypertension and Heart Disease


No charge after $9 copay after plan deductible



Tier 2: Brand-Name drugs designated as preferred on the Prescription Drug List with no Generic equivalentAsthma, Diabetes, Hyperlipidemia, Hypertension and Heart Disease





Tier 3: Brand-Name drugs with a Generic equivalent and drugs designated as non-preferred on the Prescription Drug ListAsthma, Diabetes, Hyperlipidemia, Hypertension and Heart Disease





Note: Oral Contraceptives are covered at $0 copay. Note: Specialty Medications, including self- and optional injectables, are limited to a 30-day supply at retail and Cigna Home Delivery Specialty Pharmacy.

Prescription Drug Products at Home Delivery Pharmacies


The amount you pay for up to a consecutive 90-day supply at a non-Network Pharmacy


Tier 1: Generic Drugs on the Prescription Drug ListAsthma, Diabetes, Hyperlipidemia, Hypertension and Heart Disease


No charge after $9 copay after plan deductible



Tier 2: Brand-Name drugs designated as preferred on the Prescription Drug List with no Generic equivalentAsthma, Diabetes, Hyperlipidemia, Hypertension and Heart Disease





Tier 3: Brand-Name drugs with a Generic equivalent and drugs designated as non-preferred on the Prescription Drug ListAsthma, Diabetes, Hyperlipidemia, Hypertension and Heart Disease





Note: Oral Contraceptives are covered at $0 copay.

40

The Cigna Open Access Plus (OAP) Plan 40

The Cigna Open Access Plus (OAP) Plan

OAP – The Cigna Open Access Plus Plan Medical Benefits – The Schedule


Open Access Plus Medical Benefits provide coverage for care In-Network and Out-of-Network. To receive Open Access Plus Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services and 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 is covered under this Plan, you must call the number on the back of your medical 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 for those 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 pay under the Plan.

Copayments/Deductibles

Copayments are expenses to be paid by you or your Dependent for covered services. Deductibles are also expenses to be paid by you or your Dependent. Deductible amounts are separate from and not reduced by Copayments. Copayments and 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 further medical 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 by the benefit Plan because of any:

● Coinsurance● Plan Deductibles● Copayments

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

● Non-compliance penalties● Provider charges in excess of the Maximum Reimbursable Charge

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

● Non-compliance penalties● Provider charges in excess of the Maximum Reimbursable Charge (also referred to as reasonable and customary charges)Accumulation of Plan Deductibles and Out-of-Pocket Maximums

Deductibles and Out-of-Pocket Maximums will cross-accumulate (that is, In-Network will accumulate to Out-of-Network and Out-of-Network will accumulate to In-Network). All other Plan maximums and service-specific maximums (dollar and occurrence) also cross-accumulate between In- and Out-of-Network, unless otherwise noted.Multiple Surgical Reductions

Multiple surgeries performed during one operating session result in payment reduction of 50 percent to the surgery of lesser charge. 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 of the surgeon’s allowable charge. (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to Coinsurance or Deductible amounts).

Co-Surgeon

The maximum amount payable will be limited to 62.5 percent of the surgeon’s allowable charge. (For purposes of this limitation, allowable charge means the amount payable to the surgeons prior to any reductions due to Coinsurance or Deductible amounts.)

41



Combined Out-of-Pocket Maximum for Pharmacy

Combined Medical/Pharmacy Out-of-Pocket: includes retail and home delivery prescription drugs

Home Delivery Pharmacy costs contribute to the combined medical/pharmacy out-of-pocket maximum

Yes

Yes


Yes

Lifetime Maximum Unlimited Unlimited

Coinsurance Levels 90% 70% of the Maximum Reimbursable Charge


Maximum Reimbursable Charge (also referred to as reasonable and customary charges) is determined based on:

● The lesser of the provider’s normal charge for a similar service or supply; or

● A percentile of charges made by providers of such service or supply in the geographic area where the service is received. These charges are compiled in a database Cigna has selected.

Note: The provider may bill you for the difference between the provider’s normal charge and the Maximum Reimbursable Charge, in addition to applicable Deductibles, Copayments and Coinsurance.

Not Applicable 150% of the Maximum Reimbursable Charge


Individual (enrolled for employee coverage)

Family Maximum (enrolled for family coverage)

Family Deductible Calculation:

Family members meet only their individual Deductible and then their claims will be covered under the Plan Coinsurance; if the family Deductible has been met prior to their individual Deductible being met, their claims will be paid at the Plan Coinsurance.

$350 per person

$1,050 per family

$750 per person

$2,250 per family

Out-of-Pocket Maximum

Individual (enrolled for employee coverage only)

Family Maximum (enrolled for family coverage)

Family Maximum Calculation:

Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%.

$5,000 per person

$10,000 per family

$10,000 per person

$20,000 per family

42




Primary Care Physician’s Office Visit

Specialty Care Physician’s Office Visits

Consultant and Referral Physician’s Services

Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with Cigna.

MDLIVE Consultations


Second Opinion Consultations

Allergy Treatment/Allergy Injection/ Allergy Serum (dispensed by the Physician in the office)

$25 per office visit copay

$40 Specialist per office visit copay; $25 per consultation

$25 PCP or $40 Specialist per office visit copay

$25 copay

100% coverage

100% coverage

100% coverage




In-Network Coverage only




Preventive Care Routine Well-Child Visits (includes immunizations)


Immunizations (including Travel Immunizations) – all ages

100% coverage

100% coverage



Mammograms, PSA, PAP Smear, Colonoscopy

Preventive Care-Related Services

Diagnostic-Related Services

Note: Based on place of service

100% coverage




Inpatient Hospital-Facility Services

Semi-Private Room and Board

Private Room










Outpatient Hospital-Facility Services

Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room


Inpatient Hospital Physician’s Visits/Consultations 90% after Plan Deductible 70% after Plan Deductible

43



Inpatient Hospital Professional Services● Surgeon● Radiologist● Pathologist● Anesthesiologist


Outpatient Professional Services● Surgeon● Radiologist● Pathologist● Anesthesiologist


Outpatient Hospital Facility 90% after Plan Deductible 70% after Plan Deductible

Independent X-ray and/or Lab Facility 100% 70% after Plan Deductible

BENEFIT HIGHLIGHTS

Laboratory ServicesCigna is contracted with two of the largest national laboratories, Laboratory Corporation of America (LabCorp) and Quest Diagnostics, Inc. (Quest), as well as several regional and local laboratories. Using these nationally contracted laboratories can help Cigna customers obtain the services they need at in-network benefit levels.

Want to spend your medical dollars wisely? Here’s how …when you need lab work done, be sure you and your provider use an in-network facility. Using out-of-network facilities will cost you more money for the same service. To make sure your lab is in network, check on myCigna.com.

By participating with two of the largest national laboratories and other regional and local laboratories, Cigna helps its customers obtain the services they need while receiving the greatest value from their Cigna medical benefits.

Non-Participating LaboratoriesCigna reimburses covered laboratory and pathology services from non-participating laboratories and health care professionals at the applicable out-of-network benefit level (if available).

Covered Services from a non-participating laboratory or non-participating health care professional may be reimbursed at the customer’s in-network benefit plan level in limited circumstances if:

● Laboratory and pathology services are associated with a true emergency service visit.● Federal or state law requires that laboratory and pathology services are to be paid at the in-network benefit level.● Laboratory and pathology services are not available from a participating laboratory and the services are Covered

Services (medically necessary and a covered benefit). Services will be reviewed to determine if Cigna’s Network Adequacy Policy applies.


Urgent Care ServicesPhysician’s Office Visit

Outpatient Professional services (radiology, pathology Physician)

Urgent Care Facility or Outpatient Facility

X-ray and/or Lab performed at the Urgent Care Facility (billed by the facility as part of the UC visit)



100% coverage

$75 per visit copay (waived if admitted)

100% coverage

100% coverage


100% coverage

$75 per visit copay (waived if admitted)

100% coverage

100% coverage

http://myCigna.com

44



Emergency Services



Outpatient Professional Services (radiology, pathology, ER physician)

X-ray and/or Lab performed at the Emergency Room Facility (billed by the facility as part of the ER visit)


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

No charge after the $25 PCP or $40 specialist per office visit copay

No charge after $150 per visit copay*

*waived if admitted

No charge

No charge

No charge

No charge

No charge after the $25 PCP or $40 specialist per office visit copay

No charge after $150 per visit copay*

*waived if admitted

No charge

No charge

No charge

No charge

Ambulance 90% after plan deductible 90% after plan deductible



Calendar Year Maximum: 120 days combined for in-network and out-of-network for all Other Health Care Services


Laboratory and Radiology Services (includes preadmission testing)


Outpatient Hospital Facility

Independent X-ray and/or Lab Facility



100%






Inpatient Facility

Outpatient Facility

$25 PCP or $40 Specialist copay






45




Calendar Year Maximum: 60 days for in-network and out-of-network for all therapies combined

Includes:

● Physical Therapy● Speech Therapy● Occupational Therapy● Pulmonary Rehab● Cognitive Therapy

Note: Speech therapy is covered for children who failed to achieve complete speech articulation due to hearing loss, corrective surgery for congenital defects, cerebral palsy, spina bifida, multiple sclerosis, autism, neurological disorders or Down Syndrome. Physical, and occupational therapy for the treatment of Autism Spectrum Disorder is unlimited.

$40 Specialist per office visit copay


Outpatient Cardiac Rehabilitation

Calendar Year Maximum: 36 days combined for in-network and out-of-network.



Chiropractic Care

Calendar Year Maximum: 20 days combined (for in-network and out-of-network)




Home Health Care

Maximum of 16 hours per day

Calendar Year Maximum: 120 days for in-network and out-of-network combined (includes outpatient private nursing when approved as Medically Necessary)



Hospice

Inpatient Services

Outpatient Services





Bereavement Counseling

Services provided as part of Hospice Care

Inpatient

Outpatient








46





Note: OB/GYN providers will be considered either a PCP or Specialist, depending on how the provider contracts with Cigna.



Delivery Facility (Inpatient Hospital, Birthing Center)









Abortion










Note: The standard benefit will include coverage for contraceptive devices (e.g., Depo-Provera and Intrauterine Devices (IUDs)). Diaphragms will also be covered when services are provided in the Physician’s office.

Surgical Sterilization Procedure for Tubal Ligation (excludes reversals)



100%

100%

100% 100% 100%




47





Surgical Sterilization Procedure for Vasectomy (excludes reversals)









Coverage will be provided for the following services:

● Testing and treatment services performed in connection with an underlying medical condition.● Testing performed specifically to determine the cause of infertility.● Treatment and/or procedures performed specifically to restore fertility (e.g., procedures to correct an infertility

condition).● Artificial insemination, In-vitro, GIFT, ZIFT, etc.● Injectable physician administered infertility drugs under both the medical plan and the pharmacy plan.

● Lifetime Maximum: $5,000 per member

Physician’sOfficeVisit(LabandRadiologyTests,Counseling)


Lifetime Maximum: $5,000 per member combined for in-network and out-of-network. Includes all related services billed with an infertility diagnosis (i.e., X-ray or lab services billed by an independent facility).





Organ Transplants

Includes all medically appropriate, non-experimental transplants


Inpatient Facility




100% at Cigna LifeSOURCE center; otherwise, 90% after Plan Deductible

100% at LifeSOURCE center; otherwise, 90% after Plan Deductible

100% coverage (only available when using LifeSOURCE facility)




Not applicable

48



Durable Medical Equipment 90% after Plan Deductible 70% after Plan Deductible

Breast Feeding Equipment and Supplies● Limited to the rental or purchase of one breast pump

per birth as ordered or prescribed by a physician when coordinated by Cigna’s Care Centrix

● Includes related supplies

100% (no deductible) 70% after Plan Deductible

External Prosthetic Appliances 90% after Plan Deductible 70% after Plan Deductible

Wigs

Covered with medical necessity


Acupuncture




Consumable Medical Supplies 90% after Plan Deductible 70% after Plan Deductible


Calendar Year Maximum: Three visits per person for in-network and out-of-network combined (however, the 3 visit limit will not apply to treatment of mental health and substance use disorder conditions).







Dental Care








Hearing Services

Note: Specific to Hearing Exam

Maximum: One visit per Calendar Year combined for in-network and out-of-network

100% coverage after the $40 per office visit copay


49



TMJ Surgical and Non-Surgical

Always excludes appliances and orthodontic treatment. Subject to Medical Necessity.



100% coverage after the $25 PCP or $40 Specialist per office visit copay




Routine Foot Disorders

Note: Only covered for services associated with Diabetes foot care and peripheral vascular disease

Not Covered Not Covered

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 expense until the medical condition is stabilized. Once the medical condition is stabilized, whether the treatment will be characterized as either a medical expense or a mental health/substance use disorder expense will be determined by the utilization review Physician in accordance with the applicable mixed services claim guidelines.

Mental Health

Inpatient (includes Acute Inpatient and Residential Treatment)


Outpatient

Outpatient Office Visit (includes individual, family and group psychotherapy, medication management, etc.)


Outpatient All Other Services (includes Partial Hospitalization, Intensive Outpatient Services, etc.)



$40 per visit copay





Substance Abuse

Inpatient

Outpatient (Includes Individual and Intensive Outpatient):


Outpatient Facility


$40 per visit copay





50

The Cigna Open Access Plus (OAP) Plan Prescription Drug Benefits 50

The Cigna Open Access Plus (OAP) Plan Prescription Drug BenefitsWhen you enroll in a Cigna medical plan, you automatically receive prescription drug benefits. The amount you pay depends on which medical plan you choose, where you purchase the prescription (retail drug store or home delivery) and whether your prescription drug is a generic, brand name formulary, or brand name non-formulary.

With the Cigna Open Access Plus Plan, you pay copay and coinsurance amounts. You have three options for filling your prescriptions:

4. Retail Pharmacy: Fill short-term prescriptions (up to a 30-day supply) at a participating retail pharmacy.

5. Mail Order: Fill long-term prescriptions (31 to 90-day supply) using Cigna Home Delivery Pharmacy, Cigna’s mail order service.

6. Cigna 90 NowSM: For Maintenance Medications, after you’ve received fills of your 30-day prescriptions, you must switch to a 90-day supply, but you’ll have more choice on where you can get your medication: either at one of the 90-day retail pharmacies in your plan’s new network or through Cigna Home Delivery PharmacySM.

Cigna Rx Savings Program

Cigna Rx Savings Program provides reduced copayments (almost 50% of standard copayments) for certain generic and brand medications to treat the following conditions: Asthma, Diabetes, Hyperlipidemia, and Hypertension and Heart Disease.

The purpose of this program is to make these drugs more affordable so you do not need more costly treatment later as a result of skipping your medications. Eligible medications are determined based on various factors, including the cost impact to the company. If your medication is eligible, you will be charged the appropriate copay at the time of purchase.

Cigna Home Delivery Specialty Pharmacy

If you or a covered family member needs an injectable or specialty medication that requires storage under special conditions such as refrigeration, or is not normally found at your retail pharmacy, you may need to fill your prescription through Cigna Specialty Pharmacy. A 30-day supply of your medication will be mailed to your home at the cost of a retail copayment. A 90-day supply through Cigna Home Delivery will cost the mail order copayment.

Your doctor should request your first prescription, but you may also have your new prescriptions filled by calling 1-800-244-6224. Medications will be sent to you within 24 to 48 hours of receipt of your prescription. After filling your first prescription, a patient care coordinator will call as a reminder a week before it is time for your next refill. Cigna Specialty Pharmacy gives extra help to patients who need specialty medication, including support from nurses and pharmacists on call 24 hours a day, 7 days a week. For more information, call 1-800-244-6224 or visit myCigna.com.

Dispense As Written

You and your doctor usually have a choice between a brand-name versus generic drug, and in most cases your prescription is filled with the generic drug unless your doctor tells the pharmacy “Dispense as Written.” However, the active ingredient(s) in generic drugs are exactly the same as in brand name drugs. In order to contain prescription drug costs, Cigna will impose tighter controls on all drugs when generics are available. If your doctor prescribes a brand name medication, you would need to pay the generic copay and difference in cost.

http://myCigna.com

51


The Cigna Open Access Plus (OAP) Prescription Drug Benefits – The Schedule


This Plan provides Prescription Drug benefits for Prescription Drug Products provided by Pharmacies as shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for Prescription Drug Products. That portion includes any applicable Copayment, Deductible and/or Coinsurance. As applicable, your Deductible or Coinsurance payment will be based on the Prescription Drug Charges when the Pharmacy is a Network Pharmacy.

Copayment

Copayment is a set dollar amount you or your Dependent are required to pay for covered Prescription Drug Products under this plan.

Deductible

The Deductible is a set amount of eligible expenses you pay each year before the medical plan starts to pay benefits.

Coinsurance

Coinsurance means the percentage of charges for covered Prescription Drug Products that you or your Dependent are required to pay under this plan.

Charges

The term Charges means the Prescription Drug Charge when the Pharmacy is a Network Pharmacy.

Cigna Pharmacy Three-Tier Coinsurance Plan

● Patient is responsible for the applicable copay based upon the tier of the dispensed medication● Self-administered injectable and optional injectable drugs – includes infertility drugs● Includes oral contraceptives – with specific products covered 100%● Lifestyle drugs included – limited to sexual dysfunction● Prescription diet drugs included● Prescription smoking cessation drugs included● Oral fertility drugs included● Insulin, glucose test strips, lancets, insulin needles and syringes, insulin pens and cartridges included● Specialty Medications including self- and optional injectables are limited to a 30-day supply at both retail and Cigna

Home Delivery Specialty Pharmacy

BENEFIT HIGHLIGHTS NETWORK PHARMCY NON-NETWORK PHARMCY

Lifetime Maximum Refer to the Medical Benefits Schedule Refer to the Medical Benefits Schedule


Individual

Family






Maintenance Drug Products must be filled in an amount equal to a consecutive 90 day supply per Prescription Order or Refill at a retail Designated Pharmacy or home delivery Pharmacy, after 3 30-day supply fills at a retail Pharmacy or home delivery Pharmacy. If you do not fill your Maintenance Drug Products in a 90-day supply at a retail Designated Pharmacy or home delivery Pharmacy after the specified 30-day supply fill limit, the Plan will not cover the Maintenance Drug Product.

Certain Preventive Care Medications covered under this plan and required as part of preventive care services (detailed information is available at www.healthcare.gov) are payable at 100% with no Copayment or Deductible, when purchased from a Network Pharmacy. A written prescription is required.

Note: Contraceptive devices and oral contraceptives are payable as shown in The Schedule.

http://www.healthcare.gov

52



Prescription Drug Products at Retail Pharmacies










No charge, subject to a minimum of $7 and a maximum of $7, then the plan pays 100%

No charge, subject to a minimum of $7 and a maximum of $7, then the plan pays 100% for the first 3 fills, then no coverage for a 30-day supply

No charge after $4 copay

$4 for the first 3 fills, then no coverage for a 30-day supply











30%, subject to a maximum of $80, then the plan pays 100%

30%, subject to a maximum of $80, then the plan pays 100% for the first 3 fills, then no coverage for a 30-day supply

15%, with a maximum of $40, then the plan pays 100%

15%, with a maximum of $40, then the plan pays 100% for the first 3 fills, then no coverage for a 30-day supply












45%, subject to a maximum of $110, then the plan pays 100% for the first 3 fills, then no coverage for a 30-day supply

25%, with a maximum of $55, then the plan pays 100%

25%, with a maximum of $55, then the plan pays 100% for the first 3 fills, then no coverage for a 30-day supply





53



Drug Products at Retail Designated Pharmacies

The amount you pay for up to a consecutive 90-day supply at a Designated Pharmacy

The amount you pay for up to a consecutive 90-day supply at a non-Designated Pharmacy



Note: In this context, a retail Designated Pharmacy is a retail Network Pharmacy that has contracted with Cigna for dispensing of covered Prescription Drug Products, including Maintenance Drug Products, in 90-day supplies.



















Note: Oral Contraceptives are covered at $0 copay

Prescription Drug Products at Home Delivery Pharmacies



Note: Specialty Prescription Drug Products are limited to up to a consecutive 30-day supply per Prescription Order or Refill.



















Note: Oral Contraceptives are covered at $0 copay

54

Medical Benefits Provisions for Open Access Plus and Choice Fund plans 54

Medical Benefits Provisions for Open Access Plus and Choice Fund plansCertification Requirements – Out-of-NetworkPreadmission Certification (PAC) and Continued Stay Review (CSR) refer to the process used to certify the Medical Necessity and length of a Hospital Confinement when you or your Dependent requires treatment in a Hospital:● as a registered bed patient;● for a Partial Hospitalization for the treatment of Mental Health or Substance Abuse; or● for Mental Health or Substance Abuse Residential Treatment Services.

You or your Dependent should request PAC prior to any nonemergency treatment in a Hospital described above.In the case of an emergency admission, you should contact the Review Organization within 72 hours after the admission. For an admission due to pregnancy, you should call the Review Organization by the end of the third month of pregnancy. CSR should be requested, prior to the end of the certified length of stay, for continued Hospital Confinement.Covered Expenses incurred will be reduced by 50 percent for Hospital charges made for each separate admission to the Hospital unless PAC is received: (a) prior to the date of admission; or (b) in the case of an emergency admission, within 72 hours after the date of admission.Covered Expenses incurred for which benefits would otherwise be payable under this Plan for the charges listed below will not include:● Hospital charges for Bed and Board, for treatment listed above for which PAC was performed, that are made for any day in

excess of the number of days certified through PAC or CSR; and● any Hospital charges for treatment listed above for which PAC was requested, but were not certified as Medically Necessary.

PAC and CSR are performed through a utilization review program by a Review Organization with which Cigna has contracted.In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this Plan, except for the Coordination of Benefits section.

Outpatient Certification Requirements – Out-of-NetworkOutpatient Certification refers to the process used to certify the Medical Necessity of outpatient diagnostic testing and outpatient procedures, including, but not limited to, those listed in this section when performed as an outpatient in a Freestanding Surgical Facility, Other Health Care Facility or a Physician’s office. You or your Dependent should call the toll-free number on the back of your ID card to determine if Outpatient Certification is required prior to any outpatient diagnostic testing or procedures.Outpatient Certification is performed through a utilization review program by a Review Organization with which Cigna has contracted. Outpatient Certification should only be requested for nonemergency procedures or services, and should be requested by you or your Dependent at least four working days (Monday through Friday) prior to having the procedure performed or the service rendered.Covered Expenses incurred will be reduced by 50 percent for charges made for any outpatient diagnostic testing or procedure performed, unless Outpatient Certification is received prior to the date the testing or procedure is performed.Covered Expenses incurred will not include expenses incurred for charges made for outpatient diagnostic testing or procedures for which Outpatient Certification was performed, but were not certified as Medically Necessary.In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this Plan, except for the Coordination of Benefits section.Including, but not limited to:● Advanced radiological imaging – CAT Scans, MRI, MRA or PET scans.● Hysterectomy.

Prior Authorization/PreauthorizedThe term Prior Authorization means the approval that a Participating Provider must receive from the Review Organization, prior to services being rendered, in order for certain services and benefits to be covered under this Policy.Services that require Prior Authorization include, but are not limited to:

● inpatient Hospital services;● inpatient services at any participating Other Health Care Facility;● residential treatment;● outpatient facility services;● advanced radiological imaging;

● nonemergency ambulance,● transplant services,● certain medical pharmaceuticals; or● partial hospitalization.

55

Medical Plan – Covered Expenses 55

Medical Plan – Covered ExpensesThe term Covered Expenses means the expenses incurred by or on behalf of a person for the charges listed below if they are incurred after he or she becomes insured for these benefits. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness, as determined by Cigna. Any applicable Copayments, Deductibles or limits are shown in The Schedule for medical plans.

Covered Expenses include:● charges made by a Hospital, on its own behalf, for Bed and Board and other Necessary Services and Supplies; except that for

any day of Hospital Confinement, Covered Expenses will not include that portion of charges for Bed and Board that is more than the Bed and Board Limit shown in The Schedule.

● charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided.

● charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient.● charges made by a Freestanding Surgical Facility, on its own behalf for medical care and treatment.● charges made on its own behalf by an Other Health Care Facility, including a Skilled Nursing Facility, a Rehabilitation

Hospital or a sub-acute facility for medical care and treatment; except that for any day of Other Health Care Facility confinement, Covered Expenses will not include that portion of charges that are in excess of the Other Health Care Facility Daily Limit shown in The Schedule.

● charges made for Emergency Services and Urgent Care.● charges made by a Physician or a Psychologist for professional services.● charges made by a Nurse, other than a member of your family or your Dependent’s family, for professional nursing service.● 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 their administration.● 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 laboratory screening test.● charges made for an annual prostate-specific antigen test (PSA).● charges for appropriate counseling or medical services connected with surgical therapies, including vasectomy and tubal

ligation.● charges made for laboratory services, radiation therapy and other diagnostic and therapeutic radiological procedures.● charges made for Family Planning, including medical history, physical exam, related laboratory tests, medical supervision in

accordance with generally accepted medical practices, other medical services, information and counseling on contraception, implanted/injected contraceptives.

● charges made for office visits, tests and counseling for Family Planning services.● charges made for the following preventive care services (detailed information is available at

healthcare.gov/coverage/preventive-care-benefits/):

1. evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force;

2. immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved;

3. for infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration;

4. for women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

● charges made for surgical or nonsurgical treatment of Temporomandibular Joint Dysfunction.● charges made for acupuncture.

http://healthcare.gov/coverage/preventive-care-benefits/

56


● charges made for orthognathic surgery to repair or correct a severe facial deformity or disfigurement that orthodontics alone cannot correct, provided:o the deformity or disfigurement is accompanied by a documented clinically significant functional impairment, and there is

a reasonable expectation that the procedure will result in meaningful functional improvement; oro the orthognathic surgery is Medically Necessary as a result of tumor, trauma, disease; oro the orthognathic surgery is performed prior to age 19 and is required as a result of severe congenital facial deformity or

congenital condition.Repeat or subsequent orthognathic surgeries for the same condition are covered only when the previous orthognathic surgery met the above requirements and there is a high probability of significant additional improvement as determined by the utilization review Physician.

Phase II cardiac rehabilitation provided on an outpatient basis following diagnosis of a qualifying cardiac condition when Medically Necessary. Phase II is a Hospital-based outpatient program following an inpatient Hospital discharge. The Phase II program must be Physician directed with active treatment and EKG monitoring.

Phase III and Phase IV cardiac rehabilitation is not covered. Phase III follows Phase II and is generally conducted at a recreational facility primarily to maintain the patient’s status achieved through Phases I and II. Phase IV is an advancement of Phase III, which includes more active participation and weight training.

Clinical TrialsCharges made for routine patient services associated with cancer clinical trials approved and sponsored by the federal government. In addition, the following criteria must be met:

● the cancer clinical trial is listed on the NIH website clinicaltrials.gov as being sponsored by the federal government;● the trial investigates a treatment for terminal cancer and: (1) the person has failed standard therapies for the disease; (2)

cannot tolerate standard therapies for the disease; or (3) no effective non-experimental treatment for the disease exists;● the person meets all inclusion criteria for the clinical trial and is not treated “off-protocol”;● the trial is approved by the Institutional Review Board of the institution administering the treatment; and● coverage will not be extended to clinical trials conducted at nonparticipating facilities if a person is eligible to participate in a

covered clinical trial from a Participating Provider.

Routine patient services do not include, and reimbursement will 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 clinical trial (i.e., protocol-induced costs);● services or supplies that, in the absence of private health care coverage, are provided by a clinical trial sponsor or other party

(e.g., device, drug, item or service supplied by manufacturer and not yet FDA approved) without charge to the trial participant.

Genetic TestingCharges made for genetic testing that uses a proven testing method for the identification of genetically linked inheritable disease. Genetic testing is covered only if:

● a person has symptoms or signs of a genetically linked inheritable disease;● it has been determined that a person is at risk for carrier status as supported by existing peer-reviewed, evidence-based,

scientific literature for the development of a genetically linked inheritable disease when the results will impact clinical outcome; or

● the therapeutic purpose is to identify specific genetic mutation that has been demonstrated in the existing peer-reviewed, evidence-based, scientific literature to directly impact treatment options.

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

Genetic counseling is covered if a person is undergoing approved genetic testing, or if a person has an inherited disease and is a potential candidate for genetic testing. Genetic counseling is limited to three visits per calendar year for both pre- and post-genetic testing.

http://clinicaltrials.gov

57


Nutritional EvaluationCharges made for nutritional evaluation and counseling when diet is a part of the medical management of a documented organic disease.

Internal Prosthetic/Medical AppliancesCharges made for internal prosthetic/medical appliances that provide permanent or temporary internal functional supports for nonfunctional body parts are covered. Medically Necessary repair, maintenance or replacement of a covered appliance is also covered.

Home Health Care ServicesCharges made for Home Health Care Services when you:

● require skilled care;● are unable to obtain the required care as an ambulatory outpatient; and● do not require confinement in a Hospital or Other Health Care Facility.

Home Health Care Services are provided under the terms of a Home Health Care Plan for the person named in that Plan. If you are a minor or an adult who is Dependent upon others for non-skilled care (e.g., bathing, eating, toileting), Home Health Care Services will only be provided for you during times when there is a family member or caregiver present in the home to meet your non-skilled care needs.

Home Health Care Services are those skilled health care services that can be provided during intermittent visits of two hours or less by Other Health Care Professionals. Necessary consumable medical supplies, home infusion therapy, and Durable Medical Equipment administered or used by Other Health Care Professionals in providing Home Health Care Services are covered. Home Health Care Services do not include services of a person who is a member of your family or your Dependent’s family or who normally resides in your house or your Dependent’s house. Physical, occupational, and speech therapy provided in the home are subject to the benefit limitations described under Short Term Rehabilitative Therapy.

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

● by a Hospice Facility for Bed and Board and Services and Supplies;● by a Hospice Facility for services provided on an outpatient basis;● by a Physician for professional services;● by a Psychologist, social worker, family counselor or ordained minister for individual and family counseling;● for pain relief treatment, including drugs, medicines and medical supplies;● by an Other Health Care Facility for:

o part-time or intermittent nursing care by or under the supervision of a Nurse;o part-time or intermittent services of an Other Health Care Professional;o physical, occupational and speech therapy;o medical supplies; drugs and medicines lawfully dispensed only on the written prescription of a physician; and laboratory

services, but only to be the extent such charges would have been payable under the Policy if the person had remained or been confined in a Hospital or Hospice Facility.

The following charges for Hospice Care Services are not included as Covered Expenses:

● for the services of a person who is a member of your family or your Dependent’s family or who normally resides in your house or your Dependent’s house;

● for any period when you or your Dependent is not under the care of a Physician;● for services or supplies not listed in the Hospice Care Program;● for any curative or life-prolonging procedures;● to the extent that any other benefits are payable for those expenses under the Policy;● for services or supplies that are primarily to aid you or your Dependent in daily living.

58


Mental Health and Substance Abuse ServicesMental Health Services are services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to Mental Health will not be considered to be charges made for treatment of Mental Health.

Substance Abuse is defined as the psychological or physical dependence on alcohol or other mind-altering drugs that requires diagnosis, care and treatment. In determining benefits payable, charges made for the treatment of any physiological conditions related to rehabilitation services for alcohol or drug abuse or addiction will not be considered to be charges made for treatment of Substance Abuse.

Inpatient Mental Health ServicesServices that are provided by a Hospital while you or your Dependent is confined in a Hospital for the treatment and evaluation of Mental Health. Inpatient Mental Health Services include Partial Hospitalization and Mental Health Residential Treatment Services.

Mental Health Residential Treatment Services are services provided by a Hospital for the evaluation and treatment of the psychological and social functional disturbances that are a result of sub-acute Mental Health conditions.

Mental Health Residential Treatment Center means an institution that:

● specializes in the treatment of psychological and social disturbances that are the result of Mental Health conditions;● provides a sub-acute, structured, psychotherapeutic treatment program, under the supervision of Physicians;● provides 24-hour care, in which a person lives in an open setting; and● is licensed in accordance with the laws of the appropriate legally authorized agency as a Residential Treatment Center.A person is considered confined in a Mental Health Residential Treatment Center when he or she is a registered bed patient in a Mental Health Residential Treatment Center upon the recommendation of a Physician.

Outpatient Mental Health ServicesServices of Providers who are qualified to treat Mental Health when treatment is provided on an outpatient basis, while you or your Dependent is not Confined in a Hospital, and is provided in an individual, group or Mental Health Intensive Outpatient Therapy Program. Covered services include, but are not limited to, outpatient treatment of: conditions such as anxiety or depression, that interfere with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; or acute exacerbation of chronic Mental Health conditions (crisis intervention and relapse prevention); and outpatient testing and assessment.

A Mental Health Intensive Outpatient Therapy Program consists of distinct levels or phases of treatment that are provided by a certified/licensed Mental Health program. Intensive Outpatient Therapy Programs provide a combination of individual, family and/or group therapy in a day, totaling nine or more hours in a week.

Inpatient Substance Abuse Rehabilitation ServicesServices provided for rehabilitation, while you or your Dependent is confined in a Hospital, when required for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs. Inpatient Substance Abuse Services include Partial Hospitalization sessions and Residential Treatment services.

Partial Hospitalization sessions are services that are provided for not less than four hours and not more than 12 hours in any 24-hour period.

Substance Abuse Residential Treatment Services are services provided by a Hospital for the evaluation and treatment of the psychological and social functional disturbances that are a result of sub-acute Substance Abuse conditions.

Substance Abuse Residential Treatment Center means an institution that:

● specializes in the treatment of psychological and social disturbances that are the result of Substance Abuse;● provides a sub-acute, structured, psychotherapeutic treatment program, under the supervision of Physicians;● provides 24-hour care, in which a person lives in an open setting; and● is licensed in accordance with the laws of the appropriate legally authorized agency as a Residential Treatment Center.

A person is considered confined in a Substance Abuse Residential Treatment Center when he or she is a registered bed patient in a Substance Abuse Residential Treatment Center upon the recommendation of a Physician.

59


Outpatient Substance Abuse Rehabilitation ServicesServices provided for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs, while you or your Dependent is not confined in a Hospital, including outpatient rehabilitation in an individual, or a Substance Abuse Intensive Outpatient Therapy Program.

A Substance Abuse Intensive Outpatient Therapy Program consists of distinct levels or phases of treatment that are provided by a certified/licensed Substance Abuse program. Intensive Outpatient Therapy Programs provide a combination of individual, family and/or group therapy in a day, totaling nine or more hours in a week.

Substance Abuse Detoxification ServicesDetoxification and related medical ancillary services are provided when required for the diagnosis and treatment of addiction to alcohol and/or drugs. Cigna will decide, based on the Medical Necessity of each situation, whether such services will be covered in an inpatient or outpatient setting.

The following are specifically excluded from Mental Health and Substance Abuse Services:

● Any court-ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations, unless Medically Necessary and otherwise covered under this Policy or agreement.

● Treatment of disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain.● Developmental disorders, including but not limited to, developmental reading disorders, developmental arithmetic disorders,

developmental language disorders or developmental 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 day care.● Psychological testing on children requested by or for a school system.● Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline.

