Common use of See xxx Clause in Contracts

See xxx. xxXxxxx.xxx or call 1-800-Cigna24 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need In Network Provider Out of Network Provider Important Information (You will pay the least) (You will pay the most) If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge/visit 20% coinsurance None Specialist visit No charge/visit 20% coinsurance None Preventive care/ screening/ immunization No charge/visit** No charge/screening** No charge/immunizations** **Deductible does not apply 20% coinsurance/visit 20% coinsurance/screening 20% coinsurance/ immunizations None None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance None Imaging (CT/PET scans, MRIs) No charge 20% coinsurance None Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs (Tier 1) $5 copay/prescription (retail 30 days), $10 copay/prescription (retail 90 days); $10 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. In-network Federally required preventive drugs will be provided at no charge Preferred brand drugs (Tier 2) $30 copay/prescription (retail 30 days), $60 copay/prescription (retail 90 days); $60 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Non-preferred brand drugs (Tier 3) $45 copay/prescription (retail 30 days), $90 copay/prescription (retail 90 days); $90 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance None Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care No charge/visit No charge/visit None Emergency medical transportation No charge No charge None Urgent care No charge/visit No charge/visit None If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Physician/surgeon fees No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. If you need mental health, behavioral health, or substance abuse services Outpatient services No charge/office visit No charge/all other services 20% coinsurance/office visit 20% coinsurance/all other services None Inpatient services No charge/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you are pregnant Office visits No charge 20% coinsurance Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Depending on the type of services, a copayment, coinsurance or deductible Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you need help recovering or have other special health needs Home health care No charge 20% coinsurance 16 hour maximum per day Rehabilitation services No charge/visit 20% coinsurance/visit Coverage for Rehabilitation, including Cardiac rehab and Chiropractic care, services is limited to 90 days annual max. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Habilitation services No charge/visit 20% coinsurance/visit Services are covered when Medically Necessary to treat a mental health condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Skilled nursing care No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Coverage is limited to 120 days annual max. Durable medical equipment No charge 20% coinsurance None Hospice services No charge/inpatient; No charge/outpatient services 20% coinsurance/inpatient; 20% coinsurance/outpatient services Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If your child needs dental or eye care Children's eye exam No charge/visit 20% coinsurance/visit Limit to one eye exam per contract year Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Long-term care • Private-duty nursing • Cosmetic surgery • Non-emergency care when traveling outside the • Routine foot care • Dental care (Adult) U.S. • Weight loss programs • Dental care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery (if you qualify for services) • Hearing aids (coverage through age 13) • Routine eye care (Adult) (limit to one exam • Chiropractic care (combined with Rehabilitation • Infertility treatment per contract year) Services)

See xxx. xxXxxxx.xxx or call 1-800-Cigna24 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need In What You Will Pay In-Network Provider Out of Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge$30 copay/visit 20% coinsurance None Specialist visit No charge$40 copay/visit 20% coinsurance None Preventive care/ screening/ immunization No charge/visit** visit No charge/screening** screening No charge/immunizations** **Deductible does not apply immunizations 20% coinsurance/visit 20% coinsurance/screening 20% coinsurance/ immunizations None None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance None Imaging (CT/PET scans, MRIs) No charge $75 copay per type of scan/day (up to a maximum of $375) 20% coinsurance None Common Medical Event Services You May Need What You Will Pay In In-Network Provider Out of Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs (Tier 1) $5 10 copay/prescription (retail 30 days), $20 copay/prescription (retail & home delivery 90 days) $10 copay/prescription (retail 90 30 days); $10 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) retail