Cigna Vision

LACERA

CIGNA VISION

EFFECTIVE DATE: July 1, 2015

CN028

3211348

This document printed in September, 2015 takes the place of any documents previously issued to you

which described your benefits.

Printed in U.S.A.

Table of Con

nts

rtification

....................................................................................................................................4

Important Notices ..........................................................................................................................6

How To File Your

Claim

...............................................................................................................7

Eligibility - Effective Date .............................................................................................................8

Retiree

Insurance

....................................................................................................................................................

Dependent Insurance

..............................................................................................................................................

Cigna Vision ...................................................................................................................................9

The

Schedule ..........................................................................................................................................................

Covered Expenses

................................................................................................................................................

Expenses Not Covered

.........................................................................................................................................

Exclusions and General Limitations ..........................................................................................10

Expenses For Which A Third Party May Be

Responsible

.......................................................11

Payment of Benefits .....................................................................................................................12

Termination Of Insurance ..........................................................................................................12

Retirees

.................................................................................................................................................................

Dependents ...........................................................................................................................................................

Federal Requirements .................................................................................................................13

Qualified Medical Child Support Order (QMCSO)

.............................................................................................

Eligibility for Coverage for Adopted

Children

.....................................................................................................

Group Plan Coverage Instead of

Medicaid

...........................................................................................................

Claim Determination

Procedures..........................................................................................................................

COBRA Continuation Rights Under Federal Law

...............................................................................................

Notice of an Appeal or a Grievance

.....................................................................................................................

When You Have A Complaint Or An Adverse Determination

Appeal

..................................17

Def

inition

s .....................................................................................................................................19

Home Office: Bloomfield, Connecticut

Mailing Address: Hartford, Connecticut 06152

CIGNA HEALTH AND LIFE INSURANCE COMPANY

a Cigna company (hereinafter called Cigna) certifies that it insures certain Employees for the benefits

provided by the following policy(s):

POLICYHOLDER: LACERA (Los Angeles County Employees Retirement Association)

GROUP POLICY(S) — COVERAGE

3211348 - VIS CIGNA VISION

EFFECTIVE DATE: July 1, 2015

This certificate describes the main features of the insurance. It does not waive or alter any of the terms of

the policy(s). If questions arise, the policy(s) will govern.

This certificate takes the place of any other issued to you on a prior date which described the

insu

rance.

HC-CER5 04-10

Explanation of

Terms

You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms

are defined in the Definitions section of your certificate.

The

Schedule

The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description

of each benefit, refer to the appropriate section listed in the Table of Contents.

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Important Notices

To contact the Department of Insurance, write or call:

Consumer Affairs Division

California Department of Insurance

Ronald Reagan Building

300 South Spring Street

Los Angeles, CA 90013

Calling within California: 1-800-927-4357

Los Angeles Area and Outside California: 1-213-897-8921

The Department of Insurance should be contacted only after

discussions with the insurer have failed to produce a

satisfactory resolution to the problem.

Important Notices

Important Information About Free Language Assistance

No Cost Language Services for members who live in

California and members who live outside of California who

are covered under a policy issued in California. You can get

an interpreter. You can get documents read to you and some

sent to you in your language. For help, call us at the number

listed on your ID card or 1-800-244-6224 for Cigna

medical/dental or 1-866-421-8629 for Cigna Behavioral

Health mental health/substance abuse. For more help call the

CA Dept. of Insurance at 1-800-927-4357. English

Servicios de idioma sin costo para miembros que viven en

California y para miembros que viven fuera de California y

que están cubiertos por una póliza emitida en California.

Puede obtener un intérprete. Puede hacer que le lean los

documentos en español y que le envíen algunos de ellos en ese

idioma. Para obtener ayuda, llámenos al número que

aparece

su tarjeta de identificación o a 1-800-244-6224 para

servicios médicos/dentales de Cigna o al 1-866-421-8629 para

servicios de salud

mental/fármacodependencia

de Cigna

Behavioral Health. Para obtener ayuda adicional, llame al

Departamento de Seguros de CA al 1-800-927-4357. Spanish

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HC-IMP9 04-10

Notice Regarding Provider Directories and Provider

Networks - Vision

A Participating Provider network consists of a group of local

practitioners who contract directly or indirectly with Cigna to

provide services to members.

You may receive a listing of Participating Providers by calling

the member services number on your benefit identification

card, or by visiting www.myCigna.com.

Notice - Participating Provider Benefits

The Vision benefit plan includes the following options:

• If you select a Participating Provider Cigna will base its

payment on the amount listed in the Schedule of Benefits.

The Participating Provider will limit his/her charge to the

Contracted Fee for the service.

• If you select a Non-Participating Provider Cigna will base

its payment on the amount listed in the Out-of-Network

section of the Schedule of Benefits. The Non-Participating

Provider may balance bill up to his/her actual charge.

Notice – Emergency Services

Emergency Services rendered by a Non-Participating Provider

will be paid at the Participating Provider benefit level in the

event a Participating Provider is not available.

HC-NO

How To File Your Claim

There’s no paperwork for In-Network care. Just show your

identification card and pay your share of the cost, if any; your

provider will submit a claim to Cigna for reimbursement. Out-

of-Network claims can be submitted by the provider if the

provider is able and willing to file on your behalf. If the

provider is not submitting on your behalf, you must send your

completed claim form and itemized bills to the claims address

listed on the claim form.

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You may get the required claim forms by calling the Cigna

customer service toll-free number located on your

identification card.

CLAIM REMINDERS

• BE SURE TO USE YOUR MEMBER ID AND

ACCOUNT/GROUP NUMBER WHEN YOU FILE

CIGNA’S CLAIM FORMS, OR WHEN YOU CALL

YOUR CIGNA CLAIM OFFICE.

YOUR MEMBER ID IS THE ID SHOWN ON YOUR

BENEFIT IDENTIFICATION CARD.

YOUR ACCOUNT/GROUP NUMBER IS SHOWN ON

YOUR BENEFIT IDENTIFICATION CARD.

• BE SURE TO FOLLOW THE INSTRUCTIONS LISTED

ON THE BACK OF THE CLAIM FORM CAREFULLY

WHEN SUBMITTING A CLAIM TO CIGNA.

