2025 Cigna Vision Plan SPD

Mid-America Apartments, L.P.

CIGNA VISION

EFFECTIVE DATE: January 1, 2025

ASO50 3332254

This document printed in March, 2025 takes the place of any documents previously issued to You which described Your benefits.

Printed in U.S.A.

HCVIS-CVR0

01-24

Table of Contents Important Information..................................................................................................................4 Important Notices..........................................................................................................................6 Eligibility - Effective Date.............................................................................................................8 How to Find a Cigna Vision Provider and File a Claim...........................................................10 Cigna Vision.................................................................................................................................11 The Schedule..........................................................................................................................................................11 Covered Expenses........................................................................................................................14 Exclusions .....................................................................................................................................14 Coordination of Benefits..............................................................................................................15 Expenses For Which A Third Party May Be Responsible.......................................................16 Payment of Benefits.....................................................................................................................17 Termination of Insurance............................................................................................................18 Federal Requirements.................................................................................................................19 Notice of Provider Directory/Networks.................................................................................................................19 Qualified Medical Child Support Order (QMCSO)...............................................................................................19 Group Plan Coverage Instead of Medicaid............................................................................................................21 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA)................................................21 Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA).....................................21 Claim Determination Procedures under ERISA....................................................................................................21 Appointment of Authorized Representative..........................................................................................................22 Vision - When You Have a Complaint or an Appeal............................................................................................22 COBRA Continuation Rights Under Federal Law................................................................................................24 ERISA Required Information................................................................................................................................27 Miscellaneous................................................................................................................................29 Definitions .....................................................................................................................................30

HCVIS-TOC0

01-24

Important Information THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY MID-AMERICA APARTMENTS, L.P. WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY (CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT INSURE THE BENEFITS DESCRIBED. THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA," "INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE." HCVIS-NOT1 01-24

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.

HCVIS-NOTICE

01-24

If you need these services, contact customer service at the toll- free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. Call 1.877.478.7557 (TTY: 800.428.4833). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1.877.478.7557 (TTY: 800.428.4833). Chinese – 注意：我們可為您免費提供語言協助服務。請致電 1.877.478.7557 （聽障專線： 800.428.4833 ）。 Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp v ề ngôn ngữ miễn phí. Vui lòng gọi 1.877.478.7557 (TTY: 800.428.4833). Korean – 주의 : 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . 1.877.478.7557 (TTY: 800.428.4833) 번으로 전화해주십시오 . Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Tumawag sa 1.877.478.7557 (TTY: 800.428.4833).

Important Notices 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 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. card, or by visiting www.myCigna.com. Notice - Participating Provider Benefits

HC-NOT55

Discrimination is Against the Law Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Cigna: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

myCigna.com

Russian – ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1.877.478.7557 (линия TTY телетайп: 800.428.4833). ﺍﻟﻤﺴﺎﻋﺪﺓ ﺧﺪﻣﺎﺕ ﻓﺈﻥ ﺍﻟﻠﻐﺔ، ﺍﺫﻛﺮ ﺗﺘﺤﺪﺙ ﻛﻨﺖ ﺇﺫﺍ : ﻣﻠﺤﻮﻇﺔ – Arabic 1.877.478.7557 ﺑﺮﻗﻢ ﺍﺗﺼﻞ . ﺑﺎﻟﻤﺠﺎﻥ ﻟﻚ ﺗﺘﻮﺍﻓﺮ ﺍﻟﻠﻐﻮﻳﺔ .( 800.428.4833 : ﻭﺍﻟﺒﻜﻢ ﺍﻟﺼﻢ ﻫﺎﺗﻒ ﺭﻗﻢ ) French Creole – ATANSYON: Gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1.877.478.7557 (TTY: 800.428.4833). French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le 1.877.478.7557 (ATS: 800.428.4833). Portuguese – ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue 1.877.478.7557 (TTY: 800.428.4833). Polish – UWAGA: Możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1 877 478 7557 (TTY: 800.428.4833). Japanese – 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1.877.478.7557 （ TTY: 800.428.4833 ）まで、お電話にてご連絡ください。 Italian – ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1.877.478.7557 (TTY: 800.428.4833). German – ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1.877.478.7557 (TTY: 800.428.4833). ﺭﺍﻳﮕﺎﻥ ﺻﻮﺭﺕ ﺑﻪ ﺯﺑﺎﻧﯽ٬ ﮐﻤﮏ ﺧﺪﻣﺎﺕ : ﺗﻮﺟﻪ – Persian (Farsi) ﺑﮕﯿﺮﻳﺪ ﺗﻤﺎﺱ 1.877.478.7557 ﺷﻤﺎﺭﻩ ﺑﺎ . ﻣﯿﺸﻮﺩ ﺍﺭﺍﺋﻪ ﺷﻤﺎ ﺑﻪ .( 800.428.4833 : ﻧﺎﺷﻨﻮﺍﻳﺎﻥ ﻭﻳﮋﻩ ﺗﻠﻔﻦ ﺷﻤﺎﺭﻩ )

