Annual Mandated Notices and Disclosures 12232025

City of Mesa Group Health Plan

Annual Required Legal Notices and Disclosures for Plan Participants

List of Notices and Disclosures Health Insurance Marketplace Coverage HIPAA Notice of Privacy Practices HIPAA Special Enrollment Notice Women’s Health and Cancer Rights Act Notice Newborns' and Mothers' Health Protection Act Medicare Part D Notice of Creditable Rx Coverage Wellness Program Notice/Disclosure Children's Health Insurance Program (CHIP) Affordable Care Act Nondiscrimination Statement and Grievance Procedure Medical Carrier Summary of Benefits and Coverage (SBC) o Basic Plan o Choice Plan o Copay Plan

If you want additional information on any of these notices or the benefits they address, contact Employee Benefits at benefits.info@mesaaz.gov or call 480-644-2299.

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Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request.

We may charge a reasonable, cost-based fee.

Ask us to correct your health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 3.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation • Contact you for fundraising efforts If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission.

• Marketing Purposes • Sale of your information

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Run our organization

• We can use and share your health information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage.

Pay for your health services

• We can use and disclose your health information as we pay for your health services.

Example: We give information about you with your medical plan to coordinate payment for medical services.

Administer your plan We may disclose your health information to your health plan sponsor for plan administration.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Do research

• We can use or share your information for health research.

Comply with the law

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Our Your Uses and Choices

Continued…

Disclosures

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

HIPAA Notice of Privacy Practices Our Responsibilities.

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.

Choices HIPAA Special Enrollment Notice This notice explains your right to enroll in or make changes to your group health insurance coverage during the plan year.

Loss of Other Coverage If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage), except as specified below for Medicaid or CHIP coverage.

Marriage, Birth or Adoption In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Medicaid or CHIP Coverage If you or your dependents become eligible to participate in a Medicaid or Children’s Health Insurance Plan (CHIP) premium assistance program, you may enroll for coverage under our health plan if you notify the plan administrator within 60 days after you become eligible to participate in Medicaid or CHIP. If you or your dependents lose coverage under a Medicaid or CHIP premium assistance program due to loss of eligibility, you may enroll in our health plan if you apply to enroll within sixty (60) days of the loss of coverage under Medicaid or CHIP. If you enroll within sixty (60) days, the effective date of coverage is the first day after your Medicaid or CHIP coverage ended.

To request special enrollment or obtain more information, contact the Plan Administrator at 480-644-2299.

Choices Women’s Health and Cancer Rights Act Notice Federal law requires the following notification: Group health plans that provide medical and surgical benefits in connection with a mastectomy must provide benefits for certain reconstructive breast surgery.

This Plan complies with the Women's Health and Cancer Rights Act (WHCRA) that indicates that for any covered individual who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with it, coverage will be provided in a manner determined in consultation with the attending physician and the patient, including: • • • •

All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema.

Coverage is subject to the Plan's normal rules, including in-network co-payments or out-of-network annual deductibles and coinsurance provisions. Please see the Plan Document-Summary Plan Description and/or Benefits Summary.

If you have any questions about this law, including Plan benefits for mastectomies or reconstructive surgery, please contact, Employee Benefits Administration Office at 480.644.2299.

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Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You’re getting this notice because you recently gained coverage under a group health plan (the City of Mesa Health Plan, “the Plan”). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice.

After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage [choose and enter appropriate information: must pay or aren’t required to pay] for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • •

Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • • • • •

Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • • • • • •

The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the City of Mesa, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • • • •

The end of employment or reduction of hours of employment; Death of the employee; [add if Plan provides retiree health coverage: Commencement of a proceeding in bankruptcy with respect to the employer;]; or The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. Written notice should be sent via first class mail or hand-delivered to the Plan Administrator and is to include your name, the qualifying event, the date of the qualifying event, and appropriate documentation in support of the qualifying event such as divorce documents or a death certificate.

Contact information for the Plan Administrator is: Employee Benefits Administration Office: 20 E Main Street, Suite 600, Mesa AZ 85201 Mailing address: P O Box 1466, Mesa AZ 85211-1466 Phone #: 480-644-2299

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Notice must be provided to the Plan Administrator within 60 days from the time you receive the Social Security determination. Written notice should be sent via first class mail or hand-delivered to the Plan Administrator and is to include the Social Security determination notice.

Contact information for the Plan Administrator is: Employee Benefits Administration Office: 20 E Main Street, Suite 600, Mesa AZ 85201 Mailing address: P O Box 1466, Mesa AZ 85211-1466 Phone #: 480-644-2299 If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period 1 to sign up for Medicare Part A or B, beginning on the earlier of

1

https://www.medicare.gov/basics/get-started-with-medicare/sign-up/when-does-medicare-coverage-start.

• •

The month after your employment ends; or The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-you.

If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan contact information City of Mesa Health Plan Employee Benefits Administration Office: 20 E Main Street, Suite 600, Mesa AZ 85201 Mailing address: P O Box 1466, Mesa AZ 85211-1466 Phone #: 480-644-2299

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State 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, contact your State Medicaid or CHIP office or dial 1877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.

This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2024. Contact your State for more information on eligibility –

ALABAMA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)

ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspx

CALIFORNIA – Medicaid Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov

FLORIDA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrec overy.com/hipp/index.html Phone: 1-877-357-3268

GEORGIA – Medicaid

INDIANA – Medicaid

GA HIPP Website: https://medicaid.georgia.gov/healthinsurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-partyliability/childrens-health-insurance-programreauthorization-act-2009-chipra Phone: 678-564-1162, Press 2

IOWA – Medicaid and CHIP (Hawki) Medicaid Website: Iowa Medicaid | Health & Human Services Medicaid Phone: 1-800-338-8366 Hawki Website: Hawki - Healthy and Well Kids in Iowa | Health & Human Services Hawki Phone: 1-800-257-8563 HIPP Website: Health Insurance Premium Payment (HIPP) | Health & Human Services (iowa.gov) HIPP Phone: 1-888-346-9562

Health Insurance Premium Payment Program All other Medicaid Website: https://www.in.gov/medicaid/ http://www.in.gov/fssa/dfr/ Family and Social Services Administration Phone: 1-800-403-0864 Member Services Phone: 1-800-457-4584

KANSAS – Medicaid Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660

KENTUCKY – Medicaid

LOUISIANA – Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp. aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kynect.ky.gov Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

MAINE – Medicaid

MASSACHUSETTS – Medicaid and CHIP

Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?langua ge=en_US Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-977-6740 TTY: Maine relay 711

MINNESOTA – Medicaid Website: https://mn.gov/dhs/health-care-coverage/ Phone: 1-800-657-3672

MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov

NEVADA – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Phone: 1-800-356-1561 CHIP Premium Assistance Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 (TTY: 711)

NORTH CAROLINA – Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.com

MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.ht m Phone: 573-751-2005

NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/programsservices/medicaid/health-insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 15218 Email: DHHS.ThirdPartyLiabi@dhhs.nh.gov

NEW YORK – Medicaid Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

NORTH DAKOTA – Medicaid Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825

OREGON – Medicaid and CHIP Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075

PENNSYLVANIA – Medicaid and CHIP Website: https://www.pa.gov/en/services/dhs/apply-formedicaid-health-insurance-premium-payment-programhipp.html Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437)

SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

TEXAS – Medicaid Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human Services Phone: 1-800-440-0493

VERMONT– Medicaid Website: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427

RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

UTAH – Medicaid and CHIP Utah’s Premium Partnership for Health Insurance (UPP) Website: https://medicaid.utah.gov/upp/ Email: upp@utah.gov Phone: 1-888-222-2542 Adult Expansion Website: https://medicaid.utah.gov/expansion/ Utah Medicaid Buyout Program Website: https://medicaid.utah.gov/buyout-program/ CHIP Website: https://chip.utah.gov/

VIRGINIA – Medicaid and CHIP Website: https://coverva.dmas.virginia.gov/learn/premiumassistance/famis-select https://coverva.dmas.virginia.gov/learn/premiumassistance/health-insurance-premium-payment-hippprograms Medicaid/CHIP Phone: 1-800-432-5924

WASHINGTON – Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

WISCONSIN – Medicaid and CHIP

WEST VIRGINIA – Medicaid and CHIP Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-6998447)

WYOMING – Medicaid

Website: https://www.dhs.wisconsin.gov/badgercareplus/p10095.htm Phone: 1-800-362-3002

Website: https://health.wyo.gov/healthcarefin/medicaid/programs -and-eligibility/ Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2024, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.