and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. In-network Federally required preventive drugs will be provided at no charge Preferred brand drugs (Tier 2) $30 25 copay/prescription (retail 30 days), $60 50 copay/prescription (retail 90 days); $60 copay/prescription (& home delivery 90 days) 20% coinsurance$25 copay/prescription (retailretail 30 days); Not covered (home delivery) Non-preferred brand drugs (Tier 3) $45 40 copay/prescription (retail 30 days), $90 80 copay/prescription (retail 90 days); $90 copay/prescription (& home delivery 90 days) 20% coinsurance$40 copay/prescription (retailretail 30 days); Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge $250 copay/visit 20% coinsurance None Per visit copay is waived for non- surgical procedures. Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care No charge$125 copay/visit No charge$125 copay/visit** **Deductible does not apply Per visit None copay is waived if admitted Emergency medical transportation No charge No charge charge** **Deductible does not apply None Urgent care No charge$75 copay/visit No charge$75 copay/visit visit** **Deductible does not apply None If you have a hospital stay Facility fee (e.g., hospital room) No charge $250 copay/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Physician/surgeon fees No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. If you need mental health, behavioral health, or substance abuse services Outpatient services No charge$40 copay/office visit No charge/all other services 20% coinsurance/office visit 20% coinsurance/all other services None Inpatient services No charge$250 copay/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In In-Network Provider Out of Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you are pregnant Office visits No charge 20% coinsurance Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Depending on the type of services, a copayment, coinsurance or deductible Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services $250 copay/admission 20% coinsurance If you need help recovering or have other special health needs Home health care No charge 20% coinsurance 16 hour maximum per day Rehabilitation services No charge$30 copay/PCP visit $40 copay/Specialist visit 20% coinsurance/PCP visit 20% coinsurance/Specialist visit Coverage for Rehabilitation, including Cardiac rehab and Chiropractic care, services is limited to 90 days annual max. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Habilitation services No charge$30 copay/PCP visit $40 copay/Specialist visit 20% coinsurance/PCP visit 20% coinsurance/Specialist visit Services are covered when Medically Necessary to treat a mental health condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Skilled nursing care No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Coverage is limited to 120 days annual max. Durable medical equipment No charge 20% coinsurance None Hospice services No charge/inpatient; No charge/outpatient services 20% coinsurance/inpatient; 20% coinsurance/outpatient services Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In In-Network Provider Out of Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If your child needs dental or eye care Children's eye exam No charge/visit 20% coinsurance/visit charge No charge Limit to one eye exam per contract calendar year Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) •  Acupuncture •  Long-term care •  Private-duty nursing •  Cosmetic surgery •  Non-emergency care when traveling outside the •  Routine foot care •  Dental care (Adult) U.S. •  Weight loss programs •  Dental care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) •   Bariatric surgery (if you qualify for services) • Chiropractic care (combined with Rehabilitation Services)   Hearing aids (coverage through age 13) • Infertility treatment  Routine eye care (Adultadult) (limit to one exam • Chiropractic care (combined with Rehabilitation • Infertility treatment per contract calendar year) Services)Note: This is an abbreviated version of the most recent Summary of Benefits available for July 1, 2019 – June 30, 2020. It summarizes the benefits in the 2020 -2023 Teacher’s contract, except for explanation of the prescription drug “edits” (managed care) that newly take effect as of July 1, 2020 per Article III(B)(2) of the teacher’s contract: (1) generic substitution with a “dispensed as written” (DAW) provider override for a brand name drug, and (2) mandatory specialty drugs dispensed through Accredo mail order specialty pharmacy. All pages of this Summary are updated annually by the insurance carrier during Open Enrollment before July 1 of each year. All annual updates and complete details on each health plan are provided to the teachers on the district website. From the “Human Resources” page, click on “Employee Benefits” and then “Medical Insurance.”

