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01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET1 of 12©Cigna 2023BENEFIT SUMMARYCigna Health and Life Insurance Co.For - BBB National Programs, Inc.Open Access Plus PlanOAPIN LowEffective - 01/01/2024Selection of a Primary Care Provider - your plan may require or allow the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. If your plan requires designation of a primary care provider, Cigna may designate one for you until you make this designation. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider.Direct Access to Obstetricians and Gynecologists - You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card.Plan HighlightsIn-NetworkLifetime MaximumUnlimitedPlan Year AccumulationYour Plan’s Deductibles, Out-of-Pockets and benefit level limits accumulate on a calendar year basis unless otherwise stated.Plan CoinsurancePlan pays 100%Plan DeductibleIndividual: $500Family: $1,000 Benefit copays/deductibles always apply before plan deductible and coinsurance. Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance.Note: Services where plan deductible applies are noted with a caret (^).Plan Out-of-Pocket MaximumIndividual: $2,000Family: $4,000 Plan deductible contributes towards your out-of-pocket maximum. All benefit copays/deductibles contribute towards your out-of-pocket maximum. Covered expenses that count towards your out-of-pocket maximum include customer paid coinsurance and charges for Mental Health and Substance Use Disorder. After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member's covered expenses. This plan includes a combined Medical/Pharmacy out-of-pocket maximum.

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET2 of 12©Cigna 2023BenefitIn-NetworkNote: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.Physician Services - Office VisitsPrimary Care Physician (PCP) Services/Office Visit$30 copay, and plan pays 100%Specialty Care Physician Services/Office Visit$40 copay, and plan pays 100%Surgery Performed in Physician's OfficePlan pays 100% ^Virtual CareDedicated Virtual Providers - MDLIVEMDLIVE Urgent Virtual Care Services$30 copay, and plan pays 100% Dedicated Virtual Providers may deliver services that are payable under other benefits (e.g., Preventive Care, Primary Care Physician, Behavioral; Dermatology/Specialty Care Physician). Lab services supporting a virtual visit must be obtained through dedicated labs. Includes charges for the delivery of medical and health-related services and consultations by dedicated virtual providers as medically appropriate through audio, video, and secure internet-based technologies.Virtual Physician Services - Office VisitsPrimary Care Physician (PCP) Services/Office Visit$30 copay, and plan pays 100%Specialty Care Physician Services/Office Visit$40 copay, and plan pays 100% Physicians may deliver services virtually that are payable under other benefits (e.g., Preventive Care, Outpatient Therapy Services). Includes charges for the delivery of medical and health-related services and consultations as medically appropriate through audio, video, and secure internet-based technologies that are similar to office visit services provided in a face-to-face setting.Preventive CarePreventive Care Office VisitPlan pays 100%Preventive ServicesPlan pays 100% Includes preventive Mammograms, Papanicolaou (Pap), Prostate Specific Antigen (PSA) tests and colorectal screenings. Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on place of service.ImmunizationsPlan pays 100%InpatientInpatient Hospital Facility ServicesPlan pays 100% ^Note: Includes all Lab and Radiology services, including Advanced Radiological Imaging as well as Medical Specialty DrugsInpatient Hospital Physician's Visit/ConsultationPlan pays 100% ^Inpatient Professional ServicesPlan pays 100% ^ For services performed by Surgeons, Radiologists, Pathologists and AnesthesiologistsOutpatientOutpatient Facility ServicesNon-surgical treatment procedures are not subject to the facility per visit deductible.$125 per admission deductible, and plan pays 100%Outpatient Professional ServicesPlan pays 100% ^

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET3 of 12©Cigna 2023BenefitIn-NetworkNote: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible. For services performed by Surgeons, Radiologists, Pathologists and AnesthesiologistsEmergency ServicesEmergency Room Includes ER Physician Charges, Lab and Radiology including Advanced Radiological Imaging (ARI) Per visit copay is waived if admitted.$200 copay, and plan pays 100%Urgent Care Facility Includes Physician Charges, Lab and Radiology$50 copay, and plan pays 100%AmbulancePlan pays 100% ^Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered. Services for Mental Health and Substance Use Disorder diagnoses will be payable according to Emergency room benefits.Inpatient Services at Other Health Care FacilitiesSkilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities Annual Limit: 60 daysPlan pays 100% ^Laboratory ServicesPhysician’s Services/Office VisitPlan pays 100% ^Independent LabPlan pays 100%Outpatient FacilityPlan pays 100%Radiology ServicesPhysician’s Services/Office VisitPlan pays 100% ^Outpatient FacilityPlan pays 100%Advanced Radiological Imaging (ARI)Includes MRI, MRA, CAT Scan, PET Scan, etc.Outpatient FacilityPlan pays 100% ^Physician’s Services/Office VisitPlan pays 100% ^Outpatient Therapy ServicesOutpatient Physical Therapy$40 copay, and plan pays 100%Annual Limits: Physical Therapy – 20 visits Limits are not applicable to mental health conditions.Note: Therapy visits, provided as part of an approved Home Health Care plan, accumulate to the applicable Home Health Care maximum.