The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2026)

Important Notice from City of Mesa About Your Prescription Drug Coverage and Medicare If you or your dependents are not eligible for Medicare, you may disregard this notice You are an active employee of the City of Mesa (or the spouse/Committed Partner or dependent of an active employee) who is enrolled in a City of Mesa Medical/Prescription Drug benefit plan. At the same time, you may be eligible for or enrolled in some or all of Medicare.

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the City of Mesa and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan.

If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. The City of Mesa has determined that the prescription drug coverage offered by the City of Mesa medical plans is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. __________________________________________________________________________

When Can You Join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

CMS Form 10182-CC

Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens to Your Current City Coverage If You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current City of Mesa drug coverage may be affected. The City’s plan does not coordinate benefits with Medicare Part D for active employees or their covered dependents. If you enroll in a Medicare Part D drug plan you may not use prescription drug coverage under the City’s plan. If you do decide to join a Medicare drug plan and drop your current coverage under our plan, be aware that you and your dependents will not be able to get back this coverage back except at the next annual open enrollment or if you have a “special enrollment” event.

When Will You Pay A Higher Premium (Penalty) To Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with the City of Mesa and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact the City of Mesa Benefits Administration Office at 480-644-2299. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the City of Mesa changes. You also may request a copy of this notice at any time.

CMS Form 10182-CC

Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: 10/01/2025 Name of Entity/Sender: City of Mesa Contact--Position/Office: City of Mesa Benefits Administration Address: P.O. Box 1466 Mesa, AZ 85211-1466 Phone Number: 480-644-2299

CMS Form 10182-CC

Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 (expires 12-31-2026)

PART A: General Information Even if you are offered health coverage through your employment, you may have other coverage options through the Health Insurance Marketplace (“Marketplace”). To assist you as you evaluate options for you and your family, this notice provides some basic information about the Health Insurance Marketplace and health coverage offered through your employment.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options in your geographic area.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable for you and doesn’t meet certain minimum value standards (discussed below). The savings that you're eligible for depends on your household income. You may also be eligible for a tax credit that lowers your costs.

Does Employment-Based Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your Marketplace coverage and may wish to enroll in your employment-based health plan. However, you may be eligible for a tax credit, and advance payments of the credit that lowers your monthly premium, or a reduction in certain cost-sharing, if your employer does not offer coverage to you at all or does not offer coverage that is considered affordable for you or meet minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more than 9.12% 1 of your annual household income, or if the coverage through your employment does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if you do not enroll in the employment-based health coverage. For family members of the employee, coverage is considered affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not exceed 9.12% of the employee’s household income..1 2 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your employment, then you may lose access to whatever the employer contributes to the employment-based coverage. Also, this employer contribution -as well as your employee contribution to employment-based coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace.

1 Indexed annually; see https://www.irs.gov/pub/irs-drop/rp-22-34.pdf for 2023.

2 An employer-sponsored or other employment-based health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs. For purposes of eligibility for the premium tax credit, to meet the “minimum value standard,” the health plan must also provide substantial coverage of both inpatient hospital services and physician services.

When Can I Enroll in Health Insurance Coverage through the Marketplace?

You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open Enrollment varies by state but generally starts November 1 and continues through at least December 15.

Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a Marketplace plan.

There is also a Marketplace Special Enrollment Period for individuals and their families who lose eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage on or after March 31, 2023, through July 31, 2024. Since the onset of the nationwide COVID-19 public health emergency, state Medicaid and CHIP agencies generally have not terminated the enrollment of any Medicaid or CHIP beneficiary who was enrolled on or after March 18, 2020, through March 31, 2023. As state Medicaid and CHIP agencies resume regular eligibility and enrollment practices, many individuals may no longer be eligible for Medicaid or CHIP coverage starting as early as March 31, 2023. The U.S. Department of Health and Human Services is offering a temporary Marketplace Special Enrollment period to allow these individuals to enroll in Marketplace coverage.

Marketplace-eligible individuals who live in states served by HealthCare.gov and either- submit a new application or update an existing application on HealthCare.gov between March 31, 2023 and July 31, 2024, and attest to a termination date of Medicaid or CHIP coverage within the same time period, are eligible for a 60-day Special Enrollment Period. That means that if you lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, you may be able to enroll in Marketplace coverage within 60 days of when you lost Medicaid or CHIP coverage. In addition, if you or your family members are enrolled in Medicaid or CHIP coverage, it is important to make sure that your contact information is up to date to make sure you get any information about changes to your eligibility. To learn more, visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325.

What about Alternatives to Marketplace Health Insurance Coverage?

If you or your family are eligible for coverage in an employment-based health plan (such as an employer-sponsored health plan), you or your family may also be eligible for a Special Enrollment Period to enroll in that health plan in certain circumstances, including if you or your dependents were enrolled in Medicaid or CHIP coverage and lost that coverage.

Generally, you have 60 days after the loss of Medicaid or CHIP coverage to enroll in an employment-based health plan, but if you and your family lost eligibility for Medicaid or CHIP coverage between March 31, 2023 and July 10, 2023, you can request this special enrollment in the employment-based health plan through September 8, 2023. Confirm the deadline with your employer or your employment-based health plan.

Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace or applying directly through your state Medicaid agency. Visit https://www.healthcare.gov/medicaid-chip/gettingmedicaid-chip/ for more details.

How Can I Get More Information?

For more information about your coverage offered through your employment, please check your health plan’s summary plan description or contact ________________________________________________________________________________________________________ ______________.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Employer name

4. Employer Identification Number (EIN) City of Mesa

86-6000252

5. Employer address

6. Employer phone number 480-644-2299

20 E. Main Street, Suite 600 7. City

8. State

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above)

9. ZIP code AZ

Mesa

85211

Employee Benefits Administration

12. Email address

benefits.info@mesaaz.gov

Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to: All employees. Eligible employees are:

Some employees. Eligible employees are:

•

With respect to dependents: We do offer coverage. Eligible dependents are: X

We do not offer coverage.

X

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. **

Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed midyear, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee) 14. Does the employer offer a health plan that meets the minimum value standard*?

Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often?

Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee.

16. What change will the employer make for the new plan year?

Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? $ b. How often?

Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

• An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

CITY OF MESA 360 WELLNESS PROGRAM NOTICE/DISCLOSURE IMPORTANT INFORMATION ABOUT THE WELLNESS PROGRAM Our City of Mesa 360 Wellness Program is voluntary and is designed to promote health or prevent disease. The term Wellness Program includes both: a. ways that we help individuals identify and reduce health risk factors, like elevated blood pressure or excess weight, along with b. ways to help individuals with chronic conditions, like diabetes, take better care of their condition, for example by working with a coach to encourage you to take the medication the doctor prescribes for your chronic condition. The Wellness Program also offers incentives for participation (such as for completing a Health Risk Appraisal questionnaire) and if you positively change behavior (such as increasing activity). All employees are eligible for incentives, but only those enrolled in a health plan can get the HRA completion incentive. Waived employees can also qualify for the other non-HRA completion incentives. Incentives can be achieved at least once a year. The time commitment required to achieve incentives in our 360 Wellness Program is reasonable. More information about our 360 Wellness Program incentives is described within the wellness website. The 360 Wellness Program incentives have been reviewed and in accordance with law, do not exceed 30% of the total cost of employee-only coverage under the plan (including employee & employer contributions). If you think you might be unable to meet a standard for a certain reward under our 360 Wellness Program, you might qualify for an opportunity to earn the same reward by a different means. If an individual has physical disabilities or a medical condition such that it is unreasonably difficult or medically inadvisable due to their medical condition to satisfy the standards of the 360 Wellness Program, then reasonable alternative standards will be made available upon request. If the individual’s personal doctor states that the alternative is not medically appropriate, a more accommodating alternative will be provided. Contact mesawellness@mesaaz.gov for information on the wellness program and for information on reasonable alternative standards and accommodations. We will work with you and, if you wish, your doctor, to find a Wellness Program standard with the same reward that is right for you considering your health status.

