Page 5 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Skilled nursing care 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. Coverage is limited to 60 days annual max. Durable medical equipment 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. Hospice services 30% coinsurance/inpatient services 30% coinsurance/outpatient services 50% coinsurance/inpatient services 50% coinsurance/outpatient services $750 penalty for no out-of-network precertification. Children's eye exam Not covered Not covered None Children's glasses Not covered Not covered None If your child needs dental or eye care Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)  Acupuncture  Bariatric surgery  Cosmetic surgery  Dental care (Adult)  Dental care (Children)  Hearing aids  Long-term care  Non-emergency care when traveling outside of the U.S.  Private-duty nursing  Routine eye care (Adult)  Routine eye care (Children)  Routine foot care  Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Chiropractic care (30 visits)  Infertility treatment (in-network only) 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 1-866-494-2111, Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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.