Timely Filing of Out-of-Network Claims

Cigna will consider claims for coverage under our plans when

proof of loss (a claim) is submitted within 365 days for Out-

of-Network benefits after services are rendered. If services are

rendered on consecutive days, such as for a Hospital

Confinement, the limit will be counted from the last date of

service. If claims are not submitted within 365 days for Out-

of-Network benefits, the claim will not be considered valid

and will be denied.

WARNING: Any person who knowingly and with intent to

defraud any insurance company or other person files an

application for insurance or statement of claim containing any

materially false information; or conceals for the purpose of

misleading, information concerning any material fact thereto,

commits a fraudulent insurance act.

HC-CLM25 01-11

V11

Eligibility - Effective Date

Retiree Insurance

This plan is offered to you as a retired Employee.

Eligibility for Retiree Insurance

You will become eligible for insurance on the date you retired

if you are in a Class of Eligible Employees.

Eligibility for Dependent Insurance

You will become eligible for Dependent insurance on the later

of:

• the day you become eligible for yourself; or

• the day you acquire your first Dependent.

Classes of Eligible Retirees

Each Retiree as reported to the insurance company by your

retirement association.

Effective Date of Retiree Insurance

You will become insured on the date you elect the insurance

by signing a written agreement with the Policyholder to make

the required contribution, but no earlier than the date you

become eligible.

You will become insured on the first day of the second month

following your retirement.

To be insured for these benefits, you must elect the insurance

for yourself no later than 60 days after your retirement.

Dependent Insurance

For your Dependents to be insured, you will have to pay the

required contribution, if any, toward the cost of Dependent

Insurance.

Effective Date of Dependent Insurance

Insurance for your Dependents will become effective on the

date you elect it by signing a written agreement with the

Policyholder to make the required contribution, but no earlier

than the day you become eligible for Dependent Insurance. All

of your Dependents as defined will be included.

For your Dependents to be insured for these benefits, you must

elect the Dependent insurance for yourself no later than 60

days after you become eligible.

Your Dependents will be insured only if you are insured.

HC-ELG39 04-10

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Cigna Vision

The S

For You and Your Dependents

Copayments

Copayments are amounts to be paid by you or your Dependent for covered services.

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

The Plan will pay 100% after

any

copayment, subject to

any

maximum shown

below

The plan will reimburse you

100%, subject to any

maximum

shown

below

Examinations

One Eye Exam every Calendar Year

$20

Copay

$25

Lenses

One pair per Calendar Year

Single Vision Lenses

Bifocal Lenses

Progressive Lenses

Trifocal Lenses

Lenticular Lenses

$40

Copay

100%

100% up to

$70

100%

$35

$45

$70

$130

Contact Lenses

One pair per

Lifetime

Elective

Hard

Lenses

Soft

Lenses

Therapeutic

100% up to $180

100% up to $230

$150

$225

Frames

One pair per Calendar Year

100% up to $50

$35

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Vision Benefits

For You and Your Dependents

Covered Expenses

Benefits Include:

Examinations – One vision and eye health evaluation

including but not limited to eye health examination, dilation,

refraction and prescription for glasses.

Lenses (Glasses) – One pair of prescription plastic or glass

lenses, all ranges of prescriptions (powers and prisms).

• Polycarbonate lenses for children under 18 years of age;

• Oversize lenses;

• Rose #1 and #2 solid tints;

• Progressive lenses covered up to amount shown in the

Schedule of Benefits.

Frames – One frame – choice of frame covered up to retail

plan allowance.

Contact Lenses – One pair or a single purchase of a supply of

contact lenses in lieu of lenses and frame benefit (may not

receive contact lenses and frames in same benefit

year).

Contact

lens allowance can be applied towards contact lens

materials as well as the cost of supplemental contact lens

professional services including fitting and evaluation, up to the

stated allowance.

Coverage for Therapeutic contact lenses will be

provided when

visual acuity cannot be corrected to 20/70 in the better eye

with eyeglasses and the fitting of the contact lenses would

obtain this level of visual acuity; and in certain cases of

anisometropia, keratoconus, or aphakis; as determined and

documented by your Vision Provider. Contact lenses fitted for

other therapeutic purposes or the narrowing of visual

fields

due

to high minus or plus correction will be covered in

accordance with the Elective contact lens benefit shown on the

Schedule of Benefits.

HC-VIS1 04-10

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Expenses Not Covered

Covered Expenses will not include, and no payment will be

made for:

• Orthoptic or vision training and any associated

supplemental testing.

• Spectacle lens treatments, “add ons”, or lens coatings not

shown as covered in the Schedule.

• Two pair of glasses, in lieu of bifocals or trifocals.

• Prescription sunglasses.

• Medical or surgical treatment of the eyes.

• Any eye examination, or any corrective eyewear, required

by an employer as a condition of employment.

• Magnification or low vision aids.

• Any non-prescription eyeglasses, lenses, or contact lenses.

• Safety glasses or lenses required for employment.

• VDT (video display terminal)/computer eyeglass benefit.

• Charges in excess of the Maximum Reimbursable Charge

for the Service or Materials.

• Charges incurred after the Policy ends or the Insured's

coverage under the Policy ends, except as stated in the

Policy.

• Experimental or non-conventional treatment or device.

• High Index lenses of any material type.

• Lens treatments or “add-ons”, except rose tints (#1 & #2),

and oversize lenses.

• For or in connection with experimental procedures or

treatment methods not approved by the American

Optometric Association or the appropriate vision specialty

society.

• Any injury or illness when paid or payable by Workers’

Compensation or similar law, or which is

work-related.

• Claims submitted and received in-excess of twelve-(12)

months from the original Date of Service.

Other Limitations are shown in the Exclusions and General

Limitations section.

HC-VIS2 04-10

Exclusions and General Limitations

Exclusions

Additional coverage limitations determined by plan or

provider type are shown in the Schedule. Payment for the

following is specifically excluded from this plan:

• treatment of an Injury or Sickness which is due to war,

declared, or undeclared.

• charges which you are not obligated to pay or for which

you are not billed or for which you would not have

bee

billed except that they were covered under this plan.

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• for or in connection with experimental procedures or

treatment methods not approved by the American

Optometric Association or the appropriate vision

specialty society.

General Limitations

No payment will be made for expenses incurred for you or any

one of your Dependents:

• for charges made by a Hospital owned or operated by or

which provides care or performs services for, the United

States Government, if such charges are directly related to a

military-service-connected

Injury or Sickness.