NOTICE REGARDING WELLNESS PROGRAM The City of Mesa’s Wellness Program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program, you will be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for blood

glucose, triglycerides, and cholesterol levels. You are also offered the opportunity to receive onsite screenings and health coaching. You are not required to complete the HRA or to participate in the blood test or other medical examinations. However, employees who choose to participate in the wellness program will receive an incentive as part of the 360 Wellness Program for approved activities. Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will receive points towards their 360 Wellness Rewards which can lead to incentives. Additional incentives of gift cards may also be available for employees who participate in certain health- related activities (attend lunch & learns, preventative screenings, participate in virtual coaching). If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting mesawellness@mesaaz.gov. The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks and may also be used to offer you services through the wellness program, such as health coaching. You also are encouraged to share your results or concerns with your own doctor. Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and the City of Mesa may use aggregate information it collects to design a program based on identified health risks in the workplace, Mesa Wellness will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law.

Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are health coaches and physicians to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact the Equal Employment Opportunity Office at

EEOO@mesaaz.gov.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2026 - 12/31/2026 City of Mesa: Open Access Plus - Basic Plan 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 www.cigna.com/sp. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.

Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have What is the overall For in-network providers: $550/individual or $1,650/family other family members on the plan, each family member must deductible?

For out-of-network providers: $1,500/individual or $4,500/family meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may Are there services covered Yes. In-network preventive care & immunizations, Diagnostic apply. For example, this plan covers certain preventive services before you meet your Skin Cancer Screening, Diagnostic Mammograms, office visits. without cost-sharing and before you meet your deductible. See a deductible? list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services?

The out-of-pocket limit is the most you could pay in a year for For in-network providers: $4,500/individual or $9,000/family What is the out-of-pocket covered services. If you have other family members in this plan, For out-of-network providers: Unlimited/individual or limit for this plan? they have to meet their own out-of-pocket limits until the overall Unlimited/family family out-of-pocket limit has been met.

Penalties for failure to obtain pre-authorization for services, What is not included in the Even though you pay these expenses, they don't count toward premiums, balance-billing charges, and health care this plan out-of-pocket limit? the out-of-pocket limit. doesn’t cover.

Page 1 of 9

Important Questions

Answers

Will you pay less if you use a network provider?

Yes. See www.cigna.com or call 1-800-Cigna24 for a list of network providers.

Do you need a referral to see a specialist?

No.

Why This Matters: 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.

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 Medical Event

If you visit a health care provider's office or clinic

What You Will Pay Services You May Need In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Primary care visit to treat an $20 copay/visit 75% coinsurance injury or illness Deductible does not apply $30 copay/office visit** Specialist visit 75% coinsurance $20 copay/MDLIVE visit** **Deductible does not apply No charge/visit** Not covered/visit No charge/screening** Not covered/screening Including Diagnostic Skin Cancer Screening and 75% coinsurance Diagnostic Mammogram No charge/immunizations** Not covered/immunizations Preventive care/ screening/ **Deductible does not apply immunization

Limitations, Exceptions, & Other Important Information None None None None

None You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

Page 2 of 9

Common Medical Event If you have a test If you need drugs to treat your illness or condition

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)

Diagnostic test (x-ray, blood 50% coinsurance work) Imaging (CT/PET scans, No charge MRIs) Retail up to 30-day supply: 20% coinsurance, $10 min/$60 max Tier 1 Generic Drugs Retail/Mail Order up to 90day supply: 20% coinsurance, $20 min/$120 max Retail up to 30-day supply: 30% coinsurance, $35 min/$110 max Tier 2 Preferred Brand Retail/Mail Order up to 90Drugs day supply: 30% coinsurance, $70 min/$220 max Retail up to 30-day supply: 50% coinsurance, $60 min/$170 max Tier 3 Non-Preferred Retail/Mail Order up to 90day supply: Brand Drugs 50% coinsurance, $120 min/$340 max

Limitations, Exceptions, & Other Important Information

75% coinsurance

None

75% coinsurance

None

Pay cash, file direct RX claim paid at in-network levels minus coinsurance/min/mas (limited to up to 30-day supplies only)

Pay cash, file direct RX claim paid at in-network levels minus coinsurance/min/mas (limited to up to 30-day supplies only)

Pay cash, file direct RX claim paid at in-network levels minus coinsurance/min/mas (limited to up to 30-day supplies only)

Some drugs require precertifications, step therapy and/or have quantity limitations. 90-day supply obtained at mail or in network Retail Pharmacies.

Specialty drugs limited to 30- day supply at MedImpact Specialty Pharmacy and may have preferred drug list with exclusions. Generic or Preferred Brand Diabetic Insulin at Generic copays to max copay $35 for 30-day supply or $105 for 90-day supply, if better. Non-Preferred Brand Diabetic Insulin at regular copays to same $35/$105 max copays, if better.

Pay penalty price if Brand drug used when Generic is available. Cost share waived for preventive generic and single source brand name contraceptive drugs/devices for women, preventive vaccinations (network participating pharmacies only). Not covered: most over-the

Page 3 of 9

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 counter drugs, drugs to treat infertility, certain dental drugs, non-prescription contraceptives, drugs on PaydHealth list for members who are required but choose not to particiapate in advocacy services.

More information about prescription drug coverage is available at MedImpact www.medimpact.com or (866) 387-3537. Mandatory Specialty Drug Advocacy at PaydHealth (877) 4221776. For Medicare eligible retiree prescription drug coverage contact VibrantRX www.MyVibrantRx.com or (844) 826-3451 (no PaydHealth required for Medicare eligible retirees) Maximum prescription drug out-of-pocket expense: $4,000 single and $8,000 family; VibrantRx Medicare Part D prescription drug maximum out-of-pocket expense $2,100/individual.

If you have outpatient surgery

Tier 4 Specialty Generic or Specialty Preferred Brand for Medicare Part D Tier 5 Specialty Preferred Brand and Tier 5 (D) Specialty NonPreferred Brand for Medicare Part D Tier 6 Specialty NonPreferred Brand for NonMedicare Part D

Specialty up to 30-day supply: 20% coinsurance, $15 min/$90 max Specialty up to 30-day supply: 30% coinsurance, $55 min/$165 max

Not covered

Specialty up to 30-day supply: 50% coinsurance, $90 min/$255 max

Facility fee (e.g., ambulatory surgery center)

50% coinsurance

75% coinsurance

Physician/surgeon fees

50% coinsurance

75% coinsurance

$750 penalty for no out-of-network precertification. $750 penalty for no out-of-network precertification.

Page 4 of 9

Common Medical Event

If you need immediate medical attention

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

Services You May Need Emergency room care

50% coinsurance

50% coinsurance

Emergency medical transportation

50% coinsurance

50% coinsurance

Urgent care Facility fee (e.g., hospital room)

50% coinsurance

50% coinsurance

50% coinsurance

75% coinsurance

Physician/surgeon fees

50% coinsurance

75% coinsurance

Outpatient services

No charge/office visit** No charge/MDLIVE visit** No charge/all other services** **Deductible does not apply

75% coinsurance/office visit 75% coinsurance/all other services

Inpatient services

No charge Deductible does not apply

75% coinsurance

Office visits

If you are pregnant

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Childbirth/delivery professional services Childbirth/delivery facility services

No charge after $400 Maternity copay Deductible does not apply No charge after $400 Maternity copay Deductible does not apply 50% coinsurance

75% coinsurance 75% coinsurance

75% coinsurance

Limitations, Exceptions, & Other Important Information Out-of-network services are paid at the in-network cost share and deductible.

