2018 COBRA

Cigna benefits at termination

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

MEDICAL, DENTAL AND VISION COSTSMedical costs Total monthly COBRA costs below do not include the additional two percent administrative fee.

Plan descriptionsEmployee

onlyEmployee &

Sp/Dom PartEmployee &

Child/renFamily

With these coverage choices, you use the Open Access Plus (OAP) network for network care.

HSA 1,600/3,200 Deductible $1,600/$3,200 Out-of-pocket: $3,750/$7,500; Coinsurance: 15% to 25% $591.26 $1,182.52 $1,123.39 $1,773.78

HSA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% to 25% $525.37 $1,050.75 $998.22 $1,576.13

Healthy Life HRA Deductible $1,600/$3,200Out-of-pocket: $3,750/$7,500; Coinsurance: 15% to 25% $605.03 $1,210.06 $1,149.56 $1,815.09

HRA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% to 25% $534.36 $1,068.72 $1,015.28 $1,603.08

With these coverage choices, you use the LocalPlus network for network care, if available in your area.

HSA 1,600/3,200 Deductible $1,600/$3,200Out-of-pocket: $3,750/$7,500; Coinsurance: 15% $562.20 $1,124.40 $1,068.19 $1,686.60

HSA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% $499.64 $999.27 $949.31 $1,498.91

Healthy Life HRA Deductible $1,600/$3,200Out-of-pocket: $3,750/$7,500; Coinsurance: 15% $575.51 $1,151.02 $1,093.47 $1,726.53

HRA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% $508.30 $1,016.60 $965.77 $1,524.90

With these coverage choices, you use the HMO network for network care, if available in your area.

So. California Network Plan Out-of-pocket: $3,750/$7,500; Coinsurance: N/A $498.91 $997.82 $947.93 $1,496.73

2018 CIGNA MEDICAL OPTIONS TOTAL MONTHLY COBRA COSTS

Dental costs

Plan descriptionsEmployee

onlyEmployee &

Sp/Dom PartEmployee &

Child/renFamily

Dental will be billed at the full COBRA cost throughout the entire COBRA continuation period.

Cigna Dental Care – HMO $28.60 $57.24 $57.24 $85.84

Cigna Dental – PPO $38.75 $77.50 $77.50 $116.25

2018 CIGNA DENTAL OPTIONS TOTAL MONTHLY COBRA COSTS

Vision costs

Plan descriptionsEmployee

onlyEmployee &

Sp/Dom PartEmployee &

Child/renFamily

Vision will be billed at the full COBRA cost throughout the entire COBRA continuation period.

Vision $6.30 $12.61 $12.61 $18.92

2018 CIGNA VISION OPTIONS TOTAL MONTHLY COBRA COSTS

See next page of this document for subsidized medical costs while on severance.See last page of this document for important information regarding COBRA medical insurance if you are Medicare eligible.If you are at least age 55 and have at least five years of service at termination, you and your eligible dependents may also be eligible for the retiree medical, dental and vision plans. For more information regarding retiree plans and costs, go to Your Cigna Life > Health & Well-Being > Ready to Retire or contact the Your Cigna Life Service Center at 800.551.3539.

MEDICAL, DENTAL AND VISION COSTS DURING SEVERANCEMedical costs Medical coverage will be billed at a subsidized rate during the severance period. At the end of the severance period, you will pay the full COBRA cost.

Plan descriptionsEmployee

onlyEmployee &

Sp/Dom PartEmployee &

Child/renFamily

With these coverage choices, you use the Open Access Plus (OAP) network for network care.

HSA 1,600/3,200 Deductible $1,600/$3,200Out-of-pocket: $3,750/$7,500; Coinsurance: 15% to 25% $206.94 $413.88 $393.19 $620.82

HSA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% to 25% $183.88 $367.76 $349.38 $551.65

Healthy Life HRA Deductible $1,600/$3,200Out-of-pocket: $3,750/$7,500; Coinsurance: 15% to 25% $211.76 $423.52 $402.35 $635.28

HRA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% to 25% $187.03 $374.05 $355.35 $561.08

With these coverage choices, you use the LocalPlus network for network care, if available in your area.

HSA 1,600/3,200 Deductible $1,600/$3,200Out-of-pocket: $3,750/$7,500; Coinsurance: 15% $196.77 $393.54 $373.87 $590.31

HSA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% $174.87 $349.74 $332.26 $524.62

Healthy Life HRA Deductible $1,600/$3,200Out-of-pocket: $3,750/$7,500; Coinsurance: 15% $201.43 $402.86 $382.71 $604.29

HRA 3,000/5,500 Deductible $3,000/$5,500Out-of-pocket: $5,500/$11,000; Coinsurance: 15% $177.91 $355.81 $338.02 $533.72

With these coverage choices, you use the HMO network for network care, if available in your area.

So. California Network Plan Out-of-pocket: $3,750/$7,500 Coinsurance: N/A $174.62 $349.24 $331.78 $523.86

2018 CIGNA MEDICAL OPTIONS MONTHLY COBRA COSTS DURING SEVERANCE

Dental costs

Vision costs

Plan descriptionsEmployee

onlyEmployee &

Sp/Dom PartEmployee &

Child/renFamily

Dental will be billed at the full COBRA cost throughout the entire COBRA continuation period.

Cigna Dental Care – HMO $28.60 $57.24 $57.24 $85.84

Cigna Dental – PPO $38.75 $77.50 $77.50 $116.25

2018 CIGNA DENTAL OPTIONS TOTAL MONTHLY COBRA COSTS

Plan descriptionsEmployee

onlyEmployee &

Sp/Dom PartEmployee &

Child/renFamily

Vision will be billed at the full COBRA cost throughout the entire COBRA continuation period.

Vision $6.30 $12.61 $12.61 $18.92

2018 CIGNA VISION OPTIONS TOTAL MONTHLY COBRA COSTS

See previous page of this document for the total COBRA costs if not receiving severance. See last page of this document for important information regarding COBRA medical insurance if you are Medicare eligible.If you are at least age 55 and have at least five years of service at termination, you and your eligible dependents may also be eligible for the retiree medical, dental and vision plans. For more information regarding retiree plans and costs, go to Your Cigna Life > Health & Well-Being > Ready to Retire or contact the Your Cigna Life Service Center at 800.551.3539.

IMPORTANT NOTICE REGARDING COBRA COVERAGE AND MEDICARE ELIGIBILITY

There are important coverage rules of which you should be aware if you are Medicare-eligible and you are considering COBRA coverage under the Cigna Medical Plan.

If you are Medicare-eligible, COBRA coverage under the Cigna Medical Plan is administered as if you are covered by Parts A and B – whether or not you have actually enrolled in Medicare. This means that even if you do not enroll in Medicare Part A and B, you will be responsible for the coverage amount that would have been paid by Medicare if you had enrolled. Since Medicare pays 80%, your COBRA benefit under the Cigna Medical Plan will be based on the remaining 20%.

For More Information About Your Cigna Medical Plan:

If you have any questions regarding your Cigna Medical Plan, please call a Cigna customer service representative at 888.992.4462. A representative is available to help, 24 hours a day, seven days a week.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

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