Microsoft word - 343392.doc

Home Office: Bloomfield, Connecticut Mailing Address: Hartford, Connecticut 06152
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
a CIGNA company (called CG)
CERTIFICATE RIDER
Policyholder: Palm Beach County Board of County Commissioners Rider Eligibility: Each Employee as reported to the insurance company by your Employer Policy No. or Nos. 3212040-PPO EFFECTIVE DATE: January 1, 2011 You will become insured on the date you become eligible, if you are in Active Service on that date, or if you are not in Active Service on that date due to your health status. However, you will not be insured for any loss of life, dismemberment or loss of income coverage until you are in Active Service. This certificate rider forms a part of the certificate issued to you by CG describing the benefits provided under the policy(ies) specified above. myCIGNA.com

The section entitled Lifetime Maximum, Preventive Care, Mammograms, PSA, PAP Smear, Mental Health and Substance
Abuse in THE SCHEDULE — Major Medical Benefits— in your certificate is changed to read as attached.
THE SCHEDULE — Prescription Drug Benefits — section in your certificate is changed to read as attached.
The page DFS1902 in your certificate coded is replaced by the page coded DFS2094 M attached to this certificate rider.
myCIGNA.com
Preferred Provider Medical Benefits
The Schedule
Lifetime Maximum
Preventive Care
Mammograms, PSA, PAP Smear
Cover screening, therapy (speech, occupational and physical) and Applied Mental Health
Substance Abuse
myCIGNA.com
Prescription Drug Benefits
The Schedule
For You and Your Dependents
This plan provides Prescription Drug benefits for Prescription Drugs and Related Supplies provided by Pharmacies as shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for Prescription Drugs and Related Supplies. That portion includes any applicable Copayment, Deductible and/or Coinsurance. Certain retail Participating Pharmacies can fill your prescription for a 90 day supply for an amount equal to 3x the retail Participating Pharmacy Copayment. Please see our website at www.CIGNA.com or call the Member Services number on your ID card for a list of retail Participating Pharmacies that offer the 3x retail Participating Pharmacy Copayment level.
Coinsurance
The term Coinsurance means the percentage of Charges for covered Prescription Drugs and Related Supplies that you or
your Dependent are required to pay under this plan.

Charges
The term Charges means the amount charged by the Insurance Company to the plan when the Pharmacy is a Participating
Pharmacy, and it means the actual billed charges when the Pharmacy is a non-Participating Pharmacy.

Copayments
Copayments are expenses to be paid by you or your Dependent for Covered Prescription Drugs and Related Supplies.
Retail Prescription Drugs
The amount you pay for each 30-
The amount you pay for each 30-
day supply
day supply
* Designated as per generally-accepted industry sources and adopted by the Insurance Company Note: Prescription smoking cessation drugs (Nicotrol NS, Zyban, Nicotrol) are covered at a $0 copay.
OTC smoking cessation drugs are covered at $0 with a valid prescription. myCIGNA.com
Mail-Order Drugs
The amount you pay for each 90-
The amount you pay for each 90-
day supply
day supply
* Designated as per generally-accepted industry sources and adopted by the Insurance Company Note: Prescription smoking cessation drugs (Nicotrol NS, Zyban, Nicotrol) are covered at a $0 copay.
OTC smoking cessation drugs are covered at $0 with a valid prescription. myCIGNA.com
No one may be considered as a Dependent of more than one Definitions
Dependent - For Medical Insurance
• your lawful spouse; • your Domestic Partner; and • any child of yours: • who is less than 26 years old; • from 26 years until the end of the calendar year in which the child reaches the age of 30, provided the child is unmarried and does not have a dependent of their own, is a Florida state resident or a full-time or part-time student, and is not covered under a plan of their own or entitled to benefits under Title XVIII of the Social Security Act. CG may require such proof at least once each year until the end of the calendar year in which he attains age 30; • who is 26 or more years old and primarily supported by you and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child's condition and dependence is not required to be submitted to CG as a condition of coverage after the date the child ceases to qualify above. However, if a claim is denied, proof must be submitted by the Employee that the child is and has continued to be mentally or physically handicapped. A child includes a legally adopted child, including that child from the date of placement in the home or from birth provided that a written agreement to adopt such child has been entered into prior to the birth of such child. Coverage for a legally adopted child will include the necessary care and treatment of an Injury or a Sickness existing prior to the date of placement or adoption. A child also includes a foster child or a child placed in your custody by a court order from the date of placement in the home. Coverage is not required if the adopted or foster child is ultimately not placed in your home. It also includes: • a stepchild who lives with you, or a child for whom you • a child born to an insured Dependent child of yours until If your Domestic Partner has a child who lives with you, that child will also be included as a Dependent. Anyone who is eligible as an Employee will not be considered as a Dependent. myCIGNA.com

Source: https://secure.co.palm-beach.fl.us/myBenefits/Documents/Current/Publications/Cigna%20CR7BIASO13-1%20PPO%20(Final%2005062011).pdf