• to the extent that payment is unlawful where the person

resides when the expenses are incurred.

• for charges which would not have been made if the person

had no insurance.

• expenses for supplies, care, treatment, or surgery that are

not Medically Necessary.

HC-EXC1 04-10

Expenses For Which A Third Party May

Be Responsible

This plan does not cover:

• Expenses incurred by you or your Dependent (hereinafter

individually and collectively referred to as a "Participant,")

for which another party may be responsible as a result of

having caused or contributed to an Injury or Sickness.

• Expenses incurred by a Participant to the extent any

payment is received for them either directly or indirectly

from a third party tortfeasor or as a result of a settlement,

judgment or arbitration award in connection with any

automobile medical, automobile no-fault, uninsured or

underinsured motorist, homeowners, workers'

compensation, government insurance (other than Medicaid),

or similar type of insurance or coverage.

Subrogation/Right of Reimbursement

If a Participant incurs a Covered Expense for which, in the

opinion of the plan or its claim administrator, another party

may be responsible or for which the Participant may receive

payment as described above:

• Subrogation: The plan shall, to the extent permitted by law,

be subrogated to all rights, claims or interests that a

Participant may have against such party and shall

automatically have a lien upon the proceeds of any recovery

by a Participant from such party to the extent of any benefits

paid under the plan. A Participant or his/her representative

shall execute such documents as may be required to secure

the plan’s subrogation rights.

• Right of Reimbursement: The plan is also granted a right of

reimbursement from the proceeds of any recovery whether

by settlement, judgment, or otherwise. This right of

reimbursement is cumulative with and not exclusive of the

subrogation right granted in paragraph 1, but only to the

extent of the benefits provided by the plan.

Lien of the Plan

By accepting benefits under this plan, a Participant:

• grants a lien and assigns to the plan an amount equal to the

benefits paid under the plan against any recovery made by

or on behalf of the Participant which is binding on any

attorney or other party who represents the Participant

whether or not an agent of the Participant or of any

insurance company or other financially responsible party

against whom a Participant may have a claim provided said

attorney, insurance carrier or other party has been notified

by the plan or its agents;

• agrees that this lien shall constitute a charge against the

proceeds of any recovery and the plan shall be entitled to

assert a security interest thereon;

• agrees to hold the proceeds of any recovery in trust for the

benefit of the plan to the extent of any payment made by the

plan.

Additional Terms

• No adult Participant hereunder may assign any rights that it

may have to recover medical expenses from any third party

or other person or entity to any minor Dependent of said

adult Participant without the prior express written

consent

the plan. The plan’s right to recover shall apply to

decedents’, minors’, and incompetent or disabled persons’

settlements or recoveries.

• No Participant shall make any settlement, which specifically

reduces or excludes, or attempts to reduce or exclude, the

benefits provided by the plan.

• The plan’s right of recovery shall be a prior lien against any

proceeds recovered by the Participant. This right of

recovery shall not be defeated nor reduced by the

application of any so-called “Made-Whole Doctrine”,

“Rimes Doctrine”, or any other such doctrine purporting to

defeat the plan’s recovery rights by allocating the proceeds

exclusively to non-medical expense damages.

• No Participant hereunder shall incur any expenses on behalf

of the plan in pursuit of the plan’s rights hereunder,

specifically; no court costs, attorneys' fees or other

representatives' fees may be deducted from the plan’s

recovery without the prior express written consent of the

plan. This right shall not be defeated by any so-called “Fund

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Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund

Doctrine”.

• The plan shall recover the full amount of benefits provided

hereunder without regard to any claim of fault on the part of

any Participant, whether under comparative negligence or

otherwise.

• In the event that a Participant shall fail or refuse to honor its

obligations hereunder, then the plan shall be entitled to

recover any costs incurred in enforcing the terms hereof

including, but not limited to, attorney’s fees, litigation, court

costs, and other expenses. The plan shall also be entitled to

offset the reimbursement obligation against any entitlement

to future medical benefits hereunder until the Participant has

fully complied with his reimbursement obligations

reunder, regardless of how those future medical benefits

are incurred.

• Any reference to state law in any other provision of this plan

shall not be applicable to this provision, if the plan is

governed by ERISA. By acceptance of benefits under the

plan, the Participant agrees that a breach hereof would cause

irreparable and substantial harm and that no adequate

remedy at law would exist. Further, the Plan shall be entitled

to invoke such equitable remedies as may be necessary to

enforce the terms of the plan, including, but not limited to,

specific performance, restitution, the imposition of an

equitable lien and/or constructive trust, as well as injunctive

relief.

HC-SUB1 V1

Payment of Benefits

To Whom Payable

Vision Benefits are payable to you, but are also assignable to

the provider. When you assign benefits to a provider, you have

assigned the entire amount of the benefits due on that claim. If

the provider is overpaid because of accepting a patient’s

payment on the charge, it is the provider’s responsibility to

reimburse the patient. Because of Cigna’s contracts with

providers, all claims from contracted providers should be

assigned.

Cigna may, at its option, make payment to you for the cost of

any Covered Expenses even if benefits have been assigned.

When benefits are paid to you or your Dependent, you or your

Dependents are responsible for reimbursing the provider.

Ambulance benefits will be paid directly to the provider of the

ambulance service.

If any person to whom benefits are payable is a minor or, in

the opinion of Cigna is not able to give a valid receipt for any

payment due him, such payment will be made to his legal

guardian. If no request for payment has been made by his legal

guardian, Cigna may, at its option, make payment to the

person or institution appearing to have assumed his custody

and support.

When one of our participants passes away, Cigna may receive

notice that an executor of the estate has been established. The

executor has the same rights as our insured and benefit

payments for unassigned claims should be made payable to the

executor.

Payment as described above will release Cigna from all

liability to the extent of any payment made.

Recovery of Overpayment

When an overpayment has been made by Cigna, Cigna will

have the right at any time to: recover that overpayment from

the person to whom or on whose behalf it was made; or offset

the amount of that overpayment from a future claim payment.

HC-POB9 04-10

Termination Of Insurance

Retirees

Your insurance will cease on the earliest date below:

• the date you cease to be in a Class of Eligible Employees or

cease to qualify for the insurance.