Out-of-network air ambulance services are paid at the in-network cost share and deductible.

None $750 penalty for no out-of-network precertification. $750 penalty for no out-of-network precertification. $750 penalty if no precert of out-ofnetwork non-routine services.

Includes medical services for MH/SA diagnoses. $750 penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses.

Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy.

Cost sharing does not apply for preventive services.

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).

Page 5 of 9

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)

Home health care

50% coinsurance

75% coinsurance

Rehabilitation services

50% coinsurance

75% coinsurance

$750 penalty for no out-of-network precertification.

Coverage is limited to 60 days annual max.

16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.)

Coverage is limited to annual max of 90 days for Cognitive therapy, Physical therapy, Occupational therapy and Speech therapy.

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Services are covered when Medically Necessary to treat a mental health condition (e.g. autism).

If you need help recovering or have other special health needs Habilitation services

50% coinsurance

75% coinsurance

Skilled nursing care

50% coinsurance

75% coinsurance

Durable medical equipment

50% coinsurance 50% coinsurance/inpatient services 50% coinsurance/outpatient services Not covered Not covered

75% coinsurance 75% coinsurance/inpatient services 75% coinsurance/outpatient services Not covered Not covered

Hospice services If your child needs dental or eye care

Limitations, Exceptions, & Other Important Information

Children's eye exam Children's glasses

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. $750 penalty for no out-of-network precertification.

Coverage is limited to 60 days annual max.

None $750 penalty for no out-of-network precertification.

None None Page 6 of 9

Common Medical Event

Services You May Need Children's dental check-up

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Not covered Not covered

Limitations, Exceptions, & Other Important Information 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  Infertility treatment  Private-duty nursing  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Dental care (Adult)  Non-emergency care when traveling outside the  Routine foot care U.S.  Dental care (Children)  Weight loss programs  Eye care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Bariatric Surgery (in-network only)  Chiropractic care  Hearing aids (in-network only/2 devices per 60 months)

Page 7 of 9

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Cigna at 1-800-Cigna24, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-800Cigna24.

Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 8 of 9

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe's Type 2 Diabetes

Mia's Simple Fracture

(9 months of in-network pre-natal care and a hospital delivery)

(a year of routine in-network care of a wellcontrolled condition)

(in-network emergency room visit and follow up care)

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance ■ Other coinsurance

$550 $30 50% 50%

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance ■ Other coinsurance

$550 $30 50% 50%

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance ■ Other coinsurance

$550 $30 50% 50%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

This EXAMPLE event includes services like: Primary care physician office visits (including

This EXAMPLE event includes services like: Emergency room care (including medical

Prescription drugs Durable medical equipment (glucose meter)

Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

Total Example Cost

Total Example Cost

$12,700

In this example, Peg would pay:

disease education) Diagnostic tests (blood work)

In this example, Joe would pay:

Cost Sharing Deductibles Copayments Coinsurance

What isn't covered

Deductibles Copayments Coinsurance

Cost Sharing $120 $700 $800

Deductibles Copayments Coinsurance

What isn't covered $20 $4,540

Limits or exclusions The total Joe would pay is

$2,800

In this example, Mia would pay:

Cost Sharing $550 $400 $3,600

Limits or exclusions The total Peg would pay is

$5,600

supplies)

$550 $70 $900

What isn't covered $40 $1,660

Limits or exclusions The total Mia would pay is

$0 $1,520

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: Basic Plan Ben Ver: 33 Plan ID: 37362030 Page 9 of 9

Discrimination is against the law.

Medical coverage

Cigna Healthcare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna Healthcare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

If you believe that Cigna Healthcare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:

Cigna Healthcare:

Cigna Healthcare Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422

• Provides free aids and services to people with disabilities to

communicate effectively with us, such as: Qualified sign language interpreters

Qualified interpreters

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

Information written in other languages

U.S. Department of Health and Human Services

Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language

is not English, such as:

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at https://www.hhs.gov/civil-rights/filing-a-complaint/complaintprocess/index.html

896375f 3/24 © 2024 Cigna Healthcare

Proficiency of Language Assistance Services English - ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna Healthcare customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish - ATENCION: Hay servicios de asistencia de idiomas, sin cargo, a su disposici6n. Si es un cliente actual de Cigna Healthcare, !lame al numero que figura en el reverso de su tarjeta de identificaci6n. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese - i±�: ft{rraJf,Sf�:9e.JftJHJ:t�!t�ia.l=l}Jij�f£ lt� Cigna Healthcare EfJJJi��P , �rlfi&fflf�Efl ID -t1r®Ef1�� �{-tg�p�ff¥Jl:ffl 1.800.244.6224 C �lr!H!H,i : �ffti 711) Vietnamese - XIN LU'U Y: Quy vi dU'Q'C c�p djch v1,1 trQ' giup v� ng6n ngQ> mien phi. Danh cha khach hang hi(m tc;1i cua Cigna Healthcare, vui long goi s6 mc;it sau the Hoi vien. Cac tmcmg hQ'p khac xin goi s6 1.800.244.6224 (TTY: Quay s6 711 ).

Korean - -?�I: �J�Oj � J..�-§-o�J..I:= ��. <2! Oj 7'1 � J..i 1:11 A� 1f-E£ Ol-§-o�� "? ��LI q_ �XH Cigna Healthcare 7�'fl 7'� 'a� 7JllJ..i := ID 7'� � �121011 �:= �2�te:!.2.£ '2:!�oH-?�J..12.. 7IE� q� ��011:= 1.800.244.6224 (TTY: qo1� 711)te:! 0 £ �2�0H-?�J..l2..

Tagalog - PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna Healthcare, tawagan ang numero sa likuran ng iyong ID card. 0 kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian - BHv1MAHv1E: BaM MoryT npeAOCTaBt,1Tb 6ecnnaTHble ycnyrn nepeBOAa. Ecm1 Bbl y)f{e y4acTByeTe B nnaHe Cigna Healthcare, no3BOHll1Te no HOMepy, yKa3aHHOMY Ha o6paTHO� CTOpOHe Bawe� 111A8HTll1q:>111Kal...\1110HHO� KapTO4Kll1 y4aCTHll1Ka nnaHa. Ecn111 Bbl He f!BmleTeCb y4aCTHIIIKOM OAHOro 1113 HaWIIIX nnaHOB, no3BOHll1Te no HOMepy 1.800.244.6224 (TTY: 711). .�I �I.hi� _)c- u.J .l.JI �)4 J�';/1 ��Y. �WI Cigna Healthcare �)l-.l .rS,] �\:i..o ��I 4_..,:ill -::.it....;.. cl.,w';/1 ��Y. - Arabic .(711 '-,-l �I :TTY) 1.800.244.6224 '-:-l �I . JI 0

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French Creole - ATANSYON: Gen sevis ed nan lang ki disponib gratis pou ou. Pou kliyan Cigna Healthcare yo, rele nimewo ki deye kat

ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French - ATTENTION: Des services d'aide linguistique vous sont proposes gratuitement. Si vous etes un client actuel de Cigna Healthcare, veuillez appeler le numero indique au verso de votre carte d'identite. Sinon, veuillez appeler le numero 1.800.244.6224 (ATS : composez le numero 711).