call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711 ）。 Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711). Korean – 주의 : 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오 . 기타 다른 경우에는 1.800.244.6224 ( TTY : 다이얼 711 ) 번으로 전화해주십시오 . Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711). French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).

HC-NOT99

07-17

Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers,

myCigna.com

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711). Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711). Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在の Cigna のお客様は、 ID カード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、 1.800.244.6224 （ TTY: 711 ）まで、お電話にてご連絡ください。 Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

• You pay any required contribution. If you were previously insured and your insurance ceased because you were no longer employed, you must satisfy the New Employee Group Waiting Period to become insured again unless you are rehired within 12 months and met the New Employee Group Waiting Period in your previous employment. If your insurance ceased because you were no longer employed in a Class of Eligible Employees, you are not required to satisfy the 30-day Waiting Period if you again become a member of a Class of Eligible Employees. You will become eligible for insurance on the first of the month on or after the date you become a member of a Class of Eligible Employees. Eligibility Waiting Period – New Hire Your Eligibility Waiting Period is: • First of the month on or after 30 days of Active Service. If you are a rehire and have met the applicable 30 day waiting period during your previous employment, the waiting period will be waived upon rehire and you will be eligible the first of the month on or after your rehire date if you are rehired within 12 months. Effective Date of Your Insurance You will become insured on the date that You elect the insurance by completing the Employer’s specified enrollment process, but no earlier than the date You become eligible You will become insured on Your first day of eligibility, following Your election, 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. Late Entrant You are a Late Entrant if: • You elect the insurance more than 31 days after You initially become eligible; or • You again elect it after You cancel Your payroll deduction (if required). If You are a Late Entrant: • You will not be able to enroll in the plan until the next annual enrollment period, except due to a life status change event.

HC-NOT97

07-17

Eligibility - Effective Date Eligible Class Each Employee as reported to Us by Your Employer. Eligibility for Vision Insurance You will become eligible for insurance on the day You complete the Eligibility Waiting Period, if any, and: • You are an eligible Full-Time Employee; • You normally work at least 30 hours a week; and

myCigna.com

Dependent Insurance For Your Dependents to be insured, You will have to pay the required contribution, if any, toward the cost of Dependent Insurance. Eligibility for Dependent Insurance You will become eligible for Dependent Insurance on the later of:

Dual Eligibility If both You and Your Spouse are in an Eligible Class of the Employer, You may each enroll individually or as a Dependent of the other, but not as both. Any eligible Dependent child may also be enrolled by either You or Your Spouse. If the Spouse who enrolls for Dependent coverage ceases to be eligible, notify Your Plan Administrator immediately for coverage to continue under the plan of the other Spouse.