See xxx. xxXxxxx.xxx or call 1-800-Cigna24 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider Important Information (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge$30 copay/visit 20% coinsurance Not covered None Specialist visit No charge$40 copay/visit 20% coinsurance Not covered None Preventive care/ screening/ immunization No charge/visit** visit No charge/screening** screening No charge/immunizations** **Deductible does not apply 20% coinsurance/visit 20% coinsurance/screening 20% coinsurance/ immunizations Not covered None None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Not covered None Imaging (CT/PET scans, MRIs) No charge 20% coinsurance $75 copay per type of scan/day (up to maximum of $375) Not covered None Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs (Tier 1) $5 10 copay/prescription (retail 30 days), $10 20 copay/prescription (retail 90 days); $10 20 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. In-network Federally required preventive drugs will be provided at no charge Preferred brand drugs (Tier 2) $30 25 copay/prescription (retail 30 days), $60 50 copay/prescription (retail 90 days); $60 50 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Non-preferred brand drugs (Tier 3) $45 40 copay/prescription (retail 30 days), $90 80 copay/prescription (retail 90 days); $90 80 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance None Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care No charge$250 copay/visit No charge/Not covered Per visit None Emergency medical transportation No charge No charge None Urgent care No charge/visit No charge/visit None If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Lesser of 50% or $300 penalty copay is waived for no precertificationnon- surgical procedures. Physician/surgeon fees No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. If you need mental health, behavioral health, or substance abuse services Outpatient services No charge/office visit No charge/all other services 20% coinsurance/office visit 20% coinsurance/all other services Not covered None Inpatient services No charge/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need immediate medical attention Emergency room care $125 copay/visit $125 copay/visit Per visit copay is waived if admitted Emergency medical transportation No charge No charge None Urgent care $75 copay/visit $75 copay/visit None If you have a hospital stay Facility fee (e.g., hospital room) $250 copay/admission Not covered None Physician/surgeon fees No charge Not covered None If you need mental health, behavioral health, or substance abuse services Outpatient services $40 copay/office visit No charge/all other services Not covered None Inpatient services $250 copay/admission Not covered None If you are pregnant Office visits No charge 20% coinsurance Not covered Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Depending on the type of services, a copayment, coinsurance or deductible Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you need help recovering or have other special health needs Home health care Childbirth/delivery professional services No charge 20% coinsurance 16 hour maximum per day Rehabilitation Not covered Childbirth/delivery facility services No charge$250 copay/visit 20% coinsurance/visit Coverage for Rehabilitation, including Cardiac rehab and Chiropractic care, services is limited to 90 days annual max. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Habilitation services No charge/visit 20% coinsurance/visit Services are admission Not covered when Medically Necessary to treat a mental health condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Skilled nursing care No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Coverage is limited to 120 days annual max. Durable medical equipment No charge 20% coinsurance None Hospice services No charge/inpatient; No charge/outpatient services 20% coinsurance/inpatient; 20% coinsurance/outpatient services Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information Home health care No charge Not covered 16 hour maximum per day Rehabilitation services $30 copay/PCP visit $40 copay/Specialist visit Not covered Coverage for Rehabilitation, including Cardiac rehab and Chiropractic care, services is limited to 90 days annual max. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. If you need help recovering or have other Habilitation services $30 copay/PCP visit $40 copay/Specialist visit Not covered Services are covered when Medically Necessary to treat a mental health special health needs condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Skilled nursing care No charge Not covered Coverage is limited to 120 days annual max. Durable medical equipment No charge Not covered None Hospice services No charge/inpatient; No charge/outpatient services Not covered None If your child needs dental or eye care Children's eye exam No charge/visit 20% coinsurance/visit charge Not covered Limit to one eye exam per contract calendar year Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Long-term care • Private-duty nursing • Cosmetic surgery • Non-emergency care when traveling outside the • Routine foot care • Dental care (Adult) U.S. • Weight loss programs • Dental care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery (if you qualify for services) • Hearing aids (coverage through age 13) • Routine eye care (Adultadult) (limit limited to one exam • Chiropractic care (combined with Rehabilitation • Infertility treatment per contract calendar year) Services)

