Medical Benefits Prior Authorization

Amazon.com Services LLC

LOCALPLUS IN-NETWORK MEDICAL

BENEFITS

Base Plan

EFFECTIVE DATE: January 1, 2024

ASO6

3345145

This document takes the place of any documents previously issued to you which described your benefits. Printed in U.S.A.

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Table of Contents

Important Information 3 Special Plan Provisions 5 Important Notices 6 How To File Your Claim 10 Eligibility and Enrollment 11 Employee Coverage 11 Dependent Coverage 11 Changes in Coverage 12 Important Information About Your Medical Plan 12 LocalPlus In-Network Medical Benefits 14 The Schedule 14 Prior Authorization/Pre-Authorized 37 Covered Expenses 37 Exclusions, Expenses Not Covered and General Limitations 50 Coordination of Benefits 53 Expenses For Which A Third Party May Be Responsible 55 Payment of Benefits 57 Termination of Coverage 57 Events that End Coverage 57 Rescissions 58 Federal Requirements 58 Notice of Provider Directory/Networks 58 Qualified Medical Child Support Order (QMCSO) 58 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) 59 Effect of Section 125 Tax Regulations on This Plan 59 Eligibility for Coverage for Adopted Children 60 Coverage for Maternity Hospital Stay 61 Women’s Health and Cancer Rights Act (WHCRA) 61 Group Plan Coverage Instead of Medicaid 61 Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) 61 Claim Determination Procedures under ERISA 61 Appointment of Authorized Representative 63 Medical - When You Have a Complaint or an Appeal 63 COBRA Continuation Rights Under Federal Law 65 ERISA Required Information 68 Definitions 70 3

Important Information

Amazon.com Services, LLC (“Amazon”) is pleased to provide you with this Summary Plan Description

(“SPD”) which describes medical benefits available to you and your covered family members under the Group Health and Welfare Plan.

This Summary Plan Description describes the LocalPlus In-Network Medical Benefits Base Plan (the “Plan”), which is a component of the Group Health and Welfare Plan. The Plan, including any benefits described in this SPD or any booklet or rider attached hereto and incorporated into this SPD, is self-funded by Amazon and participating subsidiaries. Amazon is financially responsible for the payment of Plan benefits. Amazon has the final discretionary authority to determine eligibility for benefits and claims and to construe the terms of the Plan.

Amazon has contracted with Cigna to process claims and for other administrative duties. Amazon has delegated to Cigna the discretionary authority to determine claims for benefits and to construe the terms used in this Plan to the extent necessary to perform Cigna’s services. Cigna doesn’t insure this Plan or any of the benefits described in this SPD. In this Summary Plan Description Cigna is called the “Claims Administrator.” This SPD is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA).

This Plan complies with the 2010 federal health care reform law, called the Affordable Care Act (see Definitions). If Congress, federal or state regulators, or the courts make further changes or clarifications regarding the Affordable Care Act and its implementing regulations, including changes which become effective on the beginning of the calendar year, this Plan will comply with them even if they are not stated in this SPD or if they conflict with statements made in this SPD. THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY AMAZON 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.

HC-NOT89

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Explanation of Terms

You will find terms starting with capital letters throughout your SPD. To help you understand your benefits, most of these terms are defined in the Definitions section of your SPD.

The Schedule

The Schedule is a brief outline of your maximum benefits which may be payable under your coverage. For a full description of each benefit, refer to the appropriate section in this SPD. 5 myCigna.com

Special Plan Provisions

Participating Providers include Physicians, Hospitals and Other Health Professionals and Other Health Care Facilities. Consult your Physician Guide for a list of Participating Providers in your area. Participating Providers are committed to providing you and your Dependents appropriate care while lowering medical costs.

Services Available in Conjunction With Your Medical Plan

The following pages describe helpful services available in conjunction with your medical plan. You can access these services by calling the toll-free number shown on the back of your ID card.

HC-SPP70 01-21

Case Management

Case Management is a service provided through a Review Organization, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a Hospital or specialized facility. Should the need for Case Management arise, a Case

Management professional will work closely with the patient, their family and the attending Physician to determine appropriate treatment options which will best meet the patient's needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis.

Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, each trained in a clinical specialty area such as trauma, high risk pregnancy and neonates, oncology, mental health, rehabilitation or general medicine and surgery. A Case Manager trained in the appropriate clinical specialty area will be assigned to you or your Dependent. In addition, Case Managers are supported by a panel of Physician advisors who offer guidance on up-to- date treatment programs and medical technology. While the Case Manager recommends alternate treatment programs and helps coordinate needed resources, the patient's attending Physician remains responsible for the actual medical care.