• the last day for which you have made any required

contribution for the insurance.

• the date the policy is canceled.

Any continuation of insurance must be based on a plan which

precludes individual selection.

Dependents

Your insurance for all of your Dependents will cease on the

earliest date below:

• the date your insurance ceases.

• the date you cease to be eligible for Dependent Insurance.

• the last day for which you have made any required

contribution for the insurance.

• the date Dependent Insurance is canceled.

The insurance for any one of your Dependents will cease on

the date that Dependent no longer qualifies as a Dependent.

HC-TRM19 04-10

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Federal Requirements

The following pages explain your rights and responsibilities

under federal laws and regulations. Some states may have

similar requirements. If a similar provision appears elsewhere

in this booklet, the provision which provides the better benefit

will apply.

HC-FED1 10-10

Qualified Medical Child Support Order

(QMCSO)

Eligibility for Coverage Under a QMCSO

If a Qualified Medical Child Support Order (QMCSO) is

issued for your child, that child will be eligible for coverage as

required by the order and you will not be considered a Late

Entrant for Dependent Insurance.

You must notify your Employer and elect coverage for that

child, and yourself if you are not already enrolled, within 31

days of the QMCSO being issued.

Qualified Medical Child Support Order Defined

A Qualified Medical Child Support Order is a

judgment,

decree

or order (including approval of a settlement agreement)

or administrative notice, which is issued pursuant to a state

domestic relations law (including a community property law),

or to an administrative process, which provides for child

support or provides for health benefit coverage to such child

and relates to benefits under the group health plan, and

satisfies all of the following:

• the order recognizes or creates a child’s right to receive

group health benefits for which a participant or beneficiary

is eligible;

• the order specifies your name and last known address, and

the child’s name and last known address, except that the

name and address of an official of a state or political

subdivision may be substituted for the child’s mailing

address;

• the order provides a description of the coverage to be

provided, or the manner in which the type of coverage is to

be determined;

• the order states the period to which it applies; and

• if the order is a National Medical Support Notice completed

in accordance with the Child Support Performance and

Incentive Act of 1998, such Notice meets the requirements

above.

The QMCSO may not require the health insurance policy to

provide coverage for any type or form of benefit or option not

otherwise provided under the policy, except that an order may

require a plan to comply with State laws regarding health care

coverage.

Payment of Benefits

Any payment of benefits in reimbursement for Covered

Expenses paid by the child, or the child’s custodial parent or

legal guardian, shall be made to the child, the child’s custodial

parent or legal guardian, or a state official whose name and

address have been substituted for the name and address of the

child.

HC-FED4 10-10

Eligibility for Coverage for Adopted Children

Any child who is adopted by you, including a child who is

placed with you for adoption, will be eligible for Dependent

Insurance, if otherwise eligible as a Dependent, upon the date

of placement with you. A child will be considered placed for

adoption when you become legally obligated to support that

child, totally or partially, prior to that child’s adoption.

If a child placed for adoption is not adopted, all health

coverage ceases when the placement ends, and will not be

continued.

The provisions in the “Exception for Newborns” section of

this document that describe requirements for enrollment and

effective date of insurance will also apply to an adopted child

or a child placed with you for adoption.

HC-FED67 09-14

Group Plan Coverage Instead of Medicaid

If your income and liquid resources do not exceed certain

limits established by law, the state may decide to pay

premiums for this coverage instead of for Medicaid, if it is

cost effective. This includes premiums for continuation

coverage required by federal law.

HC-FED13 10-10

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Claim Determination Procedures

The following complies with federal law. Provisions of the

laws of your state may supersede.

Postservice Claim Determinations

When you or your representative requests payment

for services

which have been rendered, Cigna will notify you of the claim

payment determination within 30 days

after receiving

the

request. However, if more time is needed

to make

determination due to matters beyond Cigna’s control, Cigna

will notify you or your representative within 30 days after

receiving the request. This notice will include the date a

determination can be expected, which will be no more than 45

days a

fter receipt of the request. If more time is needed

because necessary information is missing from the request, the

notice will also specify what information is needed, and you or

your representative must provide the specified information

within 45 days after receiving the notice. The determination

period will be suspended on the date Cigna sends such a notice

of missing information, and resume on the date you or your

representative responds to the notice.

HC-FED40 04-12

COBRA Continuation Rights Under Federal

Law

For You and Your Dependents

What is COBRA Continuation Coverage?

Under federal law, you and/or your Dependents must be given

the opportunity to continue health insurance when there is a

“qualifying event” that would result in loss of coverage under

the Plan. You and/or your Dependents will be permitted to

continue the same coverage under which you or your

Dependents were covered on the day before the qualifying

event occurred, unless you move out of that plan’s coverage

area or the plan is no longer available. You and/or yo

Dependents cannot change coverage options until the next

open enrollment period.

When is COBRA Continuation Available?

For you and your Dependents, COBRA continuation is

available for up to 18 months from the date of the qualifying

event if the event would result in a loss of coverage under the

Plan termination for any reason, other than gross misconduct

misconduct prior to 18 months from the date you retire.

For your Dependents, COBRA continuation coverage is

available for up to 36 months from the date of the following

qualifying events if the event would result in a loss of

coverage under the Plan:

• your death;

• your divorce or legal separation; or

• for a Dependent child, failure to continue to qualify as a

Dependent under the

Plan.

Who is Entitled to COBRA Continuation?

Only a “qualified beneficiary” (as defined by federal law) may

elect to continue health insurance coverage. A qualified

beneficiary may include the following individuals who were

covered by the Plan on the day the qualifying event occurred:

you, your spouse, and your Dependent children. Each

qualified beneficiary has their own right to elect or decline

COBRA continuation coverage even if you decline or are not

eligible for COBRA continuation.

The following individuals are not qualified beneficiaries for

purposes of COBRA continuation: domestic partners,

grandchildren (unless adopted by you), stepchildren (unless

adopted by you). Although these individuals do not have an

independent right to elect COBRA continuation coverage, if

you elect COBRA continuation coverage for yourself, you

may also cover your Dependents even if they are not

considered qualified beneficiaries under COBRA. However,

such individuals’

coverage will terminate when your COBRA

continuation coverage terminates. The sections titled

“Secondary Qualifying Events” and “Medicare Extension For

Your Dependents” are not applicable to these individuals.