See xxx. xxXxxxx.xxx or call 1-800-Cigna24 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need In What You Will Pay In-Network Provider Out of Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge/visit 20% coinsurance None Specialist visit No charge/visit 20% coinsurance None Preventive care/ screening/ immunization No charge/visit** No charge/screening** No charge/immunizations** **Deductible does not apply 20% coinsurance/visit 20% coinsurance/screening 20% coinsurance/ immunizations None None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance None Imaging (CT/PET scans, MRIs) No charge 20% coinsurance None Common Medical Event Services You May Need What You Will Pay In In-Network Provider Out of Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs (Tier 1) $5 copay/prescription (retail 30 days), $10 copay/prescription (retail 90 days); $10 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. In-network Federally required preventive drugs will be provided at no charge Preferred brand drugs (Tier 2) $30 copay/prescription (retail 30 days), $60 copay/prescription (retail 90 days); $60 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Non-preferred brand drugs (Tier 3) $45 copay/prescription (retail 30 days), $90 copay/prescription (retail 90 days); $90 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance None Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care No charge/visit No charge/visit None Emergency medical transportation No charge No charge None Urgent care No charge/visit No charge/visit None If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Physician/surgeon fees No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. If you need mental health, behavioral health, or substance abuse services Outpatient services No charge/office visit No charge/all other services 20% coinsurance/office visit 20% coinsurance/all other services None Inpatient services No charge/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In In-Network Provider Out of Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you are pregnant Office visits No charge 20% coinsurance Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you need help recovering or have other special health needs Home health care No charge 20% coinsurance 16 hour maximum per day Rehabilitation services No charge/visit 20% coinsurance/visit Coverage for Rehabilitation, including Cardiac rehab and Chiropractic care, services is limited to 90 days annual max. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Habilitation services No charge/visit 20% coinsurance/visit Services are covered when Medically Necessary to treat a mental health condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Skilled nursing care No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Coverage is limited to 120 days annual max. Durable medical equipment No charge 20% coinsurance None Hospice services No charge/inpatient; No charge/outpatient services 20% coinsurance/inpatient; 20% coinsurance/outpatient services Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In In-Network Provider Out of Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If your child needs dental or eye care Children's eye exam No charge/visit 20% coinsurance/visit Limit to one eye exam per contract year Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) •  Acupuncture •  Long-term care •  Private-duty nursing •  Cosmetic surgery •  Non-emergency care when traveling outside the •  Routine foot care •  Dental care (Adult) U.S. •  Weight loss programs •  Dental care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) •   Bariatric surgery (if you qualify for services) • Chiropractic care (combined with Rehabilitation Services)   Hearing aids (coverage through age 13) • Infertility treatment  Routine eye care (Adult) (limit to one exam • Chiropractic care (combined with Rehabilitation • Infertility treatment per contract year) Services)Note: This is an abbreviated version of the most recent Summary of Benefits available for July 1, 2019 – June 30, 2020. It summarizes the benefits in the 2020 -2023 Teacher’s contract, except for explanation of the prescription drug “edits” (managed care) that newly take effect as of July 1, 2020 per Article III(B)(2) of the teacher’s contract: (1) generic substitution with a “dispensed as written” (DAW) provider override for a brand name drug, and (2) mandatory specialty drugs dispensed through Accredo mail order specialty pharmacy. All pages of this Summary are updated annually by the insurance carrier during Open Enrollment before July 1 of each year. All annual updates and complete details on each health plan are provided to the teachers on the district website. From the “Human Resources” page, click on “Employee Benefits” and then “Medical Insurance.” Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2019 - 06/30/2020 Simsbury, Board of Education - SEA: Open Access Plus IN (HMO) Coverage for: Individual/Individual + Family | Plan Type: OAP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at xxx.xxxxx.xxx/xx. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call 1-800-Cigna24 to request a copy.