Durable Medical EquipmentCharges made for purchase or rental of Durable Medical Equipment that is ordered or prescribed by a Physician and provided by a vendor approved by Cigna for use outside a Hospital or Other Health Care Facility. Coverage for repair, replacement or duplicate equipment is provided only when required due to anatomical change and/or reasonable wear and tear. All maintenance and repairs that result from a person’s misuse are the person’s responsibility. Coverage for Durable Medical Equipment is limited to the lowest-cost alternative as determined by the utilization review Physician.

Durable Medical Equipment is defined as items that are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of Injury or Sickness; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, Hospital beds, respirators, wheelchairs and dialysis machines.

Durable Medical Equipment items that are not covered include, but are not limited to, those that are listed below:

● Bed-related Items: bed trays, over-the-bed tables, bed wedges, pillows, custom bedroom equipment, mattresses, including non-power mattresses, custom mattresses and Posturepedic® mattresses.

● Bath-related Items: bath lifts, non-portable 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 or gyroscopic mobility systems, roll-about chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized – manual hydraulic lifts are covered if patient is two-person transfer) and auto tilt chairs.

● Fixtures to Real Property: ceiling lifts and wheelchair ramps.● Car/VanModifications.● Air Quality Items: room humidifiers, vaporizers, air purifiers and electrostatic machines.● Blood-/Injection-related Items: blood pressure cuffs, centrifuges, NovoPens and needleless injectors.● Other Equipment: heat lamps, heating pads, cryounits, cryotherapy machines, electronic-controlled therapy units, ultraviolet

cabinets, sheepskin pads and boots, postural drainage board, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, any exercise equipment and diathermy machines.

60


External Prosthetic Appliances and DevicesCharges made or ordered by a Physician for the initial purchase and fitting of external prosthetic appliances and devices available only by prescription that are necessary for the alleviation or correction of Injury, Sickness or congenital defect.

Coverage for External Prosthetic Appliances is limited to the most appropriate and cost-effective alternative as determined by the utilization review Physician. External prosthetic appliances and devices shall include prostheses/prosthetic appliances and devices, orthoses and orthotic devices, braces, and splints.

Prostheses/Prosthetic Appliances and DevicesProstheses/prosthetic appliances and devices are defined as fabricated replacements for missing body parts. Prostheses/prosthetic appliances and devices include, but are not limited to:

● basic limb prostheses;● terminal devices, such as hands or hooks; and● speech prostheses.

Orthoses and Orthotic DevicesOrthoses and orthotic devices are defined as orthopedic appliances or apparatuses used to support, align, prevent or correct deformities. Coverage is provided for custom foot orthoses and other orthoses as follows:

● Non-foot orthoses – only the following non-foot orthoses are covered:o rigid and semi-rigid custom fabricated orthoses,o semi-rigid prefabricated and flexible orthoses; ando rigid prefabricated orthoses, including preparation, fitting and basic additions, such as bars and joints.

● Custom foot orthoses – custom foot orthoses are only covered as follows:o for persons with impaired peripheral sensation and/or altered peripheral circulation (e.g., diabetic neuropathy and

peripheral vascular disease);o when the foot orthosis is an integral part of a leg brace and is necessary for the proper functioning of the brace;o when the foot orthosis is for use as a replacement or substitute for missing parts of the foot (e.g., amputated toes) and is

necessary for the alleviation or correction of Injury, Sickness or congenital defect; ando for persons with neurologic or neuromuscular condition (e.g., cerebral palsy, hemiplegia, spina bifida) producing spasticity,

malalignment, or pathological positioning of the foot, and there is reasonable expectation of improvement.The following are specifically excluded orthoses and orthotic devices:

● prefabricated foot orthoses;● cranial banding and/or cranial orthoses. Other similar devices are excluded, except when used postoperatively for synostotic

plagiocephaly. When used for this indication, the cranial orthosis will be subject to the limitations and maximums of the External Prosthetic Appliances and Devices benefit;

● orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers;● orthoses primarily used for cosmetic rather than functional reasons; and● orthoses primarily for improved athletic performance or sports participation.

BracesA Brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body, and that allows for motion of that part.

The following braces are specifically excluded: Copes scoliosis braces.

61


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

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

● Replacement due to regular wear. Replacement for damage due to abuse or misuse by the person will not be covered.● Replacement will be provided when anatomic change has rendered the external prosthetic appliance or device ineffective.

Anatomic change includes significant weight gain or loss, atrophy and/or growth.

Coverage for replacement is limited as follows:

● No more than once every 24 months for persons 19 years of age and older; and● No more than once every 12 months for persons 18 years of age and under.● Replacement due to a surgical alteration or revision of the site.

The following are specifically excluded external prosthetic appliances and devices:

● External and internal power enhancements or power controls for prosthetic limbs and terminal devices; and● Myoelectric prostheses peripheral nerve stimulators.

Infertility ServicesCharges made for services related to diagnosis of infertility and treatment of infertility once a condition of infertility has been diagnosed. Services include, but are not limited to: infertility drugs that are administered or provided by a Physician, approved surgeries and other therapeutic procedures that have been demonstrated in existing peer-reviewed, evidence-based, scientific literature to have a reasonable likelihood of resulting in pregnancy; laboratory tests; sperm washing or preparation; artificial insemination; diagnostic evaluations; gamete intrafallopian transfer (GIFT); in-vitro fertilization (IVF); zygote intrafallopian transfer (ZIFT); and the services of an embryologist.

Infertility is defined as the inability of opposite sex partners to achieve conception after one year of unprotected intercourse; or the inability of a woman to achieve conception after six trials of artificial insemination over a one-year period. This benefit includes diagnosis and treatment of both male and female infertility.

However, the following are specifically excluded infertility services:

● reversal of male and female voluntary sterilization;● infertility services when the infertility is caused by or related to voluntary sterilization;● donor charges and services;● cryopreservation of donor sperm and eggs; and● any experimental, investigational or unproven infertility procedures or therapies.

Short Term Rehabilitative TherapyShort Term Rehabilitative Therapy that is part of a rehabilitation program, including physical, speech, occupational, cognitive, osteopathic manipulative and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting.

The following limitation applies to Short Term Rehabilitative Therapy: Occupational therapy is provided only for purposes of enabling persons to perform the activities of daily living after an Illness or Injury or Sickness.

Short Term Rehabilitative Therapy services that are not covered include, but are not limited to:

● Sensory integration therapy, group therapy; treatment of dyslexia; behavior modification or myofunctional therapy for dysfluency, such as stuttering or other involuntarily acted conditions without evidence of an underlying medical condition or neurological disorder;

● Treatment for functional articulation disorder such as correction of tongue thrust, lisp, verbal apraxia or swallowing dysfunction that is not based on an underlying diagnosed medical condition or Injury; and

● Maintenance or preventive treatment consisting of routine, long term or non-Medically Necessary care provided to prevent recurrence or to maintain the patient’s current status.

Services that are provided by a chiropractic Physician are not covered. These services include the conservative management of acute neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to restore motion, reduce pain and improve function.

62


Chiropractic Care ServicesCharges made for diagnostic and treatment services utilized in an office setting by chiropractic Physicians. Chiropractic treatment includes the conservative management of acute neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to specific joints to restore motion, reduce pain and improve function. For these services you have direct access to qualified chiropractic Physicians.

The following limitation applies to Chiropractic Care Services: Occupational therapy is provided only for purposes of enabling persons to perform the activities of daily living after an Injury or Sickness.

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

● services of a chiropractor that are not within his scope of practice, as defined by state law;● charges for care not provided in an office setting; and● maintenance or preventive treatment consisting of routine, long term or non-Medically Necessary care provided to prevent

recurrence or to maintain the patient’s current status; and vitamin therapy.

Transplant ServicesCharges made for human organ and tissue Transplant services that include solid organ and bone marrow/stem cell procedures at designated facilities throughout the United States or its territories. This coverage is subject to the following conditions and limitations:

● Transplant services include the recipient’s medical, surgical and Hospital services; inpatient immunosuppressive medications; and costs for organ or bone marrow/stem cell procurement.

● Transplant services are covered only if they are required to perform any of the following human-to-human organ or tissue transplants: allogeneic bone marrow/stem cell, autologous bone marrow/stem cell, cornea, heart, heart/lung, kidney, kidney/pancreas, liver, lung, pancreas or intestine, which includes small bowel-liver or multi-visceral.

● All Transplant services, other than cornea, are covered at 100 percent when received at Cigna LifeSOURCE Transplant Network® facilities.

● Cornea transplants are not covered at Cigna LifeSOURCE Transplant Network® facilities.● Transplant services, including cornea, received at participating facilities specifically contracted with Cigna for those

Transplant services, other than Cigna LifeSOURCE Transplant Network® facilities, are payable at the in-network level. Transplant services received at any other facilities, including non-Participating Providers and Participating Providers not specifically contracted with Cigna for Transplant services, are not covered.

● Coverage for organ procurement costs is limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, Hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. Costs related to the search for, and identification of a bone marrow or stem cell donor for an allogeneic transplant are also covered.

Transplant Travel ServicesCharges made for reasonable travel expenses incurred by you in connection with a preapproved organ/tissue transplant are covered subject to the following conditions and limitations: Transplant travel benefits are not available for cornea transplants. Benefits for transportation, lodging and food are available to you only if you are the recipient of a preapproved organ/tissue transplant from a designated Cigna LifeSOURCE Transplant Network® facility. The term recipient is defined to include a person receiving authorized transplant-related services during any of the following:

● evaluation;● candidacy;● transplant event; or● post-transplant care.

Travel expenses for the person receiving the transplant will include charges for:

● transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility);

● lodging while at, or traveling to and from the transplant site; and● food while at, or traveling to and from the transplant site.

63


In addition to your coverage for the charges associated with the items above, such charges will also be considered covered travel expenses for one companion to accompany you. The term companion includes your Spouse, a member of your family, your legal guardian, or any person not related to you, but actively involved as your caregiver. The following are specifically excluded travel expenses:

● travel costs incurred due to travel within 60 miles of your home;● laundry bills;● telephone bills;● alcohol or tobacco products; and● charges for transportation that exceed coach class rates.

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

Breast Reconstruction and Breast ProsthesesCharges made for reconstructive surgery following a mastectomy; benefits include:

● surgical services for reconstruction of the breast on which surgery was performed;● surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance;● post-operative breast prostheses; and● mastectomy bras and external prosthetics, limited to the lowest-cost alternative available that meets external prosthetic

placement needs.

During all stages of mastectomy, treatment of physical complications, including lymphedema therapy, are covered.

Reconstructive SurgeryCharges made for reconstructive surgery or therapy to repair or correct a severe physical deformity or disfigurement that is accompanied by functional deficit (other than abnormalities of the jaw or conditions related to TMJ disorder), provided that:

● the surgery or therapy restores or improves function;● reconstruction is required as a result of Medically Necessary, non-cosmetic surgery; or● the surgery or therapy is performed prior to age 19 and is required as a result of the congenital absence or agenesis (lack of

formation or development) of a body part.

Repeat or subsequent surgeries for the same condition are covered only when there is the probability of significant additional improvement as determined by the utilization review Physician.

MDLIVE™ ConsultationsMDLIVE offers you a way to access health care when you cannot get to your regular physician and need guidance about diagnosis and treatment. MDLIVE:

● Gives you access to more than 2,000 internal medicine, family practice and pediatric physicians on call throughout the U.S. through online video consultations, phone consultations and email.

● Provides immediate, on-demand 24/7/365 access to affordable, quality non-urgent care through a national network of licensed, board-certified U.S.-based doctors and pediatricians.

Open Access Plus members who use MDLIVE will pay a copay of $25 per consultation. Choice Fund w/HSA members will pay $38 until the deductible is met, then coinsurance.

If you are already enrolled in a Cigna medical plan, you can pre-register with MDLIVE. Visit mdlive.com/westernunion or call 1-888-726-3171, toll free.

http://mdlive.com/westernunion

64

Prescription Drug Benefits and Exclusions 64

Prescription Drug Benefits and Exclusions Covered ExpensesIf you or any one of your Dependents, while insured for Prescription Drug Benefits, incurs expenses for charges made by a Pharmacy, for Medically Necessary Prescription Drug Products ordered by a Physician, Cigna will provide coverage for those expenses as shown in The Schedule. Your benefits may vary depending on which of the Prescription Drug list tiers the Prescription Drug Product is listed or the Pharmacy that provides the Prescription Drug Product. Coverage under your plan’s Prescription Drug Benefits also includes Medically Necessary Prescription Drug Products dispensed pursuant to a prescription Order or Refill issued to you or your Dependents by a licensed Dentist for the prevention of infection or pain in conjunction with a dental procedure.

When you or a Dependent are issued a Prescription Order or Refill for Medically Necessary Prescription Drug Products as part of the rendering of Emergency Services and Cigna determines that it cannot reasonably be filled by a Network Pharmacy, the prescription will be covered by Cigna, as if filled by a Network Pharmacy. Your payment will be based on the Usual and Customary charge submitted by the Non-Network Pharmacy.

Prescription Drug List ManagementThe Prescription Drug List (or formulary) offered under your Employer’s plan is managed by the Cigna Business Decision Team. Your plan’s Prescription Drug List coverage tiers may contain Prescription Drug Products that are Generic Drugs, Brand Drugs or Specialty Prescription Drug Products. The Business Decision Team makes the final assignment of a Prescription Drug Product to a certain coverage tier on the Prescription Drug List and decides whether utilization management requirements or other coverage conditions should apply to a Prescription Drug Product by considering a number of factors including, but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, the P&T Committee’s evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug Product, as well as whether certain supply limits or other utilization management requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug Product’s acquisition cost including, but not limited to, assessments on the cost effectiveness of the Prescription Drug Product and available rebates. When considering a Prescription Drug Product for tier placement on the Prescription Drug List or other coverage conditions, the Business Decision Team reviews clinical and economic factors regarding enrollees as a general population across its book-of-business. Regardless of its eligibility for coverage under the plan, whether a particular Prescription Drug Product is appropriate for you or any of your Dependents is a determination that is made by you or your Dependent and the prescribing Physician.

The coverage status of a Prescription Drug Product may change periodically for various reasons. For example, a Prescription Drug Product may be removed from the market, a New Prescription Drug Product in the same therapeutic class as a Prescription Drug Product may become available, or other market events may occur. Market events that may affect the coverage status of a Prescription Drug Product include, but are not limited to, an increase in the acquisition cost of a Prescription Drug Product. As a result of coverage changes, for the purposes of benefits the plan may require you to pay more or less for that Prescription Drug Product, to obtain the Prescription Drug Product from a certain Pharmacy(ies) for coverage, or try another covered Prescription Drug Product(s). Please access the internet through the website shown on your ID card or call member services at the telephone number on your ID card for the most up-to-date tier status, utilization management, or other coverage limitations for a Prescription Drug Product.

LimitationsIn the event you or your Dependent insist on a more expensive Brand Drug where a Generic Drug is available, you will be financially responsible for the amount by which the cost of the Brand Drug exceeds the cost of the Generic Drug, plus any required Generic Drug Copayment and/or Coinsurance. In this case, the amount by which the cost of the Brand Drug exceeds the cost of the Generic Drug will not apply to your Deductible, if any, or Out of Pocket Maximum. However, in the event your Physician determines that the Generic Drug is not an acceptable alternative for you (and indicates Dispensed as Written on the Prescription Order or Refill), you will only be responsible for payment of the appropriate Brand Drug Coinsurance and/or Copayment after satisfying your Deductible, if any.

Step TherapyCertain Prescription Drug Products are subject to step therapy requirements. This means that in order to receive Benefits for such Prescription Drug Products you are required to try a different Prescription Drug Product(s) first. You may identify whether a particular Prescription Drug Product is subject to step therapy requirements at the website shown on your ID card or by calling member services at the telephone number on your ID card.

65


Supply LimitsBenefits for Prescription Drug Products are subject to the supply limits that are stated in The Schedule. For a single Prescription Order or Refill, you may receive a Prescription Drug Product up to the stated supply limit.

Some products are subject to additional supply limits, quantity limits or dosage limits based on coverage criteria that has been approved based on consideration of the P&T Committee’s clinical findings. Coverage criteria is subject to periodic review and modification. The limit may restrict the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month’s supply, or may require that a minimum amount be dispensed.

You may determine whether a Prescription Drug Product has been assigned a dispensing supply limit or similar limit or requirement at the website shown on your ID card or by calling member services at the telephone number on your ID card.

Specialty Prescription Drug Products Benefits are provided for Specialty Prescription Drug Products. If you require Specialty Prescription Drug Products, you may be directed to a Designated Pharmacy with whom Cigna has an arrangement to provide those Specialty Prescription Drug Products.

Designated PharmaciesIf you require certain Prescription Drug Products, including, but not limited to, Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drug Products. If you are directed to a Designated Pharmacy and you choose not to obtain your Prescription Drug Product from a Designated Pharmacy, you may not receive coverage for the Prescription Drug Product or be subject to the non-Network Pharmacy Benefit, if any, for that Prescription Drug Product. Refer to your Schedule of Benefits for further information.

New Prescription Drug ProductsThe Business Decision Team may or may not place a New Prescription Drug Product on the Prescription Drug List tier upon its market entry. The Business Decision Team will use reasonable efforts to make a tier placement decision for a New Prescription Drug Product within six months of its market availability. The Business Decision Team’s tier placement decision shall be based on consideration of, without limitation, the P&T Committee’s clinical review of the New Prescription Drug Product and economic factors. If a New Prescription Drug Product not listed on the Prescription Drug List is approved by Cigna or its Review Organization as Medically Necessary in the interim, the New Prescription Drug Product shall be covered at the applicable coverage tier as set forth in The Schedule.

Your Payments Covered Prescription Drug Products purchased at a Pharmacy are subject to any applicable Deductible, Copayments or Coinsurance shown in The Schedule. Please refer to The Schedule for any required Copayments, Coinsurance, Deductibles or Out-of-Pocket Maximums.

After satisfying the plan Deductible, if any, your responsibility for a covered Prescription Drug Product will always be the lowest of:

● the Copayment or Coinsurance for the Prescription Drug Product; or ● the Prescription Drug Charge for the Prescription Drug Product; or ● the Pharmacy’s Usual and Customary (U&C) charge for the Prescription Drug Product.

When a treatment regimen contains more than one type of Prescription Drug Products that are packaged together for your or your Dependent’s convenience, any applicable Copayment or Coinsurance may apply to each Prescription Drug Product.

Any Prescription Drug Product not listed on the Prescription Drug List that is not otherwise excluded and Cigna or its Review Organization approves as Medically Necessary shall be covered at the applicable coverage tier as set forth in The Schedule.

The amount you or your Dependent pays for any excluded Prescription Drug Product or other product or service will not be included in calculating any applicable plan Out-of-Pocket Maximum. You are responsible for paying 100% of the cost (the amount the Pharmacy charges you) for any excluded Prescription Drug Product or other product, and any negotiated Prescription Drug Charge will not be available to you.

66


Exclusions and Expenses Not CoveredCoverage exclusions listed under the “Exclusions, Expenses Not Covered and General Limitations” section also apply to benefits for Prescription Drug Products. In addition, the exclusions listed below apply to benefits for Prescription Drug Products. When an exclusion or limitation applies to only certain Prescription Drug Products, you can access the Internet through the website shown on your ID card or call member services at the telephone number on your ID card for information on which Prescription Drug Products are excluded.

● coverage for Prescription Drug Products for the amount dispensed (days’ supply) which exceeds the applicable supply limit, or is less than any applicable supply minimum set forth in The Schedule, or which exceeds quantity limit(s) or dosage limit(s) set by the P&T Committee.

● more than one Prescription Order or Refill for a given prescription supply period for the same Prescription Drug Product prescribed by one or more Physicians and dispensed by one or more Pharmacies.

● Prescription Drug Products dispensed outside the jurisdiction of the United States, except as required for emergency or Urgent Care treatment.

● Prescription Drug Products which are prescribed, dispensed or intended to be taken by or administered to you while you are a patient in a licensed Hospital, Skilled Nursing Facility, rest home, rehabilitation facility, or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceutical products.

● Prescription Drug Products furnished by the local, state or federal government (except for a Network Pharmacy owned or operated by a local, state or federal government).

● Prescription and non-prescription supplies other than supplies covered as Prescription Drug Products.

● vitamins, except prenatal vitamins that require a Prescription Order or Refill, unless coverage for such product(s) is required by federal or state law.

● medications used for cosmetic purposes, including, without limitation, medications used to reduce wrinkles, medications used to promote hair growth, or medications used to control perspiration and fade cream products.

● Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken or destroyed.

● Medical Pharmaceuticals covered solely under the plan’s medical benefits.

● any ingredient(s) in a compounded Prescription Drug Product that has not been approved by the U.S. Food and Drug Administration (FDA).

● medications available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless state or federal law requires coverage of such medications or the over-the-counter medication has been designated as eligible for coverage as if it were a Prescription Drug Product.

● certain Prescription Drug Products that are a Therapeutic Equivalent or Therapeutic Alternative to an over-the-counter drug(s), or are available in over-the-counter form. Such coverage determinations may be made periodically, and benefits for a Prescription Drug Product that was previously excluded under this provision may be reinstated at any time.

● any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of Sickness or Injury, unless coverage for such product(s) is required by federal or state law.

● immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis.

● certain Prescription Drug Products that are a Therapeutic Equivalent or Therapeutic Alternative to another covered Prescription Drug Product(s). Such coverage determinations benefits for a Prescription Drug Product that was previously excluded under this provision may be reinstated at any time.

● medications that are experimental investigational or unproven as described under the “General Exclusion and Limitations” section of your plan’s certificate.

Other limitations are shown in the Medical Plan and Exclusions and Limitations section of your SPD.

67

Medical Plan Exclusions and Limitations 67

Medical Plan Exclusions, Expenses Not Covered and General LimitationsExclusions and Expenses Not Covered Additional coverage limitations determined by plan or provider type are shown in The Schedule. Payment for the followingisspecificallyexcludedfromthisplan:

● care for health conditions that are required by state or local law to be treated in a public facility.● care required by state or federal law to be supplied by a public school system or school district.● care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and

facilities are reasonably available.● treatment of an Injury or Sickness which is due to war, declared, or undeclared, riot or insurrection.● charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed

except that they were covered under this plan. For example, if Cigna determines that a provider or pharmacy is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on The Schedule) without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider or pharmacy represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a non-Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received.

● charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law.

● assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.

● for or in connection with experimental, investigational or unproven services.Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be:

o not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed;

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

o the subject of review or approval by an Institutional Review Board for the proposed use except as provided in the “Clinical Trials” section(s) of this plan; or

o the subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the “Clinical Trials” section(s) of this plan.

In determining whether drug or Biologic therapies are experimental, investigational and unproven, the utilization review Physician may review, without limitation, U.S. Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scientific literature.

● cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem.

● The following services are excluded from coverage regardless of clinical indications: abdominoplasty; panniculectomy; rhinoplasty; blepharoplasty; redundant skin surgery; removal of skin tags; acupressure; craniosacral/cranial therapy; dance therapy, movement therapy; applied kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.

● dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. Charges made for services or supplies provided for or in connection with an accidental Injury to sound natural teeth are covered provided a continuous course of dental treatment is started within six months of an accident. Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.

68


● for medical and surgical services, initial and repeat, intended for the treatment or control of obesity including clinically severe (morbid) obesity, including: medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a Physician or under medical supervision.

● unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required 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 such treatment is prescribed by a Physician and listed as covered in this plan.● any services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of

erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation.● medical and Hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under

this plan.● nonmedical counseling or ancillary services, including but not limited to Custodial Services, education, training, vocational

rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities, autism or intellectual disabilities.

● therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.

● consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the “Home Health Services” or “Breast Reconstruction and Breast Prostheses” sections of this plan.

● private Hospital rooms and/or private duty nursing except as provided under the Home Health Services provision.● personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn

infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness.

● artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets and dentures.

● aids or devices that assist with nonverbal communications, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.

● eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post-cataract surgery).

● routine refractions, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.● all noninjectable prescription drugs, unless Physician administration or oversight is required, injectable prescription drugs

to the extent they do not require Physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in this plan.

● routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular 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 testing method

performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.● dental implants for any condition.● fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation

of scheduled services where in the utilization review Physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

● blood administration for the purpose of general improvement in physical condition.● cost of biologicals that are medications for the purpose of travel, or to protect against occupational hazards and risks.● cosmetics, dietary supplements and health and beauty aids.● all nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism.● medical treatment for a person age 65 or older, who is covered under this plan as a retiree, or their Dependent, when payment

is denied by the Medicare plan because treatment was received from a non-Participating Provider.● medical treatment when payment is denied by a Primary Plan because treatment was received from a non-Participating Provider.

69


● for or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit.● email consultations.● charges for the delivery of health-related services and information via telecommunications technologies, including telephones

and “Skype Like” consultations via personal computers or smart phones, unless provided as specifically described under Covered Services.

● massage therapy.

General LimitationsNo payment will be made for expenses incurred for you or any one of your Dependents: for charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected Injury or Sickness.

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

● to the extent that payment is unlawful where the person resides when the expenses are incurred.● for charges which would not have been made if the person had no insurance.● to the extent that they are more than Maximum Reimbursable Charges.● to the extent of the exclusions imposed by any certification requirement shown in this plan.● expenses for supplies, care, treatment, or surgery that are not Medically Necessary.● charges made by any covered provider who is a member of your or your Dependent’s family.● expenses incurred outside the United States other than expenses for Medically Necessary urgent or emergent care while

temporarily traveling abroad.

70

Coordination of Benefits 70

Coordination of BenefitsThis section applies if you or any one of your Dependents is covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan.

Definitions

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

Plan

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

● Group insurance and/or group-type coverage, whether insured or self-insured, that neither can be purchased by the general public nor is individually underwritten, including closed panel coverage.

● Coverage under Medicare and other governmental benefits as permitted by law, excepting Medicaid and Medicare supplement policies.

● Medical benefits coverage of group, group-type, and individual automobile contracts.● Each Plan or part of a Plan that has the right to coordinate benefits will be considered a separate Plan.

Closed Panel Plan

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

Primary Plan

The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan.

Secondary Plan

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

Allowable Expense

A necessary, reasonable and customary service or expense, including Deductibles, Coinsurance or Copayments, that is covered in full or in part by any Plan covering you. When a Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.

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

● An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense.● If you are confined to a private Hospital room and no Plan provides coverage for more than a semi-private room, the

difference in cost between a private and semi-private room is not an Allowable Expense.● If you are covered by two or more Plans that provide services or supplies on the basis of reasonable and customary fees, any

amount in excess of the highest reasonable and customary fee is not an Allowable Expense.● If you are covered by one Plan that provides services or supplies on the basis of reasonable and customary fees and one

Plan that provides services and supplies on the basis of negotiated fees, the Primary Plan’s fee arrangement shall be the Allowable Expense.

● If your benefits are reduced under the Primary Plan (through the imposition of a higher Copayment amount, higher Coinsurance percentage, a Deductible and/or a penalty) because you did not comply with Plan provisions or because you did not use a preferred provider, the amount of the reduction is not an Allowable Expense. Such Plan provisions include second surgical opinions and precertification of admissions or services.

Claim Determination Period

A calendar year, but does not include any part of a year during which you are not covered under this Policy or any date before this section or any similar provision takes effect.

71


Reasonable Cash Value

An amount that a duly licensed provider of health care services usually charges patients and that is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area where the health care service is rendered under similar or comparable circumstances.

Order of Benefit Determination RulesA Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan. If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use:

● The Plan that covers you as an enrollee or an Employee shall be the Primary Plan and the Plan that covers you as a Dependent shall be the Secondary Plan.

● If you are a Dependent Child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan that covers the parent whose birthday falls first in the calendar year as an enrollee or Employee.

If you are the Dependent of divorced or separated parents, benefits for the Dependent shall be determined in the following order:

1. first, if a court decree states that one parent is responsible for the child’s health care expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge;

2. then, the Plan of the parent with custody of the child;

3. then, the Plan of the Spouse of the parent with custody of the child;

4. then, the Plan of the parent not having custody of the child; and

5. finally, the Plan of the Spouse of the parent not having custody of the child.

The Plan that covers you as an active Employee (or as that Employee’s Dependent) shall be the Primary Plan, and the Plan that covers you as laid-off or retired Employee (or as that Employee’s Dependent) shall be the secondary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.

The Plan that covers you under a right of continuation that is provided by federal or state law shall be the Secondary Plan, and the Plan that covers you as an active Employee or retiree (or as that Employee’s Dependent) shall be the Primary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.

If one of the Plans that covers you is issued out of the state whose laws govern this Policy, and determines the order of benefits based upon the gender of a parent, and as a result, the Plans do not agree on the order of benefit determination, the Plan with the gender rules shall determine the order of benefits.

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

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

Effect on the Benefits of This PlanIf this Plan is the Secondary Plan, this Plan may reduce benefits so that the total benefits paid by all Plans during a Claim Determination Period are not more than 100 percent of the total of all Allowable Expenses.

The difference between the amount that this Plan would have paid if this Plan had been the Primary Plan, and the benefit payments that this Plan had actually paid as the Secondary Plan, will be recorded as a benefit reserve for you. Cigna will use this benefit reserve to pay any Allowable Expense not otherwise paid during the Claim Determination Period.

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

● Cigna’s obligation to provide services and supplies under this Policy;● whether a benefit reserve has been recorded for you; and● whether there are any unpaid Allowable Expenses during the Claims Determination Period.

If there is a benefit reserve, Cigna will use the benefit reserve recorded for you to pay up to 100 percent of the total of all Allowable Expenses. At the end of the Claim Determination Period, your benefit reserve will return to zero and a new benefit reserve will be calculated for each new Claim Determination Period.

72


Recovery of Excess BenefitsIf Cigna pays charges for benefits that should have been paid by the Primary Plan, or if Cigna pays charges in excess of those for which Cigna is obligated to provide under the Policy, Cigna will have the right to recover the actual payment made or the Reasonable Cash Value of any services.

Cigna will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, health care Plan or other organization. If Cigna requests, you must execute and deliver to Cigna such instruments and documents as Cigna determines are necessary to secure the right of recovery.

Right to Receive and Release InformationCigna, without consent or notice to you, may obtain information from and release information to any other Plan with respect to you in order to coordinate your benefits pursuant to this section. You must provide Cigna with any information it requests in 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 under the Primary Plan) is required before the claim will be processed for payment. If no response is received within 90 days of the request, the claim will be denied. If the requested information is subsequently received, the claim will be processed.

73

Medicare Eligible 73

Medicare EligibleCigna will pay as the Secondary Plan as permitted by the Social Security Act of 1965, as amended, for the following:

a. a former Employee who is eligible for Medicare and whose insurance is continued for any reason as provided in this Plan;b. a former Employee’s Dependent, or a former Dependent Spouse, who is eligible for Medicare and whose insurance is

continued for any reason as provided in this Plan;c. an Employee whose Employer and each other Employer participating in the Employer’s Plan have fewer than 100

Employees, and that Employee is eligible for Medicare due to disability;d. the Dependent of an Employee whose Employer and each other Employer participating in the Employer’s Plan have fewer

than 100 Employees, and that Dependent is eligible for Medicare due to disability;e. an Employee or a Dependent of an Employee of an Employer who has fewer than 20 Employees, if that person is eligible

for Medicare due to age;f. an Employee, retired Employee, Employee’s Dependent or retired Employee’s Dependent who is eligible for Medicare

due to End Stage Renal Disease after that person has been eligible for Medicare for 30 months.

Cigna will assume the amount payable under:

● Part A of Medicare for a person who is eligible for that Part without premium payment, but has not applied, to be the amount he or she would receive if he or she had applied.

● Part B of Medicare for a person who is entitled to be enrolled in that Part, but is not, to be the amount he or she would receive if he or she were enrolled.

● Part B of Medicare for a person who has entered into a private contract with a provider, to be the amount he or she would receive in the absence of such private contract.

A person is considered eligible for Medicare on the earliest date any coverage under Medicare could become effective for him.

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

Under federal law, the Medicare Secondary Payer Rules do not apply to Domestic Partners covered under a group health Plan when Medicare coverage is due to age. Therefore, when Medicare coverage is due to age, Medicare is always the Primary Plan for a person covered as a Domestic Partner, and Cigna is the Secondary Plan. However, when Medicare coverage is due to disability, the Medicare Secondary Payer Rules explained above will apply.

74

DPPO – Cigna Dental Preferred Provider Organization Plan 74

DPPO – Cigna Dental Preferred Provider Organization Plan

DPPO – Cigna Dental Preferred Provider Organization Plan – The Schedule


The Dental Benefits Plan offered by your Employer includes Participating and non-Participating Providers. If you select a Participating Provider, your cost will be less than if you select a non-Participating Provider.

Emergency Services

The Benefit Percentage payable for Emergency Services charges made by a non-Participating Provider is the same Benefit Percentage as for Participating Provider Charges. Dental Emergency Services are required immediately to either alleviate pain or to treat the sudden onset of an acute dental condition. These are usually minor procedures performed in response to serious symptoms, which temporarily relieve significant pain, but do not effect a definitive cure, and which, if not rendered, will likely result in a more serious dental or medical complication.

Deductibles

Deductibles are 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 further dental Deductible for the rest of that year.

Participating Provider Payment

Participating Provider services are paid based on the Contracted Fee agreed upon by the provider and Cigna.

Non-Participating Provider Payment

Non-Participating Provider services are paid based on the Maximum Reimbursable Charge. For this Plan, the Maximum Reimbursable Charge is calculated at the 90th percentile of all provider charges in the geographic area.

Simultaneous Accumulation of Amounts

Benefits paid for Participating and non-Participating Provider services will be applied toward both the Participating and non-Participating Provider Maximum shown in The Schedule.

Expenses incurred for either Participating or non-Participating Provider charges will be used to satisfy both the Participating and non-Participating Provider Deductibles shown in The Schedule.

BENEFIT HIGHLIGHTS PARTICIPATING PROVIDER

NON-PARTICIPATING PROVIDER

Classes I, II, III, V and IX, Combined Calendar Year Maximum $2,000

Class IV Lifetime Maximum

(Orthodontia – in-network and out-of-network combined)

$1,500 $1,500


Individual

Family Maximum

$50 per person (not applicable to Class I)

$150 per family (not applicable to Class I)

75


BENEFIT HIGHLIGHTS PARTICIPATING PROVIDER

NON-PARTICIPATING PROVIDER

Class I Services

Preventive and Diagnostic Care 100% 100%

Class II Services

Basic Restorative, Endodontics, Periodontics, Prosthodontic Maintenance and Oral Surgery


Class III Services

Major Restorative, Dentures and Bridgework 60% after Plan Deductible 60% after Plan Deductible

Class IV Services

Orthodontia – applies only to a Dependent Child less than 19 years of age

50% (no deductible) 50% (no deductible)

Class V Services

Temporomandibular Joint Dysfunction (TMJ) 60% after Plan Deductible 60% after Plan Deductible

Class IX Services

Dental Implants 60% after Plan Deductible 60% after Plan Deductible

Covered Dental ExpenseCovered Dental Expense means that a portion of a Dentist’s charge that is payable for a service delivered to a covered person, provided:

● the service is ordered or prescribed by a Dentist;● is essential for the necessary care of teeth;● the service is within the scope of coverage limitations;● the Deductible amount in The Schedule has been met;● the maximum benefit in The Schedule has not been exceeded;● the charge does not exceed the amount allowed under the Alternate Benefit Provision;● for Class I, II or III, the service is started and completed while coverage is in effect.