• the day You become eligible for Yourself; or • the day You acquire Your first Dependent. Effective Date of Dependent Insurance

HCVIS-ELG0 M

01-24

Insurance for your Dependents will become effective on the date you elect it by completing the Employer’s specified enrollment process, but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included. Your Dependents will be insured only if You are insured. Late Entrant - Dependent You are a Late Entrant for Dependent Insurance if: • You elect that insurance more than 31 days after You initially become eligible for it; or • You again elect it after You cancel Your payroll deduction (if required). If You are a Late Entrant: • You will not be able to enroll in the plan until the next annual enrollment period, except due to a life status change event. 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 coverage, 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 vision coverage ceases when the placement ends, and will not be continued. The provisions in the Exception for Newborns provision 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. Exception for Newborns Any Dependent child born while you are insured will become insured on the date of his birth if you elect Dependent Insurance no later than 31 days after his birth. If you do not elect to insure your newborn child within such 31 days, no benefits for expenses incurred will be payable for that child.

myCigna.com

Claim Reminders BE SURE TO USE YOUR MEMBER ID AND ACCOUNT/GROUP NUMBER WHEN YOU FILE CLAIM FORMS, OR WHEN YOU CALL OUR 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 US. Timely Filing of Claims We will consider claims for coverage under Your plan when proof of loss (a claim) is submitted to Us within: • 12 months for In-Network claims • 12 months for Out-of-Network claims after services are rendered. If services are rendered on consecutive days, the limit will be counted from the last date of service. If claims are not submitted to Us within the timeframe shown above, the claim will not be considered valid and will be denied. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible. NOTE : We consider one month to equal 30 days regardless of the number of days within a calendar month. 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, may be guilty of committing a fraudulent insurance act determined by a court of law.

How to Find a Cigna Vision Provider and File a Claim Cigna Vision Providers To find a Cigna Vision Provider, or to get a claim form, You should visit myCigna.com and use the link on the vision coverage page, or You may call Customer Service using the toll-free number on Your identification card. How to File a Claim Reimbursement/Filing a Claim When You have an exam or purchase Vision Materials from a Cigna Vision Provider You pay any applicable Copayment, Coinsurance or Deductible shown in The Schedule at the time of purchase. You do not need to file a claim form. There is no paperwork to submit for Covered Vision Services received from a Participating Provider. If You have an exam or purchase Vision Materials from a provider who is not a Cigna Vision Provider, You pay the full cost at the time of purchase. You must submit a claim form to be reimbursed or the claim can be submitted by the provider if the provider is able and willing to file on Your behalf. If Your plan provides coverage when care is received only from a Participating Provider, You may still have claims for services received from a Non-Participating Provider. For example, when Emergency Services are received from a Non- Participating Provider, You should follow the claim submission instructions for those claims. 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 below. Send a completed Cigna Vision claim form and itemized receipt to: Cigna Vision, Claims Dept. c/o FAA PO Box 8504 Mason, OH 45040-7111 Cigna Vision will pay for covered expenses within ten business days of receiving the completed claim form and itemized receipt. You may get the required claim forms from the website listed on Your identification card, if You received one, or by calling Customer Services using the toll-free number listed below. Cigna’s Toll Free Number(s): 1-(800) CIGNA 24 (1-800-244-6224) or 1-(888)-353-2653

HCVIS-CLM0

01-24

myCigna.com

Cigna Vision The Schedule

For You and Your Dependents Allowance The maximum amount Cigna will pay each Covered Person per Calendar Year, the member is responsible for any amount over the allowance. Copayments Copayments are amounts to be paid by you or your Dependent for covered services. Calendar Year The term Calendar Year means the period that begins on January 1st and ends on December 31st of that year.

