2026 CIGNA Silver PFA Summary of Benefits

CIGNA Plan Deductible: Individual: $4,000 Family: $8,000 Plan Debit Card Deductible Responsibility: Debit Card Allotment: Individual: $1,500 Family: $3,000 Member Deductible Responsibility: Member pays the remaining Individual: $2,500 Family: $5,000 Office & Specialist Visit: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Emergency Room (waived if admitted): Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Inpatient Hospitalization: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Day Surgery: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance High Tech Imaging (MRI, CT Scans, PET): Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Diagnostic Tests, Labs & X-Rays: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Once employee reaches $6,500 individual and $13,000 for Family of out of pocket max expenses employees can manually submit remaining expenses for reimbursement. Deductible applies then; Prescription Drugs: Retail - 30 Day Supply Tier 1: 30% coinsurance Tier 2: 30% coinsurance Tier 3: 30% coinsurance Prescription Drugs: Mail Order - 90 Day Supply Tier 1: 30% coinsurance Tier 2: 30% coinsurance Tier 3: 30% coinsurance Your employer AESOP Auto Parts has arranged for Reimbursement Specialists, Inc. (RSI) to administer the deductible portions of your CIGNA health plan. You will be provided a RSI debit card preloaded with an allotment of funds to be used on eligible deductible expenses associated with your plan. The benefits shown here are a snapshot of the benefits provided by your employer. For a detailed explanation of your benefits see the CIGNA benefit summaries. January 1, 2026– December 31, 2026 Silver PFA PLAN

Our RSI Client Advocate Claims Team is here to help you. If you or your doctor have a question regarding the plan, a specific claim or a bill please contact us Phone: 833-732-6367 E-mail: claims@rsiadmin.com Reimbursement Specialists, Inc. | 120 Longwater Drive Suite 102 | Norwell, MA 02061 HOW THE DEDUCTIBLE & PRESCRIPTION PORTIONS OF YOUR CIGNA PLAN WORK  You and/or your family visit a provider (doctor, hospital, ER, etc.) • Show your CIGNA ID Card to the provider  Provider: • Bills CIGNA  CIGNA: • Adjudicates claim • Notifies/pays provider • Sends a Summary of Health Plan Payments to you and your provider. The Summary is not a bill and should be saved for your records!  You: • Receive your CIGNA EOB and adjusted provider bill. Once they match use your RSI debit card for payment • You are responsible to pay your portion of the deductible to your provider once your debit card is exhausted Once employee reaches $6,500 individual and $13,000 for Family of deductible expenses employees can manually submit remaining expenses for reimbursement. You can submit claims through your RSI employee portal or submit to the RSI email at Claims@rsiadmin.com