Secondary Qualifying Events

If, as a result of your termination of employment or

reduction

work hours, your Dependent(s) have elected COBRA

continuation coverage and one or more Dependents experience

another COBRA qualifying event, the affected Dependent(s)

may elect to extend their COBRA continuation coverage for

an additional 18 months (7 months if the secondary event

occurs within the disability extension period) for a maximum

of 36 months from the initial qualifying event. The second

qualifying event must occur before the end of the initial 18

months of COBRA continuation coverage or within the

disability extension period discussed below. Under no

circumstances will COBRA continuation coverage be

available for more than 36 months from the initial qualifying

event. Secondary qualifying events are: your death; your

divorce or legal separation; or, for a Dependent child, failure

to continue to qualify as a Dependent under the Plan.

Disability Extension

If, after electing COBRA continuation coverage due to your

termination of employment or reduction in work hours, you or

one of your Dependents is determined by the Social Security

Administration (SSA) to be totally disabled under Title II or

XVI of the SSA, you and all of your Dependents who have

elected COBRA continuation coverage may extend such

continuation for an additional 11 months, for a maximum of

29 months from the initial qualifying event.

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To qualify for the disability extension, all of the following

requirements must be satisfied:

• SSA must determine that the disability occurred prior to or

within 60 days after the disabled individual elected COBRA

continuation coverage; and

• A copy of the written SSA determination must be provided

to the Plan Administrator within 60 calendar days after the

date the SSA determination is made AND before the end of

the initial 18-month continuation period.

If the SSA later determines that the individual is no longer

disabled, you must notify the Plan Administrator within 30

days after the date the final determination is made by SSA.

The 11-month disability extension will terminate for all

covered persons on the first day of the month that is more than

30 days after the date the SSA makes a final determination

that the disabled individual is no longer disabled.

All causes for “Termination of COBRA Continuation” listed

below will also apply to the period of disability extension.

Termination of COBRA Continuation

COBRA continuation coverage will be terminated upon the

occurrence of any of the following:

• The balance of 18 months from the date you retire;

• upon cancellation of the retiree plan, the balance of 18

months from the date you retire if your former Employer

provides coverage for active Employees;

• the end of the COBRA continuation period of 29 or 36

months from the date you retire, as applicable;

• failure to pay the required premium within 30 calendar days

after the due date;

• cancellation of the Employer’s policy with Cigna;

• after electing COBRA continuation coverage, a qualified

beneficiary enrolls in Medicare (Part A, Part B, or both);

• after electing COBRA continuation coverage, a qualified

beneficiary becomes covered under another group health

plan, unless the qualified beneficiary has a condition for

which the new plan limits or excludes coverage under a pre-

existing condition provision. In such case coverage will

continue until the earliest of: the end of the applicable

maximum period; the date the pre-existing condition

provision is no longer applicable; or the occurrence of an

event described in one of t

he first three bullets above;

• any reason the Plan would terminate coverage of a

participant or beneficiary who is not receiving continuation

coverage (e.g., fraud).

Employer’s Notification Requirements

Your former Employer is required to provide you and/or your

Dependents with the following notices:

• An initial notification of COBRA continuation rights must

be provided within 90 days after your (or your spouse’s)

coverage under the Plan begins (or the Plan first becomes

subject to COBRA continuation requirements, if later). If

you and/or your Dependents experience a qualifying event

before the end of that 90-day period, the initial notice must

be provided within the time frame required for the COBRA

continuation coverage election notice as explained below.

• A COBRA continuation coverage election notice must be

provided to you and/or your Dependents within the

following timeframes:

• if the Plan provides that COBRA continuation coverage

and the period within which an Employer must notify the

Plan Administrator of a qualifying event starts upon the

loss of coverage, 44 days after loss of coverage under the

Plan;

• if the Plan provides that COBRA continuation coverage

and the period within which an Employer must notify the

Plan Administrator of a qualifying event starts upon the

occurrence of a qualifying event, 44 days after the

qualifying event occurs; or

• in the case of a multi-employer plan, no later than 14 days

after the end of the period in which Employers must

provide notice of a qualifying event to the Plan

Administrator.

How to Elect COBRA Continuation Coverage

The COBRA coverage election notice will list the individuals

who are eligible for COBRA continuation coverage and

inform you of the applicable premium. The notice will also

include instructions for electing COBRA continuation

coverage. You must notify the Plan Administrator of your

election no later than the due date stated on the COBRA

election notice. If a written election notice is required, it must

be post-marked no later than the due date stated on the

COBRA election notice. If you do n

ot make proper

notification by the due date shown on the notice, you and your

Dependents will lose the right to elect COBRA continuation

coverage. If you reject COBRA continuation coverage before

the due date, you may change your mind as long as you

furnish a completed election form before the due date.

Each qualified beneficiary has an independent right to elect

COBRA continuation coverage. Continuation coverage may

be elected for only one, several, or for all Dependents who are

qualified beneficiaries. Parents may elect to continue coverage

on behalf of their Dependent children. You or your spouse

may elect continuation coverage on behalf of all the qualified

beneficiaries. You are not required to elect COBRA

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continuation coverage in order for your Dependents to elect

COBRA continuation.

How Much Does COBRA Continuation Coverage Cost?

Each qualified beneficiary may be required to pay the entire

cost of continuation coverage. The amount may not exceed

102% of the cost to the group health plan (including both

Employer and Employee contributions) for coverage of a

similarly situated active Employee or family member. The

premium during the 11-month disability extension may not

exceed 150% of the cost to the group health plan (including

both employer and employee contributions) for coverage of a

similarly situated active Employee or family member.

For example: If the retiree alone elects COBRA continuation

coverage, the retiree will be charged 102% (or 150%) of the

active Employee premium. If the spouse or one Dependent

child alone elects COBRA continuation coverage, they will be

charged 102% (or 150%) of the active Employee premium. If

more than one qualified beneficiary elects COBRA

continuation coverage, they will be charged 102% (or 150%)

of the applicable family premium.

When and How to Pay COBRA Premiums

First payment for COBRA continuation

If you elect COBRA continuation coverage, you do not have

send any payment with the election form. However, you must

make your first payment no later than 45 calendar days after

the date of your election. (This is the date the Election Notice

is postmarked, if mailed.) If you do not make your first

payment within that 45 days, you will lose all COBRA

continuation rights under the Plan.