Portuguese - ATENCAO: Tern ao seu dispor servi<;:os de assistencia lingufstica, totalmente gratuitos. Para clientes Cigna Healthcare atuais, ligue para o numero que se encontra no verso do seu cartao de identifica<;:ao. Caso contrario, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish - UWAGA: w celu skorzystania z dost�pnej, bezpfatnej pomocy j�zykowej, obecni klienci firmy Cigna Healthcare mog9 dzwonic pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese - 51�$:I:.W : 87$:iR7;£-it�n��-g-, �*{O) �iRsz::titt-!::'A7;£-c'f1Jffll,'tctdt*9 o IJH'IO)Cigna HealthcareO)S��J�;;t:_ ID:b- t-:'� jijO)�it:ffl:�*c\ s�it,LZc'Ji�( tc.�l,'o f-O){{Q0)7J�i, 1.800.244.6224 (TTY: 711) *c\ s�it,LZc'Ji�( tc.�l,'o Italian - ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna Healthcare attuali, chiamare ii numero sul retro della tessera di identificazione. In caso contrario, chiamare ii numero 1.800.244.6224 (utenti TTY: chiamare ii numero 711).

German - ACHTUNG: Die Leistungen der Sprachunterstotzung stehen Ihnen kostenlos zur Verfugung. Wenn Sie gegenwartiger Cigna Healthcare-Kunde sind, rufen Sie bitte die Nummer auf der Ruckseite lhrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wahlen Sie 711).

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2026 - 12/31/2026 City of Mesa: Open Access Plus - Choice Plan 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 www.cigna.com/sp. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.

Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have What is the overall For in-network providers: $300/individual or $900/family other family members on the plan, each family member must deductible?

For out-of-network providers: $1,500/individual or $4,500/family meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may Are there services covered Yes. In-network preventive care & immunizations, Diagnostic apply. For example, this plan covers certain preventive services before you meet your Skin Cancer Screening, Diagnostic Mammograms. without cost-sharing and before you meet your deductible. See a deductible? list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services?

The out-of-pocket limit is the most you could pay in a year for For in-network providers: $3,000/individual or $6,000/family What is the out-of-pocket covered services. If you have other family members in this plan, For out-of-network providers: Unlimited/individual or limit for this plan? they have to meet their own out-of-pocket limits until the overall Unlimited/family family out-of-pocket limit has been met.

Penalties for failure to obtain pre-authorization for services, What is not included in the Even though you pay these expenses, they don't count toward premiums, balance-billing charges, and health care this plan out-of-pocket limit? the out-of-pocket limit. doesn’t cover.

Page 1 of 8

Important Questions

Answers

Will you pay less if you use a network provider?

Yes. See www.cigna.com or call 1-800-Cigna24 for a list of network providers.

Do you need a referral to see a specialist?

No.

Why This Matters: 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.

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 Medical Event

If you visit a health care provider's office or clinic

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)

Primary care visit to treat an 20% coinsurance/visit injury or illness Specialist visit 20% coinsurance/visit No charge/visit** No charge/screening** Including Diagnostic Skin Cancer Screening and Diagnostic Mammogram Preventive care/ screening/ No charge/immunizations** immunization

50% coinsurance

None

50% coinsurance Not covered/visit Not covered/screening

None None None

50% coinsurance Not covered/immunizations

None You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

50% coinsurance

None

50% coinsurance

None

**Deductible does not apply

If you have a test

Diagnostic test (x-ray, blood 20% coinsurance work) Imaging (CT/PET scans, No charge MRIs)

Limitations, Exceptions, & Other Important Information

Page 2 of 8

Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at MedImpact www.medi mpact.com or (866) 387- 3537. Mandatory Specialty Drug Advocacy with PaydHealth (877) 4221776. For Medicare eligible retiree prescription drug coverage contact VibrantRX www.MyVibrantRx.com or (844) 826-3451 (no PaydHealth required for Medicare eligible retirees).

Maximum prescription drug out-of-pocket expense:

Services You May Need

Tier 1 Generic Drugs

Tier 2 Preferred Brand Drugs

Tier 3 Non-Preferred Brand Drugs

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Retail up to 30-day supply: 20% coinsurance, $10 Pay cash, file direct RX claim min/$60 max paid at in-network levels minus Retail/Mail Order up to 90coinsurance/min/max limited to day supply: 20% 30-day supplies only coinsurance, $20 min/$120 max Retail up to 30-day supply: 30% coinsurance, $35 Pay cash, file direct RX claim min/$110 max paid at in-network levels minus coinsurance/min/max limited to Retail/Mail Order up to 90day supply: 30% coinsurance, 30-day supplies only $70 min/$220 max Retail up to 30-day supply: 50% coinsurance, $60 Pay cash, file direct RX claim min/$170 max paid at in-network levels minus coinsurance/min/max limited to Retail/Mail Order up to 90day supply: 50% coinsurance, 30-day supplies only $120 min/$340 max

Limitations, Exceptions, & Other Important Information Some drugs require precertifications, step therapy and/or have quantity limitations. 90-day supply obtained at mail order or in network Retail Pharmacies.Specialty drugs limited to 30-day supply at MedImpact Specialty Pharmacy and may have preferred drug list with exclusions. Diabetic Insulin regular copays per coverage tier to max copay $35 for 30-day supply or $105 for 90-day supply, if better. Generic and Preferred Brand Diabetic supplies and equipment 100% covered. Pay penalty price if Brand drug used when Generic is available. Cost share waived for preventive generic and single source brand name contraceptive

Page 3 of 8

Common Medical Event $4,000 single and $8,000 family; VibrantRx Medicare Part D prescription drug maximum out-of-pocket expense $2,100/individual.

Services You May Need

Tier 4 Specialty Generic or Specialty Preferred Brand for Medicare Part D Tier 5 Specialty Preferred Brand and Tier 5 (D) Specialty NonPreferred Brand for Medicare Part D Tier 6 Specialty NonPreferred Brand for NonMedicare Part D

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Specialty up to 30-day supply: 20% coinsurance, $15 min/$90 max Specialty up to 30-day supply: 30% coinsurance, $55 min/$165 max

Not Covered

Limitations, Exceptions, & Other Important Information drugs/devices for women, preventive vaccinations (network participating pharmacies only). Not covered: most over-the-counter drugs, drugs to treat infertility, certain dental drugs, nonprescription contraceptives, drugs on PaydHealth list for members who are required but choose not participate in advocacy services.

Specialty up to 30-day supply: 50% coinsurance, $90 min/$255 max

Facility fee (e.g., ambulatory surgery center)

20% coinsurance

50% coinsurance

Physician/surgeon fees

20% coinsurance

50% coinsurance

Emergency room care

20% coinsurance

20% coinsurance

Emergency medical transportation

20% coinsurance

20% coinsurance

Urgent care Facility fee (e.g., hospital room)

20% coinsurance

20% coinsurance

20% coinsurance

50% coinsurance

Physician/surgeon fees

20% coinsurance

50% coinsurance

$750 penalty for no out-of-network precertification. $750 penalty for no out-of-network precertification.

Out-of-network services are paid at the in-network cost share and deductible.

Out-of-network air ambulance services are paid at the in-network cost share and deductible.

None $750 penalty for no out-of-network precertification. $750 penalty for no out-of-network precertification.

Page 4 of 8

Common Medical Event

If you need mental health, behavioral health, or substance abuse services

Services You May Need

Outpatient services

No charge/office visit** No charge/all other services** **Deductible does not apply

50% coinsurance/office visit 50% coinsurance/all other services

Inpatient services

No charge Deductible does not apply

50% coinsurance

Office visits

If you are pregnant

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Childbirth/delivery professional services

No charge after $400 Maternity copay Deductible does not apply No charge after $400 Maternity copay Deductible does not apply

50% coinsurance 50% coinsurance

Childbirth/delivery facility services

20% coinsurance

50% coinsurance

Home health care

20% coinsurance

50% coinsurance

Rehabilitation services

20% coinsurance/visit

50% coinsurance/visit

If you need help recovering or have other special health needs

Limitations, Exceptions, & Other Important Information $750 penalty if no precert of out-ofnetwork non-routine services.