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET4 of 12©Cigna 2023BenefitIn-NetworkNote: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.Outpatient Speech Therapy, Hearing Therapy and Occupational Therapy$40 copay, and plan pays 100%Annual Limits: Speech, Hearing and Occupational Therapies – 60 visits Limits are not applicable to mental health conditions for Speech and Occupational Therapies.Note: Therapy visits, provided as part of an approved Home Health Care plan, accumulate to the applicable Home Health Care maximum.Chiropractic Care$40 copay, and plan pays 100%Annual Limit: Chiropractic Care – 20 visitsHospiceInpatient FacilitiesPlan pays 100% ^Outpatient ServicesPlan pays 100% ^Note: Includes Bereavement counseling provided as part of a hospice program.Medical Pharmaceutical DrugsOutpatient FacilityPlan pays 100% ^Physician's OfficePlan pays 100% ^HomePlan pays 100% ^Note: This benefit only applies to the cost of the Infusion Therapy drugs administered. This benefit does not cover the related Facility, Office Visit or Professional charges.Family PlanningWomen’s ServicesPlan pays 100%Includes contraceptive devices as ordered or prescribed by a physician and surgical sterilization services, such as tubal ligation (excludes reversals)Men’s ServicesCoverage varies based on Place of ServiceIncludes surgical sterilization services, such as vasectomy (excludes reversals)AbortionAbortion ServicesCoverage varies based on Place of ServiceNote: Elective and non-elective procedures

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET5 of 12©Cigna 2023BenefitIn-NetworkNote: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.InfertilityInfertility TreatmentNote: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness.Other Health Care Facilities/ServicesHome Health CarePlan pays 100% ^ Annual Limit: 60 visits (The limit is not applicable to mental health and substance use disorder conditions.)Organ TransplantsCovered same as Inpatient benefit Services paid at in-network level if performed at Cigna LifeSOURCE Transplant Network® Facilities. Travel Maximum - Cigna LifeSOURCE Transplant Network® Facility Only: Unlimited maximum per Transplant per LifetimeDurable Medical Equipment and External Prosthetic Appliances Annual Limit: UnlimitedPlan pays 100% ^Breast Feeding Equipment and Supplies Limited to the rental of one breast pump per birth as ordered or prescribed by a physician Includes related suppliesPlan pays 100%Temporomandibular Joint Disorder (TMJ) Annual Limit: Unlimited for Surgical and Non-Surgical treatmentCoverage varies based on Place of ServiceNote: Provided on a limited, case-by-case basis. Excludes appliances and orthodontic treatment.Hearing AidsPlan pays 100% ^ $1,500 maximum per device (per ear)  Maximum of 2 devices (one per ear) per 24 months Includes testing and fitting of hearing aid devices Coverage through age 18Acupuncture Annual Limit: 20 visits$40 copay, and plan pays 100%Note: Services where plan deductible applies are noted with a caret (^).Mental Health and Substance Use DisorderInpatient Mental HealthPlan pays 100% ^Outpatient Mental Health – Physician’s Office$40 copay, and plan pays 100%Outpatient Mental Health – All Other ServicesPlan pays 100%Inpatient Substance Use DisorderPlan pays 100% ^Outpatient Substance Use Disorder – Physician’s Office$40 copay, and plan pays 100%Outpatient Substance Use Disorder – All Other ServicesPlan pays 100%