Subsequent payments

After you make your first payment for COBRA continuation

coverage, you will be required to make subsequent payments

of the required premium for each additional month of

coverage. Payment is due on the first day of each month. If

you make a payment on or before its due date, your coverage

under the Plan will continue for that coverage period without

any break.

Grace periods for subsequent payments

Although subsequent payments are due by the first day of the

month, you will be given a grace period of 30 days after the

first day of the coverage period to make each monthly

payment. Your COBRA continuation coverage will be

provided for each coverage period as long as payment for that

coverage period is made before the end of the grace period for

that payment. However, if your payment is received after the

due date, your coverage under the Plan

may be suspended

during this time. Any providers who contact the Plan to

confirm coverage during this time may be informed that

coverage has been suspended. If payment is received before

the end of the grace period, your coverage will be reinstated

back to the beginning of the coverage period. This means that

any claim you submit for benefits while your coverage is

suspended may be denied and may have to be resubmitted

once your coverage is reinstated. If you fail to make

payment

before the end of the grace period for that coverage

period, you will lose all rights to COBRA continuation

coverage under the Plan.

You Must Give Notice of Certain Qualifying Events

If you or your Dependent(s) experience one of the following

qualifying events, you must notify the Plan Administrator

within 60 calendar days after the later of the date the

qualifying event occurs or the date coverage would cease as a

result of the qualifying event:

• Your divorce or legal separation; or

• Your child ceases to qualify as a Dependent under the Plan.

• The occurrence of a secondary qualifying event as discussed

under “Secondary Qualifying Events” above (this

notice

must

be received prior to the end of the initial 18- or 29-

month COBRA period).

(Also refer to the section titled “Disability Extension” for

additional notice requirements.)

Notice must be made in writing and must include: the name of

the Plan, name and address of the Employee covered under the

Plan, name and address(es) of the qualified beneficiaries

affected by the qualifying event; the qualifying event; the date

the qualifying event occurred; and supporting documentation

(e.g., divorce decree, birth certificate, disability determination,

etc.).

Newly Acquired Dependents

If you acquire a new Dependent through marriage, birth,

adoption or placement for adoption while your coverage is

being continued, you may cover such Dependent under your

COBRA continuation coverage. However, only your newborn

or adopted Dependent child is a qualified beneficiary and may

continue COBRA continuation coverage for the remainder of

the coverage period following your early termination of

COBRA coverage or due to a secondary qualifying event.

COBRA c

overage for your Dependent spouse and any

Dependent children who are not your children (e.g.,

stepchildren or grandchildren) will cease on the date your

COBRA coverage ceases and they are not eligible for a

secondary qualifying event.

COBRA Continuation for Retirees Following Employer’s

Bankruptcy

If you are covered as a retiree, and a proceeding in bankruptcy

is filed with respect to the Employer under Title 11 of the

United States Code, you may be entitled to COBRA

continuation coverage. If the bankruptcy results in a loss of

coverage for you, your Dependents or your surviving spouse

within one year before or after such proceeding, you and your

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covered Dependents will become COBRA qualified

beneficiaries with respect to the bankruptcy. You will be

entitled to COBRA continuation coverage until your death.

Your surviving spouse and covered Dependent children will

be entitled to COBRA continuation coverage for up to 36

months following your death. However, COBRA continuation

coverage will cease upon the occurrence of any of the events

listed under “Termination of COBRA Continuation” above.

Interaction With Other Continuation Benefits

You may be eligible for other continuation benefits under state

law. Refer to the Termination section for any

other

continuation

benefits.

HC-FED66 07-14

Notice of an Appeal or a Grievance

The appeal or grievance provision in this certificate may be

superseded by the law of your state. Please see your

explanation of benefits for the applicable appeal or grievance

procedure.

Cigna Vision Second Level Appeals Address

Please submit your Level 2 Grievance documents to the

following address:

Cigna

NAU National Appeals Unit

P.O. Box 188044

Chattanooga, TN 37422

HC-SPP4 04-10

When You Have A Complaint Or An

Adverse Determination Appeal

For the purposes of this section, any reference to "you",

"your” or "Member" also refers to a representative or provider

designated by you to act on your behalf, unless otherwise

noted.

We want you to be completely satisfied with the care you

receive. That is why we have established a process for

addressing your concerns and solving your problems.

Start with Customer Service

We are here to listen and help. If you have a concern regarding

a person, a service, the quality of care, or contractual benefits,

you can call our toll-free number and explain your concern to

one of our Customer Service representatives. Please call us at

the Customer Service Toll-Free Number that appears on your

Benefit Identification card, explanation of benefits or claim

form.

We will do our best to resolve the matter on your initial

contact. If we need more time to review or investigate your

concern, we will get back to you as soon as possible, but in

any case within 30 days.

If you are not satisfied with the results of a coverage decision,

you can start the appeals procedure.

Internal Appeal Procedure

Cigna has a one-step appeal procedure for appeals decisions.

To initiate an appeal, you must submit a request for an appeal

in writing within 365 days of receipt of a denial notice to the

following address:

Cigna

National Appeals Organization (NAO)

PO Box 188011

Chattanooga, TN 37422

You should state the reason why you feel your appeal should

be approved and include any information supporting your

appeal. If you are unable or choose not to write, you may ask

to register your appeal by telephone. Call us at the toll-free

number on your Benefit Identification card, explanation of

benefits or claim form.

Your appeal will be reviewed and the decision made by

someone not involved in the initial decision. Appeals

involving Medical Necessity or clinical appropriateness will

be considered by a health care professional.

We will respond in writing with a decision within 30 calendar

days after we receive an appeal for a required pre-service or

concurrent care coverage determination (decision). We will

respond within 30 calendar days after we receive an appeal for

a post-service coverage determination. If more time or

information is needed to make the determination, we

will

notify

you in writing to request an extension of up to 30

calendar days and to specify any additional information

needed to complete the review. Please note that the California

Department of Insurance (CDI) does not require you to

participate in Cigna's appeals review for more than 30 days

although you may choose to do so. At the completion of this

30-day-review period, when the disputed decision is upheld or

your case remains unresolved, you may apply to the CDI for a

review of your case.