Includes medical services for MH/SA diagnoses. $750 penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses.

Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy.

Cost sharing does not apply for preventive services.

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). $750 penalty for no out-of-network precertification.

Coverage is limited to 60 days annual max.

16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.)

Coverage is limited to annual max of 90 days for Cognitive therapy, Physical therapy, Occupational therapy and Speech therapy Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Page 5 of 8

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 Services are covered when Medically Necessary to treat a mental health condition (e.g. autism).

Habilitation services

50% coinsurance/visit

Skilled nursing care

20% coinsurance

50% coinsurance

Durable medical equipment

20% coinsurance 20% coinsurance/inpatient services 20% coinsurance/outpatient services Not covered Not covered Not covered

50% coinsurance 50% coinsurance/inpatient services 50% coinsurance/outpatient services Not covered Not covered Not covered

Hospice services

If your child needs dental or eye care

20% coinsurance/visit

Children's eye exam Children's glasses Children's dental check-up

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. $750 penalty for no out-of-network precertification.

Coverage is limited to 60 days annual max.

None $750 penalty for no out-of-network precertification.

None None 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.)  Cosmetic surgery  Infertility treatment  Private-duty nursing  Dental care (Adult)  Long-term care  Routine eye care (Adult)  Dental care (Children)  Non-emergency care when traveling outside the  Routine foot care U.S.  Eye care (Children)  Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Acupuncture ($1,000)  Chiropractic care  Hearing aids (in-network only/2 devices per 60 months)  Bariatric Surgery (in-network only)

Page 6 of 8

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Cigna at 1-800-Cigna24, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-800Cigna24.

Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe's Type 2 Diabetes

Mia's Simple Fracture

(9 months of in-network pre-natal care and a hospital delivery)

(a year of routine in-network care of a wellcontrolled condition)

(in-network emergency room visit and follow up care)

■ The plan's overall deductible ■ Specialist coinsurance ■ Hospital (facility) coinsurance ■ Other coinsurance

$300 20% 20% 20%

■ The plan's overall deductible ■ Specialist coinsurance ■ Hospital (facility) coinsurance ■ Other coinsurance

$300 20% 20% 20%

■ The plan's overall deductible ■ Specialist coinsurance ■ Hospital (facility) coinsurance ■ Other coinsurance

$300 20% 20% 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

This EXAMPLE event includes services like: Primary care physician office visits (including

This EXAMPLE event includes services like: Emergency room care (including medical

Prescription drugs Durable medical equipment (glucose meter)

Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

Total Example Cost

Total Example Cost

disease education) Diagnostic tests (blood work)

$12,700

In this example, Peg would pay:

In this example, Joe would pay:

Cost Sharing Deductibles Copayments Coinsurance

What isn't covered

Deductibles Copayments Coinsurance

Cost Sharing $300 $500 $900

Deductibles Copayments Coinsurance

What isn't covered $20 $2,620

Limits or exclusions The total Joe would pay is

$2,800

In this example, Mia would pay:

Cost Sharing $300 $400 $1,900

Limits or exclusions The total Peg would pay is

$5,600

supplies)

$300 $10 $500

What isn't covered $40 $1,740

Limits or exclusions The total Mia would pay is

$0 $810

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: Choice Plan Ben Ver: 33 Plan ID: 37362033 Page 8 of 8

Discrimination is against the law.

Medical coverage

Cigna Healthcare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna Healthcare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

If you believe that Cigna Healthcare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:

Cigna Healthcare:

Cigna Healthcare Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422

• Provides free aids and services to people with disabilities to

communicate effectively with us, such as: Qualified sign language interpreters

Qualified interpreters

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

Information written in other languages

U.S. Department of Health and Human Services

Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language

is not English, such as:

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at https://www.hhs.gov/civil-rights/filing-a-complaint/complaintprocess/index.html

896375f 3/24 © 2024 Cigna Healthcare

Proficiency of Language Assistance Services English - ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna Healthcare customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish - ATENCION: Hay servicios de asistencia de idiomas, sin cargo, a su disposici6n. Si es un cliente actual de Cigna Healthcare, !lame al numero que figura en el reverso de su tarjeta de identificaci6n. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese - i±�: ft{rraJf,Sf�:9e.JftJHJ:t�!t�ia.l=l}Jij�f£ lt� Cigna Healthcare EfJJJi��P , �rlfi&fflf�Efl ID -t1r®Ef1�� �{-tg�p�ff¥Jl:ffl 1.800.244.6224 C �lr!H!H,i : �ffti 711) Vietnamese - XIN LU'U Y: Quy vi dU'Q'C c�p djch v1,1 trQ' giup v� ng6n ngQ> mien phi. Danh cha khach hang hi(m tc;1i cua Cigna Healthcare, vui long goi s6 mc;it sau the Hoi vien. Cac tmcmg hQ'p khac xin goi s6 1.800.244.6224 (TTY: Quay s6 711 ).

Korean - -?�I: �J�Oj � J..�-§-o�J..I:= ��. <2! Oj 7'1 � J..i 1:11 A� 1f-E£ Ol-§-o�� "? ��LI q_ �XH Cigna Healthcare 7�'fl 7'� 'a� 7JllJ..i := ID 7'� � �121011 �:= �2�te:!.2.£ '2:!�oH-?�J..12.. 7IE� q� ��011:= 1.800.244.6224 (TTY: qo1� 711)te:! 0 £ �2�0H-?�J..l2..

Tagalog - PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna Healthcare, tawagan ang numero sa likuran ng iyong ID card. 0 kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian - BHv1MAHv1E: BaM MoryT npeAOCTaBt,1Tb 6ecnnaTHble ycnyrn nepeBOAa. Ecm1 Bbl y)f{e y4acTByeTe B nnaHe Cigna Healthcare, no3BOHll1Te no HOMepy, yKa3aHHOMY Ha o6paTHO� CTOpOHe Bawe� 111A8HTll1q:>111Kal...\1110HHO� KapTO4Kll1 y4aCTHll1Ka nnaHa. Ecn111 Bbl He f!BmleTeCb y4aCTHIIIKOM OAHOro 1113 HaWIIIX nnaHOB, no3BOHll1Te no HOMepy 1.800.244.6224 (TTY: 711). .�I �I.hi� _)c- u.J .l.JI �)4 J�';/1 ��Y. �WI Cigna Healthcare �)l-.l .rS,] �\:i..o ��I 4_..,:ill -::.it....;.. cl.,w';/1 ��Y. - Arabic .(711 '-,-l �I :TTY) 1.800.244.6224 '-:-l �I . JI 0

0

0

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French Creole - ATANSYON: Gen sevis ed nan lang ki disponib gratis pou ou. Pou kliyan Cigna Healthcare yo, rele nimewo ki deye kat

ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French - ATTENTION: Des services d'aide linguistique vous sont proposes gratuitement. Si vous etes un client actuel de Cigna Healthcare, veuillez appeler le numero indique au verso de votre carte d'identite. Sinon, veuillez appeler le numero 1.800.244.6224 (ATS : composez le numero 711).

Portuguese - ATENCAO: Tern ao seu dispor servi<;:os de assistencia lingufstica, totalmente gratuitos. Para clientes Cigna Healthcare atuais, ligue para o numero que se encontra no verso do seu cartao de identifica<;:ao. Caso contrario, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish - UWAGA: w celu skorzystania z dost�pnej, bezpfatnej pomocy j�zykowej, obecni klienci firmy Cigna Healthcare mog9 dzwonic pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese - 51�$:I:.W : 87$:iR7;£-it�n��-g-, �*{O) �iRsz::titt-!::'A7;£-c'f1Jffll,'tctdt*9 o IJH'IO)Cigna HealthcareO)S��J�;;t:_ ID:b- t-:'� jijO)�it:ffl:�*c\ s�it,LZc'Ji�( tc.�l,'o f-O){{Q0)7J�i, 1.800.244.6224 (TTY: 711) *c\ s�it,LZc'Ji�( tc.�l,'o Italian - ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna Healthcare attuali, chiamare ii numero sul retro della tessera di identificazione. In caso contrario, chiamare ii numero 1.800.244.6224 (utenti TTY: chiamare ii numero 711).

