Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: Beginning on or after 01/01/2023

Cigna+Oscar Open Access Plus Silver $2600 Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the
cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a
summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-855-OSCAR-55 or visit
https://www.hioscar.com/business/cigna?redirect=cignaoscar.com& For general definitions of common terms, such as allowed amount, balance billing, coinsurance,
copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-OSCAR-55 to
request a copy.

Important Questions Answers Why This Matters:

Generally, you must pay all of the costs from providers up to the deductible amount
$2,600 individual / $5,200 family for in-
What is the overall before this plan begins to pay. If you have other family members on the plan, each
network and $5,500 individual / $11,000 family
deductible? family member must meet their own individual deductible until the total amount of
for out-of-network deductible expenses paid by all family members meets the overall family deductible.
Yes. Preventive care, Pre-and post-natal This plan covers some items and services even if you haven’t yet met the deductible
preventive care, PCP/Specialist visits, Ind
Are there services covered amount. But a copayment or coinsurance may apply. For example, this plan covers
Lab, Urgent Care, outpatient mental
before you meet your certain preventive services without cost sharing and before you meet your deductible.
health/substance use disorders office visits,
deductible? See a list of covered preventive services at
T1 Prescription Drugs, Home health care, https://www.healthcare.gov/coverage/preventive-care-benefits/.
Child Vision and Dental Check-up.
Yes. $300 individual / $600 family for
Are there other deductibles You must pay all of the costs for these services up to the specific deductible amount
prescription drug coverage. No other specific
for specific services? before this plan begins to pay for these services.
deductibles.

What is the out-of-pocket limit $8,950 individual / $17,900 family for in-
for this plan?
What is not included in the
out-of-pocket limit?
Will you pay less if you use a
network provider?
Do you need a referral to see
a specialist?
network and $17,800 individual / $35,600
family for out-of-network
Premiums, balance billing charges, and
healthcare this plan does not cover, and
manufacturer drug coupons
Yes. See www.hioscar.com/care-options or
call 1-855-OSCAR-55 for a list of network
providers.
No.
The out-of-pocket limit is the most you could pay in a year for covered services. If you
have other family members in this plan, they have to meet their own out-of-pocket
limits until the overall family out-of-pocket limit has been met.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might
receive a bill from a provider for the difference between the provider’s charge and what
your plan pays (balance billing). Be aware, your network provider might use an out-of-
network provider for some services (such as lab work). Check with your provider before
you get services.
You can see the specialist you choose without a referral.

Cigna+Oscar Open Access Plus Silver $2600 Off-Ex Small Group CA 2023 SBC Page 1 of 7
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Services You Limitations, Exceptions, & Other
Common Medical Event Network Provider (You will pay the Out-of-Network Provider (You will
May Need Important Information*
least) pay the most)
Cost share applies to both in-person
Primary care visit and virtual visits. Virtual Urgent Care
$60 copayment/visit Deductible does 50% coinsurance subject to
to treat an injury visits from Oscar-designated
not apply deductible
or illness Telemedicine Providers are covered in
full; Deductible does not apply.
Cost share applies to both in-person
If you visit a health care and virtual visits. Virtual Urgent Care
$95 copayment/visit Deductible does 50% coinsurance subject to
provider’s office or clinic Specialist visit visits from Oscar-designated
not apply deductible Telemedicine Providers are covered in
full; Deductible does not apply.
If you receive Non-Preventive
Preventive care/ 50% coinsurance subject to services during a preventive visit, the
screening/ No charge deductible applicable cost share will apply to
immunization those Non-Preventive services.
40% coinsurance subject to
Diagnostic test (x- deductible (X-rays), No charge 50% coinsurance subject to Preauthorization required for certain
(OV/Independent labs), 40%
ray, blood work) Deductible services.
coinsurance subject to deductible (All
If you have a test other outpatient labs)
Preauthorization required.
Imaging (CT/PET 40% coinsurance subject to 50% coinsurance subject to Preauthorization is not required in an
scans, MRIs) deductible deductible emergency.
Retail is limited to a 30-day supply.
$25 copayment/prescription
If you need drugs to treat Generic drugs Mail Order is limited to a 90-day
Deductible does not apply (retail), $75 Not Covered
your illness or condition (Tier 1) supply and is subject to 3x retail cost-
copayment/prescription Deductible sharing amount. Preauthorization/step
does not apply (mail order) therapy may be required.
More information about
prescription drug coverage $80 copayment/prescription subject to Retail is limited to a 30-day supply.
is available at prescription drug deductible (retail), Mail Order is limited to a 90-day
https://hioscar.com/drug- Preferred brand $240 copayment/prescription subject Not Covered supply and is subject to 3x retail cost-
formularies drugs (Tier 2) to prescription drug deductible (mail sharing amount. Preauthorization/step
order) therapy may be required.