IN-NETWORK **

OUT-OF-NETWORK

BENEFIT HIGHLIGHTS

The Plan will pay 100% after any Copayment or Coinsurance,

The Plan will reimburse you at 100%, subject to any maximum Allowance shown below

subject to any maximum Allowance shown below

EXAMINATION(S): Comprehensive Examination One Eye Exam every Calendar Year

$10 Copayment

$45

myCigna.com

IN-NETWORK **

OUT-OF-NETWORK

BENEFIT HIGHLIGHTS

VISION MATERIALS: Eyeglass Lenses One pair per Calendar Year

$20 Copayment

One pair of standard prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms). Including: Clear or sun lenses. Polycarbonate Eyeglass Lenses for children under 19 years of age. Oversized Eyeglass Lenses. Rose #1 & 2 solid tints. Single Vision Lenses

100% after Eyeglass Lens Copayment 100% after Eyeglass Lens Copayment 100% after Eyeglass Lens Copayment 100% after Eyeglass Lens Copayment 100% after Lenses & Frames copayment

$40

Lined Bifocal Lenses

$65

Lined Trifocal Lenses

$75

Lenticular Lenses

$100

Progressive Lenses

$75

Contact Lenses and Professional Services (in lieu of eyeglass lenses and frames, in same frequency period) (may not receive eyeglass lenses, contact lenses and frames in the same frequency period) One pair of Elective conventional contact lenses or a single purchase of a supply of disposable contact lenses, One pair per Calendar Year Elective

up to $130

$105

Therapeutic

100%

$210

Frames One pair in any 2 Calendar Years

up to $150

$83

**coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information.

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Vision Benefits** Please be aware that the Vision network is different from the network of your medical and/or dental benefits. Covered Expenses For You and Your Dependents Benefits Include: Examination(s) Comprehensive Examination - One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction and prescription for glasses. Retinal Screening – One retinal imaging, which takes digital pictures of the inside of the eye. Does not replace a dilate eye examination. Must be in conjunction with an eye Examination. Contact Lens Professional Services (Fit & Follow-up) – All fitting and evaluation services provided by a Vision Provider. Available when an eye Examination has been completed. Materials Vision Materials Coverage Eyeglass Lenses (Glasses) – One pair of prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms). • Clear or sun lenses. • Polycarbonate lenses for children under 19 years of age. • Oversize eyeglass lenses. • Rose #1 and #2 solid tints. • Coverage for One of the following eyeglass lens types:

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. OTHER OPTIONAL VISION BENEFITS: **coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information.

HCVIS-COV0

01-24

Vision Benefits For You and Your Dependents Exclusions Vision Expenses will not include, and no payment will be made for: • Orthoptic or vision training and any associated supplemental testing. • Medical or surgical treatment, services or supplies for the treatment of the eyes or supporting structures. • Refraction, when not provided as part of a Comprehensive Eye Examination. • Any eye examination, or any corrective eyewear, required by an employer as a condition of employment. • Charges incurred after the Policy ends or the insured's coverage under the Policy ends, except as stated in the Policy. • Services rendered after the date a Covered Person ceases to be covered under the Policy, except when Vision Materials are ordered before coverage ended and are delivered within 31 days from date of such order. • Experimental or non-conventional treatment or device. • Charges in excess of the usual and customary charge for the service or materials. • 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.

• Single Vision Eyeglass Lenses (pair) • Lined Bifocal Eyeglass Lenses (pair) • Lined Trifocal Eyeglass Lenses (pair) • Lenticular Eyeglass Lenses (pair)

• Progressive lenses covered up to bifocal lens amount. Frames – One frame - choice of frame covered up to retail plan allowance. Contact Lenses and Professional Services – One pair or a single purchase of a supply of contact lenses in lieu of eyeglass lenses and frame benefit (may not receive eyeglass lenses, contact lenses and frames in same benefit year). Contact lens retail 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

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• Claims submitted and received in excess of 12 months from the original date of service. • Electronic vision devices. • Magnification or low vision aids. • 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 sunglass 'add-ons' or lens coatings not shown as covered in The Schedule. • Any non-prescription (minimum RX required) eyeglasses, lenses, or contact lenses. • Safety glasses or lenses required for employment. • Solutions, cleaning products or frame cases. • Lost, stolen or broken lenses, frames, glasses, or contact lenses that are replaced before the next benefit frequency when Vision Materials would next become available. • For cosmetic contact lenses that do not improve vision. Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply.