See xxx. xxXxxxx.xxx or call 1-800-Cigna24 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need In Network Provider Out of Network Provider Important Information (You will pay the least) (You will pay the most) If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge$30 copay/visit 20% coinsurance None Specialist visit No charge$40 copay/visit 20% coinsurance None Preventive care/ screening/ immunization No charge/visit** visit No charge/screening** screening No charge/immunizations** **Deductible does not apply immunizations 20% coinsurance/visit 20% coinsurance/screening 20% coinsurance/ immunizations None None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance None Imaging (CT/PET scans, MRIs) No charge $75 copay per type of scan/day (up to a maximum of $375) 20% coinsurance None Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs (Tier 1) $5 10 copay/prescription (retail 30 days), $20 copay/prescription (retail & home delivery 90 days) $10 copay/prescription (retail 90 30 days); $10 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) retail and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. In-network Federally required preventive drugs will be provided at no charge Preferred brand drugs (Tier 2) $30 25 copay/prescription (retail 30 days), $60 50 copay/prescription (retail 90 days); $60 copay/prescription (& home delivery 90 days) 20% coinsurance$25 copay/prescription (retailretail 30 days); Not covered (home delivery) Non-preferred brand drugs (Tier 3) $45 40 copay/prescription (retail 30 days), $90 80 copay/prescription (retail 90 days); $90 copay/prescription (& home delivery 90 days) 20% coinsurance$40 copay/prescription (retailretail 30 days); Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge $250 copay/visit 20% coinsurance None Per visit copay is waived for non- surgical procedures. Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care No charge$125 copay/visit No charge$125 copay/visit** **Deductible does not apply Per visit None copay is waived if admitted Emergency medical transportation No charge No charge charge** **Deductible does not apply None Urgent care No charge$75 copay/visit No charge$75 copay/visit visit** **Deductible does not apply None If you have a hospital stay Facility fee (e.g., hospital room) No charge $250 copay/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Physician/surgeon fees No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. If you need mental health, behavioral health, or substance abuse services Outpatient services No charge$40 copay/office visit No charge/all other services 20% coinsurance/office visit 20% coinsurance/all other services None Inpatient services No charge$250 copay/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you are pregnant Office visits No charge 20% coinsurance Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Depending on the type of services, a copayment, coinsurance or deductible Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge $250 copay/admission 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you need help recovering or have other special health needs Home health care No charge 20% coinsurance 16 hour maximum per day Rehabilitation services No charge$30 copay/PCP visit $40 copay/Specialist visit 20% coinsurance/PCP visit 20% coinsurance/Specialist visit Coverage for Rehabilitation, including Cardiac rehab and Chiropractic care, services is limited to 90 days annual max. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Habilitation services No charge$30 copay/PCP visit $40 copay/Specialist visit 20% coinsurance/PCP visit 20% coinsurance/Specialist visit Services are covered when Medically Necessary to treat a mental health condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Skilled nursing care No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Coverage is limited to 120 days annual max. Durable medical equipment No charge 20% coinsurance None Hospice services No charge/inpatient; No charge/outpatient services 20% coinsurance/inpatient; 20% coinsurance/outpatient services Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If your child needs dental or eye care Children's eye exam No charge/visit 20% coinsurance/visit charge No charge Limit to one eye exam per contract calendar year Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Long-term care • Private-duty nursing • Cosmetic surgery • Non-emergency care when traveling outside the • Routine foot care • Dental care (Adult) U.S. • Weight loss programs • Dental care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery (if you qualify for services) • Hearing aids (coverage through age 13) • Routine eye care (Adultadult) (limit to one exam per • Chiropractic care (combined with Rehabilitation • Infertility treatment per contract calendar year) Services)) Note: This is an abbreviated version of the most recent Summary of Benefits available for July 1, 2019 – June 30, 2020. It summarizes the benefits in the 2020 -2023 Teacher’s contract, except for explanation of the prescription drug “edits” (managed care) that newly take effect as of July 1, 2020 per Article III(B)(2) of the teacher’s contract: (1) generic substitution with a “dispensed as written” (DAW) provider override for a brand name drug, and (2) mandatory specialty drugs dispensed through Accredo mail order specialty pharmacy. All pages of this Summary are updated annually by the insurance carrier during Open Enrollment before July 1 of each year. All annual updates and complete details on each health plan are provided to the teachers on the district website. From the “Human Resources” page, click on “Employee Benefits” and then “Medical Insurance.”