• You, your Dependent or an attending Physician can request Case Management services by calling the toll-free number shown on your ID card during normal business hours, Monday through Friday. In addition, your Employer, a claim office or a utilization review program (see the PAC/CSR section of your certificate) may refer an

individual for Case Management.

• The Review Organization assesses each case to determine whether Case Management is appropriate.

• You or your Dependent is contacted by an assigned Case Manager who explains in detail how the program works. Participation in the program is voluntary - no penalty or benefit reduction is imposed if you do not wish to participate in Case Management.

• Following an initial assessment, the Case Manager works with you, your family and Physician to determine the needs of the patient and to identify what alternate treatment programs are available (for example, in-home medical care in lieu of an extended Hospital convalescence). You are not penalized if the alternate treatment program is not followed.

• The Case Manager arranges for alternate treatment services and supplies, as needed (for example, nursing services or a Hospital bed and other Durable Medical Equipment for the home).

• The Case Manager also acts as a liaison between the Plan, the patient, their family and Physician as needed (for example, by helping you to understand a complex medical diagnosis or treatment plan).

• Once the alternate treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient's needs.

While participation in Case Management is strictly voluntary, Case Management professionals can offer quality, cost- effective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need.

HC-SPP2 04-10

V1

Additional Programs

We may, from time to time, offer or arrange for various entities to offer discounts, benefits, or other consideration to our members for the purpose of promoting the general health and well being of our members. We may also arrange for the reimbursement of all or a portion of the cost of services 6 myCigna.com

provided by other parties to the Employer. Contact us for details regarding any such arrangements.

HC-SPP3 04-10

V1

Incentives to Participating Providers

Cigna continuously develops programs to help our customers access quality, cost-effective health care. Some programs include Participating Providers receiving financial incentives from Cigna for providing care to members in a way that meets or exceeds certain quality and/or cost-efficiency standards, when, in the Participating Provider’s professional judgment, it is appropriate to do so within the applicable standard of care. For example, some Participating Providers could receive financial incentives for prescribing lower-cost prescription drugs to manage certain conditions, utilizing or referring you to alternative sites of care as determined by your Plan rather than in a more expensive setting, or achieving particular outcomes for certain health conditions. Participating Providers may also receive purchasing discounts when purchasing certain prescription drugs from Cigna affiliates. Such programs can help make you healthier, decrease your health care costs, or both. These programs are not intended to affect your access to the health care that you need. We encourage you to talk to your Participating Provider if you have questions about whether they receive financial incentives from Cigna and whether those incentives apply to your care. HC-SPP85 01-24

Care Management and Care Coordination Services

Your Plan may enter into specific collaborative arrangements with health care professionals committed to improving quality care, patient satisfaction and affordability. Through these collaborative arrangements, health care professionals commit to proactively providing participants with certain care management and care coordination services to facilitate achievement of these goals. Reimbursement is provided at 100% for these services when rendered by designated health care professionals in these collaborative arrangements. HC-SPP27 06-15

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Important Notices

Important Information

Rebates and Other Payments

Cigna or its affiliates may receive rebates or other remuneration from pharmaceutical manufacturers in

connection with certain Medical Pharmaceuticals covered under your Plan. These rebates or remuneration are not obtained on you or your Employer’s or Plan’s behalf or for your benefit.

Cigna, its affiliates and the Plan are not obligated to pass these rebates on to you, or apply them to your Plan’s Deductible if any or take them into account in determining your

Copayments and/or Coinsurance. Cigna and its affiliates or designees, conduct business with various pharmaceutical manufacturers separate and apart from this Plan’s Medical Pharmaceutical benefits. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical

manufacturers pursuant to such arrangements are not related to this Plan. Cigna and its affiliates are not required to pass on to you, and do not pass on to you, such amounts.

Coupons, Incentives and Other Communications

At various times, Cigna or its designee may send mailings to you or your Dependents or to your Physician that

communicate a variety of messages, including information about Medical Pharmaceuticals. These mailings may contain coupons or offers from pharmaceutical manufacturers that enable you or your Dependents, at your discretion, to purchase the described Medical Pharmaceutical at a discount or to obtain it at no Charge. Pharmaceutical manufacturers may pay for and/or provide the content for these mailings. Cigna, its affiliates and the Plan are not responsible in any way for any decision you make in connection with any coupon, incentive, or other offer you may receive from a pharmaceutical manufacturer or Physician.

HC-IMP304 01-22

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

7 myCigna.com

• 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 phone 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 ************@*****.*** 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 ************@*****.***. 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-***-****, 1-800-***-**** (TDD)

Complaint forms are available at

http://www.hhs.gov/ocr/office/file/index.html.