You may request that the appeal process be expedited if, your

treating Physician certifies in writing that an imminent and

serious threat to your health may exist, including, but not

limited to, serious pain, the potential loss of life, limb, or

major bodily function, or the immediate and serious

deterioration of your health.

When an appeal is expedited, we will respond orally with a

decision within 72 hours, followed up in writing. The CDI

myCigna.com

allows you to apply for an independent medical review after

this expedited decision if you are unsatisfied with our

determination.

Independent Medical Review Procedures

When the disputed decision is upheld or your case remains

unresolved after 30 days and when your case meets the criteria

outlined below, you are eligible to apply to the CDI for an

Independent Medical Review (IMR). The CDI has final

authority to accept or deny cases for the IMR process. If your

case is not accepted for IMR, the CDI will treat your

application as a request for the CDI itself to review your issues

and concerns. Prior to application for an IMR, you are free to

ek other avenues of appeal with Cigna. If you choose to do

so, you will not forfeit your eligibility to apply for the IMR.

The Independent Medical Review Organization is composed

of persons who are not employed by Cigna or any of its

affiliates. A decision to use the voluntary level of appeal will

not affect the claimant's rights to any other benefits under the

Policy.

There is no charge for you to apply for or participate in this

IMR process. Cigna will abide by the decision of the

Independent Medical Review Organization.

In order to qualify for an IMR, certain conditions must be met:

your Physician has recommended a health care service as

Medically Necessary and Cigna has disagreed with this

determination, or you have received urgent care or emergency

services that a Physician has deemed Medically Necessary and

Cigna has disagreed with this determination, or you have been

seen by a Physician for the diagnosis or treatment of the

medical condition for which you are seeking an independent

medical

review and Cigna has determined these services as not

Medically Necessary or clinically appropriate. Administrative,

eligibility or benefit coverage limits or exclusions are not

eligible for an independent medical appeal under this process.

You remain entitled to send such issues to the CDI for a

Department review.

Independent Review Process for Experimental and

Investigational Therapies

Special provisions apply to the IMR process for coverage

decisions related to experimental or investigational therapies.

If Cigna denies your appeal because the requested service or

treatment is experimental or investigational, Cigna will send

you a letter within 5 business days of making the denial

decision. The letter will include:

• a notice explaining your right to an IMR;

• an IMR application;

• a Physician Certification Form for your Physician to

complete which certifies that you have a life-threatening or

seriously debilitating condition; your Physician’s

certification must also indicate that standard therapies have

not been effective in treating your condition or the requested

therapy is likely to be more beneficial than any standard

therapy as documented in two separate sources of medical

or scientific evidence;

• an envelope for you to return the completed forms to us.

A “life-threatening” condition means either or both of the

following:

• diseases or conditions where the likelihood of death is high

unless the course of the disease is interrupted.

• diseases or conditions with potentially fatal outcomes,

where the end point of clinical intervention is survival.

• a “seriously debilitating” condition means diseases or

conditions that cause major irreversible morbidity.

“Medical and scientific evidence” means any of the following:

• peer-reviewed scientific studies published in or accepted for

publication by medical journals that meet nationally

recognized requirements for scientific manuscripts and that

submit most of their published articles for review by experts

who are not part of the editorial staff.

• peer-reviewed literature, biomedical compendia and other

medical literature that meet the criteria of the National

Institutes of Health's National Library of Medicine for

indexing in Index Medicus, Excerpta Medicus (EMBASE),

Medline and MEDLARS data base Health Services

Technology Assessment Research (HSTAR).

• medical journals recognized by the Secretary of Health and

Human Services, under Section 1861(t)(2) of the Social

Security Act.

• either of the following standard reference compendia: The

American Hospital Formulary Service-Drug Information,

the American Dental Association Accepted Dental

Therapeutics and The United States Pharmacopoeia-Drug

Information.

• any of the following reference compendia if recognized by

the Federal Center for Medicare and Medicaid Services as

part of an anticancer chemotherapeutic regimen: The

Elsevier Gold Standard's Clinical Pharmacology, The

National Comprehensive Cancer Network Drug and

Biologics Compendium, The Thomson Micromedex

DrugDex.

• findings, studies, or research conducted by or under the

auspices of federal government agencies and nationally

recognized federal research institutes, including the Federal

Agency for Health Care Policy and Research, National

Institutes of Health, National Cancer Institute, National

Academy of Sciences, Health Care Financing

Administration, Congressional Office of Technology

Assessment, and any national board recognized by the

National Institutes of Health for the purpose of evaluating

the medical value

of health services.

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• peer-reviewed abstracts accepted for presentation at major

medical association meetings.

The IMR will be conducted by an Independent Medical

Review Organization which is qualified to review issues

related to experimental and investigational therapies as

selected by the CDI. The IMR must be completed within 30

calendar days. If your physician determines that the proposed

therapy which is the subject of the IMR would be significantly

less effective if not initiated promptly, an expedited IMR is

available. An expedited IMR will be completed within 7

calendar days from the date an expedited IMR was requested.

This timeframe may be extended by up to 3 calendar days if

there is a delay in providing any documents which the

Independent Medical Review Organization requests for

review. The IMR’s decision must state the reason that the

therapy should or should not be covered, citing your specific

medical condition, the relevant documents, and the relevant

medical and scientific evidence. Cigna will cover the services

subject to the terms and conditions generally applicable to

other benefits under your policy.

Appeal to the State of California

We will provide you with an application and instructions on

how to apply to the CDI for an IMR. You must submit the

application to the CDI within 180 days of your receipt of our

appeal review denial. In compelling circumstances, the

Commissioner of Insurance may grant an extension.

The Independent Medical Review Organization will render an

opinion within 30 days. If a delay would be detrimental

your

medical condition, you may apply to the Department for

an expedited review of your case. If accepted, the Independent

Medical Review Organization will render a decision in three

days.