• Medical or Vision benefits coverage of group, group-type, and individual automobile contracts. Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan Closed Panel Plan A Plan that provides medical or vision benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel. Primary Plan The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan. Secondary Plan A Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to You. Reasonable Cash Value An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service if rendered under similar or comparable circumstances by other health care providers located within the immediate geographic area where A Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan. If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use: • The Plan that covers a person as an Employee shall be the Primary Plan and the Plan that covers a person as a Dependent shall be the Secondary Plan. • For a Dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which covers the parent whose birthday falls first in the Calendar Year. • For the Dependent of divorced or separated parents, benefits for the Dependent shall be determined in the following order: • first, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge; the health care service was delivered. Order of Benefit Determination Rules

HCVIS-EXC0

01-24

Coordination of Benefits This section applies if You or any one of Your Dependents are covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Coverage under this Plan plus another Plan will not guarantee 100% reimbursement. Definitions For the purposes of this section, the following terms have the meanings set forth below: Plan Any of the following that provides benefits or services for medical or vision care or treatment: • Group insurance and/or group-type coverage, whether insured or self-insured which neither can be purchased by the general public nor is individually underwritten including closed panel coverage. • Governmental benefits as permitted by law, excepting Medicaid, Medicare and Medicare supplement policies.

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• then, the Plan of the parent with custody of the child; • then, the Plan of the Spouse of the parent with custody of the child; • then, the Plan of the noncustodial parent of the child, and • finally, the Plan of the Spouse of the parent not having custody of the child. • The Plan that covers You as an active Employee (or as that Employee's Dependent)shall be the Primary Plan and the Plan that covers You as a laid-off or retired Employee (or as that Employee's Dependent)shall be the Secondary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply. • The Plan that covers You under a right of continuation which is provided by federal or state law shall be the Secondary Plan and the Plan that covers You as an Employee in Active Service (or as that Employee's Dependent)shall be the Primary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply. • If one of the Plans that covers You is issued out of the state whose laws govern this Policy, and determines the order of benefits based upon the gender of a parent, and as a result, the Plans do not agree on the order of benefit determination, the Plan with the gender rules shall determine the order of benefits. If none of the above rules determines the order of benefits, the Plan that has covered You for the longer period of time shall be primary. Effect on the Benefits of This Plan If this Plan is the Secondary Plan, the benefits that would be payable under this Plan in the absence of Coordination will be reduced by the benefits payable under all other Plans for the expense covered under this Plan. When a Plan provides benefits in the form of services, the Reasonable Cash Value of each service rendered will be considered both an expense incurred and a benefit payable. Recovery of Excess Benefits If We pay charges for services and supplies that should have been paid by the Primary Plan, We will have the right to recover such payments. We will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, healthcare plan or other organization. If We request, You must execute and deliver to Us such

instruments and documents as We determine are necessary to secure the right of recovery. Right to Receive and Release Information We, without consent or notice to You, may obtain information from and release information to any other Plan with respect to You in order to coordinate Your benefits pursuant to this section. You must provide Us with any information We request in order to coordinate Your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, You will be advised that the "other coverage" information, (including an Explanation of Benefits paid under the Primary Plan) is required before the claim will be processed for payment. If no response is received within 55 days of the request, the claim will be closed. If the requested information is subsequently received, the claim will be processed.