HC-NOT96 07-17

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. Otherwise, call 1-800-***-**** (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-***-**** (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-***-**** 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-***-**** (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-***-****

(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-***-**** (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-***-****

(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-***-****

(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).

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

8 myCigna.com

identyfikacyjnej. Wszystkie inne osoby prosimy o

skorzystanie z numeru 1-800-***-**** (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-***-**** (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-***-**** an (TTY: Wählen Sie 711).

HC-NOT97 07-17

Federal CAA - Consolidated Appropriations Act and TIC

- Transparency in Coverage Notice

Cigna will make available an internet-based self-service tool for use by individual customers, as well as certain data in machine-readable file format on a public website, as required under the Transparency in Coverage rule. Customers can access the cost estimator tool on myCigna.com. Updated machine-readable files can be found on Cigna.com and/or CignaForEmployers.com on a monthly basis.

Pursuant to Consolidated Appropriations Act (CAA), Section 106, Cigna will submit certain air Ambulance claim information to the Department of Health and Human Services

(HHS) in accordance with guidance issued by HHS.

Subject to change based on government guidance for CAA Section 204, Cigna will submit certain prescription drug and health care spending information to HHS through Plan Lists Files (P1-P3) and Data Files (D1-D8) (D1-D2) for an Employer without an integrated pharmacy product aggregated at the market segment and state level, as outlined in guidance. HC-IMP353 01-24

Federal CAA - Consolidated Appropriations Act

Continuity of Care

In certain circumstances, if you are receiving continued care from an In-Network provider or facility, and that provider’s network status changes from In-Network to Out-of-Network, you may be eligible to continue to receive care from the provider at the In-Network cost-sharing amount for up to 90 days from the date you are notified of your provider’s termination. A continuing care patient is an individual who is:

• Undergoing treatment for a serious and complex condition

• Pregnant and undergoing treatment for the pregnancy

• Receiving inpatient care

• Scheduled to undergo urgent or emergent surgery, including postoperative

• Terminally ill (having a life expectancy of 6 months or less) and receiving treatment from the provider for the illness If applicable, Cigna will notify you of your continuity of care options.

Appeals

Any external review process available under the Plan will apply to any adverse determination regarding claims subject to the No Surprises Act.

Provider Directories and Provider Networks

A list of network providers is available to you, without Charge, by visiting the website or calling the phone number on your ID card. The network consists of providers, including Hospitals, of varied specialties as well as generic practice, affiliated or contracted with Cigna or an organization contracting on its behalf.

Provider directory content is verified and updated, and processes are established for responding to provider network status inquiries, in accordance with applicable requirements of the No Surprises Act.

If you rely on a provider’s In-Network status in the provider directory or by contacting Cigna at the website or phone number on your ID card to receive covered services from that provider, and that network status is incorrect, then your Plan cannot impose Out-of-Network cost shares to that covered service. In-Network cost share must be applied as if the covered service were provided by an In-Network provider. 9 myCigna.com

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, access the website or call the phone number on your ID card.

Selection of a Primary Care Provider

This Plan generally allows 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. For children, you may designate a pediatrician as the primary care provider. For information on how to select a primary care provider, and for a list of the participating primary care providers, access the website or call the phone number on your ID card.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an Out-of- Network provider at an In-Network Hospital or ambulatory surgical center, you are protected from balance billing. In these situations, you should not be charged more than your Plan’s Copayments, Coinsurance, and/or Deductible. What is “balance billing” (sometimes called “surprise billing”)?

When you see a Physician or other health care provider, you may owe certain out-of-pocket costs, such as a Copayment, Coinsurance, and/or Deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that is not in your health plan’s network.

“Out-of-Network” means providers and facilities that have not signed a contract with your health plan to provide services. Out-of-Network providers may be allowed to bill you for the difference between what your Plan pays and the full amount charged for a service. This is called “balance billing”. This amount is likely more than In-Network costs for the same service and might not count toward your Plan’s Deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care

– such as when you have an emergency or when you schedule a visit at an In-Network facility but are unexpectedly treated by an Out-of-Network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for:

• Emergency Services – If you have an Emergency Medical Condition and get Emergency Services from an Out-of- Network provider or facility, the most they can bill you is your Plan’s In-Network cost-sharing amount (such as a Copayments, Coinsurance, and Deductibles). You cannot be balanced billed for these Emergency Services. This includes services you may get after you are in stable condition, unless you give written consent and give up your

protections not to be balanced billed for these post- stabilization services.