Alternative Benefit ProvisionIf more than one covered service will treat a dental condition, payment is limited to the least costly service, provided it is a professionally accepted, necessary and appropriate treatment.

If the covered person requests or accepts a more costly covered service, he or she is responsible for expenses that exceed the amount covered for the least costly service. Therefore, Cigna recommends Predetermination of Benefits before major treatment begins.

Predetermination of BenefitsPredetermination of Benefits is a voluntary review of a Dentist’s proposed treatment Plan and expected charges. It is not preauthorization of service and is not required.

The treatment Plan should include supporting preoperative X-rays and other diagnostic materials as requested by Cigna’s dental consultant. If there is a change in the treatment Plan, a revised Plan should be submitted.

Cigna will determine covered dental expenses for the proposed treatment Plan. If there is no Predetermination of Benefits, Cigna will determine covered dental expenses when it receives a claim.

Review of proposed treatment is advised whenever extensive dental work is recommended (when charges exceed $200).

Predetermination of Benefits is not a guarantee of a set payment. Payment is based on the services that are actually delivered and the coverage in force at the time services are completed.

76


Missing Teeth LimitationThere is no payment for replacement of teeth that are missing when a person first becomes insured.

Covered Dental ServicesThe following section lists covered dental services. Cigna may agree to cover expenses for a service not listed. To be considered, the service should be identified using the American Dental Association Uniform Code of Dental Procedures and Nomenclature, or by description and then submitted to Cigna.

Payment for a service delivered by a Participating Provider is the Contracted Fee, times the benefit percentage that applies to the class of service, as specified in The Schedule. The covered person is responsible for the balance of the Contracted Fee.

Payment for a service delivered by a non-Participating Provider is the Maximum Reimbursable Charge times the benefit percentage that applies to the class of service, as specified in The Schedule. The covered person is responsible for the balance of the provider’s actual charge.

Class I Services – Diagnostic and Preventive

● Clinical oral examination – Only two per person per calendar year.● X-rays – Complete series – Only one per person, including panoramic film, in any three calendar years.● Bitewing X-rays – Only two charges per person per calendar year.● Panoramic (Panorex) X-ray – Only one per person in any three calendar years.● Prophylaxis (Cleaning) – Only two per person per calendar year.● Periodontal maintenance procedures (following active therapy), Periodontal Prophylaxis – Only two times per calendar year.● Topical application of fluoride (excluding prophylaxis) – Limited to persons less than 19 years old. Only one per person per

calendar year.● Topical application of sealant, per tooth, on a posterior tooth for a person less than 14 years old – Only one treatment per

tooth in any three calendar years.● Space Maintainers, fixed unilateral – Limited to non-orthodontic treatment.

Class II Services – Basic Restorations, Endodontics, Periodontics, Prosthodontic Maintenance and Oral Surgery

● Amalgam Filling● Composite/Resin Filling● Root Canal Therapy – Any X-ray, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and

not a separate Dental Service.● Osseous Surgery – Flap entry and closure is part of the allowance for osseous surgery and not a separate Dental Service.● Periodontal Scaling and Root Planing – Entire mouth.● Local anesthetic, analgesic and routine postoperative care for extractions and other oral surgery procedures are not separately

reimbursed, but are considered as part of the submitted fee for the global surgical procedure.● General Anesthesia – Paid as a separate benefit only when medically or dentally necessary, as determined by Cigna, and when

administered in conjunction with complex oral surgical procedures that are covered under this Plan.● Sedation – Paid as a separate benefit only when medically or dentally necessary, as determined by Cigna, and when

administered in conjunction with complex oral surgical procedures that are covered under this Plan.● Palliative (emergency) treatment of dental pain, minor procedures, when no other definitive Dental Services are performed.

(Any X-ray taken in connection with such treatment is a separate Dental Service.)

Class III Services – Major Restorations, Dentures and Bridgework

Crowns

Crown restorations are Dental Services only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration.

● Porcelain Fused to High Noble Metal● Full Cast, High Noble Metal● Three-Fourths Cast, Metallic

77


Removable Appliances

● Complete (Full) Dentures, Upper or Lower● Partial Dentures● Lower, Cast Metal Base with Resin Saddles (including any conventional clasps, rests and teeth)● Upper, Cast Metal Base with Resin Saddles (including any conventional clasps rests and teeth)

Fixed Appliances

● Bridge Pontics – Cast High Noble Metal● Bridge Pontics – Porcelain Fused to High Noble Metal● Bridge Pontics – Resin with High Noble Metal● Retainer Crowns – Resin with High Noble Metal● Retainer Crowns – Porcelain Fused to High Noble Metal● Retainer Crowns – Full Cast High Noble Metal● Prosthesis Over Implant – A prosthetic device, supported by an implant or implant abutment is a Covered Expense.

Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the existing prosthesis is at least five calendar years old, is not serviceable and cannot be repaired.

● Adjustments – Complete Denture: Any adjustment of or repair to a denture within six months of its installation is not a separate Dental Service.

● Replacement Bridge● Routine Extractions● Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth

o Removal of Impacted Tooth, Soft Tissueo Removal of Impacted Tooth, Partially Bonyo Removal of Impacted Tooth, Completely Bony

Class IV Services – Orthodontics

Each month of active treatment is a separate Dental Service.

Covered Expenses include:

● Orthodontic work-up, including X-rays, diagnostic casts and treatment Plan and the first month of active treatment, including all active treatment and retention appliances.

● Continued active treatment after the first month.● Fixed or Removable Appliances – Only one appliance per person for tooth guidance or to control harmful habits.

The total amount payable for all expenses incurred for Orthodontics for a Dependent Child less than 19 years of age during his lifetime will not be more than the Orthodontia Maximum shown in The Schedule.

Payments for comprehensive full-banded Orthodontic treatment are made in installments. Benefit payments will be made every three months. The first payment is due when the appliance is installed. Later payments are due at the end of each three-month period. The first installment is 25 percent of the charge for the entire course of treatment. The remainder of the charge is prorated over the estimated duration of treatment. Payments are only made for services provided while such child is insured. If insurance coverage ends or treatment ceases, payment for the last three-month period will be prorated.

Class V Services – Temporomandibular Joint Dysfunction

Only the dental service listed below will be considered covered expenses for the treatment of Temporomandibular Joint Dysfunction:

● Office Visit – Adjustment to Appliance: No more than six adjustments in six consecutive months after seating or placement of appliance.

● Transcutaneous Electro-neural Stimulation: No more than four treatments in a six-month period.● Trigger Point Injection of Local Anesthetic into Muscle Fascia: No more than four treatments in a six-month period.● Mandibular Orthopedic Repositioning Appliance: Only one appliance per person in any five-year period.

78


Class IX Services – Implants

Covered Dental Expenses include:

the surgical placement of the implant body or framework of any type;● any device, index, or surgical template guide used for implant surgery;● prefabricated or custom implant abutments; or● removal of an existing implant. Implant removal is covered only if the implant is not serviceable and cannot be repaired.Implant coverage has a separate Deductible amount, yearly maximum and/or lifetime maximum as shown in The Schedule.

Dental PPO Expenses Not CoveredCovered Expenses will not include, and no payment will be made for:● services performed solely for cosmetic reasons;● replacement of a lost or stolen appliance;● replacement of a bridge, crown or denture within 5 years after the date it was originally installed unless: the replacement

is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits;

● any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards;● procedures, appliances or restorations (except full dentures) whose main purpose is to: change vertical dimension; stabilize

periodontally involved teeth; or restore occlusion;● porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars;● bite registrations; precision or semiprecision attachments; or splinting;● instruction for plaque control, oral hygiene and diet;● dental services that do not meet common dental standards;● services that are deemed to be medical services;● services and supplies received from a Hospital;● services for which benefits are not payable according to the “General Limitations” section.

Dental PPO General LimitationsNo payment will be made for expenses incurred for you or any one of your Dependents:● for or in connection with an Injury arising out of, or in the course of, any employment for wage or profit;● for or in connection with a Sickness which is covered under any workers’ compensation or similar law;● for charges made by a Hospital owned or operated by or which provides care or performs services for, the United States

Government, if such charges are directly related to a military-service-connected condition;● services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;● to the extent that payment is unlawful where the person resides when the expenses are incurred;● for charges which the person is not legally required to pay. For example, if Cigna determines that a provider is or has waived,

reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Schedule) without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received;

● charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law;

● for charges which would not have been made if the person had no insurance;● to the extent that billed charges exceed the rate of reimbursement as described in the Schedule;● for charges for unnecessary care, treatment or surgery;● to the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a

public program, other than Medicaid;● for or in connection with experimental procedures or treatment methods not approved by the American Dental Association or

the appropriate dental specialty society.

79

DHMO – Cigna Dental Health Maintenance Organization Plan 79

DHMO – Cigna Dental Health Maintenance Organization Plan

For You and Your DependentsYou choose a primary care dentist from Cigna’s network to provide dental care, and you pay a discounted fee for covered expenses at the time of service. The discounted fees are listed on your patient charge schedule and you pay no more than the amount listed. Under this plan, any services you receive must be coordinated by your primary care dentist.

Your patient charge schedule is included with your DHMO ID card and also available on WU Life.

If you need specialty dental care, you can obtain a referral from your primary dental provider. If you receive care from an out-of-network dentist, you pay the entire cost out of your own pocket.



N/A N/A

80

Filing Medical and Dental Claims 80

Filing Medical and Dental ClaimsHow to File Your ClaimThe prompt filing of any required claim form will result in faster payment of your claim.

You may get the required claim forms from your Benefit Plan Administrator. All fully completed claim forms and bills should be sent directly to your servicing Cigna Claim Office.

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

Hospital ConfinementIf possible, get your Group Medical Insurance claim form before you are admitted to the Hospital. This form will make your admission easier and any cash deposit usually required will be waived.

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

Doctor’s Bills and Other Medical ExpensesThe first Medical Claim should be filed as soon as you have incurred covered expenses. Itemized copies of your bills should be sent with the claim form. If you have any additional bills after the first treatment, file them periodically.

Claim Reminders● BesuretouseyourMemberIDandaccountnumberwhenyoufileCigna’sclaimforms,orwhenyoucallyour

Cignaclaimoffice.o YourMemberIDistheIDshownonyourbenefitidentificationcard.o Youraccountnumberistheseven-digitpolicynumbershownonyourbenefitidentificationcard.

● Promptfilingofanyrequiredclaimformsresultsinfasterpaymentofyourclaims.

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

Timely Filing of Out-of-Network ClaimsCigna will consider claims for coverage under Cigna’s Plans when proof of loss (a claim) is submitted within 180 days for Out-of-Network benefits after services are rendered. If services are rendered on consecutive days, such as for a Hospital Confinement, the limit will be counted from the last date of service. If claims are not submitted within 180 days for Out-of-Network benefits, the claim will not be considered valid and will be denied.

Expenses for Which a Third Party May Be ResponsibleThis Plan does not cover:

● Expenses incurred by you or your Dependent (hereinafter individually and collectively referred to as a “Participant,”) for which another party may be responsible as a result of having caused or contributed to an Injury or Sickness.

● Expenses incurred by a Participant to the extent any payment is received for them either directly or indirectly from a third party tortfeasor or as a result of a settlement, judgment or arbitration award in connection with any automobile medical, automobile no-fault, uninsured or underinsured motorist, homeowners, workers’ compensation, government insurance (other than Medicaid) or similar type of insurance or coverage.

Subrogation/Right of ReimbursementIf a Participant incurs a Covered Expense for which, in the opinion of the Plan or its claim Administrator, another party may be responsible, or for which the Participant may receive payment as described above:

● Subrogation: The Plan shall, to the extent permitted by law, be subrogated to all rights, claims or interests that a Participant may have against such party and shall automatically have a lien upon the proceeds of any recovery by a Participant from such party to the extent of any benefits paid under the Plan. A Participant or his/her representative shall execute such documents as may be required to secure the Plan’s subrogation rights.

● Right of Reimbursement: The Plan is also granted a right of reimbursement from the proceeds of any recovery whether by settlement, judgment or otherwise. This right of reimbursement is cumulative with and not exclusive of the subrogation right granted in paragraph 1, but only to the extent of the benefits provided by the Plan.

81

Filing Medical and Dental Claims 81

Lien of the PlanBy accepting benefits under this Plan, a Participant:● grants a lien and assigns to the Plan an amount equal to the benefits paid under the Plan against any recovery made by or on

behalf of the Participant, which is binding on any attorney or other party who represents the Participant whether or not an agent of the Participant or of any insurance company or other financially responsible party against whom a Participant may have a claim, provided said attorney, insurance carrier or other party has been notified by the Plan or its agents;

● agrees that this lien shall constitute a charge against the proceeds of any recovery, and the Plan shall be entitled to assert a security interest thereon; and

● agrees to hold the proceeds of any recovery in trust for the benefit of the Plan to the extent of any payment made by the Plan.

Additional Terms● No adult Participant hereunder may assign any rights that it may have to recover medical expenses from any third party or

other person or entity to any minor Dependent of said adult Participant without the prior express written consent of the Plan. The Plan’s right to recover shall apply to decedents’, minors’, and incompetent or disabled persons’ settlements or recoveries.

● No Participant shall make any settlement that specifically reduces or excludes, or attempts to reduce or exclude, the benefits provided by the Plan.

● The Plan’s right of recovery shall be a prior lien against any proceeds recovered by the Participant. This right of recovery shall not be defeated nor reduced by the application of any so-called “Made-Whole Doctrine,” “Rimes Doctrine” or any other such doctrine purporting to defeat the Plan’s recovery rights by allocating the proceeds exclusively to non-medical expense damages.

● No Participant hereunder shall incur any expenses on behalf of the Plan in pursuit of the Plan’s rights hereunder:o Specifically: No court costs, attorneys’ fees or other representatives’ fees may be deducted from the Plan’s recovery without

the prior express written consent of the Plan.o This right shall not be defeated by any so-called “Fund Doctrine,” “Common Fund Doctrine” or “Attorney’s Fund Doctrine.”

● The Plan shall recover the full amount of benefits provided hereunder without regard to any claim of fault on the part of any Participant, whether under comparative negligence or otherwise.

● In the event that a Participant shall fail or refuse to honor its obligations hereunder, then the Plan shall be entitled to recover any costs incurred in enforcing the terms hereof including, but not limited to, attorney’s fees, litigation, court costs and other expenses. The Plan shall also be entitled to offset the reimbursement obligation against any entitlement to future medical benefits hereunder until the Participant has fully complied with his reimbursement obligations hereunder, regardless of how those future medical benefits are incurred.

● Any reference to state law in any other provision of this Plan shall not be applicable to this provision, if the Plan is governed by ERISA.

● By acceptance of benefits under the Plan, the Participant agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist.

● Further, the Plan shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the Plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief.

● It is a Participant’s duty to notify the Plan within 10 days of the date when any notice is given to any party, including an insurance company or attorney, of the Participant’s intention to pursue or investigate a claim to recover damages or obtain compensation due to such Participant’s injury, illness or condition. A Participant and such Participant’s agents agree to provide the Plan or its representatives notice of any recovery the Participant or the Participant’s agents obtain prior to receipt of such recovery funds or within 5 days if no notice was given prior to receipt. Further, a Participant and such Participant’s agents agree to provide notice prior to any disbursement of settlement or any other recovery funds obtained.

● If a Participant hereunder fails to pursue any right to recovery, the Participant agrees to execute an assignment of rights, assigning the Participant’s right to the Plan so the Plan can pursue an action or claim.

● A Participant hereunder will fully cooperate with the Plan’s efforts to recover the amounts the Plan has paid to the Participant by providing information requested by the Plan and executing documents as the Plan may require to facilitate enforcement of its subrogation or reimbursement rights.

● A Participant hereunder will do nothing to harm the Plan’s subrogation or reimbursement rights or harm the Plan’s ability to enforce the terms of these subrogation or reimbursement provisions.

● By acceptance of benefits under the Plan, the Participant agrees that if the Participant fails to follow his or her obligations under the Plan, the Plan will have no obligation to pay any benefits incurred by the Participant. In the Plan’s discretion, the Participant’s failure may result in a forfeiture of payment by the Plan of future benefits, and any funds or benefits otherwise payable under the Plan to the Participant may be withheld until the Participant satisfies his or her obligations to the Plan.

82

Payment of Benefits 82

Payment of BenefitsTo Whom PayableAll Medical and Dental Benefits are payable to you. However, at the option of Cigna, all or any part of them may be paid directly to the person or institution on whose charge claim is based.

Medical Benefits are not assignable unless agreed to by Cigna. Cigna may, at its option, make payment to you for the cost of any Covered Expenses received by you or your Dependent from a non-Participating Provider even if benefits have been assigned. When benefits are paid to you or your Dependent, you or your Dependent is responsible for reimbursing the Provider. If any person to whom benefits are payable is a minor or, in the opinion of Cigna, is not able to give a valid receipt for any payment due him, such payment will be made to his legal guardian. If no request for payment has been made by his legal guardian, Cigna may, at its option, make payment to the person or institution appearing to have assumed his custody and support.

If you die while any of these benefits remain unpaid, Cigna may choose to make direct payment to any of your following living relatives: spouse, mother, father, child or children, brothers or sisters; or to the executors or Administrators of your estate.

Payment as described above will release Cigna from all liability to the extent of any payment made.

Time of PaymentBenefits will be paid by Cigna when it receives due proof of loss.

Recovery of OverpaymentWhen an overpayment has been made by Cigna, Cigna will have the right, at any time, to:

● recover that overpayment from the person to whom or on whose behalf it was made; or● offset the amount of that overpayment from a future claim payment.

If the plan makes an overpayment (including a full payment if the full payment should not have been made under the terms of the plan), an equitable lien will be created on that overpayment and the overpayment will be held in trust for the benefit of the plan. The lien will remain in effect until the plan is repaid in full.

Calculation of Covered ExpensesCigna, in its discretion, will calculate Covered Expenses following evaluation and validation of all provider billings in accordance with the methodologies:

● in the most recent edition of the Current Procedural terminology.● as reported by generally recognized professionals or publications.

MiscellaneousIf you are a Cigna Dental Plan member, you may be eligible for additional dental benefits during certain episodes of care. For example, certain frequency limitations for dental services may be relaxed for pregnant women, diabetics or those with cardiac disease. Please review your Plan enrollment materials for details.

83

Medical Benefits Extension 83

Medical Benefits ExtensionDuring Hospital ConfinementIf the Medical Benefits under this Plan cease for you or your Dependent, and you or your Dependent is confined in a Hospital on that date, Medical Benefits will be paid for Covered Expenses incurred in connection with that Hospital Confinement. However, no benefits will be paid after the earliest of:

● the date you exceed the Maximum Benefit, if any, shown in The Schedule;● the date you are covered for medical benefits under another group Plan;● the date you or your Dependent is no longer Hospital Confined; or● three months from the date your Medical Benefits cease.

The terms of this Medical Benefits Extension will not apply to a child born as a result of a pregnancy that exists when your Medical Benefits cease or your Dependent’s Medical Benefits cease.

Claim Determination Procedures Under ERISAThe following complies with federal law. Provisions of the laws of your state may supersede.

Procedures Regarding Medical Necessity DeterminationsIn general, health services and benefits must be Medically Necessary to be covered under the Plan. The procedures for determining Medical Necessity vary, according to the type of service or benefit requested, and the type of health Plan. Medical Necessity determinations are made on either a pre-service, concurrent, or post-service basis, as described below:

● Certain services require prior authorization in order to be covered. This prior authorization is called a “pre-service Medical Necessity determination.” The Certificate describes who is responsible for obtaining this review. You or your authorized representative (typically, your health care provider) must request Medical Necessity determinations according to the procedures described below, in the Certificate, and in your provider’s network participation documents as applicable.

● When services or benefits are determined to be not Medically Necessary, you or your representative will receive a written description of the adverse determination, and may appeal the determination. Appeal procedures are described in the Certificate, in your provider’s network participation documents, and in the determination notices.

Pre-service Medical Necessity DeterminationsWhen you or your representative request a required Medical Necessity determination prior to care, Cigna will notify you or your representative of the determination within 15 days after receiving the request. However, if more time is needed due to matters beyond Cigna’s control, Cigna will notify you or your representative within 15 days after receiving your request. This notice will include the date a determination can be expected, which will be no more than 30 days after receipt of the request. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information to Cigna within 45 days after receiving the notice. The determination period will be suspended on the date Cigna sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice.

If the determination periods above would seriously jeopardize your life or health, your ability to regain maximum function, or in the opinion of a Physician with knowledge of your health condition, cause you severe pain that cannot be managed without the requested services, Cigna will make the pre-service determination on an expedited basis. Cigna’s Physician reviewer, in consultation with the treating Physician, will decide if an expedited determination is necessary. Cigna will notify you or your representative of an expedited determination within 72 hours after receiving the request.

However, if necessary information is missing from the request, Cigna will notify you or your representative within 24 hours after receiving the request to specify what information is needed. You or your representative must provide the specified information to Cigna within 48 hours after receiving the notice. Cigna will notify you or your representative of the expedited benefit determination within 48 hours after you or your representative responds to the notice. Expedited determinations may be provided orally, followed within three days by written or electronic notification.

If you or your representative fails to follow Cigna’s procedures for requesting a required pre-service Medical Necessity determination, Cigna will notify you or your representative of the failure and describe the proper procedures for filing within five days (or 24 hours, if an expedited determination is required, as described above) after receiving the request. This notice may be provided orally, unless you or your representative requests written notification.

84


Concurrent Medical Necessity DeterminationsWhen an ongoing course of treatment has been approved for you and you wish to extend the approval, you or your representative must request a required concurrent Medical Necessity determination at least 24 hours prior to the expiration of the approved period of time or number of treatments. When you or your representative requests such a determination, Cigna will notify you or your representative of the determination within 24 hours after receiving the request.

Post-service Medical Necessity DeterminationsWhen you or your representative requests a Medical Necessity determination after services have been rendered, Cigna will notify you or your representative of the determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond Cigna’s control, Cigna will notify you or your representative within 30 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 45 days after receipt of the request.

If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information to Cigna within 45 days after receiving the notice. The determination period will be suspended on the date Cigna sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice.

Post-service Claim DeterminationsWhen you or your representative requests payment for services that have been rendered, Cigna will notify you of the claim payment determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond Cigna’s control, Cigna will notify you or your representative within 30 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 45 days after receipt of the request. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information within 45 days after receiving the notice. The determination period will be suspended on the date Cigna sends such a notice of missing information, and resume on the date you or your representative responds to the notice.

Notice of Adverse DeterminationEvery notice of an adverse benefit determination will be provided in writing or electronically, and will include all of the following that pertain to the determination: information sufficient to identify the claim; the specific reason or reasons for the adverse determination; reference to the specific Plan provisions on which the determination is based; a description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary; a description of the Plan’s review procedures and the time limits applicable, including a statement of a claimant’s rights to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on appeal; upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your claim; and an explanation of the scientific or clinical judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar exclusion or limit; information about any office of health insurance consumer assistance or ombudsman available to assist you with the appeal process; and in the case of a claim involving urgent care, a description of the expedited review process applicable to such claim.

When You Have a Complaint or an AppealFor the purposes of this section, any reference to “you” or “your” also refers to a representative or provider designated by you to act on your behalf; unless otherwise noted.

We want you to be completely satisfied with the care you receive. That is why Cigna has established a process for addressing your concerns and solving your problems.

Start With Customer Service

We are here to listen and help. If you have a concern regarding a person, a service, the quality of care, contractual benefits, or a rescission of coverage, you may call the toll-free number on your ID card, explanation of benefits, or claim form and explain your concern to one of Cigna’s Customer Service representatives. You may also express that concern in writing.

Cigna will do its best to resolve the matter on your initial contact. If Cigna needs more time to review or investigate your concern, Cigna will get back to you as soon as possible, but in any case within 30 days. If you are not satisfied with the results of a coverage decision, you may start the appeals procedure.

85


Internal Appeals Procedure

To initiate an appeal, you must submit a request for an appeal in writing to Cigna within 180 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask Cigna to register your appeal by telephone. Call or write Cigna at the toll-free number on your ID card, explanation of benefits, or claim form.

Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving Medical Necessity or clinical appropriateness will be considered by a health care professional.

Cigna will respond in writing with a decision within 30 calendar days after Cigna receives an appeal for a required pre-service or concurrent care coverage determination or a post-service Medical Necessity determination. Cigna will respond within 60 calendar days after Cigna receives an appeal for any other post-service coverage determination. If more time or information is needed to make the determination, Cigna will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review.

In the event any new or additional information (evidence) is considered, relied upon or generated by Cigna in connection with the appeal, Cigna will provide this information to you as soon as possible and sufficiently in advance of the decision, so that you will have an opportunity to respond. Also, if any new or additional rationale is considered by Cigna, Cigna will provide the rationale to you as soon as possible and sufficiently in advance of the decision so that you will have an opportunity to respond.

You may request that the appeal process be expedited if:

(a) the time frames under this process would seriously jeopardize your life, health or ability to regain maximum functionality or in the opinion of your Physician would cause you severe pain which cannot be managed without the requested services; or

(b) your appeal involves non-authorization of an admission or continuing inpatient Hospital stay.If you request that your appeal be expedited based on (a) above, you may also ask for an expedited external review at the same time, if the time to complete an expedited review would be detrimental to your medical condition. When an appeal is expedited, Cigna will respond orally with a decision within 72 hours, followed up in writing.

External Review Procedure

If you are not fully satisfied with the decision of Cigna’s internal appeal review and the appeal involves medical judgment or a rescission of coverage, you may request that your appeal be referred to an Independent Review Organization (IRO). The IRO is composed of persons who are not employed by Cigna, or any of its affiliates. A decision to request an external review to an IRO will not affect the claimant’s rights to any other benefits under the plan.

There is no charge for you to initiate an external review. Cigna and your benefit plan will abide by the decision of the IRO.

To request a review, you must notify the Appeals Coordinator within 4 months of your receipt of Cigna’s appeal review denial. Cigna will then forward the file to a randomly selected IRO. The IRO will render an opinion within 45 days.

When requested, and if a delay would be detrimental to your medical condition, as determined by Cigna’s Physician reviewer, or if your appeal concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but you have not yet been discharged from a facility, the external review shall be completed within 72 hours.

NoticeofBenefitDeterminationonAppeal

Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse determination, will include: information sufficient to identify the claim; the specific reason or reasons for the adverse determination; reference to the specific plan provisions on which the determination is based; a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other Relevant Information as defined below; a statement describing any voluntary appeal procedures offered by the plan and the claimant’s right to bring an action under ERISA section 502(a), if applicable; upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar exclusion or limit; and information about any office of health insurance consumer assistance or ombudsman available to assist you in the appeal process. A final notice of an adverse determination will include a discussion of the decision.

You also have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the decision on review. You or your plan may have other voluntary alternative dispute resolution options such as Mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your State insurance regulatory agency. You may also contact the Plan Administrator.

86


Relevant Information

Relevant information is any document, record or other information which: was relied upon in making the benefit determination; was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination; or constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

Legal Action

If your plan is governed by ERISA, you have the right to bring a civil action under section 502(a) of ERISA if you are not satisfied with the outcome of the Appeals Procedure. In most instances, you may not initiate a legal action against Cigna until you have completed the appeal processes.

87

Employee Assistance Program 87

Employee Assistance ProgramThe Employee Assistance Program (EAP) helps you deal with a wide range of life issues with a focus on work, family and wellness. There’s no charge to you for this service. Cigna Employee Assistance Program is the EAP vendor selected to administer EAP services. The EAP also provides you and your eligible dependents with work/life services and resources.

You and your eligible dependents have access to trained professional counselors over the telephone 24 hours per day, 7 days per week. Eligible dependents are defined as your household members living together in the same household.

Counselors provide confidential support to help you handle both small problems and major issues in your life.

The EAP provides confidential counseling related to the following situations:

● family problems● relationship problems● emotional concerns● alcohol/drug problems

The EAP provides work/life services and resources, which include but are not limited to:

● Dependent care resources and referral● Family planning (for example, adoption assistance and parenting)● Elder/adult care referrals● Education assistance (colleges and universities)

How the EAP WorksFor advice or counseling, call the EAP and speak to an EAP counselor. The counselor evaluates the situation with you and recommends a course of action. Recommendations can include:

● On-the-phone discussion with an EAP counselor● A series of one-on-one counseling sessions with an EAP counselor

The EAP counselor will tell you how many counseling sessions are available to you at no cost to you. You and your eligible dependents may speak with an EAP counselor over the telephone as often as needed. You and your eligible dependents are able to receive up to 5 in-person EAP counseling visits per issue per year.

If you’re eligible for one-on-one counseling, you need to consider whether to seek additional assistance outside the EAP when you reach the benefit limit. If you seek assistance outside the EAP, you pay the cost for additional counseling on your own; you should consider obtaining covered services through the medical plan.

Your choice to use the services under the EAP is entirely voluntary. Employment or advancement at Western Union is not affected by your decision to use, or not to use, the services offered by the program.

Your discussions with the EAP counselors are completely confidential. No one, other than the program personnel and other professionals you see upon the recommendation of a counselor, will know when you contact the program or an outside professional unless you choose to tell someone, you give written permission to release information, or if the service provider is required by law to release the information.

Continuation Under COBRAIf you or your eligible dependents lose coverage in certain circumstances, you or your dependents may be able to purchase a temporary extension of EAP coverage at group rates (COBRA premium rate) through COBRA.

Treatment Not Covered by the EAPThe medical treatment of a condition isn’t included under EAP coverage. However, the counseling related to you or your dependent’s ability to handle a situation is covered by the EAP.

How to Use the EAPCall Cigna Employee Assistance Program at 1-877-622-4327.

For online tools and resources on a wide variety of subjects, visit cignabehavioral.com (Company ID “westernunion”).

http://cignabehavioral.com

88

Cigna Global Health Benefits Plan 88

Cigna Global Health Benefits PlanWestern Union has partnered with Cigna Global Health Benefits (CGHB) to provide expatriates (domestic employees on short term work assignments outside of the U.S.) and Third Country Nationals (TCNs) and other employees whom Western Union advises with a global health care plan that provides quality health care, timely reimbursements and CGHB’s 24-hour free telephone and fax services to its International Services Center, as well as secure email communications through cignaenvoy.com to help you use and understand your global benefits. The CGHB International Service Centers can provide multilingual expert advice and professional support, or connect you with a doctor.

The CGHB global health care benefits program provides coverage outside the U.S. and offers a PPO (Preferred Provider) plan for medical services received inside the U.S. This means you can use any provider of your choice whenever you receive medical care; however, you are able to take advantage of network discounts when using a Cigna network PPO provider when inside the U.S. The Cigna Global Health Benefits Plan is a bundled medical, dental and vision benefit plan. You have unlimited provider choice for dental and vision services. The schedule for Comprehensive Medical, Prescription Drugs and Dental benefits are listed below. For more detailed information, please see the certificate for the CGHB program.

EnrollmentShould you become eligible for the Cigna Global Health Benefits Plan due to an applicable work assignment, Western Union will coordinate enrollment of you and your family members into the CGHB plan.

How to Contact CGHB● Secure website – cignaenvoy.com (requires your password issued upon enrollment for personal registration)● Toll-free telephone number:1-800-441-2668 (if dialing internationally use your country’s AT&T USADirect access number)● Toll-free TDD telephone number for hearing impaired: 1-800-558-3604● Direct telephone number: 1-302-797-3100● Toll-free facsimile number: 1-800-243-6998● Direct facsimile number: 001-302-797-3150Cigna Global Health Benefits International Service Centers are open 24 hours a day, 7 days a week, 365 days a year.



89


CGHB Preferred Provider Medical Benefits – The Schedule


Preferred Provider Medical Benefits provide coverage for care in the United States (In & Out-of-Network) and International. To receive Preferred Provider Medical Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for services and supplies. That portion is the Deductible or Coinsurance.

Coinsurance

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

Deductibles

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

Out-of-Pocket Expenses

Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan. The following Expenses contribute to the Out-of-Pocket Maximum, and when the Out-of-Pocket Maximum shown in The Schedule is reached, they are payable by the benefit plan at 100%:

● Coinsurance.● Plan Deductible.

Once the Out-of-Pocket Maximum is reached for covered services that apply to the Out-of-Pocket Maximum, any benefit deductibles are no longer required.

The following Out-of-Pocket Expenses and charges do not contribute to the Out-of-Pocket Maximum, and they are not payable by the benefit plan at 100% when the Out-of-Pocket Maximum shown in The Schedule is reached:

● 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 cross-accumulate between U.S. In-Network, U.S. Out-of-Network and International. All other plan maximums and service-specific maximums (dollar and occurrence) will also cross-accumulate.

Multiple Surgical Reduction

Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. 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 as specified in Cigna Reimbursement Policies.

Co-Surgeon

The maximum amount payable will be limited to charges made by co-surgeons as specified in Cigna Reimbursement Policies.

90


BENEFIT HIGHLIGHTS INTERNATIONAL U.S. IN-NETWORK

U.S. OUT-OF-NETWORK

Lifetime Maximum Unlimited Unlimited Unlimited

EmergencyEvacuationorRepatriationBenefits 100% 100% 100% not subject to plan deductible

The Percentage of Covered Expenses the Plan Pays 90% 90% 80% of the Maximum Reimbursable Charge


Maximum Reimbursable Charge is determined based on:

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

● a percentile of charges made by providers of such service or supply in the geographic area where the service is received. These charges are compiled in a database Cigna has selected.

Note: The provider may bill you for the difference between the provider’s normal charge and the Maximum Reimbursable Charge, in addition to applicable deductibles and coinsurance.

U.S. Claims Only Not Applicable 80th Percentile


Individual

Family Maximum

Notes:

● Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance.

● If the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance.

$0 per person

$0 per family

$0 per person

$0 per family

$250 per person

$500 per family

Combined Medical/Pharmacy Calendar Year Deductible

Combined Medical/Pharmacy Deductible: includes retail and home delivery prescription drugs

No

No

Yes

91



U.S. OUT-OF-NETWORK


Individual

Family Maximum

Notes:

● Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%.

● If the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%.