HCVIS-COB1

01-24

Expenses For Which A Third Party May Be Responsible This plan does not cover: • Expenses incurred by You or Your Dependent(s)for which another party may be responsible as a result of having caused or contributed to an injury or sickness. • Expenses incurred by You or Your Dependent(s)to the extent any payment is received 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. The coverage under this plan is secondary to any automobile no-fault or similar coverage. Right of Reimbursement If a Covered Person incurs expenses for Covered Vision Services for which another party may be responsible or for which the Covered Person may receive payment as described above, We will be granted a right of reimbursement, to the extent of the benefits provided by Us, from the proceeds of any recovery whether by settlement, judgment, or otherwise. Lien of the Plan By accepting benefits under this plan, a Covered Person: • grants a lien and assigns to Us an amount equal to the benefits paid under this plan against any recovery made by

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or on behalf of the Covered Person which is binding on any attorney or other party who represents the Covered Person whether or not an agent of the Covered Person or of any insurance company or other financially responsible party against whom a Covered Person may have a claim provided said attorney, insurance carrier or other party has been notified by Us or Our agents; • agrees that this lien shall constitute a charge against the proceeds of any recovery and We shall be entitled to assert a security interest thereon; • agrees to hold the proceeds of any recovery in trust for Our benefit to the extent of any payment made by Us. Additional Terms • No adult Covered Person may assign any rights that the Covered Person may have to recover vision expenses from any third party or other person or entity to any Dependent child without Our prior express written consent. Our right to recover shall apply to decedents’, minors’, and incompetent or disabled persons’ settlements or recoveries. • No Covered Person shall make any settlement, which specifically reduces or excludes, or attempts to reduce or exclude, the benefits provided by the plan. • Our right of recovery shall be a prior lien against any proceeds recovered by the Covered Person. 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 Our recovery rights by allocating the proceeds exclusively to non-vision expense damages. • No Covered Person shall incur any expenses on behalf of the plan in pursuit of the plan’s rights. Specifically; no court costs, attorneys' fees, or other representatives' fees may be deducted from the plan’s recovery without Our prior express written consent. This right shall not be defeated by any so-called “Fund Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund Doctrine”. • We shall recover the full amount of benefits provided under the plan without regard to any claim of fault on the part of any Covered Person, whether under comparative negligence or otherwise. • We hereby disavow all equitable defenses in the pursuit of Our right of recovery. Our recovery rights are neither affected nor diminished by equitable defenses. • In the event that a Covered Person fails or refuses to honor his obligations under the plan. We shall be entitled to recover any costs incurred in enforcing the terms of the Policy including, but not limited to, attorney’s fees, litigation, court costs, and other expenses. We shall also be

entitled to offset the reimbursement obligation against any entitlement to future vision benefits under the Covered Person has fully complied with his reimbursement obligations, regardless of how those future vision 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 Covered Person agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, We 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. • Covered Persons must assist Us in pursuing any recovery rights by providing requested information.

HCVIS-SUB0

01-24

Payment of Benefits Assignment and Payment of Benefits

You may not assign to any party, including, but not limited to, a provider of healthcare services/items, Your right to benefits under this plan, nor may You assign any administrative, statutory, or legal rights or causes of action You may have under ERISA, including, but not limited to, any right to make a claim for plan benefits, to request plan or other documents, to file appeals of denied claims or grievances, or to file lawsuits under ERISA. Any attempt to assign such rights shall be void and unenforceable under all circumstances. You may, however, authorize Us to pay any healthcare benefits under this Policy to a Participating or Non- Participating Provider . When You authorize the payment of Your healthcare benefits to a Participating or Non- Participating Provider , You authorize the payment of the entire amount of the benefits due on that claim. If a provider is overpaid because of accepting duplicate payments from You and Us, it is the provider’s responsibility to reimburse the overpayment to You. We may pay all healthcare benefits for Covered Vision Services directly to a Participating Provider without Your authorization. You may not interpret or rely upon this discrete authorization or permission to pay any healthcare benefits to a Participating or Non-Participating Provider as the authority to assign any other rights under this Policy to any party, including, but not limited to, a provider of healthcare services/items.