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET6 of 12©Cigna 2023Note: Services where plan deductible applies are noted with a caret (^).Annual Limits: Unlimited maximumNotes: Inpatient includes Acute Inpatient and Residential Treatment. Outpatient - Physician's Office - may include Individual, family and group therapy, psychotherapy, medication management, etc. Outpatient - All Other Services - may include Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy), etc.Important Note on Mental Health and Substance Use Disorder Coverage: Covered medical services listed above, which are received to diagnose or treat a Mental Health or Substance Use Disorder condition will be payable according to this section titled “Mental Health and Substance Use Disorder.”PharmacyIn-NetworkOut-of-NetworkCost Share and SupplyPharmacy Cost Share Retail – up to 90-day supply(except Specialty up to 30-day supply) Home Delivery – up to 90-day supply(except Specialty up to 30-day supply) Specialty Drugs provided at Home Delivery at the Retail (per 30-day supply) cost share.Retail (per 30-day supply):Generic: You pay $15Preferred Brand: You pay $35Non-Preferred Brand: You pay $50Retail and Home Delivery (per 90-day supply):Generic: You pay $45Preferred Brand: You pay $105Non-Preferred Brand: You pay $150Retail:You pay 20%Your plan pays 80%Home Delivery:Not Covered Cigna 90 Now CVS: Retail drugs for a 30 day supply may be obtained In-Network at a wide range of pharmacies across the nation although prescriptions for a 90 day supply (such as maintenance drugs) will be available at select network pharmacies. Walgreens will be considered Out-of-Network for a 90 day supply. Cigna 90 Now Program: You can choose to fill your medications in a 30- or 90-day supply. If you choose to fill a 30-day prescription, it can be filled at any network retail pharmacy or network home delivery pharmacy. If you choose to fill a 90-day prescription, it must be filled at a 90-day network retail pharmacy or network home delivery pharmacy to be covered by the plan. Specialty medications are used to treat an underlying disease which is considered to be rare and chronic including, but not limited to, multiple sclerosis, hepatitis C or rheumatoid arthritis. Specialty Drugs may include high cost medications as well as medications that may require special handling and close supervision when being administered. When you request a brand drug, you pay the brand cost share plus the cost difference between the brand and generic drugs up to the cost of the brand drug (unless the physician indicates "Dispense As Written" DAW) (MAC B). Your pharmacy benefits share an out-of-pocket maximum with the medical/behavioral benefits.Preventive Drugs:Federally required preventive drugs will not be subject to deductible and will be provided at no charge. In addition, In-Network Generic preventive drugs and products included in the Preventive Package will be provided at no charge. This may apply to drugs for:Asthma, Cholesterol Lowering, Depression, Diabetes (including diabetic supplies but excluding continuous glucose monitor supplies), Heart Disease and Stroke, High Blood Pressure, Osteoporosis, Prenatal Vitamins

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET7 of 12©Cigna 2023PharmacyIn-NetworkOut-of-NetworkFor Delaware residents:For prescription drug plans that include a mail order drug plan (home delivery), the copayment for a 90-day supply at retail or mail order pharmacies will be equal to three times the copayment for a 30-day supply. The copayment for a 90-day supply when obtained from either a retail or mail order drug pharmacy will be equal. The mail order drug plan coinsurance level for a 90-day supply will be the same as the retail coinsurance level. Each prescription order or refill will be limited to up to a consecutive 90-day supply at a mail order or retail participating pharmacy, unless limited by the drug manufacturer's packaging or other applicable law.Drugs CoveredPrescription Drug List:Your Cigna Performance Prescription Drug List includes a full range of drugs including all those required under applicable health care laws. To check which drugs are included in your plan, please log on to myCigna.com.Some highlights: Coverage includes Self Administered injectable drugs, but excludes infertility drugs. Contraceptive devices and drugs are covered with federally required products covered at 100%. Prescription smoking cessation drugs are covered.Pharmacy Program InformationPharmacy Clinical Management: EssentialYour plan features drug management programs and edits to ensure safe prescribing, and access to medications proven to be the most reliable and cost effective for the medical condition, including: Prior authorization requirements Step Therapy on select classes of medications and drugs new to the market Quantity limits, including maximum daily dose edits, quantity over time edits, duration of therapy edits, and dose optimization edits Age edits, and refill-too-soon edits Plan exclusion edits Current users of Step Therapy medications will be allowed one 30-day fill during the first three months of coverage before Step Therapy program applies. Your plan includes Specialty Drug Management features, such as prior authorization and quantity limits, to ensure the safe prescribing and access to specialty medications. For customers with complex conditions taking a specialty medication, we will offer Accredo Therapeutic Resource Centers (TRCs) to provide specialty medication and condition counseling. For customers taking a specialty medication not dispensed by Accredo, Cigna experts will offer this important specialty medication and condition counseling.Patient Assurance ProgramYour plan includes the Patient Assurance Program, which waives the deductible and reduces the amount you owe for certain medications used to treat chronic conditions included in the program. Additionally: Any amount you pay for these medications only count toward meeting your out-of-pocket maximum. Any discount provided by a pharmaceutical manufacturer for these medications only count toward meeting your out-of-pocket maximum.