$1,000 per person

$2,000 per family

$1,000 per person

$2,000 per family

$2,000 per person

$4,000 per family

Combined Medical/Pharmacy Out-of-Pocket Maximum

Combined Medical/Pharmacy Out-of-Pocket: includes retail and home delivery prescription drugs

Yes No Yes


Physician’s Office visit


Second Opinion Consultations (provided on a voluntary basis)

Allergy Treatment/Injections

Allergy Serum (dispensed by the Physician in the office)

90%

90%

90%

90%

90%

90%

90%

90%

90%

90%

80% after plan deductible





Preventive Care


Immunizations – all ages

100%

100%

100%

100%

100% (not subject to plan deductible)


Travel Immunizations

For Employees and Dependents

100% 100% 100% (not subject to plan deductible)

PrescriptionDrugBenefit

Purchased outside the United States

90% Refer to the Prescription Drug Benefits Schedule

Refer to the Prescription Drug Benefits Schedule

Mammograms, PSA, PAP Smear and Colorectal Cancer Screenings


92



U.S. OUT-OF-NETWORK

Lead Poisoning Screening Tests

For Children under age 6


Inpatient Hospital – Facility Services

Semi-Private Room and Board

Private Room


90%


Limited to the semi-private room rate (Private Room covered outside the U.S. only if no semi-private room equivalent is available)


90%








Outpatient Facility Services

Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room

90% 90% 80% after plan deductible

Inpatient Hospital Physician’s Visits/Consultations


Inpatient Hospital Professional Services

● Surgeon● Radiologist● Pathologist● Anesthesiologist


Outpatient Professional Services

● Surgeon● Radiologist● Pathologist● Anesthesiologist


93



U.S. OUT-OF-NETWORK

Emergency and Urgent Care Services



Outpatient Professional services (radiology, pathology and ER Physician)

Urgent Care Facility

X-ray and/or Lab performed at the Emergency Room/ Urgent Care Facility (billed by the facility as part of the ER/UC visit)



Ambulance

90%

90%

90%

90%

90%

90%

90%

90%

90%

90%

90%

90%

90%

90%

90%

100%

90% (except if not true emergency, then 70% after plan deductible)










Calendar Year Maximum: 120 days combined


Laboratory and Radiology Services (includes pre-admission testing)

Physician’s Office Visit Outpatient Hospital Facility Independent X-ray and/or Lab Facility

90% 90% 90%

90% 90% 90%

80% after plan deductible 80% after plan deductible 80% after plan deductible


Physician’s Office Visit Inpatient Facility Outpatient Facility

90% 90% 90%

90% 90% 90%


94



U.S. OUT-OF-NETWORK


Calendar Year Maximum: 60 days for all therapies combined

Includes:

● Cardiac Rehab● Physical Therapy● Speech Therapy● Occupational Therapy● Pulmonary Rehab● Cognitive TherapyNote: The Short Term Rehabilitative Therapy maximum does not apply to the treatment of autism.


Chiropractic Care



90%

90%


Alternative Therapies and Non-traditional Medical Services (Outside the United States)

Herbalist, Massage Therapist, Naturopath

Calendar Year Maximum: $1,000

90% Not covered Not covered

Acupuncture 90% 90% 80% after plan deductible

Home Health Care

Calendar Year Maximum:

120 days (includes outpatient private nursing when approved as medically necessary)


Hospice

Inpatient Services

Outpatient Services (same coinsurance level as Home Health Care)

90%

90%

90%

90%



Bereavement Counseling

Services provided as part of: Hospice Care

Inpatient

Outpatient


90%

90%


90%

90%





95


BENEFIT HIGHLIGHTS INTERNATIONAL U.S. IN-NETWORK U.S. OUT-OF-NETWORK





Delivery – Facility (Inpatient Hospital, Birthing Center)

90%

90%

90%

90%

90%

90%

90%

90%





Abortion



90% 90% 90% 90%

90% 90% 90% 90%

80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible


Office Visits and Counseling

Lab and Radiology Tests

Note: Includes coverage for contraceptive devices (e.g., Depo-Provera and Intrauterine Devices (IUDs) as ordered or prescribed by a physician. Diaphragms also are covered when services are provided in the physician’s office.

Surgical Sterilization Procedures for Tubal Ligation (excludes reversals)


100%

100%

100% 100% 100% 100%

100%

100%

100% 100% 100% 100%



100% (not subject to plan deductible) 100% (not subject to plan deductible) 100% (not subject to plan deductible) 100% (not subject to plan deductible)

96


BENEFIT HIGHLIGHTS INTERNATIONAL U.S. IN-NETWORK U.S. OUT-OF-NETWORK


Office Visits and Counseling

Lab and Radiology Tests Surgical Sterilization

Procedures for Vasectomy (excludes reversals)


90%

90%

90% 90% 90% 90%

90%

90%

90% 90% 90% 90%





Services Not Covered include:

● Testing performed specifically to determine the cause of infertility.

● Treatment and/or procedures performed specifically to restore fertility (e.g., procedures to correct an infertility condition).

● Artificial means of becoming pregnant (e.g., Artificial Insemination, In-vitro, GIFT, ZIFT, etc.).

Note: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness.

Not Covered Not Covered Not Covered

Organ Transplants

Includes all medically appropriate, non-experimental transplants

Physician’s Office Visit Inpatient Facility Physician’s Services


90% 90% 90%

U.S. In-Network Coverage Only

90% 90% 90%

No Charge (only available when using Cigna LifeSOURCE facility)


Not Covered U.S. In-Network Coverage Only

Durable Medical Equipment 90% 90% 80% after plan deductible

External Prosthetic Appliances 90% 90% 80% after plan deductible

Diabetic Equipment 90% 90% 80% after plan deductible

97



U.S. OUT-OF-NETWORK

TMJ Treatment

Benefit Lifetime Maximum: $1,000


HearingBenefit

One examination per 24-month period


Hearing Aid Maximum

Up to $1,000 per hearing aid unit necessary for each hearing impaired ear every 3 years for a dependent child under age 24.


Wigs (for hair loss due to alopecia areata)

Calendar Year Maximum: $500



Calendar Year Maximum: 3 visits per person; however, the 3-visit limit will not apply to treatment of diabetes.


90% 90% 90% 90%

90% 90% 90% 90%


Nutritional Formulas 90% 90% 80% after plan deductible

Dental Care



90% 90% 90% 90%

90% 90% 90% 90%


98



U.S. OUT-OF-NETWORK

Obesity/Bariatric Surgery

Note: Coverage is provided subject to medical necessity and clinical guidelines subject to any limitations shown in the “Exclusions, Expenses Not Covered and General Limitations” section of this certificate. Contact Cigna prior to incurring such costs.


Lifetime Maximum: $10,000 – Applies to surgical procedure

90% 90% 90% 90%

90% 90% 90% 90%


Routine Foot Disorders

Not covered except for services associated with foot care for diabetes and 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 expense until the medical condition is stabilized. 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 be determined by the utilization review Physician in accordance with the applicable mixed services claim guidelines.

Mental Health

Inpatient Facility

Outpatient (Includes Individual, Group and Intensive Outpatient):

Physician’s Office Visit Outpatient Facility

90%

90% 90%

90%

90% 90%


80% after plan deductible 80% after plan deductible

Substance Abuse

Inpatient Facility

Outpatient (Includes Individual and Intensive Outpatient):

Physician’s Office Visit Outpatient Facility

90%

90% 90%

90%

90% 90%


80% after plan deductible 80% after plan deductible

99

Cigna Global Health Benefits Plan Preferred Provider Medical Benefits 99

Cigna Global Health Benefits Plan Preferred Provider Medical BenefitsCertification Requirements – U.S. Out-of-Network


Pre-AdmissionCertification/ContinuedStayReviewforHospitalConfinement

Pre-Admission Certification (PAC) and Continued Stay Review (CSR) refer to the process used to certify the Medical Necessity and length of a Hospital Confinement when you or your Dependent require treatment in a Hospital:

● as a registered bed patient;● for a Partial Hospitalization for the treatment of Mental Health or Substance Abuse;● for Mental Health or Substance Abuse Residential Treatment Services.You or your Dependent should request PAC prior to any non-emergency treatment in a Hospital described above. In the case of an emergency admission, you should contact the Review Organization within 48 hours after the admission. For an admission due to pregnancy, you should call the Review Organization by the end of the third month of pregnancy. CSR should be requested, prior to the end of the certified length of stay, for continued Hospital Confinement.

Covered Expenses incurred will not include the first $300 of Hospital charges made for each separate admission to the Hospital unless PAC is received: prior to the date of admission; or in the case of an emergency admission, within 48 hours after the date of admission.

Covered Expenses incurred for which benefits would otherwise be payable under this plan for the charges listed below will be reduced by 50%:

● Hospital charges for Bed and Board, for treatment listed above for which PAC was performed, which are made for any day in excess of the number of days certified through PAC or CSR; and

● any Hospital charges for treatment listed above for which PAC was requested, but which was not certified as Medically Necessary.

PAC and CSR are performed through a utilization review program by a Review Organization with which Cigna has contracted.

In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this plan, except for the “Coordination of Benefits” section.

Covered Expenses

The term Covered Expenses means the expenses incurred by or on behalf of a person for the charges listed below if they are incurred after he or she becomes insured for these benefits. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness, as determined by Cigna. Any applicable Deductibles or limits are shown in The Schedule.


● charges made by a Hospital, on its own behalf, for Bed and Board and other Necessary Services and Supplies; except that for any day of Hospital Confinement, Covered Expenses will not include that portion of charges for Bed and Board which is more than the Bed and Board Limit shown in The Schedule.

● charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided.

● charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient.● charges made by a Free-Standing Surgical Facility, on its own behalf for medical care and treatment.● charges made on its own behalf, by an Other Health Care Facility, including a Skilled Nursing Facility, a Rehabilitation

Hospital or a subacute facility for medical care and treatment; except that for any day of Other Health Care Facility confinement, Covered Expenses will not include that portion of charges which are in excess of the Other Health Care Facility Daily Limit shown in The Schedule.

● charges made for Emergency Services and Urgent Care.● charges made by a Physician or a Psychologist for professional services.● charges made by a Nurse, other than a member of your family or your Dependent’s family, for professional nursing service.● 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 their administration.● charges made for laboratory services, radiation therapy and other diagnostic and therapeutic radiological procedures.

100


● charges made for Family Planning, including medical history, physical exam, related laboratory tests, medical supervision in accordance with generally accepted medical practices, other medical services, information and counseling on contraception, implanted/injected contraceptives, after appropriate counseling, medical services connected with surgical therapies (tubal ligations, vasectomies).

● charges made for the following preventive care services (detailed information is available at healthcare.gov/coverage/preventive-care-benefits/):o evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United

States Preventive Services Task Force;o immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the

Centers for Disease Control and Prevention with respect to the Covered Person involved;o for infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive

guidelines supported by the Health Resources and Services Administration;o for women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive

guidelines supported by the Health Resources and Services Administration.● charges made for or in connection with mammograms, including:

o a baseline mammogram for asymptomatic women at least age 35;o a mammogram every one or two years for asymptomatic women ages 40–49, but no sooner than two years after a woman’s

baseline mammogram;o an annual mammogram for women age 50 and over; ando when prescribed by a Physician, a mammogram, anytime, regardless of the woman’s age.

● charges made for or in connection with travel immunization for Employees and Dependents.● surgical or nonsurgical treatment of TMJ dysfunction.● charges made for or in connection with one baseline lead poison screening test for Dependent children at or around 12

months of age, or in connection with lead poison screening and diagnostic evaluations for Dependent children under the age of 6 years who are at high risk for lead poisoning according to guidelines set by the Division of Public Health.

● charges made for children from birth to age 18 for immunization against:o diphtheria;o hepatitis B;o measles;o mumps;o pertussis;o polio;o rubella;o tetanus;o varicella;o Haemophilus influenzae B; ando hepatitis A.

● charges made for treatment of Serious Mental Illness. Such Covered Expenses will be payable the same as for other illnesses. Any Mental Illness Maximums in The Schedule and any Full Payment Area exceptions for mental illness will not apply to Serious Mental Illness.

● charges made for U.S. FDA-approved prescription contraceptive drugs and devices and for outpatient contraceptive services including consultations, exams, procedures, and medical services related to the use of contraceptives and devices.

● charges made for Diabetic supplies as recommended in writing or prescribed by a Participating Physician or Other Participating Health Care Professional, including insulin pumps and blood glucose meters.

● scalp hair prostheses worn due to alopecia areata.● colorectal cancer screening for persons 50 years of age or older or those at high risk of colon cancer because of family history

of familial adenomatous polyposis; family history of hereditary nonpolyposis colon cancer; chronic inflammatory bowel disease; family history of breast, ovarian, endometrial, colon cancer or polyps; or a background, ethnicity or lifestyle such that the health care provider treating the participant or beneficiary believes he or she is at elevated risk. Coverage will include screening with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy, or in appropriate circumstances radiologic imaging or other screening modalities, provided as determined by the Secretary of Health and Social Services of Delaware after consideration of recommendations of the Delaware Cancer Consortium and the most recently published


101


recommendations established by the American College of Gastroenterology, the American Cancer Society, the United States Preventive Task Force Services, for the ages, family histories and frequencies referenced in such recommendations and deemed appropriate by the attending Physician. Also included is the use of anesthetic agents, including general anesthesia, in connection with colonoscopies and endoscopies performed in accordance with generally-accepted standards of medical practice and all applicable patient safety laws and regulations, if the use of such anesthetic agents is medically necessary in the judgment of the treating Physician.

● hearing aids for Dependent children up to age 24.● nutritional formulas, low protein modified food products, or other medical food consumed or administered enterally

(via tube or orally) which are medically necessary for the therapeutic treatment of inherited metabolic diseases, such as phenylketonuria (PKU), maple syrup urine disease, urea cycle disorders, tyrosinemia, and homocystinuria, when administered under the direction of a Physician.

Clinical TrialsCharges made for routine patient services associated with cancer clinical trials approved and sponsored by the federal government. In addition the following criteria must be met:

● the cancer clinical trial is listed on the NIH website clinicaltrials.gov as being sponsored by the federal government;● the trial investigates a treatment for terminal cancer and: the person has failed standard therapies for the disease; cannot

tolerate standard therapies for the disease; or no effective nonexperimental treatment for the disease exists;● the person meets all inclusion criteria for the clinical trial and is not treated “off-protocol”;● the trial is approved by the Institutional Review Board of the institution administering the treatment; and● coverage will not be extended to clinical trials conducted at nonparticipating facilities if a person is eligible to participate in a

covered clinical trial from a Participating Provider.

Routine patient services do not include, and reimbursement will 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 clinical trial (i.e., protocol-induced costs);● services or supplies which, in the absence of private health care coverage, are provided by a clinical trial sponsor or other

party (e.g., device, drug, item or service supplied by manufacturer and not yet FDA approved) without charge to the trial participant.

Genetic TestingCharges made for genetic testing that uses a proven testing method for the identification of genetically linked inheritable disease. Genetic testing is covered only if:

● a person has symptoms or signs of a genetically linked inheritable disease;● it has been determined that a person is at risk for carrier status as supported by existing peer-reviewed, evidence-based,

scientific literature for the development of a genetically linked inheritable disease when the results will impact clinical outcome; or

● the therapeutic purpose is to identify specific genetic mutation that has been demonstrated in the existing peer-reviewed, evidence-based, scientific literature to directly impact treatment options.

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

Genetic counseling is covered if a person is undergoing approved genetic testing, or if a person has an inherited disease and is a potential candidate for genetic testing. Genetic counseling is limited to 3 visits per calendar year for both pre- and post-genetic testing.

Nutritional EvaluationCharges made for nutritional evaluation and counseling when diet is a part of the medical management of a documented organic disease.

http://clinicaltrials.gov

102


Internal Prosthetic/Medical AppliancesCharges made for internal prosthetic/medical appliances that provide permanent or temporary internal functional supports for nonfunctional body parts are covered. Medically Necessary repair, maintenance or replacement of a covered appliance is also covered.

Obesity TreatmentCharges made for medical and surgical services only at approved centers for the treatment or control of clinically severe (morbid) obesity as defined below and if the services are demonstrated, through existing peer reviewed, evidence based, scientific literature and scientifically based guidelines, to be safe and effective for the treatment or control of the condition. Clinically severe (morbid) obesity is defined by the National Heart, Lung and Blood Institute (NHLBI) as a Body Mass Index (BMI) of 40 or greater without comorbidities, or a BMI of 35-39 with comorbidities. The following items are specifically excluded:

● medical and surgical services to alter appearances or physical changes that are the result of any medical or surgical services performed for the treatment or control of obesity or clinically severe (morbid) obesity; and

● weight loss programs or treatments, whether or not they are prescribed or recommended by a Physician or under medical supervision.

Orthognathic SurgeryOrthognathic surgery to repair or correct a severe facial deformity or disfigurement that orthodontics alone cannot correct, provided:

● the deformity or disfigurement is accompanied by a documented clinically significant functional impairment, and there is a reasonable expectation that the procedure will result in meaningful functional improvement; or

● the orthognathic surgery is Medically Necessary as a result of tumor, trauma, disease or;● the orthognathic surgery is performed prior to age 19 and is required as a result of severe congenital facial deformity or

congenital condition.

Repeat or subsequent orthognathic surgeries for the same condition are covered only when the previous orthognathic surgery met the above requirements, and there is a high probability of significant additional improvement as determined by the utilization review Physician.

Home Health ServicesCharges made for Home Health Services when you:

● require skilled care;● are unable to obtain the required care as an ambulatory outpatient; and● do not require confinement in a Hospital or Other Health Care Facility.Home Health Services are provided only if Cigna has determined that the home is a medically appropriate setting. If you are a minor or an adult who is dependent upon others for nonskilled care and/or custodial services (e.g., bathing, eating, toileting), Home Health Services will be provided for you only during times when there is a family member or care giver present in the home to meet your nonskilled care and/or custodial services needs.

Home Health Services are those skilled health care services that can be provided during visits by Other Health Care Professionals. The services of a home health aide are covered when rendered in direct support of skilled health care services provided by Other Health Care Professionals. A visit is defined as a period of 2 hours or less. Home Health Services are subject to a maximum of 16 hours in total per day. Necessary consumable medical supplies and home infusion therapy administered or used by Other Health Care Professionals in providing Home Health Services are covered. Home Health Services do not include services by a person who is a member of your family or your Dependent’s family or who normally resides in your house or your Dependent’s house even if that person is an Other Health Care Professional. Skilled nursing services or private duty nursing services provided in the home are subject to the Home Health Services benefit terms, conditions and benefit limitations. Physical, occupational, and other Short Term Rehabilitative Therapy services provided in the home are not subject to the Home Health Services benefit limitations in The Schedule, but are subject to the benefit limitations described under Short Term Rehabilitative Therapy Maximum shown in The Schedule.

103


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

● by a Hospice Facility for Bed and Board and Services and Supplies;● by a Hospice Facility for services provided on an outpatient basis;● by a Physician for professional services;● by a Psychologist, social worker, family counselor or ordained minister for individual and family counseling;● for pain relief treatment, including drugs, medicines and medical supplies;● by an Other Health Care Facility for:

o part-time or intermittent nursing care by or under the supervision of a Nurse;o part-time or intermittent services of an Other Health Care Professional;

● physical, occupational and speech therapy;● medical supplies; drugs and medicines lawfully dispensed only on the written prescription of a Physician; and laboratory

services; but only to the extent such charges would have been payable under the policy if the person had remained or been Confined in a Hospital or Hospice Facility.

The following charges for Hospice Care Services are not included as Covered Expenses:

● for the services of a person who is a member of your family or your Dependent’s family or who normally resides in your house or your Dependent’s house;

● for any period when you or your Dependent is not under the care of a Physician;● for services or supplies not listed in the Hospice Care Program;● for any curative or life-prolonging procedures;● to the extent that any other benefits are payable for those expenses under the policy;● for services or supplies that are primarily to aid you or your Dependent in daily living.

Mental Health and Substance Abuse ServicesMental Health Services are services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to Mental Health will not be considered to be charges made for treatment of Mental Health.

Substance Abuse is defined as the psychological or physical dependence on alcohol or other mind-altering drugs that requires diagnosis, care, and treatment. In determining benefits payable, charges made for the treatment of any physiological conditions related to rehabilitation services for alcohol or drug abuse or addiction will not be considered to be charges made for treatment of Substance Abuse.

Inpatient Mental Health Services

Services that are provided by a Hospital while you or your Dependent is Confined in a Hospital for the treatment and evaluation of Mental Health. Inpatient Mental Health Services include Partial Hospitalization and Mental Health Residential Treatment Services.

Partial Hospitalization sessions are services that are provided for not less than 4 hours and not more than 12 hours in any 24-hour period.

Mental Health Residential Treatment Services are services provided by a Hospital for the evaluation and treatment of the psychological and social functional disturbances that are a result of subacute Mental Health conditions.

Mental Health Residential Treatment Center means an institution which specializes in the treatment of psychological and social disturbances that are the result of Mental Health conditions; provides a subacute, structured, psychotherapeutic treatment program, under the supervision of Physicians; provides 24-hour care, in which a person lives in an open setting; and is licensed in accordance with the laws of the appropriate legally authorized agency as a residential treatment center.

A person is considered confined in a Mental Health Residential Treatment Center when he or she is a registered bed patient in a Mental Health Residential Treatment Center upon the recommendation of a Physician.

104


Outpatient Mental Health Services

Services of Providers who are qualified to treat Mental Health when treatment is provided on an outpatient basis, while you or your Dependent is not Confined in a Hospital, and is provided in an individual, group or Mental Health Intensive Outpatient Therapy Program. Covered services include, but are not limited to, outpatient treatment of conditions such as:

● anxiety or depression which interfere with daily functioning;● emotional adjustment or concerns related to chronic conditions, such as psychosis or depression;● emotional reactions associated with marital problems or divorce;● child/adolescent problems of conduct or poor impulse control;● affective disorders;● suicidal or homicidal threats or acts;● eating disorders; or● acute exacerbation of chronic Mental Health conditions (crisis intervention and relapse prevention) and outpatient testing

and assessment.A Mental Health Intensive Outpatient Therapy Program consists of distinct levels or phases of treatment that are provided by a certified/licensed Mental Health program. Intensive Outpatient Therapy Programs provide a combination of individual, family and/or group therapy in a day, totaling nine or more hours in a week.

Inpatient Substance Abuse Rehabilitation ServicesServices provided for rehabilitation, while you or your Dependent is Confined in a Hospital, when required for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs. Inpatient Substance Abuse Services include Partial Hospitalization sessions and Residential Treatment services.

Partial Hospitalization sessions are services that are provided for not less than 4 hours and not more than 12 hours in any 24-hour period.

Substance Abuse Residential Treatment Services are services provided by a Hospital for the evaluation and treatment of the psychological and social functional disturbances that are a result of subacute Substance Abuse conditions.

Substance Abuse Residential Treatment Center means an institution which specializes in the treatment of psychological and social disturbances that are the result of Substance Abuse; provides a subacute, structured, psychotherapeutic treatment program, under the supervision of Physicians; provides 24-hour care, in which a person lives in an open setting; and is licensed in accordance with the laws of the appropriate legally authorized agency as a residential treatment center.

A person is considered confined in a Substance Abuse Residential Treatment Center when he or she is a registered bed patient in a Substance Abuse Residential Treatment Center upon the recommendation of a Physician.

Outpatient Substance Abuse Rehabilitation ServicesServices provided for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs, while you or your Dependent is not Confined in a Hospital, including outpatient rehabilitation in an individual, or a Substance Abuse Intensive Outpatient Therapy Program.

A Substance Abuse Intensive Outpatient Therapy Program consists of distinct levels or phases of treatment that are provided by a certified/licensed Substance Abuse program. Intensive Outpatient Therapy Programs provide a combination of individual, family and/or group therapy in a day, totaling nine, or more hours in a week.

Substance Abuse Detoxification ServicesDetoxification and related medical ancillary services are provided when required for the diagnosis and treatment of addiction to alcohol and/or drugs. Cigna will decide, based on the Medical Necessity of each situation, whether such services will be provided in an inpatient or outpatient setting.

ExclusionsThe following are specifically excluded from Mental Health and Substance Abuse Services:

● any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Necessary and otherwise covered under this policy or agreement.

● treatment of disorders which have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain.

105


● developmental disorders, including but not limited to, developmental reading disorders, developmental arithmetic disorders, developmental language disorders or developmental 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 day care.● psychological testing on children requested by or for a school system.● occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline.

Durable Medical EquipmentCharges made for purchase or rental of Durable Medical Equipment that is ordered or prescribed by a Physician and provided by a vendor approved by Cigna for use outside a Hospital or Other Health Care Facility. Coverage for repair, replacement or duplicate equipment is provided only when required due to anatomical change and/or reasonable wear and tear. All maintenance and repairs that result from a person’s misuse are the person’s responsibility. Coverage for Durable Medical Equipment is limited to the lowest-cost alternative as determined by the utilization review Physician.

Durable Medical Equipment is defined as items which are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of Injury or Sickness; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, respirators, wheel chairs, and dialysis machines.

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

● Bed-related Items: bed trays, over the bed tables, bed wedges, pillows, custom bedroom equipment, mattresses, including nonpower mattresses, custom mattresses and Posturepedic® 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 or gyroscopic mobility systems, roll about chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized – manual hydraulic lifts are covered if patient is two-person transfer), and auto tilt chairs.

● Fixtures to Real Property: ceiling lifts and wheelchair ramps.● Car/VanModifications.● Air Quality Items: room humidifiers, vaporizers, air purifiers 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, postural drainage board, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, any exercise equipment and diathermy machines.

External Prosthetic Appliances and DevicesCharges made or ordered by a Physician for: the initial purchase and fitting of external prosthetic appliances and devices available only by prescription which are necessary for the alleviation or correction of Injury, Sickness or congenital defect. Coverage for External Prosthetic Appliances is limited to the most appropriate and cost effective alternative as determined by the utilization review Physician.

External prosthetic appliances and devices shall include prostheses/prosthetic appliances and devices, orthoses and orthotic devices; braces; and splints.

Prostheses/prosthetic Appliances and DevicesProstheses/prosthetic appliances and devices are defined as fabricated replacements for missing body parts. Prostheses/prosthetic appliances and devices include, but are not limited to:

● basic limb prostheses;● terminal devices such as hands or hooks; and● speech prostheses.

106


Orthoses and Orthotic DevicesOrthoses and orthotic devices are defined as orthopedic appliances or apparatuses used to support, align, prevent or correct deformities. Coverage is provided for custom foot orthoses and other orthoses as follows:

● Non-foot orthoses – only the following non-foot orthoses are covered:o rigid and semi-rigid custom fabricated orthoses;o semi-rigid prefabricated and flexible orthoses; ando rigid prefabricated orthoses including preparation, fitting and basic additions, such as bars and joints.

● Custom foot orthoses – custom foot orthoses are only covered as follows:o for persons with impaired peripheral sensation and/or altered peripheral circulation (e.g., diabetic neuropathy and

peripheral vascular disease);o when the foot orthosis is an integral part of a leg brace and is necessary for the proper functioning of the brace;o when the foot orthosis is for use as a replacement or substitute for missing parts of the foot (e.g., amputated toes) and is

necessary for the alleviation or correction of Injury, Sickness or congenital defect; ando for persons with neurologic or neuromuscular condition (e.g., cerebral palsy, hemiplegia, spina bifida) producing spasticity,

malalignment, or pathological positioning of the foot and there is reasonable expectation of improvement.The following are specifically excluded orthoses and orthotic devices:

● prefabricated foot orthoses;● cranial banding and/or cranial orthoses. Other similar devices are excluded except when used postoperatively for synostotic

plagiocephaly. When used for this indication, the cranial orthosis will be subject to the limitations and maximums of the External Prosthetic Appliances and Devices benefit;

● orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers;● orthoses primarily used for cosmetic rather than functional reasons; and● orthoses primarily for improved athletic performance or sports participation.

BracesA Brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part.

The following braces are specifically excluded: Copes scoliosis braces.

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

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

● replacement due to regular wear. Replacement for damage due to abuse or misuse by the person will not be covered.● replacement will be provided when anatomic change has rendered the external prosthetic appliance or device ineffective.

Anatomic change includes significant weight gain or loss, atrophy and/or growth.● Coverage for replacement is limited as follows:

o no more than once every 24 months for persons 19 years of age and older;o no more than once every 12 months for persons 18 years of age and under; ando replacement due to a surgical alteration or revision of the site.

The following are specifically excluded external prosthetic appliances and devices:

● external and internal power enhancements or power controls for prosthetic limbs and terminal devices; and● myoelectric prostheses peripheral nerve stimulators.

Short Term Rehabilitative TherapyShort Term Rehabilitative Therapy that is part of a rehabilitation program, including physical, speech, occupational, cognitive, osteopathic manipulative, cardiac rehabilitation and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting.

The following limitation applies to Short Term Rehabilitative Therapy: Occupational therapy is provided only for purposes of enabling persons to perform the activities of daily living after an Illness or Injury or Sickness.

107


Short Term Rehabilitative Therapy services that are not covered include, but are not limited to:

● sensory integration therapy, group therapy;● treatment of dyslexia;● behavior modification or myofunctional therapy for dysfluency, such as stuttering or other involuntarily acted conditions

without evidence of an underlying medical condition or neurological disorder;● treatment for functional articulation disorder, such as correction of tongue thrust, lisp, verbal apraxia or swallowing

dysfunction that is not based on an underlying diagnosed medical condition or Injury; and● maintenance or preventive treatment consisting of routine, long term or non-Medically Necessary care provided to prevent

recurrence or to maintain the patient’s current status.

Multiple outpatient services provided on the same day constitute one day.

Services that are provided by a chiropractic Physician are not covered. These services include the conservative management of acute neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to restore motion, reduce pain and improve function.

Chiropractic Care ServicesCharges made for diagnostic and treatment services utilized in an office setting by chiropractic Physicians. Chiropractic treatment includes the conservative management of acute neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to specific joints to restore motion, reduce pain, and improve function.

The following limitation applies to Chiropractic Care Services: Occupational therapy is provided only for purposes of enabling persons to perform the activities of daily living after an Injury or Sickness.

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

● services of a chiropractor which are not within his scope of practice, as defined by state law;● charges for care not provided in an office setting;● maintenance or treatment consisting of routine, long term or non-Medically Necessary care provided to prevent recurrence or

to maintain the patient’s current status;● vitamin therapy.

Alternative Therapies and Non-traditional Medical ServicesCharges for Alternative Therapies and Non-traditional Medical Services limited to $1,000 per calendar year. Alternative Therapies and Non-traditional Medicine include services provided by an Herbalist, or Naturopath, or for Massage Therapy when these services are provided for a covered condition outside the United States in accordance with customary local practice and the practitioner is operating within the scope of his/her license, and the treatment is medically necessary, cost-effective, and provided in an appropriate setting.

Breast Reconstruction and Breast ProsthesesCharges made for reconstructive surgery following a mastectomy. Benefits include:

● surgical services for reconstruction of the breast on which surgery was performed;● surgical services for reconstruction of the nondiseased breast to produce symmetrical appearance;● postoperative breast prostheses; and● mastectomy bras and external prosthetics, limited to the lowest-cost alternative available that meets external prosthetic

placement needs.● During all stages of mastectomy, treatment of physical complications, including lymphedema therapy, are covered.

Reconstructive SurgeryCharges made for reconstructive surgery or therapy to repair or correct a severe physical deformity or disfigurement which is accompanied by functional deficit (other than abnormalities of the jaw or conditions related to TMJ disorder), provided that:

● the surgery or therapy restores or improves function;● reconstruction is required as a result of Medically Necessary, noncosmetic surgery; or● the surgery or therapy is performed prior to age 19 and is required as a result of the congenital absence or agenesis (lack of

formation or development) of a body part.● Repeat or subsequent surgeries for the same condition are covered only when there is the probability of significant additional

improvement as determined by the utilization review Physician.

108


Transplant ServicesCharges made for human organ and tissue Transplant services which include solid organ and bone marrow/stem cell procedures. This coverage is subject to the following conditions and limitations.● Transplant services include:

o the recipient’s medical, surgical and Hospital services;o inpatient immunosuppressive medications; ando costs for organ or bone marrow/stem cell procurement.

● Transplant services are covered only if they are required to perform any of the following human to human organ or tissue transplants:o allogeneic bone marrow/stem cell;o autologous bone marrow/stem cell;o cornea;o heart;o heart/lung;o kidney;o kidney/pancreas;o liver;o lung;o pancreas; oro intestine, which includes small bowel-liver or multi-visceral.

● Cornea transplants are not covered at Cigna LifeSOURCE Transplant Network® facilities. Transplant services, including cornea, received at participating facilities specifically contracted with Cigna for those Transplant services, other than Cigna LifeSOURCE Transplant Network® facilities, are payable at the U.S. In-Network level. Transplant services received at any other facilities, including Non-Participating Providers and Participating Providers not specifically contracted with Cigna for Transplant services, are covered at the Out-of-Network level.

● Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. Costs related to the search for, and identification of a bone marrow or stem cell donor for an allogeneic transplant are also covered.

Transplant Travel ServicesCharges made for reasonable travel expenses incurred by you in connection with a preapproved organ/tissue transplant are covered subject to the following conditions and limitations. Transplant travel benefits are not available for cornea transplants. Benefits for transportation, lodging and food are available to you only if you are the recipient of a preapproved organ/tissue transplant from a designated Cigna LifeSOURCE Transplant Network® facility.The term recipient is defined to include a person receiving authorized transplant-related services during any of the following: evaluation, candidacy, transplant event, or post-transplant care. Travel expenses for the person receiving the transplant will include charges for: transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility); lodging while at, or traveling to and from the transplant site; and food while at, or traveling to and from the transplant site.In addition to your coverage for the charges associated with the items above, such charges will also be considered covered travel expenses for one companion to accompany you. The term companion includes your spouse, a member of your family, your legal guardian, or any person not related to you, but actively involved as your caregiver.The following are specifically excluded travel expenses:● travel costs incurred due to travel within 60 miles of your home;● laundry bills;● telephone bills;● alcohol or tobacco products; and● charges for transportation that exceed coach class rates.These benefits are only available when the covered person is the recipient of an organ transplant. No benefits are available when the covered person is a donor.

109


Prescription Drug Benefits (purchased outside the United States)If you or any one of your Dependents, while insured for Prescription Drug Benefits, incurs expenses for charges made by a Pharmacy, for Medically Necessary Prescription Drugs or Related Supplies ordered by a Physician outside the United States, Cigna will provide coverage for those expenses as shown in the Medical Schedule. Coverage also includes Medically Necessary Prescription Drugs and Related Supplies dispensed for a prescription issued to you or your Dependents by a licensed dentist for the prevention of infection or pain in conjunction with a dental procedure.

Coverage for Prescription Drugs and Related Supplies purchased at a Pharmacy is subject to the Coinsurance shown in The Schedule. Please refer to The Schedule for any required Coinsurance or Maximums if applicable.

Medications required as part of preventive care services (detailed information is available at healthcare.gov/coverage/preventive-care-benefits/) are covered at 100%.