*For more information about limitations and exceptions, see the plan or policy document at https://www.hioscar.com/forms/2023/ca
Cigna+Oscar Open Access Plus Silver $2600 Off-Ex Small Group CA 2023 SBC Page 2 of 7
 What You Will Pay
Services You Limitations, Exceptions, & Other
Common Medical Event Network Provider (You will pay the Out-of-Network Provider (You will
May Need Important Information*
least) pay the most)

If you need drugs to treat $125 copay/prescription subject to Retail is limited to a 30-day supply.
your illness or condition Non-preferred prescription drug deductible (retail), Mail Order is limited to a 90-day
brand drugs (Tier $375 copay/prescription subject to Not Covered supply and is subject to 3x retail cost-
3) prescription drug deductible (mail sharing amount. Preauthorization/step
More information about order) therapy may be required.
prescription drug coverage
is available at 30% coinsurance subject to Limited to a 30-day supply up to $250
https://hioscar.com/drug- Specialty drugs prescription drug deductible (retail/mail Not Covered per script. Preauthorization/step
formularies (Tier 4) order) therapy may be required.
Facility fee (e.g., 40% coinsurance subject to 50% coinsurance subject to
ambulatory deductible (surgical and non-surgical Preauthorization may be required.
If you have outpatient Deductible
surgery center) services)
surgery
Physician/surgeon 40% coinsurance subject to 50% coinsurance subject to Preauthorization may be required.
fees deductible deductible
Cost-share waived if admitted. See
40% coinsurance subject to 40% coinsurance subject to
Emergency room Medical Inpatient Services or Mental
deductible (ER Facility Fee/ER deductible (ER Facility Fee/ER
care Health Services for details on
Physician Fee) Physician Fee) emergency admissions.
Emergency transportation services by
an Out-of-Network provider, including
air ambulance, are covered if the
services are for an emergency
condition. Non-emergency ambulance
transportation by a licensed
If you need immediate Emergency ambulance service is covered when
medical attention 40% coinsurance subject to 40% coinsurance subject to
medical the vehicle transports the member to
deductible deductible
transportation or from covered services, and the use
of other means of transportation may
endanger the insured’s life. The cost
share also applies to covered non-
emergency transportation.
Preauthorization is required for
nonemergency transportation.
$75 copayment/visit Deductible does 50% coinsurance subject to
Urgent care –––––––––––none–––––––––––
not apply deductible

*For more information about limitations and exceptions, see the plan or policy document at https://www.hioscar.com/forms/2023/ca
Cigna+Oscar Open Access Plus Silver $2600 Off-Ex Small Group CA 2023 SBC Page 3 of 7
 What You Will Pay
Services You Limitations, Exceptions, & Other
Common Medical Event Network Provider (You will pay the Out-of-Network Provider (You will
May Need Important Information*
least) pay the most)
Preauthorization required. However,
Facility fee (e.g., 40% coinsurance subject to 50% coinsurance subject to preauthorization is not required for
hospital room) deductible deductible
If you have a hospital emergency admissions.
stay Preauthorization is required. However,
Physician/surgeon 40% coinsurance subject to 50% coinsurance subject to Preauthorization is not required for
fees deductible deductible emergency admissions.
$60 copayment/visit Deductible does Preauthorization may be required for
Outpatient not apply (office visit), 40% 50% coinsurance subject to Other Outpatient Services.
If you need mental services coinsurance subject to deductible deductible Preauthorization is not required for
health, behavioral health, (other outpatient services) Outpatient Office visits.
or substance abuse
services Preauthorization required. However,
40% coinsurance subject to 50% coinsurance subject to
Inpatient services preauthorization is not required for
deductible deductible emergency admissions.
Depending on the type of services, a
50% coinsurance subject to copayment, coinsurance, or deductible
Office Visits No charge deductible may apply. Cost-sharing does not
apply for preventive services.
Childbirth/delivery 40% coinsurance subject to 50% coinsurance subject to
If you are pregnant professional Preauthorization is required.
deductible deductible
services
Preauthorization is required for a
Childbirth/delivery 40% coinsurance subject to 50% coinsurance subject to hospital stay that will exceed 48 hours
facility services deductible deductible following a vaginal birth or 96 hours
following a cesarean section.
100 visits per plan year. (The limit is
$95 copayment/visit Deductible does 50% coinsurance subject to not applicable to mental health and
Home health care not apply deductible substance use disorder conditions.)
If you need help Preauthorization is required.
recovering or have other Rehabilitation 40% coinsurance subject to 50% coinsurance subject to
special health needs –––––––––––none–––––––––––
services deductible deductible
Habilitation 40% coinsurance subject to 50% coinsurance subject to –––––––––––none–––––––––––
services deductible deductible