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET8 of 12©Cigna 2023Additional InformationCigna Diabetes Prevention Program in collaboration with OmadaCigna Diabetes Prevention Program in collaboration with Omada is a program to help you avoid the onset of diabetes, as well as health risks that might lead to heart disease or a stroke. The program is covered by your health plan at the preventive level, just like for your wellness visit. Program participants have access to a professional virtual health coach, an online support group, interactive lessons, and a smart-technology scale. The program will help you make small changes in your eating, activity, sleep, and stress to achieve healthy weight loss through a series of 16 weekly lessons and tools to help you maintain weight loss over time. You will also be offered the opportunity to join a gym for a low monthly fee and no enrollment fee.Out-of-Network Emergency Services Charges1. Emergency Services are covered at the In-Network cost-sharing level as required by applicable state or federal law if services are received from a non-participating (Out-of-Network) provider.2. The allowable amount used to determine the Plan's benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-of-Network provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or as required by applicable state or federal law.The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is not responsible for any charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card.Medicare CoordinationIn accordance with the Social Security Act of 1965, this plan will pay as the Secondary plan to Medicare Part A and B as follows:(a) a former Employee such as a retiree, a former Disabled Employee, a former Employee's Dependent, or an Employee's Domestic Partner who is also eligible for Medicare and whose insurance is continued for any reason as provided in this plan (including COBRA continuation);(b) an Employee, a former Employee, an Employee’s Dependent, or former Employee’s Dependent, who is eligible for Medicare due to End Stage Renal Disease after that person has been eligible for Medicare for 30 months.When a person is eligible for Medicare A and B as described above, this plan will pay as the Secondary Plan to Medicare Part A and B regardless if the person is actually enrolled in Medicare Part A and/or Part B and regardless if the person seeks care at a Medicare Provider or not for Medicare covered services.One GuideAvailable by phone or through myCigna mobile application. One Guide helps you navigate the health care system and make the most of your health benefits and programs.Complete Care ManagementPre-authorization is required on all inpatient admissions and selected outpatient procedures, diagnostic testing, and outpatient surgery. Network providers are contractually obligated to perform pre-authorization on behalf of their customers.Pre-Existing Condition Limitation (PCL) does not apply.Well-Being Solution: Core Plus Health Assessment Device/App Integration Personalized online content and data-driven actions Social connections/challenges

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET9 of 12©Cigna 2023DefinitionsCoinsurance - After you've reached your deductible, you and your plan share some of your medical costs. The portion of covered expenses you are responsible for is called Coinsurance.Copay - A flat fee you pay for certain covered services such as doctor's visits or prescriptions.Deductible - A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered services.Out-of-Pocket Maximum - Specific limits for the total amount you will pay out of your own pocket before your plan coinsurance percentage no longer applies. Once you meet these maximums, your plan then pays 100 percent of the "Maximum Reimbursable Charges" or negotiated fees for covered services.Place of Service - Your plan pays based on where you receive services. For example, for hospital stays, your coverage is paid at the inpatient level.Prescription Drug List - The list of prescription brand and generic drugs covered by your pharmacy plan.Professional Services - Services performed by Surgeons, Assistant Surgeons, Hospital Based Physicians, Radiologists, Pathologists and AnesthesiologistsTransition of Care - Provides in-network health coverage to new customers when the customer's doctor is not part of the Cigna network and there are approved clinical reasons why the customer should continue to see the same doctor.ExclusionsExclusions and Expenses Not CoveredAdditional coverage limitations determined by plan or provider type are shown in the Schedule. Payment for the following is specifically excluded from this plan: Care for health conditions that are required by state or local law to be treated in a public facility. Care required by state or federal law to be supplied by a public school system or school district. Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available. Treatment of an Injury or Sickness which is due to war, declared, or undeclared, riot or insurrection. Charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan. Custodial care of a member whose health is stabilized and whose current condition is not expected to significantly or objectively improve or progress over a specified period of time. Custodial care does not seek a cure, can be provided in any setting and may be provided between periods of acute or inter-current health care needs. Custodial care includes any skilled or non skilled health services or personal comfort and convenience services which provide general maintenance, supportive, preventive and/or protective care. This includes assistance with, performance of, or supervision of: walking, transferring or positioning in bed and range of motion exercises; self administered medications; meal preparation and feeding by utensil, tube or gastronomy; oral hygiene, skin and nail care, toilet use, routine enemas; nasal oxygen applications, dressing changes, maintenance of in-dwelling bladder catheters, general maintenance of colostomy ileostomy, gastronomy, tracheostomy and casts. For or in connection with experimental, investigational or unproven services.o Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the utilization review Physician to be:o Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed;o Not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or Sickness for which its use is proposed;o The subject of review or approval by an Institutional Review Board for the proposed use except as provided in the “Clinical Trials” sections of this plan; oro The subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the “Clinical Trials” sections of this plan. In determining whether drug or Biologic therapies are experimental, investigational and unproven, the utilization review Physician may review, without