Exclusions:

No payment will be made for the following expenses:

● drugs available over the counter that do not require a prescription by applicable law;● any drug that is a pharmaceutical alternative to an over-the-counter drug other than insulin;● a drug class in which at least one of the drugs is available over the counter and the drugs in the class are deemed to be

therapeutically equivalent as determined by the P&T Committee;● injectable infertility drugs and any injectable drugs that require Physician supervision and are not typically considered self-

administered drugs. The following are examples of Physician supervised drugs:o injectables used to treat hemophilia and RSV (respiratory syncytial virus);o chemotherapy injectables; ando endocrine and metabolic agents;

● Food and Drug Administration (FDA)-approved drugs used for purposes other than those approved by the FDA unless the drug is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, The American Medical Association Drug Evaluations; or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal;

● prescription vitamins (other than prenatal vitamins), pediatric multivitamins containing fluoride, and dietary supplements;● anabolic steroids;● diet pills or appetite suppressants (anorectics);● prescription smoking cessation products;● drugs used for cosmetic purposes, such as:

o drugs used to reduce wrinkles;o drugs to promote hair growth;o drugs used to control perspiration; ando fade cream products;

● replacement of Prescription Drugs and Related Supplies due to loss or theft;● drugs used to enhance athletic performance;● drugs which are to be taken by or administered to you while you are a patient in a licensed Hospital, Skilled Nursing

Facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals;

● prescriptions more than one year from the original date of issue.


110

Cigna Global Health Benefits Plan Prescription Drug Benefits 110

Cigna Global Health Benefits Plan Prescription Drug BenefitsCovered ExpensesIf you or any one of your Dependents, while insured for Prescription Drug Benefits, incurs expenses for charges made by a Pharmacy, for Medically Necessary Prescription Drugs or Related Supplies ordered by a Physician, Cigna will provide coverage for those expenses as shown in The Schedule. Coverage also includes Medically Necessary Prescription Drugs and Related Supplies dispensed for a prescription issued to you or your Dependents by a licensed dentist for the prevention of infection or pain in conjunction with a dental procedure.

LimitationsEach Prescription Order or refill shall be limited as follows:

● up to a consecutive 30-day supply at a retail Pharmacy unless limited by the drug manufacturer’s packaging; or● up to a consecutive 90-day supply at a home delivery Pharmacy, unless limited by the drug manufacturer’s packaging; or● to a dosage and/or dispensing limit as determined by the P&T Committee.

Your PaymentsCoverage for Prescription Drugs and Related Supplies purchased at a Pharmacy is subject to the Copayment or Coinsurance shown in The Schedule, after you have satisfied your Prescription Drug Deductible, if applicable. Please refer to The Schedule for any required Copayments, Coinsurance, Deductibles or Maximums if applicable.

ExclusionsNo payment will be made for the following expenses:

● drugs available over the counter that do not require a prescription by federal or state law;● any drug that is a pharmaceutical alternative to an over-the-counter drug other than insulin;● a drug class in which at least one of the drugs is available over the counter and the drugs in the class are deemed to be

therapeutically equivalent as determined by the P&T Committee;● injectable infertility drugs and any injectable drugs that require Physician supervision and are not typically considered self-

administered drugs. The following are examples of Physician supervised drugs:o injectables used to treat hemophilia and RSV (respiratory syncytial virus);o chemotherapy injectables; ando endocrine and metabolic agents;

● Food and Drug Administration (FDA)-approved drugs used for purposes other than those approved by the FDA unless the drug is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, The American Medical Association Drug Evaluations; or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal;

● prescription and nonprescription supplies (such as ostomy supplies), devices, and appliances other than Related Supplies;● implantable contraceptive products;● diet pills or appetite suppressants (anorectics);● anabolic steroids;● prescription smoking cessation products;● drugs used for cosmetic purposes such as:

o drugs used to reduce wrinkles;o drugs to promote hair growth;o drugs used to control perspiration; ando fade cream products;

● replacement of Prescription Drugs and Related Supplies due to loss or theft;● drugs used to enhance athletic performance;● drugs which are to be taken by or administered to you while you are a patient in a licensed Hospital, Skilled Nursing

Facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals;

111


● prescriptions more than one year from the original date of issue;● any drugs that are experimental or investigational as described under the Medical “Exclusions” section of your certificate.

Other limitations are shown in the Medical “Exclusions” section of Cigna’s certificate.

Reimbursement/Filing a ClaimWhen you or your Dependents purchase your Prescription Drugs or Related Supplies through a retail Participating Pharmacy, you pay any applicable Copayment or Coinsurance shown in The Schedule at the time of purchase. You do not need to file a claim form.

If you or your Dependents purchase your Prescription Drugs or Related Supplies through a non-Participating Pharmacy, you pay the full cost at the time of purchase. You must submit a claim form to be reimbursed.

To purchase Prescription Drugs or Related Supplies from a home delivery Participating Pharmacy, see your home delivery drug introductory kit for details, or contact Member Services for assistance.

See your Employer’s Benefit Plan Administrator to obtain the appropriate claim form.

112


Cigna Global Health Benefits Plan Prescription Drug Benefits – The Schedule

This section describes coverage for Prescriptions obtained inside the United States only.

Prescriptions obtained outside of the United States are covered under the Preferred Provider Medical Benefits section of this certificate.


This plan provides Prescription Drug benefits for Prescription Drugs and Related Supplies provided by Pharmacies as shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for Prescription Drugs and Related Supplies. That portion includes any applicable Copayment, Deductible and Coinsurance.

Coinsurance

The term Coinsurance means the percentage of Charges for covered Prescription Drugs and Related Supplies that you or your Dependent are required to pay under this plan.

Charges

The term Charges means the amount charged by the Insurance Company to the plan when the Pharmacy is a Participating Pharmacy, and it means the actual billed charges when the Pharmacy is a non-Participating Pharmacy.

Copayments

Copayments are expenses to be paid by you or your Dependent for Covered Prescription Drugs and Related Supplies.

Deductibles

Deductibles are expenses to be paid by you or your Dependent for Covered Prescription Drugs and Related Supplies. These Deductibles are in addition to any copayments or coinsurance.

BENEFIT HIGHLIGHTS PARTICIPATING PHARMACY

NON-PARTICIPATING PHARMACY

Retail Prescription Drugs The amount you pay for each 30-day supply

The amount you pay for each 30-day supply

Medications required as part of preventive care services (detailed information is available at healthcare.gov/coverage/preventive-care-benefits/) are covered at 100% with no copayment or deductible.

Generic* $10 Copay 20% after plan deductible

Home Delivery Prescription Drugs The amount you pay for each 90-day supply

The amount you pay for each 90-day supply

Preferred and Non-Preferred Brand-Name $20 copay 20% after plan deductible

Medications required as part of preventive care services (detailed information is available at healthcare.gov/coverage/preventive-care-benefits/) are covered at 100% with no copayment or deductible

Generic* $30 copay U.S. In-Network coverage only

Preferred and Non-Preferred Brand-Name* $60 copay U.S. In-Network coverage only

* Designated as per generally accepted industry sources and adopted by the Insurance Company



113

Emergency Evacuation 113

Emergency EvacuationIf you suffer a life-threatening/limb-threatening medical condition, and Cigna, and/or its designee, determines that adequate medical facilities are not available locally, Cigna, or its designee, will arrange for an emergency evacuation to the nearest facility capable of providing adequate care. You must contact Cigna at the phone number indicated on your identification card to begin this process.

In making their determinations, Cigna, and/or its designee, will consider the nature of the emergency, your condition and ability to travel, as well as other relevant circumstances including airport availability, weather conditions, and distance to be covered. Your medical condition must require the accompaniment of a qualified healthcare professional during the entire course of your evacuation to be considered an emergency and requiring emergency evacuation. Transportation will be provided by medically equipped specialty aircraft, commercial airline, train or ambulance depending upon the medical needs and available transportation specific to each case.

RepatriationFollowing any covered emergency evacuation, Cigna will pay for one of the following:

● If it is deemed Medically Necessary and appropriate by the Cigna medical director, you will be transferred to your permanent residence via a one-way economy airfare; or

● You will be transferred back to your original work location or the location from which you were evacuated via a one-way economy airfare.

If your transportation needs to be medically supervised, a qualified medical attendant will escort you. Additionally, if Cigna and/or its designee, determines a mode of transport other than economy class seating on a commercial aircraft is required, Cigna or its designee will arrange accordingly, and such will be covered by Cigna.

NotificationExpenses incurred for your evacuation or repatriation without the approval and authorization of Cigna and/or its designee will not be Covered Expenses. Only those expenses approved by Cigna will be eligible for coverage and/or reimbursement under the terms of your plan.

Emergency Family Travel Arrangements and Confinement VisitationIf Cigna determines that you are expected to require hospitalization in excess of 7 days at the location to which you are to be evacuated, an economy round-trip airfare will be provided to the place of hospitalization for an individual chosen by you. If your Dependent Child is evacuated, one economy round-trip airfare will be provided to a parent or legal guardian regardless of the number of days that the Dependent child is hospitalized.

Return of Dependent ChildrenIf Dependent child(ren) are left unattended by virtue of the evacuee’s absence alone following a covered evacuation, a one-way economy airfare will be provided to their place of residence.

Repatriation of Mortal RemainsThe costs associated with the transportation of mortal remains from the place of death to the home country will be covered. In addition, assistance will be provided by Cigna or its designee for organizing or obtaining the necessary clearances for the repatriation of mortal remains.

114

Emergency Evacuation 114

General Limitations / Exclusions for Evacuation BenefitsNo payment will be made for charges for:

● services rendered without the authorization or intervention of Cigna or its designee;● non-emergency, routine or minor medical problems, tests and exams where there is no clear or significant risk of death or

imminent serious Injury or harm to you;● a condition which would allow for treatment at a future date convenient to you and which does not require emergency

evacuation or repatriation;● medical care or services scheduled for member or provider’s convenience which are not considered an emergency;● expenses incurred if the original or ancillary purpose of your trip is to obtain medical treatment;● services provided for which no charge is normally made;● expenses incurred while serving in the armed forces of another country;● transportation for your vehicle and/or other personal belongings involving intercontinental and/or marine transportation;● service provided other than those indicated in this certificate;● injury or sickness caused by war, or an act of war, whether declared or undeclared, riot, civil commotion or police action;● death caused by war, or an act of war, whether declared or undeclared, riot, civil commotion or police action; or● for claim payments that are illegal under applicable law.

115

Cigna Global Health Benefits Plan Vision Benefits 115

Cigna Global Health Benefits Plan Vision BenefitsCovered ExpensesBenefits Include:

Examinations

One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction and prescription for glasses.

Lenses (Glasses)

One pair of prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms).

● Polycarbonate lenses for children under 18 years of age;● Oversize lenses;● Rose #1 and #2 solid tints;● Progressive lenses covered up to bifocal lenses amount.● Frames – one frame – choice of frame covered, up to retail plan allowance.

Contact Lenses

One pair or a single purchase of a supply of contact lenses in lieu of lenses and frame benefit (may not receive contact lenses and frames in same benefit year).

Contact lens allowance can be applied towards contact lens materials as well as the cost of supplemental contact lens professional services including fitting and evaluation, up to the stated allowance.

Expenses Not Covered

Covered Expenses will not include, and no payment will be made for:

● Orthoptic or vision training and any associated supplemental testing.● Spectacle lens treatments, “add-ons,” or lens coatings not shown as covered in The Schedule.● Two pair of glasses, in lieu of bifocals or trifocals.● Prescription sunglasses.● Medical or surgical treatment of the eyes.● Any eye examination, or any corrective eyewear, required by an employer as a condition of employment.● Magnification or low vision aids.● Any non-prescription eyeglasses, lenses, or contact lenses.● Safety glasses or lenses required for employment.● VDT (video display terminal)/computer eyeglass benefit.● Charges in excess of the Maximum Reimbursable Charge for the Service or Materials.● Charges incurred after the Policy ends or the Insured’s coverage under the Policy ends, except as stated in the Policy.● Experimental or non-conventional treatment or device.● High Index lenses of any material type.● Lens treatments or “add-ons,” except rose tints (#1 & #2), and oversize lenses.● For or in connection with experimental procedures or treatment methods not approved by the American Optometric

Association or the appropriate vision specialty society.● Any injury or illness when paid or payable by Workers’ Compensation or similar law, or which is work-related.● Claims submitted and received in-excess of one year (365 days) from the original Date of Service.

Other Limitations are shown in the Exclusions and General Limitations section.

116

Cigna Global Health Benefits Plan Vision Benefits 116

CGHB Vision – The Schedule For You and Your Dependents


U.S. OUT-OF-NETWORK

Examinations

One Eye Exam every 24 consecutive months


Lenses & FramesOne pair of glasses or contact lenses per 24 consecutive months

Maximum Benefit: $250


117

Cigna Global Health Benefits Plan Dental Preferred Provider Insurance 117

Cigna Global Health Benefits Plan Dental Preferred Provider InsuranceCovered Dental ExpenseCovered Dental Expense means that portion of a Dentist’s charge that is payable for a service delivered to a covered person provided:

● the service is ordered or prescribed by a Dentist;● is essential for the Necessary care of teeth;● the service is within the scope of coverage limitations;● the deductible amount in The Schedule has been met;● the maximum benefit in The Schedule has not been exceeded;● the charge does not exceed the amount allowed under the Alternate Benefit Provision;● for Class I, II or III the service is started and completed while coverage is in effect, except for services described in the

“Benefits Extension” section.

Alternate Benefit ProvisionIf more than one covered service will treat a dental condition, payment is limited to the least costly service provided it is a professionally accepted, necessary and appropriate treatment.

If the covered person requests or accepts a more costly covered service, he or she is responsible for expenses that exceed the amount covered for the least costly service. Therefore, Cigna recommends Predetermination of Benefits before major treatment begins.

Predetermination of BenefitsPredetermination of Benefits is a voluntary review of a Dentist’s proposed treatment plan and expected charges. It is not preauthorization of service and is not required.

The treatment plan should include supporting pre-operative X-rays and other diagnostic materials as requested by Cigna’s dental consultant. If there is a change in the treatment plan, a revised plan should be submitted.

Cigna will determine covered dental expenses for the proposed treatment plan. If there is no Predetermination of Benefits, Cigna will determine covered dental expenses when it receives a claim.

Review of proposed treatment is advised whenever extensive dental work is recommended when charges exceed $200.

Predetermination of Benefits is not a guarantee of a set payment. Payment is based on the services that are actually delivered and the coverage in force at the time services are completed.

Covered ServicesThe following section lists covered dental services. Cigna may agree to cover expenses for a service not listed. To be considered, the service should be identified using the American Dental Association Uniform Code of Dental Procedures and Nomenclature, or by description and then submitted to Cigna.

Dental PPO – Participating and Non-Participating ProvidersPlan payment for a covered service delivered by a Participating Provider is the Contracted Fee for that procedure, times the benefit percentage that applies to the class of service, as specified in The Schedule.

The covered person is responsible for the balance of the Contracted Fee.

Plan payment for a covered service delivered by a non-Participating Provider is the Maximum Reimbursable Charge for that procedure, times the benefit percentage that applies to the class of service, as specified in The Schedule.

The covered person is responsible for the balance of the non-Participating Provider’s actual charge.

Class I Services – Diagnostic and Preventive

● Clinical oral examination – only 2 per person per calendar year.● Palliative (emergency) treatment of dental pain, minor procedures, when no other definitive Dental Services are performed.

(Any X-ray taken in connection with such treatment is a separate Dental Service.)● X-rays:

o Complete series or Panoramic (Panorex)o Only one per person, including panoramic film, in any 3 calendar years.

118


● Bitewing X-rays – Only 2 charges per person per calendar year.● Prophylaxis (Cleaning):

o Including Periodontal maintenance procedures (following active therapy)o Only 2 per person per calendar year.

● Topical application of fluoride (excluding prophylaxis)o Limited to persons less than 19 years old.o Only 1 per person per calendar year.

● Topical application of sealant, per tooth, on a posterior tooth – only 1 treatment per tooth in any 3 calendar years.● Space Maintainers, fixed unilateral – limited to nonorthodontic treatment.

Class II Services – Basic Restorations, Endodontics, Periodontics, Prosthodontic Maintenance and Oral Surgery

● Amalgam Filling● Composite/Resin Filling● Root Canal Therapy – any X-ray, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and

not a separate Dental Service.● Osseous Surgery – flap entry and closure is part of the allowance for osseous surgery and not a separate Dental Service.● Periodontal Scaling and Root Planing – entire mouth● Adjustments – complete denture: any adjustment of or repair to a denture within 6 months of its installation is not a separate

Dental Service.● Recement Bridge● Routine Extractions● Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of

Tooth:o Removal of Impacted Tooth, Soft Tissueo Removal of Impacted Tooth, Partially Bonyo Removal of Impacted Tooth, Completely Bony

● Local anesthetic, analgesic and routine postoperative care for extractions and other oral surgery procedures are not separately reimbursed, but are considered as part of the submitted fee for the global surgical procedure.

● General Anesthesia – Paid as a separate benefit only when Medically or Dentally Necessary, as determined by Cigna, and when administered in conjunction with complex oral surgical procedures which are covered under this plan.

● I.V. Sedation – Paid as a separate benefit only when Medically or Dentally Necessary, as determined by Cigna, and when administered in conjunction with complex oral surgical procedures which are covered under this plan.

Class III Services – Major Restorations, Dentures and Bridgework

Crowns

Crown restorations are Dental Services only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration.

● Porcelain Fused to High Noble Metal● Full Cast, High Noble Metal● Three-Fourths Cast, MetallicRemovable Appliances

● Complete (Full) Dentures, Upper or Lower● Partial Dentures● Lower, Cast Metal Base with Resin Saddles (including any conventional clasps, rests and teeth)● Upper, Cast Metal Base with Resin Saddles (including any conventional clasps rests and teeth)

Fixed Appliances

● Bridge Pontics – Cast High Noble Metal● Bridge Pontics – Porcelain Fused to High Noble Metal Bridge Pontics – Resin with High Noble Metal● Retainer Crowns – Resin with High Noble Metal Retainer Crowns – Porcelain Fused to High Noble● Metal Retainer Crowns – Full Cast High Noble Metal

119


● Prosthesis Over Implant:o A prosthetic device, supported by an implant or implant abutment is a Covered Expense.o Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the

existing prosthesis is at least 5 calendar years old, is not serviceable and cannot be repaired.

Class IV Services – Orthodontics

Each month of active treatment is a separate Dental Service.


● Orthodontic work-up including X-rays, diagnostic casts and treatment plan and the first month of active treatment including all active treatment and retention appliances.

● Continued active treatment after the first month.● Fixed or Removable Appliances – Only one appliance per person for tooth guidance or to control harmful habits.

The total amount payable for all expenses incurred for Orthodontics during a Dependent child’s lifetime will not be more than the Orthodontia Maximum shown in The Schedule.

Dental Expenses Not CoveredCovered Expenses will not include, and no payment will be made for:

● services performed solely for cosmetic reasons;● replacement of a lost or stolen appliance;● replacement of a bridge, crown or denture within 5 years after the date it was originally installed unless:

o the replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or

o the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits;

● any replacement of a bridge, crown or denture which is or can be made usable according to common dental standards;● procedures, appliances or restorations (except full dentures) whose main purpose is to:

o change vertical dimension;o diagnose or treat conditions or dysfunction of the temporomandibular joint;o stabilize periodontally involved teeth; oro restore occlusion;

● porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars;● bite registrations; precision or semiprecision attachments; or splinting;● instruction for plaque control, oral hygiene and diet;● dental services that do not meet common dental standards;● services that are deemed to be medical services;● services and supplies received from a Hospital;● the surgical placement of an implant body or framework of any type;● surgical procedures in anticipation of implant placement;● any device, index, or surgical template guide used for implant surgery;● treatment or repair of an existing implant;● prefabricated or custom implant abutments;● removal of an existing implant;● services for which benefits are not payable according to the General Limitations section.

120


Cigna Global Health Benefits Plan Dental Preferred Provider Insurance – The Schedule


The Dental Benefits Plan offered by your Employer includes two options. When you select a Participating Provider, this plan pays a greater share of the cost than if you were to select a non-Participating Provider.

Deductibles

Deductibles are 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 further dental deductible for the rest of that year.

Participating Provider Payment

Participating Provider services are paid based on the Contracted Fee agreed upon by the provider and the Insurance Company.

Non-Participating Provider Payment

Non-Participating Provider services are paid based on the Maximum Reimbursable Charge. For this plan, the Maximum Reimbursable Charge is calculated at the 80th percentile of all provider charges in the geographic area.

BENEFIT HIGHLIGHTS

Classes I, II, III Combined Calendar Year Maximum

$2,000

Class IV Lifetime Maximum $1,500


Individual

Family Maximum

$50 per person

$150 per family

Class I

Preventive Care 100% (not subject to plan deductible)

Class II

Basic Restorative


Class III

Major Restorative


Class IV

Orthodontia

Class IV Orthodontia applies only to a Dependent Child less than 19 years of age

50% after orthodontia lifetime plan deductible

121

Exclusions, Expenses Not Covered and General Limitations 121

Exclusions, Expenses Not Covered and General LimitationsExclusions and Expenses Not CoveredAdditional coverage limitations determined by plan or provider type are shown in The Schedule. Payment for the following is specifically excluded from this plan:

● care for health conditions that are required by state or local law to be treated in a public facility.● care required by state or federal law to be supplied by a public school system or school district.● care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and

facilities are reasonably available.● for or in connection with an Injury or Sickness which is due to war, declared or undeclared, riot, civil commotion or police

action which occurs in the Employee’s country of citizenship.● for claim payments that are illegal under applicable law.● charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed

except that they were covered under this plan.● assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or

self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.● for or in connection with experimental, investigational or unproven services.

● Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug or Biologic therapies or devices that are determined by the utilization review Physician to be:

o not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed;

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

o the subject of review or approval by an Institutional Review Board for the proposed use except as provided in the “Clinical Trials” section of this plan; or

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

In determining whether drug or Biologic therapies are experimental, investigational and unproven, the utilization review Physician may review without limitation, U.S. Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scienctific literature.

● cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem.

● The following services are excluded from coverage, regardless of clinical indications:o Macromastia or Gynecomastia Surgeries;o Abdominoplasty;o Panniculectomy;o Rhinoplasty;o Blepharoplasty;o Redundant skin surgery;o Removal of skin tags;o Acupressure;o Craniosacral/cranial therapy;o Dance therapy, movement therapy;o Applied kinesiology;o Rolfing;o Prolotherapy; ando Extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.

122


● Medical and surgical services, initial and repeat, intended for the treatment or control of obesity, except for treatment of clinically severe (morbid) obesity as shown in Covered Expenses, including:o medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the

management of obesity or clinically severe (morbid) obesity; ando weight loss programs or treatments, whether prescribed or recommended by a Physician or under medical supervision.

● unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required 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 such treatment is prescribed by a Physician and listed as covered in this plan.● infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro

fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage.

● reversal of male or female voluntary sterilization procedures.● any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited

to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation.● medical and Hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under

this plan.● nonmedical counseling or ancillary services, including, but not limited to, Custodial Services, education, training, vocational

rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities, autism or intellectual disabilities.

● therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including, but not limited to, routine, long-term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.

● consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to, bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the “Home Health Services” or “Breast Reconstruction and Breast Prostheses” sections of this plan.

● private hospital rooms and/or private duty nursing except as provided under the Home Health Services provision.● personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn

infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness.

● artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets and wigs other than for scalp hair prostheses worn due to alopecia areata.

● hearing aids, including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs), except as covered under this plan as shown in the Covered Expenses section. A hearing aid is any device that amplifies sound.

● aids or devices that assist with nonverbal communications, including, but not limited to, communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.

● eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.● all noninjectable prescription drugs, unless physician administration or oversight is required, injectable prescription drugs

to the extent they do not require Physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in this plan.

● routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular 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 testing method

performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.● dental implants for any condition.● fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation

of scheduled services where in the utilization review Physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

123


● blood administration for the purpose of general improvement in physical condition.● cosmetics, dietary supplements and health and beauty aids.● all nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism.● medical treatment for a person age 65 or older, who is covered under this plan as a retiree, or their Dependent, when

payment is denied by the Medicare plan because treatment was received from a nonparticipating provider.● medical treatment when payment is denied by a Primary Plan because treatment was received from a nonparticipating

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

General LimitationsNo payment will be made for expenses incurred for you or any one of your Dependents:

● for charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected Injury or Sickness.

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

● to the extent that payment is unlawful where the person resides when the expenses are incurred.● for charges which would not have been made if the person had no insurance.● to the extent that they are more than Maximum Reimbursable Charges.● to the extent of the exclusions imposed by any certification requirement shown in this plan.● expenses for supplies, care, treatment, or surgery that are not Medically Necessary.● charges made by any covered provider who is a member of your family or your Dependent’s Family.

124

Cigna Global Health Benefits – Coordination of Benefits 124

Cigna Global Health Benefits – Coordination of BenefitsThis section applies if you or any one of your Dependents is covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. For claims incurred within the United States, you should file all claims under each Plan. For claims incurred outside the United States, if you file claims with more than one Plan, you must indicate, at the time of filing a claim under this Plan, that you also have or will be filing your claim under another Plan.

DefinitionsFor the purposes of this section, the following terms have the meanings set forth below:

PlanAny of the following that provides benefits or services for medical, dental or vision care or treatment:● Group insurance and/or group-type coverage, whether insured or self-insured which neither can be purchased by the general

public, nor is individually underwritten, including closed panel coverage.● Coverage under Medicare and other governmental benefits as permitted by law, excepting Medicaid and Medicare

supplement policies.● Medical benefits coverage of group, group-type, and individual automobile contracts.Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan.

Closed Panel PlanA Plan that provides medical or dental benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel.

Primary PlanThe Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan.

Secondary PlanA Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to you.

Allowable ExpenseA necessary, reasonable and customary service or expense, including deductibles or coinsurance that is covered in full or in part by any Plan covering you. When a Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following:● An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense.● If you are confined to a private Hospital room and no Plan provides coverage for more than a semi-private room, the

difference in cost between a private and semi-private room is not an Allowable Expense.● If you are covered by two or more Plans that provide services or supplies on the basis of reasonable and customary fees, any

amount in excess of the highest reasonable and customary fee is not an Allowable Expense.● If you are covered by one Plan that provides services or supplies on the basis of reasonable and customary fees and one Plan

that provides services and supplies on the basis of negotiated fees, the Primary Plan’s fee arrangement shall be the Allowable Expense.

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

Claim Determination PeriodA calendar year, but does not include any part of a year during which you are not covered under this policy or any date before this section or any similar provision takes effect.

Reasonable Cash ValueAn amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area where the health care service is rendered under similar or comparable circumstances.

125

Cigna Medical Benefits Abroad Traveler Insurance Plan 125

Cigna Medical Benefits Abroad Traveler Insurance PlanCigna Global Health Benefits (CGHB) is Western Union’s international health care insurance carrier. You and dependents/guests traveling with you (“you” or “your”) will use the CGHB Medical Benefits Abroad benefits program if you have an accident or illness while you are on an approved business trip for Western Union outside your country of residence or permanent assignment. CGHB Medical Benefits Abroad is an international business travel plan which provides emergency and urgent medical care, medical benefits and health-related services to employees and dependents/guests traveling internationally on business for a period of six months or less (i.e., traveling outside the U.S. on authorized company business). All eligible Western Union employees are automatically enrolled in this program.

Additional information as well as an ID card can be found at the Western Union Health & Life Benefits website (cigna.com/westernunion). The member ID card and summary documents are also located on WU Life.

When securing medical urgent care and/or emergency services while on business outside the U.S., you will have to pay for services and submit a claim to CGHB for reimbursement. Prior to or immediately following securing medical services, you should contact a member representative at CGHB Global Health Benefits at 1-800-243-1348 for information and/or assistance with accessing care overseas. You will need the company’s employer ID (05306A).

When traveling on company business outside the U.S., be sure to visit WU Life to print and pack the CGHB Member Benefits Abroad ID card and newsletter.


126

Cigna Medical Benefits Abroad Traveler Insurance Plan 126

International Business Travel Plan Type of Coverage

Business Travel and Business Sojourn (leisure travel in conjunction with a business trip)

Business Travel Requirements

Travel outside home country (maximum of 180 consecutive days for any one Business Trip with no more than 270 travel days in a 12-month period). If country of residence and/or domicile is the United States or any U.S. Territory/Protectorate, travel between any combination of the 50 United States and U.S. Territories/Protectorates is considered traveling within home country.

Eligibility Provision

Employee All full-time active employees and part-time employees who are traveling on the business of, or at the expense of the Policyholder outside their country of residence or permanent assignment.

Dependents For the employee’s dependent spouse or domestic partner and dependent children (up to age 26 years) to be insured, they will need to be traveling with the eligible employee who is traveling at the expense of the policyholder outside their country of residence or permanent assignment. Dependents are not eligible for Accidental Death and Dismemberment coverage.

Plan Features

Individual Deductible None

Calendar Year Plan Maximum $250,000

Emergency Assistance Services Maximum

$100,000 per calendar year

(separate from calendar year plan maximum)

Private Room Limit The institution’s semi-private rate

Plan Payment Percentages

Hospital Services 100%

Physician Services 100%

Other Medical Expenses 100%

Medical Expenses Not Covered

Some examples of expenses that are not covered by CGHB Medical Benefits Abroad include*:

● Routine Care, such as Routine Wellness, Physical Exams and Gynecological Exams● Routine Maternity Expenses● Non-Emergency Mental Health and Substance Abuse Expenses● Second Surgical Opinion● Home Health Care or Custodial Services● Dental Services

This plan covers doctor visits, hospital prescription drug coverage and inpatient hospital expenses for urgent and emergency care. In addition, CGHB Medical Benefits Abroad provides coverage for emergency medical evacuations and repatriation while on a business trip.

127

Vision Coverage 127

Vision CoverageThe Vision Plan has a network of participating eye care providers that provide vision care services at negotiated rates. Vision Service Plan (VSP) administers the Vision Plan.

If you choose coverage, your benefits depend on whether you use a network doctor or out-of-network provider.

● Once you enroll, the plan pays for covered services once each calendar year (January 1 through December 31).● You have access to a large network of participating VSP doctors.● When you use a network doctor, he or she will contact the plan administrator (VSP) directly to determine the amount the plan

will pay for vision services.● If you use a network doctor, there are no claim forms. After you pay your copayment, your VSP provider will submit claims

to VSP on your behalf.● You can receive discounts for additional services for cosmetic reasons, such as tinted lenses, progressive/blended bifocals, or

scratch coatings.● When referred by your network doctor to a participating laser vision center, you can receive a discount towards

photorefractive keratectomy (PRK) or laser in-situ kertomileusis (LASIK) corrective surgery. Check with the plan administrator (VSP) to locate a doctor near you.

● There is no member ID card issued to members.● If you use a network doctor, you receive the highest level of benefits.● If you use out-of-network providers:

o You receive limited benefits according to a fixed schedule.o You need to file a claim with the plan administrator (VSP) to be reimbursed.

If you choose to receive cosmetic features (for example, scratch or other coatings, progressive, blended, oversize, laminated, or UV protected), you’ll be responsible for the cost of the features. You can receive cosmetic features at a discounted rate determined by the Vision Service Plan when using a network provider. The plan provides a 20% discount when you purchase non-covered lenses from the same network doctor from whom you had an exam during that calendar year.

Frames purchased from a network doctor that are not covered in full are eligible for a 20% discount. The plan also provides a 20% discount when you purchase non-covered complete pair of glasses from the same network doctor from whom you had an exam during that calendar year.

Vision Service Plan has also contracted with many laser vision correction centers to offer a savings from what you would pay without being a Vision Service Plan participant. You may receive an average discount of 15% off the regular price or 5% off the promotional price if the service is at a contracted facility.

To find in-network providers in your area, call the Vision Service Plan 1-800-877-7195, or visit their website (vsp.com).

Vision Service Plan BenefitsThe amount the Vision Service Plan pays for expenses relating to eye exams, glasses, and contact lenses depends on whether you use in-network or out-of-network providers.

Vision care services and vision care materials may be received from any licensed optometrist, ophthalmologist, or optician, whether a member or nonmember provider.

http://vsp.com

128

Vision Coverage 128

If You Use Network Providers

Benefit Description Copay Frequency

YourCoveragewithVSPDoctorsandAffiliateProviders*

WellVision Exam ● Focuses on your eyes and overall wellness $10 Every calendar year

Prescription Glasses $20 See frame and lenses

Frame● $150 allowance for a wide selection of frames● $80 allowance at Costco● 20% savings on the amount over your allowance

Included in Prescription Glasses

Every calendar year

Lenses● Single vision, lined bifocal, and lined trifocal lenses● Polycarbonate lenses for dependent children

Included in Prescription Glasses

Every calendar year

Lens Enhancements

● Standard progressive lenses● Premium progressive lenses● Custom progressive lenses● Average savings of 20-25% on other lens enhancements

$55$95 - $105$150 - $175

Every calendar year

Contacts

(instead of glasses)● $150 allowance for contacts; copay does not apply● Contact lens exam (fitting and evaluation)

Up to $60 Every calendar year

Diabetic Eyecare Plus Program

● Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.

$20 As needed

Extra Savings

Glasses and Sunglasses

● Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.● 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP

doctor within 12 months of your last WellVision Exam.Laser Vision Correction

● Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

*Coveragewitharetailchainaffiliatemaybedifferent.Onceyourbenefitiseffective,visitvsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

The plan will provide coverage for eyeglass lenses, frames, or contact lenses once each calendar plan year (January 1 through December 31).

To find out which frames are covered, contact VSP (1-800-877-7195) or your network provider.

If You Use Out-of-Network Providers

Your Coverage with Other Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP doctor.

Exam . . . . . up to $45 Frame . . . . up to $70

Single Vision Lenses . . . . up to $30 Lined Bifocal Lenses . . . up to $50

Lined Trifocal Lenses . . . up to $65 Progressive Lenses . . . . . up to $50 Contacts . . . . up to $120

http://vsp.com/specialoffers

http://vsp.com

http://vsp.com

129

Vision Coverage 129

What’s Not CoveredThe Vision Service Plan is designed to cover your basic vision needs. If you want to purchase certain optional services and materials, such as types of lenses that are considered cosmetic, you’ll be responsible for the cost.

Here are examples of expenses that the plan doesn’t cover. This list isn’t exhaustive.

● More than one pair of prescription lenses (either eyeglasses or contacts) and frames and more than one vision exam every year● Frames costing more than the plan allowance● The extra charge for lenses that are blended bifocals, color coated, scratch-coated, dyed, oversized, photochromic, multifocal,

laminated, antireflective, tinted, mirror coated, or ultraviolet protected lenses● Contact lens insurance and cleaning kits● Any medical or surgical eye treatment● Two pairs of glasses instead of bifocals● Services or supplies not prescribed by a licensed optometrist or ophthalmologist and lenses that don’t require a prescription● Services or supplies that are experimental● Services or supplies for which coverage is provided or available under any other company-provided benefit program or

workers’ compensation● Vision examinations or any materials furnished for any condition, disease, ailment, or injury arising during the course of

employment● Certain limitations on low vision care● Replacement of lenses and frames furnished under the plan that are lost or broken, except at normal intervals when services

are otherwise available

If you have any questions about whether an expense is covered, call VSP.

Filing Vision Service Plan Claims

For In-Network Expenses

When you incur in-network vision care expenses, identify yourself as a Vision Service Plan (VSP) member. Your participating eye care provider will submit claims for you.

For Out-of-Network Expenses

When you incur out-of-network vision care expenses, you’re responsible for paying the bill and filing a claim for reimbursement with VSP. You must submit the claim within 6 months from the date of service.