*For more information about limitations and exceptions, see the plan or policy document at https://www.hioscar.com/forms/2023/ca
Cigna+Oscar Open Access Plus Silver $2600 Off-Ex Small Group CA 2023 SBC Page 4 of 7
 What You Will Pay
Services You Limitations, Exceptions, & Other
Common Medical Event Network Provider (You will pay the Out-of-Network Provider (You will
May Need Important Information*
least) pay the most)
Skilled nursing 40% coinsurance subject to 50% coinsurance subject to 100 days per benefit period.
care deductible deductible Preauthorization is required.
If you need help Durable medical 40% coinsurance subject to 50% coinsurance subject to
recovering or have other Preauthorization may be required.
equipment deductible deductible
special health needs
40% coinsurance subject to 50% coinsurance subject to
Hospice services Preauthorization is required.
deductible deductible
Children’s eye 50% coinsurance subject to One (1) exam per plan year for
No charge
exam deductible children up to age 19.
If your child needs dental Children’s glasses No charge 50% coinsurance subject to One (1) prescribed lenses and frames
or eye care deductible per plan year for children up to age 19.
Children’s dental 50% coinsurance subject to
No charge One (1) preventive visit per 6 months
check-up deductible
Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Cosmetic surgery Long-term care Weight loss programs (does not apply to Preventive
Dental care (Adult) Non-emergency care when traveling outside the care related weight loss interventions)
Hearing aids U.S.
Infertility treatment Routine eye care (Adult)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Abortion Chiropractic care Routine foot care

Acupuncture Private-duty nursing - 100 visits/year combined with
Bariatric surgery home health care

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to
you too, including buying individual insurance coverage through the Health Insurance Marketplace Covered California. For more information about Covered California, visit
www.coveredca.com or call 1-800-300-1506.

*For more information about limitations and exceptions, see the plan or policy document at https://www.hioscar.com/forms/2023/ca
Cigna+Oscar Open Access Plus Silver $2600 Off-Ex Small Group CA 2023 SBC Page 5 of 7
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:Cigna
c/o Oscar Insurance Company, 1-855-672-2789, P.O. Box 52146 Phoenix, AZ 85072-2146 California Department of Insurance Consumer Services, Division 300 South
Spring Street, South Tower, Los Angeles, CA 90013 www.insurance.ca.govCalling within California: 1-800-927-HELP (4357). TDD: 1-800-482-4TDD. Department of Labor’s
Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-855-OSCAR-55.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa
Tagalog tumawag sa 1-855-OSCAR-55.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-855-OSCAR-55.Navajo (Dine): Dinek'ehgo shika at'ohwol
ninisingo, kwiijigo holne' 1-855-OSCAR-55.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.

*For more information about limitations and exceptions, see the plan or policy document at https://www.hioscar.com/forms/2023/ca
Cigna+Oscar Open Access Plus Silver $2600 Off-Ex Small Group CA 2023 SBC Page 6 of 7
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the
actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance)
and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage
examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

The plan’s overall deductible $2,600 The plan’s overall deductible $2,600 The plan’s overall deductible $2,600
Specialist copayment $95 Specialist copayment $95 Specialist copayment $95
Hospital (facility) coinsurance 40% Hospital (facility) coinsurance 40% Hospital (facility) coinsurance 40%
Other coinsurance 40% Other coinsurance 40% Other coinsurance 40%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies)
Childbirth/delivery professional services education) Diagnostic test (x-ray)
Childbirth/delivery facility services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $2,600 Deductibles * $1,300 Deductibles $2,600
Copayments $20 Copayments $1,500 Copayments $200
Coinsurance $3,100 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $5,720 The total Joe would pay is $2,800 The total Mia would pay is $2,800

*NOTE: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?" row above.
The plan would be responsible for the other costs of these EXAMPLE covered services.
Cigna+Oscar Open Access Plus Silver $2600 Off-Ex Small Group CA 2023 SBC Page 7 of 7