German - ACHTUNG: Die Leistungen der Sprachunterstotzung stehen Ihnen kostenlos zur Verfugung. Wenn Sie gegenwartiger Cigna Healthcare-Kunde sind, rufen Sie bitte die Nummer auf der Ruckseite lhrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wahlen Sie 711).

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2026 - 12/31/2026 City of Mesa: Open Access Plus - Copay Plan 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 www.cigna.com/sp. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-Cigna24 to request a copy.

Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have What is the overall For in-network providers: $0/individual or $0/family other family members on the plan, each family member must deductible?

For out-of-network providers: $1,500/individual or $4,500/family meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may Are there services covered apply. For example, this plan covers certain preventive services before you meet your Yes. Out-of-network emergency room visits. without cost-sharing and before you meet your deductible. See a deductible? list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services?

The out-of-pocket limit is the most you could pay in a year for For in-network providers: $4,600/individual or $9,200/family What is the out-of-pocket covered services. If you have other family members in this plan, For out-of-network providers: Unlimited/individual or limit for this plan? they have to meet their own out-of-pocket limits until the overall Unlimited/family family out-of-pocket limit has been met.

Penalties for failure to obtain pre-authorization for services, What is not included in the Even though you pay these expenses, they don't count toward premiums, balance-billing charges, and health care this plan out-of-pocket limit? the out-of-pocket limit. doesn’t cover.

Page 1 of 8

Important Questions

Answers

Will you pay less if you use a network provider?

Yes. See www.cigna.com or call 1-800-Cigna24 for a list of network providers.

Do you need a referral to see a specialist?

No.

Why This Matters: 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.

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 Medical Event

If you visit a health care provider's office or clinic

If you have a test

What You Will Pay Services You May Need In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) Primary care visit to treat an $25 copay/office visit 50% coinsurance injury or illness $20 copay/MDLIVE visit $50 copay/office visit Specialist visit 50% coinsurance $40 copay/MDLIVE visit No charge/visit Not covered/visit No charge/screening Not covered/screening Including Diagnostic Skin Cancer Screening and 50% coinsurance Diagnostic Mammogram Preventive care/ screening/ No charge/immunizations Not covered/immunizations immunization

Diagnostic test (x-ray, blood No charge work)

50% coinsurance

Limitations, Exceptions, & Other Important Information None None None None

None You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

None

Page 2 of 8

Common Medical Event

Services You May Need Imaging (CT/PET scans, MRIs)

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at MedImpact www.medi mpact.com or (866) 387- 3537. Mandatory Specialty Drug Advocacy with PaydHealth (877) 4221776. For Medicare eligible retiree prescription drug coverage contact VibrantRX www.MyVibrantRx.com or (844) 826-3451 (no PaydHealth required for Medicare eligible retirees).

Maximum prescription drug out-of-pocket expense: $4,000 single and $8,000 family; VibrantRx Medicare Part D prescription drug maximum out-of-pocket expense $2,100/individual.

Tier 1 Generic Drugs

Tier 2 Preferred Brand Drugs

Tier 3 Non-Preferred Brand Drugs Tier 4 Specialty Generic or Specialty Preferred Brand for Medicare Part D Tier 5 Specialty Preferred Brand and Tier 5 (D) Specialty NonPreferred Brand for Medicare Part D Tier 6 Specialty NonPreferred Brand for NonMedicare Part D

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) No charge Retail up to 30-day supply: 20% coinsurance, $10 min/$60 max Retail/Mail Order up to 90day supply: 20% coinsurance, $20 min/$120 max Retail up to 30-day supply: 30% coinsurance, $35 min/$110 max Retail/Mail Order up to 90day supply: 30% coinsurance, $70 min/$220 max Retail up to 30-day supply: 50% coinsurance, $60 min/$170 max Retail/Mail Order up to 90day supply: 50% coinsurance, $120 min/$340 max

50% coinsurance

None

Pay cash, file direct RX claim paid at in-network levels minus coinsurance/min/max (limited to up to 30-day supplies only)

Some drugs require precertifications, step therapy and/or have quantity limitations. 90-day supply obtained at mail order or in network Retail Pharmacies. Specialty drugs limited to 30- day supply at MedImpact Specialty Pharmacy and may have preferred drug list with exclusions.

Generic or Preferred Brand Diabetic Insulin at Generic copays to max copay $35 for 30-day supply or $105 for 90-day supply, if better. NonPreferred Brand Diabetic Insulin at regular copays to same $35/$105 max copays, if better. Pay penalty price if Brand drug used when Generic is available. Cost share waived for preventive generic and single source brand name contraceptive drugs/devices for women, preventive vaccinations (network participating pharmacies only). Not covered: most over-the-counter drugs, drugs to treat infertility, certain dental drugs, nonprescription contraceptives, drugs on PaydHealth list for members who are required but choose not to participate in advocacy services.

Pay cash, file direct RX claim paid at in-network levels minus coinsurance/min/max (limited to up to 30-day supplies only) Pay cash, file direct RX claim paid at in-network levels minus coinsurance/min/max (limited to up to 30-day supplies only)

Specialty up to 30-day supply: 20% coinsurance, $15 min/$90 max Specialty up to 30-day supply: 30% coinsurance, $55 min/$165 max Specialty up to 30-day supply: 50% coinsurance, $90 min/$255 max

Limitations, Exceptions, & Other Important Information

Not covered

Page 3 of 8

Common Medical Event If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

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)

Facility fee (e.g., ambulatory surgery center)

$250 copay/visit

50% coinsurance

Physician/surgeon fees

No charge

50% coinsurance

Emergency room care

$200 copay/visit

$200 copay/visit Deductible does not apply

Emergency medical transportation

No charge

No charge Deductible does not apply

Urgent care Facility fee (e.g., hospital room)

$60 copay/visit

50% coinsurance

$400 copay/admission

50% coinsurance

Physician/surgeon fees

No charge

50% coinsurance

Outpatient services

No charge/office visit No charge/MDLIVE visit No charge/all other services

50% coinsurance/office visit 50% coinsurance/all other services

Inpatient services

No charge

50% coinsurance

Office visits If you are pregnant Childbirth/delivery professional services

No charge after $400 Maternity copay Deductible does not apply No charge after $400 Maternity copay Deductible does not apply

50% coinsurance 50% coinsurance

Limitations, Exceptions, & Other Important Information $750 penalty for no out-of-network precertification. Per visit copay is waived for non-surgical procedures. $750 penalty for no out-of-network precertification.

Per visit copay is waived if admitted.

Out-of-network services are paid at the in-network cost share.

Out-of-network air ambulance services are paid at the in-network cost share and deductible. Services for MH/SA diagnoses will be payable according to Emergency room care benefits.

None $750 penalty for no out-of-network precertification. $750 penalty for no out-of-network precertification. $750 penalty if no precert of out-ofnetwork non-routine services.

Includes medical services for MH/SA diagnoses. $750 penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses.

Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy.

Cost sharing does not apply for preventive services.

Depending on the type of services, a Page 4 of 8

Common Medical Event

Services You May Need

Childbirth/delivery facility services

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) $400 copay/ inpatient admission, then plan pays 100% 50% coinsurance $250 copay/ outpatient admission, then plan pays 100%

Home health care

No charge

50% coinsurance

Rehabilitation services

$30 copay/visit

50% coinsurance/visit

If you need help recovering or have other special health needs

Limitations, Exceptions, & Other Important Information copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). $750 penalty for no out-of-network precertification.

Coverage is limited to 60 days annual max.

16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.)