Call VSP at 1-800-877-7195 to get a claim form and filing instructions.

The instructions on the claim form should be followed carefully. Be sure all questions are answered fully and any required statements and bills are submitted with the claim form.

The claim form must include the following information:

● The name, address, and phone number of the out-of-network provider● Your Personal Identification Number● Your name, phone number, and address● The name of the group (Western Union)● The patient’s name, date of birth, phone number, and address● The patient’s relationship to you (such as “self,” “spouse,” “child,” or “student”)

Mail the original claim form and itemized bills to:

Vision Service Plan P.O. Box 997105 Sacramento, CA 95899-7105

1-800-877-7195 vsp.com

http://vsp.com

130

Vision Coverage 130

How to Appeal Denied ClaimsOnce you turn in your vision claim, the plan administrator will review the claim and make a decision. Claims may be denied in some situations. You have the right to appeal denied claims by following the claim review process.

Right of RecoveryIf any claim or benefit is overpaid, the plan reserves the right to recover the overpayment or to reduce any future payments. The person receiving the benefit must produce any instruments or papers necessary to ensure this right of recovery.

131

Flexible Spending Accounts 131

Flexible Spending AccountsA Flexible Spending Account (FSA) allows you to set aside a portion of your salary in a tax-deferred account. You can then use the money in your account(s) to reimburse yourself for qualified health care and dependent care expenses. Your taxable salary is reduced by the amount you set aside in your account(s), so you pay lower income taxes and Social Security taxes. If you participate in the Cigna Choice Fund with HSA, you cannot contribute to a Health Care FSA.

HEALTH CARE ACCOUNT DEPENDENT CARE ACCOUNT

Your Maximum Annual Contribution

$2,600 (Includes any employer contribution)

$5,000 (Includes any employer contribution)

Your Employer’s Annual Contribution

$0

(the “Indexed” annual contribution amount) $2,600 will be determined for years going forward.

$1,300 or $1,560

Care Dollars Benefit (if eligible)

Your Annual Claim Submission Deadline

Claims must be received by Cigna by April 30 Claims must be received by Cigna by April 30

Grace Period March 15 March 15

How Flexible Spending Accounts WorkYou fund your FSA(s) by directing a portion of your earnings to your account(s) on a pre-tax basis. You cannot deposit cash directly into your account(s). Once you decide how much you’ll contribute for the year, you cannot change your election unless you have a qualified family status change, nor can you transfer money from one FSA to another.

How Much You Can ContributeYou and Western Union can contribute up to $2,600 to your Health Care FSA each year. If you enroll during the year, you will be allowed up to the $2,600 maximum, spread across the number of pay periods left in that calendar year.

Carefully calculate the amount you contribute to your Flexible Spending Accounts. The IRS imposes a “use it or lose it” rule on FSA plans: you forfeit any money that remains in your account after reimbursement of your eligible expenses for the year including any grace period.

Limits and RestrictionsTo preserve the favorable tax treatment of your contributions, there are several important limitations that you should understand before participating in the FSA. First of all, an FSA is what is known as a “use it or lose it” arrangement, which means that if you do not spend all of the money in your account, you lose the unspent balance. Second, you cannot fund your account as you go along − you must decide how much to deposit for the year before each year begins – so you have to be careful in calculating your anticipated expenses for the coming year. Once you decide your contribution amount, you cannot change it during the year unless you experience a qualified family status change, so you should plan to deposit only as much as you expect to spend in the upcoming year.

● Having a Health Care FSA limits your deductions for health care expenses. However, keep in mind that you can deduct unreimbursed health care expenses from your federal income tax only if they exceed the threshold established by the Internal Revenue Service.

● To be eligible for reimbursement from the Health Care FSA, the expenses must be for you, your child or a tax-qualified dependent. A tax-qualified dependent is someone for whom you can claim a tax exemption. Some of the dependents you cover under your medical plan may not be tax-qualified dependents (for example: domestic partners are not usually considered tax-qualified dependents).

● Having a Dependent Care FSA limits the tax credits you may be able to take for dependent care expenses. You can use both the FSA and tax credit, provided you do not claim the same expenses for both. However, federal regulations require that your dependent care tax credit be reduced dollar for dollar by whatever you put into your FSA. You should ask your tax advisor to help you choose the right alternative for your tax bracket.

132


● Establishing an FSA may have an impact on your cash flow. The way an FSA works you essentially have to “pay twice” for your eligible expenses — first via the payroll deductions that you direct to your Account and again when you actually incur (and pay) the expense. It isn’t until you receive your tax-free reimbursement from your FSA that you realize the FSA’s full benefit. You should take this “cash flow effect” into account before deciding whether or not to sign up for the FSA.

● You cannot transfer funds between the Health Care and Dependent Care FSA.● You cannot carry over any unclaimed FSA balances from one year to the next. Any funds remaining in your Health Care

and/or Dependent Care FSA on December 31 will be forfeited unless they are used to cover expenses incurred during that calendar year and Cigna receives your claim for reimbursement by the following April 30 (unless grace period applies, see below).

● A grace period extension provides you with an additional 2½ months after the close of a plan year to incur eligible Health Care FSA expenses that will be reimbursed from your remaining prior plan year’s balance. Any funds remaining in your FSA on December 31 can be used for eligible expenses incurred between January 1 and March 15 of the next plan year.

In addition to the yearly limits on what you can direct to your FSA, the Internal Revenue Service requires plans to prove that they don’t favor “highly compensated” employees. If the Company’s FSA do not pass this test, the contributions made by highly compensated employees may have to be reduced or reclassified as after-tax contributions. If this happens, the Company will notify those affected.

Additional Limits on Dependent Care FSA Contributions

If Your Spouse Also Contributes to a Dependent Care FSA

The IRS sets additional limits on your contributions if you’re married and your spouse has a Dependent Care FSA through his or her employer:

● You are limited to a combined Dependent Care FSA contribution of $5,000 in a calendar year. This limit applies whether you have one or more dependents receiving care.

● If you file separate federal income tax returns, the most you can contribute is $2,500 a year.● If you file a joint return, you can’t contribute more than you earn (or what your spouse earns, if it’s less than what you earn

for the year, with a $5,000 limit).● If your spouse is either disabled or a full-time student, the IRS considers your spouse’s earnings to be $250 a month if you

have one eligible dependent and $500 if you have more than one eligible dependent.

How Participating in the FSA Affects Taxes and Other BenefitsEstablishing an FSA can also affect your tax strategy when you file your income tax return. You should consult with a tax advisor before signing up for the FSA – you can’t change your election once you’ve made it, unless you have a qualified family status change (as explained in Making Changes).

The Tax AdvantagesThe Internal Revenue Code allows your employer to take the money you direct to your FSA out of your pay before federal and Social Security (FICA) taxes are deducted. That lowers your taxable income, so you pay less federal income tax and Social Security tax. Depending on where you live, your tax savings could be even greater, since most states recognize the tax-free status of FSA funds. What’s more, any reimbursements you receive from your FSA are free from federal tax as long as you have not taken (or do not intend to take) a tax deduction or credit for related expenses when you file your federal tax return.

Limits on DeductionsParticipating in the FSA can affect your tax strategy when you file your income tax return.

● Setting up a Health Care FSA limits your deductions for health care expenses. Keep in mind, however, that you can deduct unreimbursed health care expenses from your federal income tax only if they exceed the annual threshold established by the Internal Revenue Service.

● Using your Dependent Care FSA for dependent care expenses limits the tax credits you can take for those expenses. The federal income tax credit lets you subtract a percentage, based on your taxable income, of your expenses for dependent care from the federal taxes you owe. You can use both your Dependent Care FSA and the tax credit, but you can’t claim the same expenses for both. Whatever you apply toward your federal income tax credit is reduced dollar-for-dollar by what you contribute to your Dependent Care FSA. Please consult your own tax advisor about changes in these amounts and your specific situation.

133


Impact on Other Benefits

Employer-sponsoredBenefits

While you are “reducing” your pay for tax purposes, your pay-related benefits (for example, any employer-sponsored life and disability insurance, and pension benefits) are not reduced. Your benefits from these plans will be based on your compensation before any amounts are deducted.

Social Security

Since your Social Security (FICA) taxes are based on your reduced pay, your future Social Security benefits may be slightly lower.

Your Flexible Spending Account StatementsThe Explanation of Benefits (EOB) that Cigna issues with each reimbursement is also a good source of information. The EOB details the amount reimbursed and your current balance.

You can access information about your FSA account status using your myCigna.com, a secure member site. In addition to finding information about your FSA account(s), you can register to have EOB’s suppressed and receive e-mail notification each time an FSA claim is paid.

Health Care Flexible Spending AccountThe Health Care FSA lets you pay many of your otherwise unreimbursed health care expenses with tax-free dollars. Since not every health care expense you incur is eligible for reimbursement through your FSA, it’s important to know which are reimbursable and which are not.

If an expense is covered under any other plan(s), you cannot submit it for reimbursement under your Health Care FSA until the expense has been considered by the other plan(s).

Eligible Health Care ExpensesYou can use your Health Care FSA to reimburse yourself for health care expenses that are considered ”medical care” under section 213(d) of the Internal Revenue Code, as long as the expenses are not reimbursed by any health care plan. Tax rules change, so you should check with your tax advisor about the eligibility of specific expenses. You can get additional information about eligible health care expenses from IRS Publication 502, “Medical and Dental Expenses,” which is available from your local IRS office and on the IRS Website at irs.gov.

● Acupuncture● Ambulance service● Artificial limbs● Auto equipment such as special hand controls to assist the physically disabled● Braille books and magazines● Chiropractic care● Contact lenses needed for medical reasons that are not covered by the Vision Care Plan● Contraceptives that are not covered by the Medical Plan● Crutches● Dental treatment not covered by the Dental Plan● Drug abuse inpatient treatment● Over-the-counter (OTC) medicines and drugs are reimbursed from a FSA only if the use of OTC medicines and drugs has

been prescribed by a doctor. This means items such as pain relievers, cold and fever remedies, antibiotic ointments, and allergy medications will require a prescription submitted along with an FSA claim form to receive reimbursement from HCFSA funds. FSA debit cards will be reprogrammed to not pay for OTC medicines and drugs at the checkout.

● Eye exams, lenses and frames not covered in full by the Vision Plan● Fertility enhancement, as follows:

o procedures such as in vitro fertilization (including temporary storage of eggs or sperm), ando infertility surgery, including an operation to reverse a prior sterilization procedure

● Guide dog or other animal used by a visually impaired or hearing-impaired person● Hearing exams and hearing aids● Hospital services

http://myCigna.com

http://irs.gov

134


● Laboratory fees

● Laser eye surgery

● Lead-based paint removal to protect a child who has, or who has had, lead paint poisoning from continued exposure

● Legal fees directly related to committing a mentally ill person

● Lodging while you receive medical care away from home. Care must be provided by a doctor in a licensed hospital or treatment facility, and the lodging must be primarily for, and essential to, medical care.

● Long term care services required by a chronically ill person, if provided in accordance with a plan of care prescribed by a licensed health care practitioner

● Medical information plan that maintains your medical information so it can be retrieved from a medical data bank for your medical care

● Medical services and supplies not covered by your medical plan

● Mental health care not covered by your medical plan

● Organ donor expenses

● Osteopathic services

● Oxygen and oxygen equipment

● Prescription drugs not covered by your medical plan

● Psychiatric care not covered by your medical plan

● Smoking cessation programs

● Specialized equipment for the disabled, including:

o cost and repair of special telephone equipment that allows a hearing-impaired person to communicate over a regular telephone, and

o equipment that displays the audio part of television programs as subtitles for hearing-impaired● Sterilization surgery● Termination of pregnancy● Transportation expenses if primarily for, and essential to, medical care● Wheelchairs

The following health care expenses also qualify for tax-free reimbursement through a Health Care FSA:● Health care copayment, deductible and coinsurance amounts. Note: if submitting a receipt for the copayment, the receipt

must clearly indicate the amount as copayment.● Health care expenses that are above the customary charge or health care plan maximums.

If you have any questions about what’s considered an eligible expense under the Health Care FSA, you can call Cigna Member Services. You can also contact your local IRS office or visit the IRS website at irs.gov.

Ineligible Health Care ExpensesJust as important as understanding what’s eligible for reimbursement through your Health Care FSA is to know what’s not generally eligible, including the following:

● Expenses for which you’ve already been reimbursed by other health care plans (including Medicare, Medicaid, and your employer’s or any other Medical, Dental and Vision Care Plans)

● Expenses incurred by anyone other than you or your qualified dependents● Expenses that are not deductible on your federal income tax return● Babysitting, child care and nursing services for a normal, healthy baby. This includes the cost of a licensed practical nurse

(L.P.N.) to care for a normal and healthy newborn.● Controlled substances● Cosmetic dental work● Cosmetic surgery (any procedure to improve the patient’s appearance that does not meaningfully promote the proper function

of the body, or prevent or treat illness or disease)● Custodial care in an institution

http://irs.gov

135


● Diaper service● Funeral and burial expenses● Health care plan contributions, including those for Medicare, your spouse’s employer’s plan, or any other private coverage● Health club dues● Household help, even if such help is recommended by a physician● Illegal medical services or supplies● Maternity clothing● Medical savings account (MSA) contributions● Over-the-counter health aids that do not treat a specific medical condition, including those recommended by your physician● Over-the-counter medicines and drugs which have not been prescribed by a doctor (these are over-the-counter medicines

and drugs, such as aspirins, allergy, motion sickness aids, that do not require a prescription to be purchased, but do require a prescription to be reimbursed with Health FSA funds).

● Over-the-counter drugs that are beneficial to health, but are not for medical care (for example: vitamins, weight loss aids)● Nutritional supplements, unless obtained legally with a physician’s prescription● Personal use items, unless the item is used primarily to prevent or alleviate a physical or mental defect or illness● Prescription drugs for cosmetic purposes● Weight-loss programs not prescribed by a doctor● Special schooling for a problem child, even if the child may benefit from the course of study or disciplinary methods● Transportation to and from work, even if a physical condition requires special means of transportation● Up-front patient administration fees paid to a physician’s practice● Vitamins or minerals taken for general health purposes

Dependent Care Flexible Spending AccountYou can use the Dependent Care FSA to reimburse yourself with tax-free funds for certain dependent care expenses incurred because you (and your spouse, if you are married) work or are looking for work.

EligibilityIf you are married, you may participate in the Dependent Care FSA only if your spouse:

● Works full-time or part-time;● Is actively looking for work; or● Has no earned income for the year and:

o is a full-time student for at least five months of the year; oro is incapable of caring for himself or herself or for the dependent.

Care$ Benefit.If your annual benefits salary is $60,000 or less and you qualify for reimbursement from a Dependent Care FSA, Western Union will deposit a Care$ Benefit (either $1,300 or $1,560) prorated annually, into a Dependent Care FSA in your name when elected during annual or new hire enrollment to help defray the cost of dependent care.

● If you do not make a payroll contribution in a Dependent Care FSA, you may elect the Care$ Benefit, in which case, Western Union will deposit $1,300.

● If you do make a payroll contribution in a Dependent Care FSA, you may elect the Care$ Benefit, in which case, Western Union will deposit $1,560.

Who Qualifies as a DependentYou can use your Dependent Care FSA to cover the expenses of dependents, which are defined as:

● Children who are under age 13 when the care is provided and for whom you can claim an exemption on your federal income tax return;

● Your spouse who is mentally or physically incapable of self-care; and● Your dependent who is physically or mentally incapable of self-care, and for whom you can claim an exemption (or could

claim as a dependent if he or she didn’t have a gross annual income of $3,000 or more).

136


You can use your Dependent Care FSA to pay expenses for a qualifying child for whom you have joint custody if you pay more than half of the child’s support and have custody during the year longer than the other parent. The costs associated with caring for the elderly also qualify for reimbursement if they live in your home at least eight hours a day and are completely incapable of caring for themselves.

Eligible Dependent Care ExpensesThe Dependent Care FSA is strictly monitored by the IRS, and only those expenses that comply with Section 129 of the Internal Revenue Code of 1986 are covered. Keep in mind that the expenses must be work-related to qualify as eligible expenses. The IRS considers expenses “work-related” only if they meet both of the following rules:

● They allow you (and your spouse) to work or look for work; and● They are for the care of a qualified person.You can pay the following work-related expenses through your Dependent Care FSA:

● Wages paid to a babysitter, unless you or your spouse claims the sitter as a dependent. Care can be provided in, or outside of, your home.

● Services of a Dependent Care Center (such as a daycare center or nursery school) if the facility:o provides care for more than six individuals (other than those who reside there),o receives a fee, payment or grant for providing its services, ando complies with all applicable state and local laws and regulations.

● Cost for adult care at facilities away from home, such as family daycare centers, as long as your dependent spends at least 8 hours at home.

● Wages paid to a housekeeper for providing care to an eligible dependent. Household services, including the cost to perform ordinary services needed to run your home which are at least partly for the care of a qualifying individual, are covered as long as the person providing the services is not your dependent under age 19 or anyone you or your spouse claim as a dependent for tax purposes.

If you have any questions about what’s considered an eligible expense under the Dependent Care FSA, you can call Cigna Member Services at 1-800-Cigna-24. You can also contact your local IRS office or visit the IRS Website at irs.gov.

Ineligible Dependent Care ExpensesYou cannot use your Dependent Care FSA to reimburse yourself for services that:

● Allow you to participate in leisure-time activities;● Are for overnight camp,● Allow you to attend school part-time;● Enable you to attend educational programs, meetings or seminars; or● Are primarily medical in nature (such as in-house nursing care).

http://irs.gov

137

Filing Flexible Spending Account Claims 137

Filing Flexible Spending Account ClaimsWhen You Can File ClaimsHealth Care and Dependent Care expenses incurred during the year and through March 15th of the following year are reimbursable through your FSAs for that year. This provision is referred to as a 2½-month grace period. If you do not spend all of the money in your FSAs by December 31 in a given year, you can use the amount left in the account to reimburse expenses incurred during the first 2½ months of the following year. So, you have until April 30 of the following year to submit a claim for health expenses incurred the year before and through March 15 of the current year.

Automatic Claim ForwardingThis automated Health Care FSA process for certain medical, dental and pharmacy expenses eliminates the need to submit a separate FSA reimbursement request. When you receive care, the health care professional will be directly reimbursed for your coinsurance and/or deductible payment amounts from the FSA if funds are available. Your Explanation of Benefits (EOB) from Cigna will indicate that the health care professional was paid in full by their FSA eliminating possibility of duplicate payment. The FSA Automatic Claim Forwarding automatically passes medical, dental and pharmacy claims processed by Cigna to your Health Care FSA so you do not have to submit a claim form. You will need to pay your copay, then your FSA will automatically reimburse you by check or direct deposit. You are automatically enrolled in the FSA Automatic Claim Forwarding. You can cancel by visiting myCigna.com, Cigna’s secure member website. If you cancel or opt out of Automatic Claim Forwarding, you will need to submit a claim form to receive reimbursements.

Simply show your Cigna medical/pharmacy ID card at any Cigna participating pharmacy and your copay will be drawn directly from your FSA balance and processed instantly through a real-time interface. You pay nothing out of your pocket for pharmacy claims while a balance remains in your Health Care FSA. You are automatically enrolled, but you can cancel by visiting myCigna.com. If you cancel or opt out of Automatic Claim Forwarding, you will need to submit a claim form to receive reimbursements.

FSA Debit Card SubmissionCigna FSA Debit Card is a convenient way to pay for certain vision expenses. Use your debit card when paying for your vision expenses without having to pay out of your pocket when a balance remains in your health care FSA. Remember to keep your receipts. If you do not respond to the reminder letter from Cigna requesting your receipts, your debit card will not be deactivated, however you will receive a 1099 form after that plan year ends. The Cigna FSA debit card will not work at medical, dental and pharmacy due to the automatic Health Care FSA feature.

Documenting Your Claim

Health Care Expenses

When you submit a claim for reimbursement from your Health Care FSA, you must provide a copy of:

● The Explanation of Benefits (EOB) you received from Cigna (or your dependent’s health care plan) showing how much, if any, of your claim was paid; or

● Itemized bills from suppliers for expenses not covered by any health care plan. The itemized bill should include the patient name, diagnosis, service provided, charge and date of service. Remember receipts must clearly indicate the amount.

Your claim will not be accepted if the required information is not provided. You can use the “Flexible Spending Account Health Care Reimbursement” form to ensure that your claim submission contains all of the required information. Copies of the form are available from Cigna Member Services, on Cigna’s secure member site (myCigna.com) and from the Western Union Health & Life Benefits Website.

http://myCigna.com

http://myCigna.com

http://myCigna.com

138

Filing Flexible Spending Account Claims 138

Dependent Care ExpensesTo file a claim for reimbursement, complete the “Dependent Care Reimbursement” form. Copies of the form are available from Cigna Member Services, on the Cigna Website and from the Western Union Health & Life Benefits Website (cigna.com/westernunion).

You must provide the following information in your claim submission:● Dependent’s name● Provider’s name, address and tax ID (or Social Security) number● The cost, nature and place of the service(s) performed● Proof of payment● An indication of whether the provider is related to you and, if so, how (if the provider is your child, you must also include the

child’s age)You can ask your dependent care provider to sign the claim form as verification of payment. Detailed bills or receipts are also considered acceptable documentation for dependent care expenses.

You are also required to report your provider’s taxpayer identification number or Social Security number when you file your tax return.

ReimbursementCigna processes FSA claims as they are received, and issues FSA claim payments daily for Health Care and Dependent Care.

You can be reimbursed through your Health Care FSA for qualifying health care expenses up to the annual amount you elected at enrollment – even if all of it hasn’t been deducted from your paychecks.

You can be reimbursed for Dependent Care FSA expenses only up to the amount in your Dependent Care FSA when you file a claim. Any unpaid amounts still due you will be processed in the next claim cycle when (and if) you have enough money in your Dependent Care FSA to cover them.

You will receive an Explanation of Benefits (EOB), which reflects the status of your account, each time you submit a request for reimbursement (for example, the amount of the claim, how much of it is eligible for reimbursement, what’s been paid to date from your FSA, any amounts still payable, and any balance remaining in your Account).

If any balance is left in your FSA(s) at the end of the year, and claims for that balance are not filed with Cigna by April 30 of the following year, the remaining balance will be lost.


139

How to Appeal a Denied Claim 139

How to Appeal a Denied ClaimHealth Care FSA/Dependent Care FSA ClaimsIf we deny your request to be paid back for a service, you can appeal it. You or your authorized representative may start the appeals procedure.

Appeals ProcedureTo initiate an appeal, you must submit a request for an appeal in writing to Cigna within 180 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable to or choose not to write, you may ask Cigna to register your appeal by telephone at the toll-free number on your Benefit Identification card, explanation of benefits, or claim form. Your appeal will be reviewed and the decision made by someone not involved in the initial decision. We will respond in writing with a decision within 60 calendar days after we receive an appeal for a reimbursement determination. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review.

140

Life and Accident Coverage 140

Life and Accident CoverageCigna (Life Insurance Company of North America) provides the Western Union life and accident insurance policy effective January 1, 2017. Life and accident benefits provide you and your family with financial protection in the event of death or serious injury. Life and accident benefits include:

● Basic and Voluntary Employee Life Insurance which pays a benefit to your beneficiary in the event of your death.● Dependent Life Insurance which pays a benefit to you or another named beneficiary in the event of your spouse’s or

child’s death.● Basic and Voluntary Accidental Death and Dismemberment (AD&D) Insurance which pays a benefit to your beneficiary

in the event of your death, or to you following accidental injury.● Dependent Accidental Death and Dismemberment (AD&D) Insurance which pays a benefit to you in the event of your

dependent’s death or to your dependent following an accidental injury.

Your BeneficiaryA beneficiary is a person you choose to receive insurance proceeds. If you do not choose a beneficiary, benefits will be paid to the first of the following that applies:

● Your surviving spouse or domestic partner● Surviving children in equal shares● Surviving parents in equal shares● Surviving siblings in equal shares● Executor or administrator of your estate

You may change your beneficiary at any time by visiting Your Benefits in Workday and making your beneficiary designation online. The change will take effect on the date you make the change, but it will not apply to any benefit amount paid before the change is made online.

If you name more than one beneficiary and your online beneficiary designation does not indicate how proceeds should be shared, they will be divided equally. If your beneficiary dies before you, his or her interest in the proceeds will end and instead be shared by any remaining beneficiaries.

Life insurance may be assigned with the consent of Cigna and Western Union.

Summary of Benefits

Coverage Benefit Payment

Basic Life Insurance

All Eligible Employees 1 times annual benefits salary

Basic Life Insurance Maximum $1,000,000

Voluntary Life Insurance

● Option 1 1 times annual benefits salary





Voluntary Life Insurance Maximum $1,000,000

141


Dependent Life Insurance

● Spouse $10,000 increments up to 50% of employee voluntary life amount; up to $250,000 maximum

● Child(ren) $5,000 or $10,000 per child

Basic AD&D Insurance

All Eligible Employees 1 times annual benefits salary up to $1,000,000 maximum

Voluntary AD&D Insurance - Employees

● Option 1 1 times annual benefits salary up to $1,000,000 maximum





Voluntary AD&D Insurance - Dependents

● Spouse only 50% of employee supplemental AD&D amount

● Spouse and child(ren) Spouse: 40% of employee amount Child(ren): 10% of employee amount

● Child(ren) only 15% of employee amount

Employee Life InsuranceBasic and Voluntary Life Insurance benefits are paid to your beneficiary if you die while you are covered by the plan. Benefits under $5,000 are paid in a single cash payment. Benefits over $5,000 are set up in an interest-bearing checkbook account.

You are automatically covered for Basic Life Insurance, and you may purchase additional amounts of Voluntary Life Insurance. Your coverage is rounded up to the highest $1,000. Western Union pays the full cost of your Basic Life Insurance, and you pay for Voluntary Life coverage with after-tax payroll contributions. You must be actively at work when coverage begins.

Your maximum amount of life insurance, Basic Life plus Voluntary Life is $2,000,000.

Imputed IncomeThe value of your basic life insurance that exceeds $50,000 is considered imputed income and therefore taxable income. The income is imputed on the cost of life insurance; you pay taxes on imputed income just as though it were part of your regular paycheck. For example, if the value of your basic life insurance is $60,000, imputed income is calculated on $10,000.

Evidence of InsurabilityCigna may require you to provide evidence of insurability (proof of your good health) if your total amount of Voluntary Life exceeds the lesser of 3 times your annual benefits salary or $300,000. You must provide the evidence:

● When you first become insured for an amount of Voluntary Life insurance over 3 times or $300,000; and● For any increase in your insurance in Voluntary Life Insurance of more than one option over 3 times salary or $300,000.

Evidence of insurability is also required for any coverage amount if you did not elect coverage when first eligible.

142


Age Reduction Rule● On the date you reach age 65, the amount of your Basic and Voluntary Life insurance is reduced to 65% of the amount shown

in the Summary of Benefits.● On your 70th birthday, your insurance is further reduced to 45% of your pre-age 65 amount.● On your 75th birthday, your insurance is further reduced to 30% of your pre-age 65 amount.● On your 80th birthday, your insurance is further reduced to 20% of your pre-age 65 amount.● Accelerated Benefit

The plan’s accelerated death benefit (ADB) feature allows you or your spouse to receive a partial life insurance benefit if you become terminally ill (life expectancy of less than 24 months) while covered by the plan. Your request to Cigna for ADB must state the benefit amount requested and include a physician’s statement that you or your spouse is terminally ill along with medical test and lab reports and any other supporting medical information. An ADB limit of 75% of the benefit amount to a maximum of $500,000 applies.

The ADB benefit may be paid in a lump sum. The life insurance benefit paid to your beneficiary will be reduced by the amount of any accelerated death benefit paid to you.

If You Are Totally Disabled

If you become totally disabled while covered by the plan and you are less than age 60 when your disability starts, your death benefit protection (Waiver of Premium) will be extended while you are disabled. This protection exempts the employee from paying premiums after disabled for 9 months (from the date of disability). If an employee is approved for life waiver of premium while they are disabled, any premium they were paying for spouse or dependent child coverage would also be waived.

Your approved total disability must begin while you are insured (Basic and, if applicable, Voluntary Life). If an employee is approved for life waiver of premium, no one needs to pay premium for the coverage. The extension period will end on the first to occur of:

● The date you are well enough to work at any reasonable job;● The date you begin work in any job for pay or profit;● The date you retire; or● The date you reach age 65.

If an employee is approved by Cigna for Life waiver of premium and they retiree with their employer, this doesn’t stop the waiver of premium benefit.

Annual Benefits SalaryYour annual benefits salary is used to calculate your coverage amount for the Basic and Voluntary Life Insurance and Basic and Voluntary AD&D Insurance Plans.

When you first join Western Union, your annual benefits salary for the rest of the plan year is calculated using your base salary. After that, your annual benefits salary is determined as of the annual “salary frozen date” – usually in October before the year in which the election takes effect. If your salary increases or decreases during the year, your annual benefits salary and coverage amounts are not adjusted until the next annual enrollment. If your salary changes because of a switch from full-time to part-time or vice versa, your annual benefits salary and coverage amounts will be adjusted. For employees whose pay is commission based, annual benefit salary for your second and later years with the Company will include commissions from the prior year.

Your annual benefits salary includes your base salary before any salary reduction for before-tax contributions to the savings plan, flexible spending accounts and other health and insurance plans. Annual benefits salary does not include overtime, bonuses, shift differential and any other form of compensation you might receive, with the exception of commissions described in the preceding paragraph.

Dependent Term Life Insurance

Dependent Life Insurance benefits are paid to you if your covered dependent dies while covered by the plan. You must elect Voluntary Life Insurance to purchase spouse and/or child life insurance coverage.The maximum amount of Dependent Spousal Life Insurance is 50% of the employee’s amount of Voluntary Life Insurance to a maximum of $250,000.

143


Evidence of InsurabilityCigna may require you to provide evidence of insurability (proof of good health) for your spouse or domestic partner in the following circumstances:

● When your spouse/domestic partner first becomes insured for an amount of Dependent Life Insurance over $50,000; and● Any time you wish to increase in the amount of insurance for your spouse/domestic partner over one option ($10,000).

Evidence of insurability is also required for any coverage amount elected for a spouse if you did not elect coverage when first eligible.

Child life insurance does not require Evidence of Insurability.

Cigna will review the evidence of insurability and inform you of the approval or denial.

Age Reduction Rule● On the date your spouse/domestic partner reach age 65, the amount of your Spouse Life insurance is reduced to 65% of the

amount shown in the Summary of Benefits.● On their 70th birthday, your insurance is further reduced to 45% of your pre-age 65 amount.● On their 75th birthday, your insurance is further reduced to 30% of your pre-age 65 amount.● On their 80th birthday, your insurance is further reduced to 20% of your pre-age 65 amount.

Suicide ExclusionNo Voluntary Life or Dependent Life benefits will be paid for death by suicide or due to intentionally self-inflicted injury within two years from the effective date of coverage. If such death occurs after one year of the coverage effective date but within one year that any increase becomes effective, no benefit will be payable for any increase. Suicidal exclusion is not applicable to Basic Life Insurance benefit.

Accidental Death and Dismemberment InsuranceAccidental Death and Dismemberment (AD&D) Insurance covers a loss due to accidental injury that occurs while you are covered by the plan. The loss must be the direct result of an accident. Benefits are payable to your beneficiary if you die, or to you if you suffer a covered loss in an accident.

You are automatically covered for Basic AD&D, and you may purchase additional amounts of Voluntary AD&D.

Cost of CoverageWestern Union pays the full cost of your Basic AD&D. You pay for Voluntary AD&D through payroll after tax deductions. You can elect coverage for yourself only or for you and your eligible family members.

How a “Loss” Is DefinedLoss means:

● Loss of your life; irrecoverable and complete;● Accidental exposure or disappearance;● Loss of your sight, irrecoverable and complete;● Loss of a hand (severance at or above the wrist joint);● Loss of a foot (severance at or above the ankle joint);● Loss of your speech, permanently and totally;● Loss of your hearing in both ears, permanently and totally;● Loss of the thumb and index finger (of the same hand by actual severance of the entire digit);● Quadriplegia (permanent and total paralysis of both arms and both legs);● Paraplegia (permanent and total paralysis of both legs);● Hemiplegia (permanent and total paralysis of both an arm and a leg on the same side of the body);● Uniplegia (irrecoverable and total paralysis of one limb);● Third Degree Burns (covering 50% or more of the person’s body).

Only one amount – the largest to which you are entitled – will be paid for all losses resulting from a single accident. The loss must take place within 365 days after an accident for AD&D benefits to be payable.

144


Benefits Example

Employee with $100,000 of coverage: Dependent benefit:

● Spouse only $50,000

● Spouse and child(ren) Spouse: $40,000 Child(ren): $10,000

● Child(ren) only $15,000

AD&D BenefitsDepending on the type of loss, the plan pays benefits as a percentage of your full benefit amount, as follows:

Type of Loss BenefitPayable*

Loss of life (including exposure or disappearance) Full benefit

Quadriplegia Full benefit

Loss of:

● both hands● both feet● eyesight in both eyes● hearing in both ears and speech● loss of one hand or one foot and sight in one eye● Quadriplegia

Full benefit

Paraplegia

Hemiplegia

75% of the full benefit


Loss of:

● one hand● one foot● the eyesight in one eye● speech● hearing (both ears)


Third-degree Burns

● 75% or more of body● between 50% - 74% of body● between 25% - 49% of body

Full benefit75% of the full benefit50% of the full benefit

Uniplegia 25% of the full benefit

Loss of thumb and index finger of the same hand

Loss of all 4 fingers of the same hand


* The full benefit, or principal sum, equals the Basic AD&D amount.

145


Age Reduction RuleOn the date your spouse/domestic partner reach age 65, the amount of your Spouse Life insurance is reduced to 65% of the amount shown in the Summary of Benefits. On their 70th birthday, your insurance is further reduced to 45% of your pre-age 65 amount. On their 75th birthday, your insurance is further reduced to 30% of your pre-age 65 amount. On their 80th birthday, your insurance is further reduced to 20% of your pre-age 65 amount.

Special Forms of AD&D CoverageThe plan pays an additional benefit in the following circumstances:

PassengerRestraintBenefitThe plan pays a benefit if you die as the result of an accident that occurs while you are the driver of, or a passenger in, a four-wheel vehicle, and you are wearing a passenger restraint at the time of the accident. The seat belt benefit is $10,000.

AirBagBenefitThe plan pays a benefit if you die as the result of an accident that occurs while you are the driver of, or a passenger in, a four-wheel vehicle, if the vehicle is equipped with a factory-installed air bag system and you are wearing a seat belt at the time of the accident. The air bag benefit is $5,000.The plan will pay no more than a combined maximum of $15,000 for the Passenger Restraint plus Air Bag benefits.

ReturnofRemainsBenefitThe plan pays a benefit for the return of your remains to the U.S. or Canada if loss of life occurred while outside a 100-mile radius of your principal place of residence. The benefit is the lesser of the covered expenses or $5,000.

ComaBenefitThe plan pays a monthly benefit if you suffer a bodily injury and are in a coma as a direct result of an accident. The coma must begin within 30 days after the accident; and continue for at least 30 consecutive days. The Coma Benefit is 1% of the full AD&D benefit.