You have the right to contact the California Department of

Insurance for assistance at any time. The Commissioner may

be contacted at the following address and fax number:

California Department of Insurance

Claims Service Bureau, Attn: IMR

300 South Spring Street

Los Angeles, CA 90013

or fax to 213-897-5891

Notice of Benefit Determination on Appeal

Every notice of an appeal decision will be provided in writing

or electronically and, if an adverse determination, will include:

information sufficient to identify the claim; the specific reason

or reasons for the denial decision; reference to the specific

Policy provisions on which the decision is based; a statement

that the claimant is entitled to receive, upon request and free

of charge, reasonable access to and copies of all documents,

records, and other Relevant Information as defined; a

statement describing any voluntary appeal procedures offered

by the plan and the claimant's right to bring an action under

ERISA section 502(a); upon request and free of charge, a copy

of any internal rule, guideline, protocol or other similar

criterion that was relied upon in making the adverse

determination regarding your appeal, and an explanation of the

scientific or clinical judgment for a determination that is based

on a Medical Necessity, experimental treatment or other

similar exclusion or limit; and information about any office of

health insurance consumer assistance or ombudsman available

to assist you in the appeal process. A final notice of adverse

determination will include a discussion of the decision.

You also have the right to bring a civil action under section

502(a) of ERISA if you are not satisfied with the decision on

review. You or your plan may have other voluntary alternative

dispute resolution options such as Mediation. One way to find

out what may be available is to contact your local U.S.

Department of Labor office and your State insurance

regulatory agency. You may also contact the Plan

Administrator.

Relevant Information

Relevant Information is any document, record, or other

information which was relied upon in making the benefit

determination; was submitted, considered, or generated in the

course of making the benefit determination, without regard to

whether such document, record, or other information was

relied upon in making the benefit determination; demonstrate

compliance with the administrative processes and safeguards

required by federal law in making the benefit determination;

or constitutes a statement of policy or guidance with respect to

the Policy concerning the denied treatment option or benefit or

the claimant's diagnosis, without regard to whether such

advice or statement was relied upon in making the benefit

determination.

Legal Action

If your plan is governed by ERISA, you have the right to bring

a civil action under section 502(a) of ERISA if you are not

satisfied with the outcome of the Appeals Procedure. In most

instances, you may not initiate a legal action against

Cigna

until

you have completed the appeal processes. However, no

action will be brought at all unless brought within three years

after proof of claim is required under the Plan.

HC-APL230 08-14

Definitions

Dependent

Dependents are:

• your lawful spouse; or

• your Domestic Partner; or

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• any child of yours who is

• less than 26 years

old.

• 26 or more years old, unmarried, and primarily supported

by you and incapable of self-sustaining employment by

reason of mental or physical disability. Proof of

the

child's

condition and dependence must be submitted to

Cigna within 31 days after the date the child ceases to

qualify above. From time to time, but not more frequently

than once a year, Cigna may require proof of the

continuation of such condition and dependence.

The term child means a child born to you or a child legally

adopted by you from the date the child is placed in your

physical custody prior to the finalization of the child’s

adoption. It also includes a stepchild or a child for whom you

are the legal guardian or your Domestic Partner’s Dependent

child.

Benefits for a Dependent child or student will continue until

the last day of the calendar month in which the limiting age is

reached.

Anyone who is eligible as an Employee will not be considered

as a Dependent.

No one may be considered as a Dependent of more than one

Employee.

HC-DFS198 04-10

V1 M

Domestic Partner

A Domestic Partner is defined as your Domestic Partner who

has registered the domestic partnership by filing a Declaration

of Domestic Partnership with the California Secretary of state

pursuant to Section 298 of the Family Code or an equivalent

document issued by a local agency of California, another state,

or a local agency of another state under which the partnership

was created.

The sections of this certificate entitled "COBRA Continuation

Rights Under Federal Law" and “Continuation of Coverage

under Cal-COBRA” will not apply to your Domestic Partner

and his or her Dependents.

HC-DFS159 04-10

Employer

The term Employer means the Policyholder and all Affiliated

Employers.

HC-DFS8 04-10

Injury

The term Injury means an accidental bodily injury.

HC-DFS12 04-10

Maximum Reimbursable Charge - Vision

The Maximum Reimbursable Charge is the lesser of:

• the provider’s normal charge; or

• the policyholder selected percentile of all charges made by

providers of such service or supply in the geographic area

where it is received.

HC-DFS13 04-10

Medicaid

The term Medicaid means a state program of medical aid for

needy persons established under Title XIX of the Social

Security Act of 1965 as amended.

HC-DFS16 04-10

Medically Necessary/Medical Necessity

Medically Necessary Covered Services and Supplies are those

determined by the Medical Director to be:

• required to diagnose or treat an illness, injury, disease or its

symptoms;

• in accordance with generally accepted standards of medical

practice;

• clinically appropriate in terms of type, frequency, extent,

site and duration;

• not primarily for the convenience of the patient, Physician

or other health care provider; and

• rendered in the least intensive setting that is appropriate for

the delivery of the services and supplies. Where applicable,

the Medical Director may compare the cost-effectiveness of

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alternative services, settings or supplies when determining

least intensive setting.

HC-DFS19 04-10

Medicare

The term Medicare means the program of medical

care

benefits

provided under Title XVIII of the Social Security Act

of 1965 as amended.

HC-DFS17 04-10

Ophthalmologist

The term Ophthalmologist means a person practicing

ophthalmology within the scope of his license. It will also

include a physician operating within the scope of his license

when he performs any of the Vision Care services described in

the policy.

HC-DFS70 04-10

Optician

The term Optician means a fabricator and dispenser of

eyeglasses and/or contact lenses. An optician fills

prescriptions for glasses and other optical aids as specified by

optometrists or ophthalmologists. The state in which an

optician practices may or may not require licensure for

rendering of these services.

HC-DFS71 04-10

Optometrist

The term Optometrist means a person practicing optometry

within the scope of his license. It will also include a physician

operating within the scope of his license when he

performs

any

of the Vision Care services described in the policy.

HC-DFS72 04-10

Retiree

The term Retiree means a retired employee and a member of

Los Angeles County Employees Retirement Association

(LACERA).

HC-DFS7 04-10

V3 M

Sickness – For Medical Insurance

The term Sickness means a physical or mental illness. It also

includes pregnancy. Expenses incurred for routine Hospital

and pediatric care of a newborn child prior to discharge from

the Hospital nursery will be considered to be incurred as a

result of Sickness.

HC-DFS50 04-10

Vision Provider

The term Vision Provider means: an optometrist,

ophthalmologist, optician or a group partnership or other

legally recognized aggregation of such professionals; duly

licensed and in good standing with the relevant public

licensing bodies to provide covered vision services within the

scope of the Vision Providers’ respective licenses.

HC-DFS73 04-10