• Certain non-emergency services at an In-Network

Hospital or ambulatory surgical center – When you get services from an In-Network Hospital or ambulatory surgical center, certain providers there may be Out-of- Network. In these cases, the most those providers can bill you is your Plan’s In-Network cost sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balanced billed.

If you get other types of services at these In-Network facilities, Out-of-Network providers cannot balance bill you, unless you give written consent and give up your protections. You are never required to give up your protections from balance billing. You also are not required to get Out-of- Network care. You can choose a provider or facility in your Plan’s network.

When balance billing is not allowed, you have these protections:

• You are only responsible for paying your share of the cost

(such as Copayments, Coinsurance, and Deductibles that you would pay if the provider were In-Network). Your health plan will pay any additional costs to Out-of-Network providers and facilities directly.

• Generally, your health plan must:

• Cover Emergency Services without requiring you to get approval in advance for services (also known as prior authorization).

• Cover Emergency Services provided by Out-of-Network providers.

• Base what you owe the provider or facility (cost sharing) on what it would pay an In-Network provider or facility and show that amount in your explanation of benefits

(EOB).

10 myCigna.com

• Count any amount you pay for Emergency Services or Out-of-Network services toward your In-Network

Deductible and out-of-pocket limit.

If you think you have been wrongly billed, contact Cigna at the phone number on your ID card. You can also contact No Surprises Help Desk at 1-800-***-**** or

www.cms.gov/nosurprises for more information about your rights under federal law.

HC-IMP326 01-24

Mental Health Parity and Addiction Equity Act of 2008

(MHPAEA) - Non-Quantitative Treatment Limitations

(NQTLs)

Federal MHPAEA regulations provide that a plan cannot impose a Non-Quantitative Treatment Limitation (NQTL) on Mental Health or Substance Use Disorder (MH/SUD) benefits in any classification unless the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits are comparable to, and are applied no more stringently than, those used in applying the NQTL to medical/surgical benefits in the same classification of benefits as written and in operation under the terms of the Plan.

Non-Quantitative Treatment Limitations (NQTLs) include (to the extent applicable under the Plan):

• Medical management standards limiting or excluding benefits based on Medical Necessity or whether the treatment is experimental or investigative;

• prescription drug formulary design;

• network admission standards;

• methods for determining In-Network and Out-of-Network provider reimbursement rates;

• step therapy a/k/a fail-first requirements; and

• exclusions and/or restrictions based on geographic location, facility type or provider specialty.

A description of your Plan’s NQTL methodologies and processes applied to medical/surgical benefits and Mental Health and Substance Use Disorder benefits is available for review by Plan Administrators (e.g., the Employer) and covered persons:

Employers (Plan Administrators):

https://cignaaccess.cigna.com/secure/app/ca/centralRepo - Log in, select Resources and Training, then select the NQTL document.

Participants: www.cigna.com\sp

To determine which document applies to your plan, select the relevant health plan product; medical management model

(inpatient only or inpatient and outpatient) which can be located in this SPD immediately following The Schedule; and pharmacy coverage.

HC-NOT113 12-22

How To File Your Claim

If your Plan provides coverage when care is received only from In-Network providers, you may still have Out-of- Network claims (for example, when Emergency Services are received from an Out-of-Network provider) and 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 on the claim form. You may get the required claim forms from the website listed on your ID card or by using the toll-free number on your ID card.

CLAIM REMINDERS

• BE SURE TO USE YOUR MEMBER ID AND

ACCOUNT/GROUP NUMBER WHEN YOU FILE

CIGNA’S CLAIM FORMS, OR WHEN YOU CALL

YOUR CIGNA CLAIM OFFICE.

YOUR MEMBER ID IS THE ID SHOWN ON YOUR

BENEFIT ID CARD.

YOUR ACCOUNT/GROUP NUMBER IS SHOWN ON

YOUR BENEFIT ID CARD.

• BE SURE TO FOLLOW THE INSTRUCTIONS LISTED

ON THE BACK OF THE CLAIM FORM CAREFULLY

WHEN SUBMITTING A CLAIM TO CIGNA.

Timely Filing of Out-of-Network Claims

Cigna will consider claims for coverage under the Plan when proof of loss (a claim) is submitted within 180 days for Out- of-Network benefits after services are rendered. If services are rendered on consecutive days, such as for a Hospital Confinement, the limit will be counted from the last date of service. If claims are not submitted within 180 days for Out- of-Network benefits, the claim will not be considered valid and will be denied.

WARNING: Any person who knowingly and with intent to defraud Amazon or other person files an application for coverage or statement of

Contact this candidate