EducationBenefitThe plan pays a benefit to each of your dependent children if you and/or your covered spouse die as a direct result of an accident. The education benefit is only paid if the employee dies as a result of a covered accident. Eligible dependents must be under age 26 and attending school (up to and including 12th grade, college or trade school) on a full-time basis at the time of your or your spouse’s death, or enrolls in college or trade school within 365 days of your or your spouse’s death.

The plan pays a benefit to your surviving spouse for costs incurred, as a result of your death, towards employment training if your spouse has enrolled for the purpose of obtaining or supplementing an independent source of income. Written proof of enrollment must be provided within 365 days of your death. The benefit is equal to 6% of the full AD&D benefit not to exceed $6,000 per year for up to 4 years.

ChildCareBenefitIf you or your covered spouse dies as a result of an accident, a child care benefit is payable on behalf of your children who are enrolled in a legally licensed day care center. The child care benefit only pays if the death is the result of a covered accident. Eligible dependents are your biological, adopted or stepchildren or any other child you support that lives with you. Eligible dependents must be under age 13 and enrolled in a legally licensed day care center on the day of the accident or within 90 days afterward. The employee also has to have legal guardianship of any other child who lives with the employee and is supported by the employee. The benefit is equal to 6% of the full AD&D benefit not to exceed $6,000 per child for up to 4 years.

What AD&D Insurance Does Not CoverCommon ExclusionsIn addition to any benefit-specific exclusions, benefits will not be paid for any Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits Section:

1. intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane;2. commission or attempt to commit a felony or an assault;3. commission of or active participation in a riot or insurrection;4. bungee jumping; parachuting; skydiving; parasailing; hang-gliding;

146


5. declared or undeclared war or act of war;6. flight in, boarding or alighting from an Aircraft or any craft designed to fly above the Earth’s surface:

a. except as a passenger on a regularly scheduled commercial airline;b. being flown by the Covered Person or in which the Covered Person is a member of the crew;c. being used for:

i. crop dusting, spraying or seeding, giving and receiving flying instruction, fire fighting, sky writing, sky diving or hang-gliding, pipeline or power line inspection, aerial photography or exploration, racing, endurance tests, stunt or acrobatic flying; or

ii. any operation that requires a special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on);

d. designed for flight above or beyond the earth’s atmosphere;e. an ultra-light or glider;f. being used for the purpose of parachuting or skydiving;g. being used by any military authority, except an Aircraft used by the Air Mobility Command or its foreign equivalent;

7. sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food;

8. travel in any Aircraft owned, leased or controlled by the Subscriber, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be ‘controlled’ by the Subscriber if the Aircraft may be used as the Subscriber wishes for more than 10 straight days, or more than 15 days in any year;

9. a Covered Accident that occurs while engaged in the activities of active duty service in the military, navy or air force of any country or international organization. Covered Accidents that occur while engaged in Reserve or National Guard training are not excluded until training extends beyond 31 days.

10. operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Covered Person has been provided a written warning against operating a vehicle while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the law of the state in which the Covered Accident occurred;

11. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;

12. in addition, benefits will not be paid for services or treatment rendered by a Physician, Nurse or any other person who is:a. employed or retained by the Subscriber;b. providing homeopathic, aroma-therapeutic or herbal therapeutic services;c. living in the Covered Person’s household;d. a parent, sibling, spouse or child of the Covered Person

Life and Accident ClaimsAll claims should be reported promptly. To receive benefits, you or your beneficiary must file a claim, including proof of loss, within 90 days after the date of the loss. There are two exceptions:

● If your coverage provides for the periodic payment of benefits at monthly or shorter intervals, the proof of loss must be provided within 90 days after the end of each payment period.

● If your claim is for charges incurred during a calendar year, the proof of loss must be provided within 90 days after the end of that year.

If, through no fault of your own, you are not able to meet the deadline for filing a claim, your claim will still be accepted if you file as soon as possible.

To file a death claim, contact the Western Union Health and Life Benefits Department at [email protected].

Claim Processing Time FramesBenefits will be paid as soon as the necessary proof to support the claim is received. You may request a review of any denied claim. You will have 60 days (180 days for Premium Waiver claims) following receipt of an adverse benefit decision to appeal the decision. The request must be submitted to Cigna in writing and include your reasons for requesting the review. You will be notified of the decision within 60 days (45 days for Premium Waiver claims) after the appeal is received. If an extension for processing the appeal is needed, the time period may be extended up to 60 days (45 days for Premium Waiver claims).


147


Physical ExamCigna has the right to examine the person whose loss is the basis of a claim. Exams will be performed when and as often as is reasonable while a claim is pending. Cigna will pay the exam costs. Cigna may, at its expense, require an autopsy unless prohibited by law.

Legal ActionNo legal action can be brought to recover a benefit after 3 years from the deadline for filing death claims.

Assignment

Assignment of life insurance coverage is permitted under the policy provided Cigna and Western Union consent to the assignment. Assignment is the signed transfer of benefits of a policy by an insured to another party

Conversion

Conversion is permitted under the life and accident policy. Conversion allows an employee the right to elect to have a new policy issued that will continue the insurance coverage on an individual basis. Conversion must be requested within 31 days of termination. You may apply for any type of life insurance offered by Cigna to persons of the same age in the amount applied. Evidence of insurability is not required.

This information is for informational purposes only and is not a contract. This information is intended to provide a general review of the plan described. Please remember that only the insurance policy can give actual terms coverage, comments, conditions and exclusions. For more information contact Cigna.

148

Business Travel Accident Coverage 148

Business Travel Accident CoverageWestern Union provides extra protection if you die or are severely injured in an accident while traveling for your job. These benefits are paid in addition to amounts paid from your life insurance and AD&PL plans. This coverage (Business Travel Accident Insurance) is insured by AIG. In certain circumstances, your spouse and your dependent children, and interns and guests of the Company are eligible for coverage when they accompany you.

● If you die as a result of a business travel accident, your beneficiary will receive benefits in addition to employee life insurance, supplemental life insurance, and AD&PL coverage, if you’re enrolled in those plans. Your beneficiary will need to file a claim for benefits.

● If the accident results in paralysis or the loss of your hand, foot, sight, hearing, speech, or thumb and index finger, you’ll receive the applicable percentage of benefits. You’ll need to file a claim for benefits.

In certain circumstances, the plan may provide other benefits, such as medical payments and dependent coverage as well.

Certain exclusions apply.

The plan provides a specific amount of coverage (called the “principal sum”) of coverage class:

Class PrincipalSum/BenefitsandLimits Accidental Death and Dismemberment

Class I – Employee (including non-US domestic employees of the Company)

4 times annual benefits salary, up to $1 million*

Class II – Spouse or Domestic Partner of the employee $50,000Class III – Dependent child(ren) of the employee $25,000Class IV – Guests of the Company $25,000Class V – Interns of the Company $25,000

* Hazards H21 (On Premises Violent Crime) and H34 (On Premises Bomb Scare) subject to a $250,000 maximum.

Once an insured member of the above classes turn age 75, the Plan reduces the principal sum by the following schedule:

Age Percent of Original Principal Sum

70–74 65% of original principal sum75–79 45% of original principal sum80–84 30% of original principal sum85 or older 15% of original principal sum

Coverage

Class I, II, III, IV, V ● H21 – On Premises Violent Crime● H34 – On Premises Bomb Scare● H38 – 24 Hour Hijacking● H39 – War Risk (Business Only)

Class I, IV, V ● H12 – 24-Hour Accident Protection While on a Trip (Business Only)Class II, III ● H44 – Family Accompanying the Insured

Who Is CoveredThe Business Travel Accident Insurance Plan provides coverage to certain classes of individuals when traveling on Western Union business.

Class I - Eligible Employee

The plan pays benefits for accidental death or injury you may incur while on a business trip. The plan does not pay benefits for accidental death or injury you may incur while on vacation or while traveling to and from work.

149


Class II and III - Eligible Spouse and Dependent Children

The plan pays benefits for accidental death or injury your spouse or child(ren) may incur while traveling with you to, from, or while at any destination on a specific Western Union business trip authorized and paid for by Western Union or a corporate domestic relocation.

Class IV - Eligible Guest

The plan pays benefits for your eligible guests when they accompany you on a specific Western Union-related business trip. Western Union must authorize such travel and pay for the associated expenses. The plan pays benefits for accidental death or injury your eligible guests may sustain while traveling with you to, from, or while at any destination. An eligible guest is a nonemployee of Western Union who is traveling with a covered employee and/or has been invited to attend an event, function, meeting, or any other company-related activity along with a covered employee or as an individual.

Class V - Eligible Interns

The plan pays benefits for eligible interns when traveling on authorized Western Union business.

Cost of CoverageWestern Union pays the full cost of business travel accident insurance. You do not make contributions for this coverage.

Covered Business TravelYou’re covered while traveling on company business. “On company business” means while on an assignment for the company. Your trip begins when you leave your residence or primary work location. Your trip continues until you return to your residence or primary work location, whichever occurs first.

You’re not covered while:

● Commuting between your home and your primary work location● You’re on vacation

If you’re working overseas on a permanent or temporary assignment, you are covered while traveling to and from the assignment. You also are covered while at your assignment at an overseas location.

Commercial AircraftYou’re covered while traveling on an aircraft if the aircraft:

● Is operated by a properly certified pilot● Has a current unrestricted airworthiness certificate● Is not being used for fire fights, power line inspection, or exploration

Benefit AmountsDepending on your loss, you or your beneficiary will receive a percentage of your business travel accident insurance benefit amount, based on the schedule of benefits.

Maximum BenefitsThe most you can receive is 100% of the full amount of your business travel accident benefit, even if more than one loss results from the same accident.

If more than one employee suffers a covered injury or dies as the result of the same business travel related accident, the maximum amount the plan will pay is $10 million. This means that the total of all benefits paid to all eligible beneficiaries and employees because of one accident can’t be more than $10 million, with the exception of the On-Premises Violent Crime and On-Premises Bomb Scare provisions, which are limited to $250,000 maximum.

Accident Medical Expense BenefitThe Business Travel Accident Insurance Plan will pay usual and customary and medically necessary charges incurred for covered accident medical services received due to an injury up to $25,000 for all injuries caused by the same accident. This benefit is payable for charges incurred within 52 weeks after the accident date causing the injury. Expenses must begin within 90 days of the accident. Arrangements must be made by Travel Guard, (AIG’s Benefits Travel Assist).

150


Covered Accident Medical Services include:● Hospital semi-private room and board● Services of a physician or a registered nurse● Ambulance service to or from a hospital● Laboratory tests● Radiological procedures● Anesthetics and the administration of anesthetics● Blood, blood products, and artificial blood products, and the transfusion thereof● Physical therapy and occupational therapy● Rental of Durable Medical Equipment● Artificial limbs, artificial eyes, or other prosthetic appliances● Medicines or drugs administered by a physician or that can be obtained only with a physician’s written prescription.

Accident Medical Services does not cover:

● Repair or replacement of existing artificial limbs, artificial eyes, or other prosthetic appliances, or rental of existing Durable Medical Equipment unless for the purpose of modifying the item because injury has caused further impairment in the underlying bodily condition.

● New, repair of, or replacement of dentures, bridges, dental implants, dental bands, braces, other dental appliances, crowns, caps, inlays or onlays, fillings or any other treatment of the teeth or gums, except for repair or replacement of sound natural teeth damaged or lost as a result of injury (not to exceed $250 per tooth per accident).

● New eye glasses or contact lenses, or eye examinations related to the correction of vision or to fit glasses or contact lenses, unless injury has caused impairment of sight.

● Repair or replacement of existing eyeglasses or contact lenses unless for the purpose of modifying the item because injury has caused further impairment of sight.

● Rental of Durable Medical Equipment where the total rental expense exceeds the usual purchase expense for similar equipment in the locality where the expense is incurred (in such case, the insurer may – but is not required to – choose to consider such purchase expense as a usual and customary covered accident medical expense in lieu of such rental expense).

● Personal comfort or convenience items, such as but not limited to hospital telephone charges, television rental, or guest meals.● Any condition for which the insured individual is entitled to benefits under any worker’s compensation or similar law.● An emergency evacuation for which any benefits are payable under the Emergency Medical Benefit.

Seat Belt and Air Bag BenefitUnder the Business Travel Accident Insurance Plan, the plan pays a seat belt and air bag benefit equal to 10% of the principal sum, up to $35,000. The plan pays benefits if the insured individual suffers a covered loss as a result of an automobile accident while both of these apply:

● Wearing a properly fastened, original, factory-installed seat belt, or an infant/child restraint system● Driving or riding in a vehicle driven by a driver who is not under the influence of alcohol or drugs

If a seat belt benefit is payable and the insured person is positioned in a seat protected by a properly functioning, properly fastened original airbag that inflates on impact, an additional benefit equal to 10% of the original principal sum (up to $35,000) will be paid.

Repatriation of Remains BenefitIf you or a covered dependent die as a result of an accident for which benefits are payable, the plans cover expenses incurred to return the body to the place of primary residence, up to a maximum of $20,000. Covered expenses include embalming or cremation and transportation of the insured’s remains. Arrangements must be made through Travel Guard, (AIG’s Benefits Travel Assist).

Emergency Evacuation BenefitIf you or a covered dependent suffer an injury or emergency sickness that requires an emergency evacuation, the plans pay for covered emergency evacuation expenses reasonably incurred (up to $50,000) related to the injury or sickness. Your physician must certify that the severity of the injury or sickness warrants the emergency evacuation and the transportation arrangements must be the most direct and economical conveyance and route possible. The arrangements must be made by Travel Guard (AIG’s Benefits Travel Assist).

151


On-premises Violent Crime BenefitUnder the Business Travel Accident Insurance Plan, coverage will be extended on Western Union’s premises should an insured person sustain an injury as a result of a criminal act of violence. This act of violence cannot be an act of:

● The insured person● An immediate family member● An employee of Western Union● A former employee of Western Union whose employment with Western Union ended less than 6 months before the date of

the act of violence● An individual who resides with the insured person on a permanent basis

A moving violation as defined under the applicable state motor vehicle laws, unless purposely directed at the insured person.

This coverage is limited to 4 times annual benefit salary to a maximum of $250,000. The maximum amount the plan will pay per accident to all covered is $10 million.

On-premises Bomb Scare BenefitUnder the Business Travel Accident Insurance Plan, coverage will be extended on Western Union’s premises should an insured person sustain an injury as a result of a bomb scare or bomb explosion directed at Western Union, its property, or assets. The bomb scare or explosion cannot be an act of the insured person, an employee, or former employee whose employment ends less than 6 months before the date of the bomb scare of explosion.

This coverage is limited to 4 times annual benefits salary to a maximum of $250,000. The maximum amount the plan will pay per accident to all covered is $10 million.

War RiskUnder the Business Travel Accident Insurance Plan, coverage will be extended to include losses resulting from declared or undeclared acts of war that occur worldwide with the exception of the United States, Canada, or the injured person’s country of permanent residence. The coverage only applies with respect to accidents that occur while within the geographic limits or territorial waters of, or airspace above the geographic limits or territorial waters of, a Designated War Risk Territory

Designated War Risk Territories can change at any time with advance notice from the carrier depending upon changes in the War Risk exposure.

24-hour HijackingThis coverage is applicable to the insured class defined above and only with respect to injury sustained by such person as a result of a hijacking of any land, water or air conveyance, except a private automobile, where the hijacking is not an act of the insured person, an immediate family member, an employee of the company, a former employee of the company whose employment with the company ended less than six months before the date of the hijacking or an individual who resides with the insured person on a permanent basis.

This coverage will not duplicate coverage under any other hazard provided by this policy nor will it apply while performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft. Exclusion 3 (i.e., declared or undeclared war) in the Exclusion section of the policy is also waived, but only with respect to injury sustained by such person under the circumstances descried in this hazard benefit. All other exclusions apply. Hijacking means taking unlawful possession of a conveyance by means of force or threats against the person(s) then rightfully occupying such conveyance.

AIG Benefits Travel AssistTravel Assistance Services are provided under the Business Travel Accident Insurance Plan. AIG Benefits Travel Assist provides the Travel Assistance Services to insured employees and other classes of covered individuals. Travel Assistance Services are provided while the covered individual is traveling a distance of 100 miles or more away from their residence or permanent place of assignment for business travel.

Travel Assistance Services include, but are not limited to:

● Pre-departure Services – You can get information on immunization requirements, appropriate medical exams and treatments, passport and visa requirements, weather, and travel hazards.

● Lost Baggage/Passport – Provides immediate telephone advice to a traveler whose baggage has been lost or delayed by a carrier. This service also notifies the appropriate authorities of a traveler’s lost passport and provides directions for replacement.

152


● Insurance Coordination – Can help you complete insurance and medical claim forms. This service can also help you verify your insurance coverage and guarantee payment to a medical provider based on the confirmation of your insurance benefits or your credit card.

● Evacuation and Repatriation – If a medical emergency requires you to be evacuated to a treatment facility, AIG Benefits Travel Assist can coordinate your emergency medical evacuation. If you should lose your life while traveling, this service can coordinate the repatriation of your remains.

● Travel Medical Emergency Services – This service can help you obtain local medical care, monitor the quality and cost of the hospital treatment, confirm travel medical expense insurance, guarantee payment to the provider of medical services using your financial resources (or that of the BTA Plan), and arrange the payment of noninsured medical expenses.

● Legal Assistance – This service can arrange help from local attorneys, embassies, and consulates.

To contact AIG Benefits Travel Assist from the United States or Canada, call 1-877-244-6871. To call collect from anywhere else in the world, contact an International Operator to place your call to Houston (Texas) at: 1-715-346-0859. You will need the Group Name (The Western Union Company), the Assistance Number (3473) and the Policy Number (GTP 0009111243).

Benefits for Other LossesIf an accident results in the paralysis or loss of your hand, foot, sight, hearing, or speech, you’ll receive a percentage of your total benefit, based on the schedule of benefits.

Schedule of BenefitsThe Business Travel Accident Insurance Plan has predetermined coverage amounts. Depending on the nature of your injury, you or your beneficiary will receive a percentage of the total coverage amount. For benefits to be payable:

● The loss suffered must be the direct result of accidental injury while traveling on company business, and from no other cause.● The loss must occur within 365 days of the accident.

The plan doesn’t cover certain exclusions or any accidental losses not listed. You or your beneficiary will receive a percentage of your principal sum for these losses:

Loss Coverage Amount

Both hands or both feet 100%

Sight of both eyes 100%

One hand and one foot 100%

One hand and the sight in one eye 100%

One foot and the sight in one eye 100%

Speech and hearing in both ears 100%

Sight in one eye 50%

One hand or one foot 50%

Speech 50%

Hearing in both ears 50%

Hearing in one ear 25%

Thumb and index finger of the same hand 25%

Loss of a hand or foot means that the hand or foot is completely severed at or above the wrist or ankle joint.

Loss of sight means the complete and permanent loss of sight.

Loss of hearing means permanent, total deafness in both ears that can’t be corrected to any functional degree by any aid or device.

Loss of speech means total and irrevocable loss of audible communication.

If an insured individual suffers more than one of the above losses as a result of the same accident, only one amount - the largest - will be paid.

153


How the Plan Pays BenefitsThe Business Travel Accident Insurance Plan will pay benefits to your beneficiary if you die as the result of a covered accidental injury. If you name more than one beneficiary, the plan pays benefits equally among the survivors unless you request otherwise.

If your covered spouse or child is eligible to receive benefits from the Business Travel Accident Insurance Plan, the plan pays benefits directly to you, provided you are living. If you are not living and your spouse dies, the plan pays benefits to your spouse’s estate. If you are not living and you covered child dies, the plan pays benefits to your spouse (if living); your child’s surviving brother and/or sisters or your child’s estate (if not other survivors).

Business Travel Accident ClaimsIf you or your covered dependent dies or suffers a covered loss as the result of an accident, you or your beneficiary should notify the Western Union Health & Life Benefits Team at [email protected].

You will be provided with the appropriate claim form. Once you have completed the form, return it to the Western Union Health & Life Benefits team, who will certify coverage and forward the claim to AIG.

Proof of ClaimThe insurer reserves the right to verify claim information. If the claim is pending, you or your covered dependent may be asked to provide additional information or take an examination at the insurer’s expense. If you or your covered dependent dies, the insurer reserves the right to request an autopsy unless forbidden by law. If a claim is denied in whole or in part, you have the right to request a review by the insurer.

ExclusionsBenefits will not be paid for any loss caused by or resulted (in whole or in part) from:

● Suicide or any attempt at suicide or intentionally self-inflicted injury or any attempt at intentionally self-inflicted injury● Injuries you receive while traveling or flying in or on (including getting in or out of, or on or off of) any vehicle used for

flying if the insured is riding as a passenger in any aircraft not intended or licensed for the transportation of passengers, or learning to perform or instructing others to perform as a pilot or crew member of any aircraft

● Declared or undeclared war, or any act of declared or undeclared war, unless specifically provided by the policy● Full-time active duty in the armed forces or any country or international authority, except National Guard or organized

reserved duty corps● The insured person being under the influence of drugs or intoxicants, unless taken under the advice of a physician● The insured person’s commission of or attempt to commit a felony

This information is for informational purposes only and is not a contract. This information is intended to provide a general review of the plan described. Please remember that only the insurance policy can give actual terms coverage, comments, conditions and exclusions. For more information, contact AIG.


154

Short Term Disability Coverage 154

Short Term Disability CoverageThe Short Term Disability (STD) plan will continue to pay a portion of your salary if you are unable to work due to a non-occupational disease or injury.

Summary of Benefits

WeeklyBenefit 66-2/3% of weekly earningsWaiting Period 7 calendar daysMaximum Duration 26 weeks

If you are totally disabled as a result of an accidental injury or illness, unable to work and under the continuing care of a doctor, the plan will pay a disability benefit equal to 66-2/3% of your weekly pay after you satisfy the 7 calendar day waiting period. You will continue to receive this amount for up to 26 weeks for a “period of disability.” Payments will end earlier if you recover from your disability and are able to return to work on full duty.

Your weekly pay includes your base salary (including your base compensation for the year, before any salary reduction for before-tax contributions to the savings plan, Flexible Spending Accounts and other health and insurance plans) and commissions paid over the last 12 months. It does not include bonuses, incentive payments, overtime and extraordinary income.

If you have given birth, you may take up to 12 weeks of paid leave, during which you will receive 100% salary continuation (any available Transition Sick Leave must be used before the 100% salary continuation begins). The requirement to satisfy an Elimination Period does not apply. The leave taken pursuant to this policy will be designated as FMLA leave if you are eligible for FMLA leave such that your STD maternity leave and FMLA leave will run concurrently. The paid leave must be taken consecutively and cannot start prior to two weeks before your due date. STD leave may start earlier if required by a medical professional. The latest the paid leave can start is the date of the birth of your child.

Periods of DisabilityA “period of disability” starts on the first day you are disabled as a direct result of a significant change in your physical or mental condition while you are covered by the plan. Once a period of disability has ended, a new one will be treated separately. If two periods of disability are due to the same or related causes and separated by less than 15 consecutive calendar days, they will be considered one period of disability. In that case, only one waiting period will apply.

Reductions in STD PaymentsThe amount that you receive under this plan will be reduced by:● A state disability plan (Cigna is the insurer and administrator for the NY and HI statutory coverage)● “No-fault” automobile insurance;● Any formal sick leave plan provided by Western Union;● Any continuance of salary, including commissions;● Any other legislated disability plan;● Any amount of disability income or retirement benefits paid under a retirement plan provided by Western Union, except for

amounts attributable to your contributions;● Vocational rehabilitation pay;● Severance pay.

What the STD Plan Does Not CoverBenefits are not paid for a disability that is the result of:● Work-related injury or illness receiving Workers’ Compensation or occupational disease benefits;● Attempted suicide while sane or insane or intentional self-inflicted injury● Declared or undeclared war or act of war;● Commission of or attempt to commit an act that is a felony in the jurisdiction where it occurred;● Insurrection, rebellion or active participation in a riot or civil commotion;● Injury incurred while serving in the armed forces;● Injury sustained while confined to a penal or correctional institution after a conviction for a criminal or other public offense;● Work performed for another employer;● Injury or illness to the extent you are entitled to payment from a third party because of a judgment or settlement due to

your disability.

155

Short Term Disability Coverage 155

When STD Benefits EndBenefits end when any one of the following events occurs:

● You are no longer disabled;● You have received benefits for the maximum week benefit period;● You fail to provide the Plan Administrator with the required information;● You die;● You cease or refuse to participate in a rehabilitation program;● You fail to attend a medical examination as requested by the Plan Administrator; or● The date your employment ends.

Filing a Short Term Disability ClaimYour Short Term Disability claim must give proof of the nature and extent of your loss. Claims should be made right away to prevent a delay in benefit payments. The deadline for filing a claim is 31 days after your benefits are first payable.

If you are unable to meet the deadline through no fault of your own, late claims will still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims will not be covered if filed more than one year after the deadline.

You should notify your supervisor and Cigna Leave Solutions of your absence by contacting Cigna 1-888-842-4462 or at myCigna.com.

OverpaymentsWestern Union has the right to:

● Require return of overpayments on request;● Stop payments until an overpayment is recovered;● Take legal action to recover an overpayment; and● Place a lien, if not prohibited by law, in the amount of the overpayment on the proceeds of other income.

Making an AppealYou have 180 days from the receipt of an adverse benefit decision to request an appeal to Cigna Leave Solutions. You will generally be notified of the decision within 45 days after your appeal is received. If special circumstances require an extension of time up to an additional 45 days, you will be notified within 45 days of receipt of your request. The notice will outline the special circumstances requiring the extension and the date a decision is expected.

You have 60 days from the date of a first adverse appeal decision to file a final level appeal. Your final level appeal should be submitted in writing. You will generally be notified of the decision within 45 days after your final level appeal is received.

When you submit your appeal, you should include all additional information and documentation to substantiate your claim, including the reasons for your request to have your claim reinstated.

http://myCigna.com

156

Long Term Disability Coverage 156

Long Term Disability CoverageWhen Short Term Disability (STD) coverage ends, the Cigna Long Term Disability (LTD) plan will continue to pay a portion of your salary if you are seriously ill or injured and unable to work.

Summary of Benefits

MonthlyBenefit● Monthly Benefit Minimum● Monthly Benefit Maximum

66-2/3% of earnings

Greater of $100 or 10% of gross benefit$20,000

Waiting Period Benefits begin on the 181st calendar day after their date of disability

If you have been disabled for more than 181 days as the result of an accidental injury or disease and are under the regular care of a doctor, you may be eligible to receive Cigna Long Term Disability income payments. After you satisfy the waiting period, as the result of an injury or sickness, monthly benefits are payable for as long as you continue to be disabled up to the benefit maximum duration for a “period of disability.” Payments will end earlier if you recover from your disability and are able to return to work.

Your monthly pay (based on annual benefit salary) includes base salary (including your base compensation for the year, before any salary reduction for before-tax contributions to the savings plan, Flexible Spending Accounts and other health and insurance plans) and annual commissions averaged over the prior 12 months. It does not include bonuses, incentive payments, overtime and extraordinary income.

The Company pays the full cost of your Long Term Disability coverage. Any benefit paid to you is taxable income and subject to federal and state tax withholding.

If you die while disabled, a single, lump-sum benefit will be paid under this provision if:

● There is an Eligible Survivor as defined below; and● A Monthly Benefit was payable under this Plan.

The benefit amount will be six times the Monthly Benefit, not reduced by other income benefits, for which you were eligible in the full month just before the month in which you die.

If you die before you are eligible for one full Monthly Benefit, however, the benefit will be six times the Monthly Benefit, not reduced by other income benefits for which you would have been eligible if you had not died, for the first full month after the month in which you die.

An Eligible Survivor

The survivor benefit is only payable if the employee passes away while receiving LTD monthly benefits.

● Your legally married spouse at the date of your death.● If there is no such spouse and your biological or legally adopted child who, when you die:

o is not married; ando is depending mainly on you for support; ando is under age 21.

Cigna may also pay the survivor benefit to anyone who is caring for and supporting an eligible survivor or, if proper claim is made, to an eligible survivor’s legally appointed guardian or committee.

Annual Benefits SalaryYour annual benefits salary is used to calculate your coverage amount for the Long Term Disability Insurance Plans.

When you first join Western Union, your annual benefits salary for the rest of the plan year is calculated using your base salary. After that, your annual benefits salary is determined as of the annual “salary frozen date” – usually at the end of September before the year in which the election takes effect. If your salary increases or decreases during the year, your annual benefits salary and coverage amounts are not adjusted until the next annual enrollment. If your salary changes because of a switch from full-time to part-time or vice versa, your annual benefits salary and coverage amounts will be adjusted. For employees whose pay is commission based, annual benefit salary for your second and later years with the Company will include commissions from prior year. Salary is frozen for the year until the next annual enrollment period which the contract notes as October 1.

Your annual benefits salary includes your base salary before any salary reduction for before-tax contributions to the savings plan, flexible spending accounts and other health and insurance plans. Annual benefits salary does not include overtime, bonuses, shift differential and any other form of compensation you might receive, with the exception of commissions described in the preceding paragraph.

157


Definition of DisabilityIn the definition of disability - the test of disability such that the employee is not able to perform the material duties of their own occupation is only applicable for 24 months. After 24 months, we would be looking at any occupation in addition to the employee being unable to earn at least 60% of their pre-disability earnings.

You meet the plan’s test of disability if you are not able to perform the material duties of your own occupation solely because of disease or injury and:

● You are receiving appropriate care and treatment and complying with the requirement of such treatment;● You are unable to earn;● During the waiting period and the next 24 months of sickness or accidental injury, more than 80% of your pre-disability

earnings or adjusted pre-disability earnings at your own occupation from any employer in your local economy; and● After such period, more than 60% of your pre-disability earnings or adjusted pre-disability earnings from any employer

in your local economy at any gainful occupation for which you are reasonably qualified taking into account your training, education and experience.

Local economy means the geographic area within which you reside and which offers suitable employment opportunities within a reasonable travel distance. If you move on or after the date you become disabled, the plan may consider both your former and current residence to be your local economy.

Successive Disabilities

If you are not eligible for Short Term Disability benefits during the Long Term Disability waiting period, two or more periods of disability must be separated by less than 31 consecutive days.

After the waiting period, if you have two or more periods of disability separated by less than 6 months, and the periods of disability are due to the same or related causes, the successive periods will be considered to be one continuous period of disability.

Mental Nervous and Alcohol Drug LimitsIf your disability is due to a mental or nervous disorder or disease, your monthly disability benefits are limited to a maximum of 24 months per occurrence.

If you are confined in a hospital or mental health facility at the end of a benefit period, the plan will continue monthly disability benefits until the end of your stay. Cigna will determine if a disability is the result of a mental or nervous disorder or disease.

Mental or nervous disorder or disease means a medical condition that meets the criteria set forth in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders as of the date of your disability, excluding conditions with demonstrable, structural brain damage.

If your disability is due to alcohol, drug or substance abuse or addiction, your disability benefits are limited to one period of disability per occurrence. During your disability, the plan will require you to participate in an alcohol, drug or substance abuse or recovery program recommended by a physician. Your disability benefits will end at the earliest of the following dates:

● 24 months of disability benefit payments;● You cease or refuse to participate in a recovery program; or● You complete a recovery program.

Work Incentive BenefitWhile you are disabled, you are encouraged to work. If you work while you are disabled and receiving monthly benefits, your monthly benefit will be adjusted.

During the first 24 months that you have such income, your monthly benefit will be reduced by the amount that exceeds 100% of your pre-disability earnings as well as Other Income benefits.

After 24 months, your monthly benefit payable is the gross disability benefit reduced by other income benefits and 50% of your disability earnings.

158


Maximum Benefit Duration (Period of Disability)Your maximum benefit duration ends at the later of:

● The calendar month in which you reach normal retirement age, as determined by the 1983 Amended Social Security Normal Retirement Age; and

● The expiration of the benefit period, after the waiting period is met, as shown in the following chart (if your period of disability starts on or after you reach age 62)

Age When Disability Starts BenefitPeriod

62 but less than 63 42 months63 but less than 64 36 months64 but less than 65 30 months65 but less than 66 24 months66 but less than 67 21 months67 but less than 68 18 months68 but less than 69 15 months69 and over 12 months

Also see the Mental Nervous and Alcohol Drug Limits section for additional information relating to benefit maximum for a “period of disability.”

1983 Amended Social Security Normal Retirement Age

Year of Birth Normal Retirement Age

Before 1938 651938 65 and 2 months1939 65 and 4 months1940 65 and 6 months1941 65 and 8 months1942 65 and 10 months1943 to 1954 661955 66 and 2 months1956 66 and 4 months1957 66 and 6 months 1958 66 and 8 months1959 66 and 10 monthsAfter 1959 67

Applying for Social Security BenefitsCigna offers assistance with the Social Security application process. When you satisfy the criteria for Social Security, Cigna’s Social Security Assistance Specialists explain the process, assist with form completion, monitor progress and receive and evaluate Social Security Administration correspondence.

Mandatory RehabilitationCigna retains the right to evaluate you for participation in an Approved Rehabilitation Program. If, in Cigna’s judgment, you are able to participate, Cigna may, in its sole discretion, require you to participate in an Approved Rehabilitation Program.

The Plan will pay for all services and supplies, approved in advance by Cigna, needed in connection with such participation, except for those for which you can otherwise receive reimbursement from any third party payor, including any governmental benefits to which you may be entitled.

159


Reductions in LTD PaymentsOther Income Benefits include:

1. any amounts received (or assumed to be received*) by you or your dependents under:

o the Canada and Quebec Pension Plans;o the Railroad Retirement Act;o any local, state, provincial or federal government disability or retirement plan or law payable for Injury or Sickness

provided as a result of employment with the Employer;o any sick leave or salary continuation plan of the Employer;o any work loss provision in mandatory “No-Fault” auto insurance.

2. any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive*) on your own behalf or for your dependents; or which your dependents receive (or are assumed to receive*) because of your entitlement to such benefits.

3. any Retirement Plan benefits funded by the Employer. “Retirement Plan” means any defined benefit or defined contribution plan sponsored or funded by the Employer. It does not include an individual deferred compensation agreement; a profit sharing or any other retirement or savings plan maintained in addition to a defined benefit or other defined contribution pension plan, or any employee savings plan including a thrift, stock option or stock bonus plan, individual retirement account or 40l(k) plan.

4. any proceeds payable under any franchise or group insurance or similar plan. If other insurance applies to the same claim for Disability, and contains the same or similar provision for reduction because of other insurance, we will pay for our pro rata share of the total claim. “Pro rata share” means the proportion of the total benefit that the amount payable under one policy, without other insurance, bears to the total benefits under all such policies.

5. any amounts received (or assumed to be received*) by you or your dependents under any workers’ compensation, occupational disease, unemployment compensation law or similar state or federal law payable for Injury or Sickness arising out of work with the Employer, including all permanent and temporary disability benefits. This includes any damages, compromises or settlement paid in place of such benefits, whether or not liability is admitted.

6. any amounts paid because of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.