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Even if the payment of healthcare benefits to a Non- Participating Provider has been authorized by You, We may make payment of benefits to You. When benefits are paid to You, You or Your Dependents are responsible for reimbursing the a Non-Participating Provider . Initial Determination A claim for vision benefits will be reviewed upon receipt. We will notify You of Our decision to approve or deny the claim within 30 days from the date You submitted the claim, unless an extension is required due to matters beyond Our control. Any extension will not be more than 15 days. If We require an extension, You will be notified in writing before the end of the initial 30 day period. The notice of extension will explain the reasons for the extension and will state when a determination will be made. If an extension is required because We require additional information from You, the time from the date of Our notice requesting further information and the time We receive the necessary information does not count toward the time period We are allowed to notify You of the claim determination. You will have 45 days from the date You receive the request for additional information to provide the requested information. Claim Denial If Your claim is denied, in whole or in part, the notification of the claim decision will state the reason why Your claim was denied and reference the specific plan provisions upon which the denial is based. If the claim is denied because more information is needed from You, the claims decision will describe the additional information needed and why such information is needed. If We relied on an internal rule or other criterion when denying the claim, the claim decision will include the rule or other criteria or will indicate that such rule or criteria was relied upon and You may request a copy free of charge. To Whom Payable Vision benefit payments are assignable to the provider. When You assign benefit payments to a provider, You have assigned the entire amount of the payment 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 Our contracts with providers, all claims from contracted providers should be assigned. We may, at Our option, make payment to You for the cost of any Covered Vision Services from a Non-Participating Provider even if benefits have been assigned. When benefits are paid to You or Your Dependent(s), You or Your Dependent(s) are responsible for reimbursing the provider. If any person to whom benefits are payable is a minor or is not able to give a valid receipt for any payment due that person,

such payment will be made to that person’s legal guardian. If no request for payment has been made by that person’s legal guardian, We will make payment to the person or institution appearing to have assumed that person’s custody and support. In the event of the death of a Covered Person, We may receive notice that an executor of the estate has been established. The executor has the same rights as the Covered Person and benefit payments for unassigned claims should be made payable to the executor. Payment as described above will release Us from all liability to the extent of any payment made. Recovery of Overpayment When We have made an overpayment, We 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. In addition, Your acceptance of benefits under this Policy and/or assignment of benefits separately creates an equitable lien by agreement pursuant to which We may seek recovery of any overpayment. You agree that in seeking recovery of any overpayment as a contractual right or as an equitable lien by agreement, We may pursue the general assets of the person or entity to whom or on whose behalf the overpayment was made.

HCVIS-POB0

01-24

Termination of Insurance Termination of Your Insurance Your insurance will cease on the earliest date below: • the last day of the calendar month in which you cease to be in a Class of Eligible Employees or cease to qualify for the insurance. • the last day of the calendar month in which you have made any required contribution for the insurance. • the date the Policy is canceled or lapses due to a nonpayment of premium. • the last day of the calendar month in which Your Active Service ends, except as described below. • Your death. Any continuation of insurance must be based on a plan which precludes individual selection.

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Temporary Layoff or Leave of Absence If your Active Service ends due to temporary layoff or leave of absence, your insurance will be continued until the date as determined by your Employer. Injury or Sickness If Your Active Service ends due to an injury or sickness, Your insurance will be continued while You remain totally and continuously disabled as a result of the injury or sickness. However, Your insurance will not continue past the date Your Employer cancels Your insurance. Termination of Insurance - Dependents Your insurance for all of Your Dependents will cease on the earliest date below: • the date Your insurance ceases; or • the date You cease to be eligible for Dependent insurance; or • the last day of the calendar month for which you have made any required contribution for the insurance. • the date Dependent insurance is canceled; or • the date that Dependent no longer qualifies as a Dependent; or • Your death. The insurance for any one of your Dependents will cease on the last day of the calendar month of which the date that Dependent no longer qualifies as a Dependent.

ID card. The network consists of vision practitioners, of varied specialties as well as general practice, affiliated or contracted with Cigna or an organization contracting on its behalf.

HC-FED78

01-24 V1

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

HCVIS-TRM0 M

01-24

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

Notice of Provider Directory/Networks Notice Regarding Provider Directories and Provider Networks A list of network providers is available to you without charge by visiting the website or by calling the phone number on your

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