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET10 of 12©Cigna 2023Exclusionslimitation, U.S. Food and Drug Administration-approved labeling, the standard medical reference compendia and peer-reviewed, evidence-based scientific literature. The plan or policy shall not deny coverage for a drug or Biologic therapy as experimental, investigational and unproven if the drug or Biologic therapy is otherwise approved by the FDA to be lawfully marketed, has not been contraindicated by the FDA for the use for which the drug or Biologic has been prescribed, and is recognized as safe and effective for the treatment of cancer in any of the standard reference compendia (American Medical Association Drug Evaluations, the American Hospital Formulary Service Drug Information, or the United States Pharmacopoeia Dispensing Information). Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance including Idiopathic Short Stature Syndrome. However, reconstructive surgery and therapy are covered as provided in the “Reconstructive Surgery” section of Covered Expenses. The following services are excluded from coverage unless Medically Necessary or subject to another exclusion:o Surgical treatment of varicose veins;o Rhinoplasty; oro Orthognathic surgeries. The following services are excluded from coverage regardless of clinical indications: macromastia or gynecomastia surgeries; abdominoplasty; panniculectomy; blepharoplasty; redundant skin surgery; removal of skin tags; acupressure; craniosacral/cranial therapy; dance therapy; movement therapy; applied kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions. Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. Charges made for services or supplies provided for or in connection with an accidental Injury to teeth are covered provided a continuous course of dental treatment is started within six months of an accident. Additionally, charges made by a Physician for any of the following surgical procedures are covered: excision of unerupted impacted wisdom tooth, including removal of alveolar bone and sectioning of tooth; removal of residual root (when performed by a Dentist other than the one who extracted the tooth). For medical and surgical services, initial and repeat, intended for the treatment or control of obesity including clinically severe (morbid) obesity, including: medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a Physician or under medical supervision. Unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations. Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan. Infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage. Reversal of male or female voluntary sterilization procedures. Any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation. Medical and Hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under this plan. Non-medical counseling and/or ancillary services including, but not limited to: Custodial Services, educational services, vocational counseling, training and rehabilitation services, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, return to work services, work hardening programs, and driver safety courses. Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected. Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET11 of 12©Cigna 2023Exclusionsdisposable medical supplies, skin preparations and test strips, except as specified in the “Home Health Services” or “Breast Reconstruction and Breast Prostheses” sections of this plan. Private Hospital rooms and/or private duty nursing except as provided under the Home Health Services provision. Personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness. Artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures and wigs. Aids, devices or other adaptive equipment that assist with non-verbal communications, including, but not limited to communication boards, pre-recorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books. Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post-cataract surgery). Routine refractions, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy. All non-injectable prescription drugs unless Physician administration or oversight is required, injectable prescription drugs to the extent they do not require Physician supervision and are typically considered self-administered drugs, non-prescription drugs, and investigational and experimental drugs, except as provided in this plan. Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary. Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs. Genetic screening or pre-implantations genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease. Dental implants for any condition. Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review Physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement in physical condition. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks. Cosmetics, dietary supplements and health and beauty aids. Enteral feedings, supplies and specially formulated medical foods that are prescribed and non-prescribed, except as specifically provided in the “Enteral Nutrition” benefit. For or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit. Telephone, email or facsimile consultations. Massage therapy.These are only the highlightsThis summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including benefits required by your state, see your employer's insurance certificate, service agreement or summary plan description -- the official plan documents. If there are any differences between this summary and the plan documents, the information in the plan documents takes precedence.All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation.

01/01/2024 VAOpen Access Plus - OAPIN LowFacets - 27137564 - V 29 - 10/20/23 02:31 PM ET12 of 12©Cigna 2023EHB State: VA

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 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 PO 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, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. 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). 896375b 05/21 © 2021 Cigna.Medical coverage DISCRIMINATION IS AGAINST THE LAW