What the LTD Plan Does Not CoverWe will not pay any Disability Benefits for a Disability that results, directly or indirectly, from:

1. suicide, attempted suicide, or self-inflicted injury while sane or insane.

2. war or any act of war, whether or not declared.

3. active participation in a riot.

4. commission of a felony.

5. the revocation, restriction or non-renewal of your license, permit or certification necessary to perform the duties of your occupation unless due solely to Injury or Sickness otherwise covered by the Policy.

In addition, we will not pay Disability Benefits for any period of Disability during which you are incarcerated in a penal or corrections institution.

Pre-Existing Condition LimitationWe will not pay benefits for any period of Disability caused or contributed to by, or resulting from, a Preexisting Condition. A “Pre-existing Condition” means any Injury or Sickness for which you incurred expenses, received medical treatment, consulted with a health professional, or took prescribed drugs or medicines, within 3 months immediately preceding the most recent effective date of insurance. The Pre-existing Condition Limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of Disability that begins after you are covered for at least 12 months after your most recent effective date of insurance, or the effective date of any added or increased benefits.

When LTD Benefits EndBenefits end when any one of the following events occurs:

● You are no longer disabled;● You have received benefits for the maximum benefit period;● You die;

160


● You cease or refuse to participate in a rehabilitation program that the insurer requires;● You fail to have a medical exam required by the insurer;● You fail to provide required proof of disability.

While you are disabled, your benefit payments will not be affected if:

● Your insurance ends; or● The group policy is amended to change your plan of benefits.

Filing a Long Term Disability ClaimYour Long Term Disability claim must give proof of the nature and extent of your loss. The deadline for filing a claim is 90 days after the end of the waiting period.

If you are unable to meet the deadline through no fault of your own, late claims will still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims will not be covered if filed more than one year after the deadline.

You should notify your supervisor and the Cigna Leave Solutions of your absence by contacting Cigna at 888-842-4462 or at myCigna.com.

OverpaymentsCigna has the right to:

● Require return of overpayments on request;● Stop payments until an overpayment is recovered;● Take legal action to recover an overpayment; and● Place a lien, if not prohibited by law, in the amount of the overpayment on the proceeds of other income.

Making an AppealYou have 180 days from the receipt of an adverse benefit decision to request an appeal to Cigna Leave Solutions. You will generally be notified of the decision within 45 days after your appeal is received. If special circumstances require an extension of time up to an additional 45 days, you will be notified within 45 days of receipt of your request. The notice will outline the special circumstances requiring the extension and the date a decision is expected.

Coordination of Group Health Benefits with LTD BenefitsIf you are applying for or approved for benefits under the LTD plan, you may be able to continue any medical, dental or vision group coverage (“Group Health Coverage”) for up to 12 months. These conditions apply:

● Your Group Health Coverage will automatically continue following your eligibility for Short Term Disability benefits.● You are eligible for continued Group Health Coverage only if you remain employed by the Company. If your employment is

terminated either by you or the Company, your eligibility for Group Health Plan Coverage terminates.● Continued Group Health Coverage may extend from the time you apply for LTD benefits, through and including any LTD claim

or appeal decisions, but in not longer than 12 months beyond the end of your eligibility for Short Term Disability benefits.● You must already have been enrolled in such coverage or you subsequently elect Group Health Coverage during the

Company’s annual open enrollment period.● You are responsible for your share of the cost of any group Health Coverage and failure to submit payment in a timely

manner may result in termination of Group Health Coverage.● Upon the end of the maximum 12 month continuation of Group Health Coverage, if you do not obtain medical documentation

authorizing your return to work, the Company may terminate your employment and also your Group Health Coverage, if any.

In addition, you may be eligible to continue to participate in the Basic or Voluntary Life Insurance while disabled. Please see paragraph, If You Are Totally Disabled, under the Life and Accident Coverage section of this document for more information. If you are totally disabled and are approved for LTD, your Basic and Voluntary Accidental Death & Dismemberment coverage will end.

Finally, there may be additional voluntary benefits, e.g. legal services you are enrolled in that will terminate upon long term disability approval. However, these benefits may be convertible into individual policies. Please email [email protected] for more information.

This information is for informational purposes only and is not a contract. This information is intended to provide a general review of the plan described. Please remember that only the insurance policy can give actual terms of coverage, comments, conditions and exclusions. For more information contact Cigna.

http://myCigna.com


161

ARAG Legal Plan 161

ARAG Legal PlanEligibility for CoverageYou or your dependents may require legal assistance now or in the future. You have the option to elect the Legal Plan. Once you enroll, you can use a network of participating law firms or you can use the law firm of your choice. This coverage is provided by the ARAG Group.

How the Plan WorksThe Legal Plan offers you access to professional legal consultation and representation at low group rates. If you need legal assistance, call the plan’s client service representative. When your spouse or eligible dependent calls, he or she must also provide your Member ID Number (for example, your Social Security Number).

If you select the telephone advice option from the provider’s automated telephone system, an attorney will explain your rights, responsibilities and options for any covered legal matter. You can also receive a list of participating plan attorneys near you. You’ll be responsible for calling and scheduling an appointment with a plan attorney. The plan will cover 100% of all attorney fees for most covered matters when using a network attorney. You have no deductibles or copayments to make or claim forms to file.

If you prefer, you can also use an attorney who is not in the plan’s network and receive reimbursement for covered services according to a set fee schedule. If you see a non-network attorney, you’ll need to file a claim form along with the attorney’s itemized bill to be reimbursed. Generally, you must pay the attorney in advance.

If there is not a network attorney in your area, ARAG Group, the plan administrator will work with you to find an attorney and still receive full plan benefits.

Contacting a Network AttorneyIt’s your responsibility to call and schedule an appointment with a network attorney. Your network attorney will assess the situation, advise you of the legal services you need, and you and he or she will determine together whether the services are covered by the plan.

Contacting a Non-network AttorneyIf you prefer to see a non-network attorney for a personal consultation, you must call the plan administrator to verify coverage. You call the attorney to set up the appointment. You generally must pay the attorney in advance. When services have been completed, you’ll need to file a claim form with the plan administrator to be reimbursed.

Telephone Network AttorneysFor the fastest answer to your legal questions, call the toll-free number for telephone service and select the Telephone Advice option from the administrator’s automated system. You’ll be connected with a law firm in your state. An attorney will explain your rights, responsibilities and options for any legal matter covered under the plan.

ConfidentialityYour attorney will represent you on an individual basis and maintain the traditional lawyer-client relationship. Any shared information or services received are treated confidentially. As a result, Western Union is unaware of the legal services you or your dependents receive.

The plan administrator or the law firm is responsible for the services provided. The plan is not liable for a network attorney’s conduct. If you have any concerns or problems with your network attorney, you can call the plan administrator immediately.

Cost of CoverageYou pay for legal plan coverage with after-tax deductions from your paychecks.

162

ARAG Legal Plan 162

Benefits ProvidedRegardless of how many times you use the plan, or how time-consuming your legal matter may be, the plan will pay benefits for certain legal services. The following are some of the services available to you, your spouse, and your “eligible dependents” (unless otherwise noted). For a full list of benefits provided, please see the ARAG policy document.

Telephone Legal Services

Through telephone consultation, you can receive legal advice, follow-up calls and correspondence, specific document preparation, review of documents up to four pages, standard will preparation.

Document Preparation

The telephone network attorney will assist you with the preparation of these documents:

● Special powers of attorney or revocations● Childcare authorizations● Bad check notices● Challenge to denial of credit● Promissory notes and affidavits related to your personal property● Bills of sale related to your personal property

Standard and Complex Will Preparation

The plan covers in-office preparation of standard will documents, which include:

● Testamentary trusts for minor children● Husband and wife standard wills● Codicils● Living wills● Changes to wills● Durable powers of attorneyThe plan also covers partial reimbursement for plan members needing more than a simple will (for example, special trust provisions within the will).

Uncontested Dissolution of Marriage

This coverage provides legal services to you in an uncontested divorce, uncontested legal separation, and/or an uncontested annulment of marriage. The plan offers advice and negotiations prior to court proceedings and court representation.

Contested Dissolution of Marriage

This coverage covers in full for the first 15 hours of legal services (additional hours at a discounted rate not to exceed $85 per hour) for contested divorce, contested legal separation, and/ or contested annulment of marriage. The plan offers advice and negotiations prior to court proceedings and court representation.

Identity Theft Services

If a plan member has been or suspects that he or she has been a victim of identity theft, the case manager will:

● Explain what identity theft is and how to prevent it.● Provide resources to minimize and recover from identity theft.● Explain relevant plan coverage.● Monitor and follow up on the situation.● Provide an identity theft victim action kit.

Name Change Proceedings

The plan offers advice prior to court representation and court representation.

Juvenile Court Proceedings

The plan covers a covered child in juvenile delinquency proceedings (except traffic matters) and in proceedings regarding your parental responsibilities for a covered child (except traffic matters). The plan also offers representation at administrative hearings and court appearances.

163

ARAG Legal Plan 163

Court Adoption Proceedings

This coverage provides representation for you and your covered spouse in court adoption proceedings, to become adoptive parents, advice, and office work and court representation for both uncontested and contested adoption proceedings.

Guardianship/Conservatorship

This coverage provides paid in full benefits for the legal fees associated with appointing a guardianship or conservator whether contested or uncontested.

Defense of Family Law Decree Motions

The plan covers the legal services associated with the legal defense against a motion to modify or the legal defense against a motion to enforce a final decree regarding alimony, child custody or child visitation rights.

Enforcement of Final Child Support Decree

The plan covers legal advice and court representation in your motion to enforce a Final Child Support Decree.

Consumer Protection

The plan offers you legal representation for legal disputes about written or implied contracts or obligations for the acquisition, lease, use or financing of goods and services, including debt collection defense in a lawsuit as either a plaintiff or a defendant.

Property Protection

The plan covers legal disputes about contracts or obligations for the purchase, sale, or financing of your primary residence, legal disputes about the contracts or obligations for the transfer of your personal property, legal disputes with your landlord regarding your rights as a tenant to your primary residence, and legal disputes about your personal property rights. The plan will offer court representation to you as a plaintiff or defendant, including all preparations for court proceedings.

Property Transfers

The plan covers the following property transactions:

● Review and preparation of the necessary documents in the purchase or sale of your primary residence, including attendance of your attorney at closing.

● Preparation and review of deeds and mortgages, except those related to refinancing of real estate property or which are otherwise covered by the plan.

● Preparation and review of promissory notes and affidavits related to your personal property, lease contracts (lessee only), and consumer credit and/or installment sale contracts.

Civil Damage Defense

The plan provides legal representation for legal defense against civil damage claims, except claims involving the ownership or use of a motorized vehicle or claims, which are covered by other insurance. The plan provides legal service including advice, negotiations, office work prior to or without court representation. This benefit only covers you as the defendant.

Criminal Misdemeanor Protection

The plan provides legal defense against criminal misdemeanor charges, except those involving a motorized vehicle. The Plan provides legal services including advice, negotiations, office work, and court representation.

DrivingPrivilegeProtection(exceptdrivingwhileundertheinfluence)

The plan provides legal defense against misdemeanor traffic charges, which could directly result in the suspension or revocation of your driver’s privilege or legal disputes regarding the reinstatement of your driver’s privilege. The plan does not provide legal defense against charges of driving while impaired, or under the influence of alcohol or drugs.

IRS Debt Collection

The plan provides legal defense against collection actions by the Internal Revenue Service (IRS). (Partial reimbursement.)

IRS Audit Program

The plan offers legal services involving personal tax IRS audits for which you receive written notice while you are covered which relates to your personal tax return. (Partial reimbursement.)

Major Trial

The plan will cover major trial beginning with the fourth day of covered contested court proceedings.

164

ARAG Legal Plan 164

Immigration Assistance

The plan provides toll-free access to an immigration case manager for advice on filing and processing applications or petitions, advice to individuals facing deportation and removal proceedings, and information on laws and regulations governing various types of immigration benefits, including asylum, adjustment of status, business visas, and employment authorizations.

Coverage Restrictions● Legal services for matters that involve Western Union or its business units or affiliates● Legal matters against the Plan Provider or Administrator● Legal services related to personal or professional business interests, investment interests, workers’ or unemployment

compensation, occupation or relocation required by an employer and/or involving patents or copyrights● Legal services for the benefit of a non-covered person, or legal services for a person other than the named insured against the

interest of another insured under the same plan● Costs related to title insurance, title search, title abstracting, and any cost other than attorney’s fees● Legal representation deemed by the providing attorney to be lacking merit or representation that is, in the judgment of the

providing attorney, in violation of attorney ethic rules

The following are excluded from payment through the plan, but information can be obtained through Telephone Legal Services:

● Legal disputes involving insurance contracts or related to structural damage, noise, visual, or other intangible hindrances arising out of or affecting real estate property.

● Legal disputes arising out of the inheritance law or involving contracts related to family law matters.● Court representation in any court action, which is or can be brought in Small Claims Court or in similar court of limited

jurisdiction, appeals, or counter-claims.● Any legal matter that occurs or is initiated prior to the effective date of the member will be considered excluded, and no

benefits will apply. ARAG Group defines “initiated” as the date when the infraction occurs, a document is filed with the court, or when an attorney is hired.

For More InformationThis information is for illustrative purposes only and is not a contract. This information is intended to provide a general review of the plan described. Please remember that only the insurance policy can give actual terms, coverage, amounts, conditions, and exclusions.

To find a participating attorney or for more information, contact ARAG Group at 1-800-247-4184 or at araggroup.com.

http://araggroup.com

165

When Coverage Ends 165

When Coverage EndsYour coverage described in this SPD can end for a number of reasons. This section explains how and why your coverage can be terminated, and how you may be able to continue coverage after it ends.

For EmployeesYour coverage under this plan ends on the first to occur of the following events:

● Your employment stops, unless you are eligible for limited continued coverage under medical, dental, vision and/or FSA plans after your employment has terminated under the terms of a Company severance policy, plan, or agreement (in the case of an insured benefit, your coverage ceases on the last day of the calendar month in which your Active Service ends*);

● The coverage described in this booklet is terminated under the group contract;● You are no longer in an eligible class for all or part of your coverage; or● You fail to make any required contribution.

Western Union will tell Cigna and other carriers the date your employment ends. Also, Cigna will use the same rule for all similarly situated employees. If you are not at work on the date employment ends, your coverage may continue up to certain limits.

Coverage ends on the last day of the month in which employment ends for life insurance plans and, except as expressly provided above, for medical, dental, and vision plans. Coverage ends on the day your employment ends for STD, LTD, FSA (except as expressly provided above) and Business Travel Insurance plans.

If you are applying for or approved for benefits under the LTD plan, you may be able to continue any medical, dental or vision group coverage (“Group Health Coverage”) for up to 12 months. These conditions apply:

● Your Group Health Coverage will automatically continue following your eligibility for Short Term Disability benefits.● You are eligible for continued Group Health Coverage only if you remain employed by the Company. If your employment is

terminated either by you or the Company, your eligibility for Group Health Plan Coverage terminates.● Continued Group Health Coverage may extend from the time you apply for LTD benefits, through and including any LTD

claim or appeal decisions, but not longer than 12 months beyond the end of your eligibility for Short Term Disability benefits. ● You must already have been enrolled in such coverage or you subsequently elect Group Health Coverage during the

Company’s annual open enrollment period.● You are responsible for your share of the cost of any group Health Coverage and failure to submit payment in a timely

manner may result in termination of Group Health Coverage.● Upon the end of the maximum 12-month continuation of Group Health Coverage, if you do not obtain medical

documentation authorizing your return to work, the Company may terminate your employment and also your Group Health Coverage, if any.

In addition, you may be eligible to continue to participate in the Basic or Voluntary Life Insurance while disabled. Please see paragraph, If You Are Totally Disabled, under the Life and Accident Coverage section of this document for more information. If you are totally disabled and are approved for LTD, your Basic and Voluntary Accidental Death & Dismemberment coverage will end.

Finally, there may be additional voluntary benefits, e.g. legal services you are enrolled in that will terminate upon long term disability approval. However, these benefits may be convertible into individual policies. Please email [email protected] for more information.

If you stop active work, contact the Western Union Benefits Service Center (1-844-449-8236), for information on whether you can continue any of your coverage.

For DependentsYour dependent’s coverage under the medical, dental, vision, dependent life, voluntary AD&D and legal assistance plans will end on the earliest to occur of the following events:

● When all dependents’ coverage under the group contract is terminated;● When a dependent becomes covered as an employee;● When he or she no longer meets the plan’s definition of a dependent (see the Eligibility section) (Your dependent child’s

coverage ends at the end of the calendar year in which he or she reaches age 26.);● When your coverage terminates.


166

When Coverage Ends 166

RescissionsYour coverage may not be rescinded (retroactively terminated) by Cigna or the Plan sponsor unless:

● the Plan sponsor or an individual (or a person seeking coverage on behalf of the individual) performs an act, practice or omission that constitutes fraud; or

● the Plan sponsor or individual (or a person seeking coverage on behalf of the individual) makes an intentional misrepresentation of material fact.

FSAs and Employment Termination

Health Care FSAIf you leave during the year, you generally have two choices for your Health Care FSA (subject to the provisions of any severance policy, plan, or agreement):

● You can close your Account, in which case you’ll have until April 30 of the next year to submit claims for expenses incurred before your termination or employment date; or

● You can continue your contributions on an after-tax basis by electing COBRA coverage. (More on COBRA follows later in this section.) In this case, you can still claim reimbursements from your account for expenses incurred after you leave through the end of the year, provided you continue your FSA participation by making after-tax contributions.

Dependent Care FSAIf you leave during the year, your contributions to your Dependent Care FSA generally end (subject to the provisions of any severance policy, plan, or agreement). However, you can still be reimbursed for eligible expenses you incur up to your last day worked. You have until April 30 of the next year to submit claims.

If You are RehiredIf you terminate employment and are rehired within the same year, it will be considered a family status change. Upon your return to work, you may reenroll in the FSAs and have your prior elections reinstated.

Continuing Coverage Under COBRAIf your health plan is subject to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your dependents have the right to continue health coverage if it ends for the reasons (“qualifying events”) described below. You may continue only the plan coverage in effect at the time and must pay required premiums.

Qualifying Events and Continuation PeriodsThe chart below outlines:

● The qualifying events that trigger the right to continue coverage;● Those eligible to elect continued coverage; and● The maximum continuation period.

Qualifying Event Causing Loss of Coverage Covered Persons Eligible for Continued Coverage

Maximum Continuation Period

Termination of active employment (except for gross misconduct)

You Your spouse Your dependent children

18 months

Reduction in work hours You Your spouse Your dependent children

18 months

Divorce or legal separation Your spouse Your dependent children

36 months

Children no longer qualify as eligible for dependent coverage

Your dependent children 36 months

Your death Your spouse Your dependent children

36 months

The required premium for the 18- or 36-month continuation period may be up to 102% of the plan cost.

167

COBRA Continuation Rights Under Federal Law 167

COBRA Continuation Rights Under Federal LawFor You and Your Dependents

What Is COBRA Continuation Coverage?

Under federal law, you and/or your Dependents must be given the opportunity to continue health insurance when there is a “qualifying event” that would result in loss of coverage under the Plan. You and/or your Dependents will be permitted to continue the same coverage under which you or your Dependents were covered on the day before the qualifying event occurred, unless you move out of that Plan’s coverage area or the Plan is no longer available. You and/or your Dependents cannot change coverage options until the next open enrollment period.

When Is COBRA Continuation Available?

For you and your Dependents, COBRA continuation is available for up to 18 months from the date of the following qualifying events if the event would result in a loss of coverage under the Plan:

● your termination of employment for any reason, other than gross misconduct, or● your reduction in work hours.

For your Dependents, COBRA continuation coverage is available for up to 36 months from the date of the following qualifying events if the event would result in a loss of coverage under the Plan:

● your death;● your divorce or legal separation; or● for a Dependent Child, failure to continue to qualify as a Dependent under the Plan.

Who Is Entitled to COBRA Continuation?

Only a “qualified beneficiary” (as defined by federal law) may elect to continue health insurance coverage. A qualified beneficiary may include the following individuals who were covered by the Plan on the day the qualifying event occurred: you, your Spouse or same-sex Spouse, Domestic Partner and your Dependent Children. Each qualified beneficiary has his or her own right to elect or decline COBRA continuation coverage even if you decline or are not eligible for COBRA continuation.

The following individuals are not qualified beneficiaries for purposes of COBRA continuation: grandchildren (unless adopted by you), stepchildren (unless adopted by you). Although these individuals do not have an independent right to elect COBRA continuation coverage, if you elect COBRA continuation coverage for yourself, you may also cover your Dependents even if they are not considered qualified beneficiaries under COBRA. However, such individuals’ coverage will terminate when your COBRA continuation coverage terminates. The sections titled Secondary Qualifying Events and Medicare Extension for Your Dependents are not applicable to these individuals.

Secondary Qualifying EventsIf, as a result of your termination of employment or reduction in work hours, your Dependent(s) have elected COBRA continuation coverage and one or more Dependents experience another COBRA qualifying event, the affected Dependent(s) may elect to extend their COBRA continuation coverage for an additional 18 months (seven months if the secondary event occurs within the disability extension period) for a maximum of 36 months from the initial qualifying event. The second qualifying event must occur before the end of the initial 18 months of COBRA continuation coverage or within the disability extension period discussed below. Under no circumstances will COBRA continuation coverage be available for more than 36 months from the initial qualifying event. Secondary qualifying events are: your death; your divorce or legal separation; or, for a Dependent Child, failure to continue to qualify as a Dependent under the Plan.

Disability ExtensionIf, after electing COBRA continuation coverage due to your termination of employment or reduction in work hours, you or one of your Dependents is determined by the Social Security Administration (SSA) to be totally disabled under title II or XVI of the SSA, you and all of your Dependents who have elected COBRA continuation coverage may extend such continuation for an additional 11 months, for a maximum of 29 months from the initial qualifying event.

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

● SSA must determine that the disability occurred prior to or within 60 days after the disabled individual elected COBRA continuation coverage; and

● A copy of the written SSA determination must be provided to the Plan Administrator within 60 calendar days after the date the SSA determination is made and before the end of the initial 18-month continuation period.

168


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

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

Medicare Extension for Your DependentsWhen the qualifying event is your termination of employment or reduction in work hours and you became enrolled in Medicare (Part A, Part B or both) within the 18 months before the qualifying event, COBRA continuation coverage for your Dependents will last for up to 36 months after the date you became enrolled in Medicare. Your COBRA continuation coverage will last for up to 18 months from the date of your termination of employment or reduction in work hours.

Termination of COBRA ContinuationCOBRA continuation coverage will be terminated upon the occurrence of any of the following:

● the end of the COBRA continuation period of 18, 29 or 36 months, as applicable;● failure to pay the required premium within 30 calendar days after the due date;● cancellation of the Employer’s Policy with Cigna;● after electing COBRA continuation coverage, a qualified beneficiary enrolls in Medicare (Part A, Part B or both);● after electing COBRA continuation coverage, a qualified beneficiary becomes covered under another group health Plan,

unless the qualified beneficiary has a condition for which the new Plan limits or excludes coverage under a Pre-existing Condition provision. In such case coverage will continue until the earliest of:(a) the end of the applicable maximum period;(b) the date the Pre-existing Condition provision is no longer applicable; or(c) the occurrence of an event described in one of the first three bullets above; or

● any reason the Plan would terminate coverage of a participant or beneficiary who is not receiving continuation coverage (e.g., fraud).

Moving Out of Employer’s Service Area or Elimination of a Service AreaIf you and/or your Dependents move out of the Employer’s service area or the Employer eliminates a service area in your location, your COBRA continuation coverage under the Plan will be limited to Out-of-Network coverage only. In-network coverage is not available outside of the Employer’s service area. If the Employer offers another benefit option through Cigna or another carrier that can provide coverage in your location, you may elect COBRA continuation coverage under that option.

Employer’s Notification RequirementsYour Employer is required to provide you and/or your Dependents with the following notices:

● An initial notification of COBRA continuation rights must be 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). If you and/or your Dependents experience a qualifying event before the end of that 90-day period, the initial notice must be provided within the time frame required for the COBRA continuation coverage election notice as explained below.

● A COBRA continuation coverage election notice must be provided to you and/or your Dependents within the following time frames:o if the Plan provides that COBRA continuation coverage and the period within which an Employer must notify the Plan

Administrator of a qualifying event starts upon the loss of coverage, 44 days after loss of coverage under the Plan;o if the Plan provides that COBRA continuation coverage and the period within which an Employer must notify the Plan

Administrator of a qualifying event starts upon the occurrence of a qualifying event, 44 days after the qualifying event occurs; or

o in the case of a multi-Employer Plan, no later than 14 days after the end of the period in which Employers must provide notice of a qualifying event to the Plan Administrator.

169


How to Elect COBRA Continuation CoverageThe COBRA coverage election notice will list the individuals who are eligible for COBRA continuation coverage and inform you of the applicable premium. The notice will also include instructions for electing COBRA continuation coverage. You must notify the Plan Administrator of your election no later than the due date stated on the COBRA election notice. If a written election notice is required, it must be postmarked no later than the due date stated on the COBRA election notice. If you do not make proper notification by the due date shown on the notice, you and your Dependents will lose the right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due date, you may change your mind as long as you furnish a completed election form before the due date.

Each qualified beneficiary has an independent right to elect COBRA continuation coverage. Continuation coverage may be elected for only one, several or all Dependents who are qualified beneficiaries. Parents may elect to continue coverage on behalf of their Dependent Children. You or your Spouse may elect continuation coverage on behalf of all the qualified beneficiaries. You are not required to elect COBRA continuation coverage in order for your Dependents to elect COBRA continuation.

How Much Does COBRA Continuation Coverage Cost?Each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount may not exceed 102 percent of the cost to the group health Plan (including both Employer and Employee contributions) for coverage of a similarly situated active Employee or family member. The premium during the 11-month disability extension may not exceed 150 percent of the cost to the group health Plan (including both Employer and Employee contributions) for coverage of a similarly situated active Employee or family member. For example:

If the Employee alone elects COBRA continuation coverage, the Employee will be charged 102 percent (or 150 percent) of the active Employee premium. If the Spouse or one Dependent Child alone elects COBRA continuation coverage, they will be charged 102 percent (or 150 percent) of the active Employee premium. If more than one qualified beneficiary elects COBRA continuation coverage, they will be charged 102 percent (or 150 percent) 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 have to send any payment with the election form. However, you must make your first payment no later than 45 calendar days after the date of your election. (This is the date the Election Notice is postmarked, if mailed.) If you do not make your first payment within 45 days, you will lose all COBRA continuation rights under the Plan.

Subsequent payments

After you make your first payment for COBRA continuation coverage, you will be required to make subsequent payments of the required premium for each additional month of coverage. Payment is due on the first day of each month. If you make a payment on or before its due date, your coverage under the Plan will continue for that coverage period without any break.

Grace periods for subsequent payments

Although subsequent payments are due by the first day of the month, you will be given a grace period of 30 days after the first day of the coverage period to make each monthly payment. Your COBRA continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if your payment is received after the due date, your coverage under the Plan may be suspended during this time. Any providers who contact the Plan to confirm coverage during this time may be informed that coverage has been suspended. If payment is received before the end of the grace period, your coverage will be reinstated back to the beginning of the coverage period. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a payment before the end of the grace period for that coverage period, you will lose all rights to COBRA continuation coverage under the Plan.

170


You Must Give Notice of Certain Qualifying EventsIf you or your Dependent(s) experience one of the following qualifying events, you must notify the Plan Administrator within 60 calendar days after the later of the date the qualifying event occurs or the date coverage would cease as a result 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 discussed under Secondary Qualifying Events above. (This notice must be received prior to the end of the initial 18- or 29-month COBRA period.)

(Also refer to the section titled Disability Extension for additional notice requirements.)

Notice must be made in writing and must include:

● the name of the Plan;● name and address of the Employee covered under the Plan;● name and address(as) of the qualified beneficiaries affected by the qualifying event;● the qualifying event;● the date the qualifying event occurred; and● supporting documentation (e.g., divorce decree, birth certificate, disability determination, etc.).

Newly Acquired DependentsIf you acquire a new Dependent through marriage, birth, adoption or placement for adoption while your coverage is being continued, you may cover such Dependent under your COBRA continuation coverage. However, only your newborn or adopted Dependent Child is a qualified beneficiary and may continue COBRA continuation coverage for the remainder of the coverage period following your early termination of COBRA coverage or due to a secondary qualifying event. COBRA coverage for your Dependent Spouse and any Dependent Children who are not your children (e.g., stepchildren or grandchildren) will cease on the date your COBRA coverage ceases and they are not eligible for a secondary qualifying event.

Other Continuation ProvisionsCoverage continued under the following provision runs concurrently with coverage continued under COBRA:

● If you were covered under this plan immediately prior to being called to active duty by any of the armed forces of the United States of America, coverage may continue for up to 24 months or the period of uniformed service leave, whichever is shortest.

● You must pay any required contributions toward the cost of the coverage during the leave.● If the leave is less than 30 days, the contribution rate will be the same as for active employees.● If the leave is longer than 30 days, the required contribution will not exceed 102% of the cost of coverage.

Continuing Coverage During an FMLA LeaveIf you are granted an approved family or medical leave of absence in accordance with the Family and Medical Leave Act of 1993 (FMLA), you may continue coverage for yourself and your eligible dependents during your approved leave. You must agree to make any required contributions.

If you are granted an approved FMLA leave for longer than the period required by FMLA, Western Union will determine how your coverage will be continued, subject to the prior written approval of Cigna.

At the time you request the leave, you must agree to make any contributions required to continue coverage.

If the plan has reduction rules that apply because of age or retirement, those rules will apply while you are on FMLA leave.

When Continued Coverage EndsCoverage will end at the first to occur of the following:

● The date you fail to make any required contribution;● The date the Company determines that your approved FMLA leave is terminated; or● The date the coverage involved discontinues for your eligible class. However, coverage for health expenses may be available

to you under another plan sponsored by the Company.

Any coverage being continued for a dependent will not be continued beyond the date it would otherwise terminate.

171


COBRA Continuation Coverage After a Terminated LeaveIf health coverage ends because your approved FMLA leave is considered terminated by your employer, you may, on the date of such termination, be eligible for continuation coverage under COBRA. COBRA coverage will be available on the same terms as though your employment terminated, other than for gross misconduct, on such date. If this plan provides any other continuation of coverage (for example, upon termination of employment, death, divorce or ceasing to be a defined dependent), you (or your eligible dependents) may be eligible for such continuation on:

● The date the Company determines that your approved FMLA leave is at an end; or● The date of the event for which the continuation is available.

Acquiring a New Dependent During an FMLA LeaveIf you acquire a new dependent while your coverage is continued during an approved FMLA leave, the dependent will be eligible for the continued coverage on the same terms as would be applicable if you were actively at work, not on an approved FMLA leave.

Uniformed Services Employment and Re-employment RightsThe Uniformed Services Employment and Re-employment Rights Act (USERRA) entitles employees covered under health plans who are absent because of active uniformed service (including National Guard duty) to continue coverage for themselves, their dependents, or both until the earlier of:

● The date the group plan is terminated;● The end of the period for which contributions are paid if you fail to make timely payment of a required contribution;● 24 months from the start of the absence; or● The day after the date on which the employee fails to report or apply for re-employment as required.

The cost of COBRA coverage may be 102% of the full cost of coverage.

172

172Important Plan Provisions 172

Important Plan ProvisionsMultiple Employers and Misstatement of FactYou cannot receive multiple coverage under this plan because you are connected with more than one employer.

If there is a misstatement of fact that affects your coverage under this plan, the true facts will be investigated to determine the coverage that applies.

Assignment of CoverageCoverage may be assigned (signed over to another person) only with Cigna’s written permission.

Your Rights as a Plan ParticipantAs a participant in this plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). No one, including your employer, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your ERISA rights. ERISA provides that all plan participants shall be entitled to:

Receive Information About Your Plan and BenefitsExamine, without charge, at the Plan Administrator’s office and at other specified locations, all documents governing the plan, including insurance contracts and a copy of the latest annual report (Form 5500 Series) that is filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.

● Obtain, upon written request to the Plan Administrator, copies of all documents governing the operation of the plan, including insurance contracts and the latest annual report (Form 5500 Series), and an updated summary plan description. The Plan Administrator may make a reasonable charge for the copies.

● Receive a summary of the plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

● Receive a copy of the procedures used by the plan for determining a qualified domestic relations order (QDRO) or a qualified medical child support order (QMCSO).

Continue Group Health Plan CoverageYou have the right to continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.

You also have the right to reduced or eliminated exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months after your enrollment date in your coverage under this plan. OneSource Virtual, the COBRA administrator selected by Western Union, is the issuer of COBRA and HIPAA notifications.

Prudent Action by Plan FiduciariesIn addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries.

No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

173

Important Plan Provisions 173

Enforce Your RightsIf your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain documents relating to the decision without charge and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator.

If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the status of a domestic relations order or a medical child support order, you may file suit in a federal court.

If it should happen that plan fiduciaries misuse the plan’s money or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Help With Your QuestionsIf you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance with obtaining documents from the Plan Administrator, you should contact:

● The nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory; or

● Division of Technical Assistance and Inquiries at:Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, D.C. 20210

You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

In providing this information, Cigna and other carriers are acting on behalf of your Plan Administrator, who remains responsible for following ERISA reporting rules and regulations in a timely and accurate manner.

EmployerIdentificationNumber 20-4531180

Confidentiality of Health Information (Your rights under the Health Insurance Portability and Accountability Act)The Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) places restrictions on when the Company may have access to certain health care information about you known as Protected Health Information (PHI). Generally, PHI is information from which your individual identity can be discerned that is transmitted or maintained in any form (e.g., electronic, paper, oral) and that is created or received by a provider, health plan or health care clearing house.

In accordance with HIPAA, The Western Union Company agrees not to use or disclose your PHI for purposes other than:

● For treatment, payment or health care operations,● As permitted or required by law, or● As authorized by you.

You will receive a Notice of Privacy Practices that describes the Plans’ policies, practices and your rights with respect to your PHI under HIPAA. For more information regarding this Notice, please go to WU Life. Or contact the Western Union Health & Life Benefits department at [email protected].


174

174174

Plan Numbers

501 Medical, Dental, Vision501 Life501 Short Term & Long Term Disability501 Legal Plan501 Employee Assistance

Type of Administration

Administrative Services Contract and Fully Insured Contracts with:

Cigna Corporate Headquarters 900 Cottage Grove Road Bloomfield, CT 06002

Fully Insured Contracts with:

Vision Service Plan 333 Quality Drive Rancho Cordova, CA 95670

ARAG Group 400 Locust Street Des Moines, IA 50309

Plan Administrator The Western Union Company Employee Benefits Committee 12510 East Belford Avenue, M21B3 Englewood, CO 80112

Agent for Service of Legal Process The Western Union Company Attn: General Counsel 12510 East Belford Avenue, M21A3 Englewood, CO 80112

End of Plan Year December 31

Source of Contributions Employer and employee

1714033 (05/2017)

the western union company - cigna · western union medical plans have no pre-existing condition...

Documents