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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,
sex, ancestry, marital status, gender identity or sexual orientation.
Cigna does not exclude people or treat them differently because of
race, color, national origin, age, disability, sex, ancestry, marital status,
gender identity or sexual orientation.
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 at all times 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
phone number shown on your ID card, and ask a Customer Service
Associate for assistance.
Non-Discrimination
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
Persons who believe they subject to unlawful discrimination should contact
the Department's Consumer Complaint Center at 1-800-927-4357, or submit
a complaint through the Department's website at www.insurance.ca.gov.
To contact the Department of Insurance, for complaints regarding the above,
a complaint may be submitted on CDI's website or You may write or call:
California Department of Insurance Consumer Services
Division 300 South Spring Street, South Tower
Los Angeles, CA 90013
www.insurance.ca.gov
1-800-927-HELP (4357). TDD:1-800-482-4TDD
f 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.
928283 10/12
 Multi-language interpreter services

Proficiency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of
your ID card.
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.
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。
Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hi ện tại của Cigna, vui lòng gọi số ở mặt
sau thẻ Hội viên.
Korean –주의:한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다.현재Cigna 가입자님들께서는ID
카드뒷면에있는전화번호로연락해주십시오.
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.
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.
‫تﺎدهابتنا لا ءﺎ‬
‫ﺣﺔماتم ةینﺎ لاﺔ رتالﺧﻣ‬. ‫ – ءلﻣﺎعل‬Arabic Cigna‫ب‬
‫ةی ﺧصلشا ﻛمﺗقاطب رهظﻲﻋﻠ‬ ‫دنومالمقرل‬ ‫ل تا لا ءﺎ‬ .‫ب نییل لا‬
Armenian(Eastern) – ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Ձեզ հասանելի են անվճար լեզվական օգնության ծառայություններ: Cigna-ի ընթացիկ
հաճախորդների համար, զանգահարեք Ձեր ճանաչողական քարտի դարձակողմում գտնվող համարով:
Punjabi (India), – ਧਿ ਆਨ ਦੋ: ਭ ਸ ਸਹ ਇਤ ਸ ਵ ਵ ,ਤ ਹ ਡ ਲਈ ਮ ਫਤ, ਉਪਲਬਧ ਹਨ. ਮ ਜ
ਦ Cigna
ਗ ਹਕ ਲਈ, ਆਪਣ ID ਕ ਰਡ ਦ ਧਪਛਲ ਨ ਬਰ 'ਤ ਕ ਲ ਕਰੋ
Khmer – ច◌◌ ណ◌◌ ប◌ ◌ (រម◌◌មណ◌ ៖សេ◌◌1ជន◌◌ យ6ង89ឥតគ◌◌តថ◌ល ៃ◌◌ គ◌◌ Bនេ◌◌◌◌ Cបអ ន
ក។
េ◌◌◌◌ Cប◌◌អ◌G◌◌ ល◌◌ជន Cigna បចច◌◌ បបនន សេ◌◌Iសេ◌◌ខសេ◌◌I6ងខន ង ថKបណណ ID របេ ◌ ◌
ក។ ◌អ ◌
Hmong– LUS CEEV: Muaj kev pab txhais lus pub dawb rau koj. Rau cov neeg qhuas tam sim no rau ntawm Cigna, hu rau tus nab npawb xov tooj nyob sab
tom qab ntawm koj daim npav ID.
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。
Hindi – *ा न द.: आपका िालए भ षा सह यता सा एवा िान:शा@ उपलB हC। Cigna का मौजादा Iा हक अपनाआईडा क डN का प छा
िालखा ना बर पर कॉल कर सकता हC।
Thai – โปรดทราบ: ารความชว◌ ดา◌ ◌ณฟร◌ ส◌าหรบ◌ นของ Cigna
ม◌บรก ยเหล อ นภาษาใหแ◌ กค ล◌กคา◌ ป◌จจบ
โปรดโทรศพทถ◌ ง◌ ย◌◌บนห รประจา◌ ตว◌ ของค◌ณ
หมายเลขทอ
◌ ลง◌ บต
‫د ﯽﻣﮫﺋراا ﻣﺎﺷﮫﺑ‬. (Farsi) Persian – ‫ﮫﺟوﺗ‬: ‫ز ﻣﮏﮐ دﻣﺎتﺧ‬،‫اﯾﮕﺎﻧر رﺗوﺻﺑﮫﺑﺎﻧﯽ‬
‫ ﻌﻠﯽﻓ ﺎنﯾ‬Cigna، ‫◌ طﻔﺎﻟ‬
ً ‫تﭘﺷرد ﮫیﮐاﻣﺎرهﺷ ﺎﺑ‬ ‫ﻣﺷ ای‬
‫ﺑﮕﯾرﯾد ﺗﺎﻣس ﺷﺎﻣﺳت ﺷﻧﺎﺳﺎﯾﯽ‬.
‫ﺎﮐرت‬ 928283 10/12