See xxx. xxXxxxx.xxx or call 1-800-Cigna24 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill xxxx from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need In What You Will Pay In-Network Provider Out of Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge$30 copay/visit 20% coinsurance Not covered None Specialist visit No charge$40 copay/visit 20% coinsurance Not covered None Preventive care/ screening/ immunization No charge/visit** visit No charge/screening** screening No charge/immunizations** **Deductible does not apply 20% coinsurance/visit 20% coinsurance/screening 20% coinsurance/ immunizations Not covered None None None You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Not covered None Imaging (CT/PET scans, MRIs) No charge 20% coinsurance $75 copay per type of scan/day (up to maximum of $375) Not covered None Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs (Tier 1) $5 10 copay/prescription (retail 30 days), $10 20 copay/prescription (retail 90 days); $10 20 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. In-network Federally required preventive drugs will be provided at no charge Preferred brand drugs (Tier 2) $30 25 copay/prescription (retail 30 days), $60 50 copay/prescription (retail 90 days); $60 50 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) Non-preferred brand drugs (Tier 3) $45 40 copay/prescription (retail 30 days), $90 80 copay/prescription (retail 90 days); $90 80 copay/prescription (home delivery 90 days) 20% coinsurance/prescription (retail); Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance None Physician/surgeon fees No charge 20% coinsurance None If you need immediate medical attention Emergency room care No charge$250 copay/visit No charge/Not covered Per visit None Emergency medical transportation No charge No charge None Urgent care No charge/visit No charge/visit None If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Lesser of 50% or $300 penalty copay is waived for no precertificationnon- surgical procedures. Physician/surgeon fees No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. If you need mental health, behavioral health, or substance abuse services Outpatient services No charge/office visit No charge/all other services 20% coinsurance/office visit 20% coinsurance/all other services Not covered None Inpatient services No charge/admission 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In In-Network Provider Out of Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need immediate medical attention Emergency room care $125 copay/visit $125 copay/visit Per visit copay is waived if admitted Emergency medical transportation No charge No charge None Urgent care $75 copay/visit $75 copay/visit None If you have a hospital stay Facility fee (e.g., hospital room) $250 copay/admission Not covered None Physician/surgeon fees No charge Not covered None If you need mental health, behavioral health, or substance abuse services Outpatient services $40 copay/office visit No charge/all other services Not covered None Inpatient services $250 copay/admission Not covered None If you are pregnant Office visits No charge 20% coinsurance Not covered Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Depending on the type of services, a copayment, coinsurance or deductible Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services No charge Not covered Childbirth/delivery facility services $250 copay/admission Not covered Common Medical Event Services You May Need What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information If you need help recovering or have other special health needs Home health care No charge 20% coinsurance Not covered 16 hour maximum per day Rehabilitation services No charge$30 copay/PCP visit 20% coinsurance$40 copay/Specialist visit Not covered Coverage for Rehabilitation, including Cardiac rehab and Chiropractic care, services is limited to 90 days annual max. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Habilitation services No charge$30 copay/PCP visit 20% coinsurance$40 copay/Specialist visit Not covered Services are covered when Medically Necessary to treat a mental health condition (e.g. autism). Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Skilled nursing care No charge 20% coinsurance Lesser of 50% or $300 penalty for no precertification. Not covered Coverage is limited to 120 days annual max. Durable medical equipment No charge 20% coinsurance Not covered None Hospice services No charge/inpatient; No charge/outpatient services 20% coinsurance/inpatient; 20% coinsurance/outpatient services Lesser of 50% or $300 penalty for no precertification. Common Medical Event Services You May Need What You Will Pay In Network Provider Out of Network Provider (You will pay the least) (You will pay the most) Limitations, Exceptions, & Other Important Information Not covered None If your child needs dental or eye care Children's eye exam No charge/visit 20% coinsurance/visit charge Not covered Limit to one eye exam per contract calendar year Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) •  Acupuncture •  Long-term care •  Private-duty nursing •  Cosmetic surgery •  Non-emergency care when traveling outside the •  Routine foot care •  Dental care (Adult) U.S. •  Weight loss programs •  Dental care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) •   Bariatric surgery (if you qualify for services) • Chiropractic care (combined with Rehabilitation Services)   Hearing aids (coverage through age 13) • Infertility treatment  Routine eye care (Adultadult) (limit limited to one exam • Chiropractic care (combined with Rehabilitation • Infertility treatment per contract calendar year) Services)Note: This is an abbreviated version of the most recent Summary of Benefits available for July 1, 2019 – June 30, 2020. It summarizes the benefits in the 2020 -2023 Teacher’s contract, except for explanation of the prescription drug “edits” (managed care) that newly take effect as of July 1, 2020 per Article III(B)(2) of the teacher’s contract: (1) generic substitution with a “dispensed as written” (DAW) provider override for a brand name drug, and (2) mandatory specialty drugs dispensed through Accredo mail order specialty pharmacy. All pages of this Summary are updated annually by the insurance carrier during Open Enrollment before July 1 of each year. All annual updates and complete details on each health plan are provided to the teachers on the district website. From the “Human Resources” page, click on “Employee Benefits” and then “Medical Insurance.”