Coverage is limited to annual max of 90 days for Cognitive therapy, Physical therapy, Occupational therapy and Speech therapy.

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

Services are covered when Medically Necessary to treat a mental health condition (e.g. autism).

Habilitation services

Skilled nursing care

$30 copay/visit

$300 copay/admission

50% coinsurance/visit

50% coinsurance

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. $750 penalty for no out-of-network precertification.

Coverage is limited to 60 days annual max.

Page 5 of 8

Common Medical Event

Services You May Need Durable medical equipment Hospice services

If your child needs dental or eye care

Children's eye exam Children's glasses Children's dental check-up

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) No charge 50% coinsurance 50% coinsurance/inpatient No charge/inpatient services services No charge/outpatient services 50% coinsurance/outpatient services Not covered Not covered Not covered Not covered Not covered Not covered

Limitations, Exceptions, & Other Important Information None $750 penalty for no out-of-network precertification.

None None 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  Infertility treatment  Private-duty nursing  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Dental care (Adult)  Non-emergency care when traveling outside the  Routine foot care U.S.  Dental care (Children)  Weight loss programs  Eye care (Children) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Bariatric Surgery (in-network only)  Chiropractic care  Hearing aids (in-network only/2 device per 60 months)

Page 6 of 8

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Cigna at 1-800-Cigna24, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-800Cigna24.

Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-244-6224.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe's Type 2 Diabetes

Mia's Simple Fracture

(9 months of in-network pre-natal care and a hospital delivery)

(a year of routine in-network care of a wellcontrolled condition)

(in-network emergency room visit and follow up care)

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance ■ Other coinsurance

$0 $50 0% 0%

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance ■ Other coinsurance

$0 $50 0% 0%

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance ■ Other coinsurance

$0 $50 0% 0%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

This EXAMPLE event includes services like: Primary care physician office visits (including

This EXAMPLE event includes services like: Emergency room care (including medical

Prescription drugs Durable medical equipment (glucose meter)

Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

Total Example Cost

Total Example Cost

disease education) Diagnostic tests (blood work)

$12,700

In this example, Peg would pay:

In this example, Joe would pay:

Cost Sharing Deductibles Copayments Coinsurance

What isn't covered

Deductibles Copayments Coinsurance

Cost Sharing $0 $800 $800

Deductibles Copayments Coinsurance

What isn't covered $20 $820

Limits or exclusions The total Joe would pay is

$2,800

In this example, Mia would pay:

Cost Sharing $0 $800 $0

Limits or exclusions The total Peg would pay is

$5,600

supplies)

$0 $400 $0

What isn't covered $40 $1,640

Limits or exclusions The total Mia would pay is

$0 $400

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: Copay Plan Ben Ver: 33 Plan ID: 37362027 Page 8 of 8

Discrimination is against the law.

Medical coverage

Cigna Healthcare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna Healthcare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

If you believe that Cigna Healthcare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:

Cigna Healthcare:

Cigna Healthcare Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422

• Provides free aids and services to people with disabilities to

communicate effectively with us, such as: Qualified sign language interpreters

Qualified interpreters

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

Information written in other languages

U.S. Department of Health and Human Services

Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language

is not English, such as:

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at https://www.hhs.gov/civil-rights/filing-a-complaint/complaintprocess/index.html

896375f 3/24 © 2024 Cigna Healthcare

Proficiency of Language Assistance Services English - ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna Healthcare customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish - ATENCION: Hay servicios de asistencia de idiomas, sin cargo, a su disposici6n. Si es un cliente actual de Cigna Healthcare, !lame al numero que figura en el reverso de su tarjeta de identificaci6n. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese - i±�: ft{rraJf,Sf�:9e.JftJHJ:t�!t�ia.l=l}Jij�f£ lt� Cigna Healthcare EfJJJi��P , �rlfi&fflf�Efl ID -t1r®Ef1�� �{-tg�p�ff¥Jl:ffl 1.800.244.6224 C �lr!H!H,i : �ffti 711) Vietnamese - XIN LU'U Y: Quy vi dU'Q'C c�p djch v1,1 trQ' giup v� ng6n ngQ> mien phi. Danh cha khach hang hi(m tc;1i cua Cigna Healthcare, vui long goi s6 mc;it sau the Hoi vien. Cac tmcmg hQ'p khac xin goi s6 1.800.244.6224 (TTY: Quay s6 711 ).

Korean - -?�I: �J�Oj � J..�-§-o�J..I:= ��. <2! Oj 7'1 � J..i 1:11 A� 1f-E£ Ol-§-o�� "? ��LI q_ �XH Cigna Healthcare 7�'fl 7'� 'a� 7JllJ..i := ID 7'� � �121011 �:= �2�te:!.2.£ '2:!�oH-?�J..12.. 7IE� q� ��011:= 1.800.244.6224 (TTY: qo1� 711)te:! 0 £ �2�0H-?�J..l2..

Tagalog - PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna Healthcare, tawagan ang numero sa likuran ng iyong ID card. 0 kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian - BHv1MAHv1E: BaM MoryT npeAOCTaBt,1Tb 6ecnnaTHble ycnyrn nepeBOAa. Ecm1 Bbl y)f{e y4acTByeTe B nnaHe Cigna Healthcare, no3BOHll1Te no HOMepy, yKa3aHHOMY Ha o6paTHO� CTOpOHe Bawe� 111A8HTll1q:>111Kal...\1110HHO� KapTO4Kll1 y4aCTHll1Ka nnaHa. Ecn111 Bbl He f!BmleTeCb y4aCTHIIIKOM OAHOro 1113 HaWIIIX nnaHOB, no3BOHll1Te no HOMepy 1.800.244.6224 (TTY: 711). .�I �I.hi� _)c- u.J .l.JI �)4 J�';/1 ��Y. �WI Cigna Healthcare �)l-.l .rS,] �\:i..o ��I 4_..,:ill -::.it....;.. cl.,w';/1 ��Y. - Arabic .(711 '-,-l �I :TTY) 1.800.244.6224 '-:-l �I . JI 0

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French Creole - ATANSYON: Gen sevis ed nan lang ki disponib gratis pou ou. Pou kliyan Cigna Healthcare yo, rele nimewo ki deye kat

ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French - ATTENTION: Des services d'aide linguistique vous sont proposes gratuitement. Si vous etes un client actuel de Cigna Healthcare, veuillez appeler le numero indique au verso de votre carte d'identite. Sinon, veuillez appeler le numero 1.800.244.6224 (ATS : composez le numero 711).

Portuguese - ATENCAO: Tern ao seu dispor servi<;:os de assistencia lingufstica, totalmente gratuitos. Para clientes Cigna Healthcare atuais, ligue para o numero que se encontra no verso do seu cartao de identifica<;:ao. Caso contrario, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish - UWAGA: w celu skorzystania z dost�pnej, bezpfatnej pomocy j�zykowej, obecni klienci firmy Cigna Healthcare mog9 dzwonic pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese - 51�$:I:.W : 87$:iR7;£-it�n��-g-, �*{O) �iRsz::titt-!::'A7;£-c'f1Jffll,'tctdt*9 o IJH'IO)Cigna HealthcareO)S��J�;;t:_ ID:b- t-:'� jijO)�it:ffl:�*c\ s�it,LZc'Ji�( tc.�l,'o f-O){{Q0)7J�i, 1.800.244.6224 (TTY: 711) *c\ s�it,LZc'Ji�( tc.�l,'o Italian - ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna Healthcare attuali, chiamare ii numero sul retro della tessera di identificazione. In caso contrario, chiamare ii numero 1.800.244.6224 (utenti TTY: chiamare ii numero 711).

German - ACHTUNG: Die Leistungen der Sprachunterstotzung stehen Ihnen kostenlos zur Verfugung. Wenn Sie gegenwartiger Cigna Healthcare-Kunde sind, rufen Sie bitte die Nummer auf der Ruckseite lhrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wahlen Sie 711).

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