IMPORTANT INFORMATION ABOUT ENROLLMENT

LOUDOUN COUNTY PUBLIC SCHOOLS DEPARTMENT OF BUSINESS & FINANCIAL SERVICES EMPLOYEE HEALTH, WELLNESS AND BENEFITS 21000 Education Court, Suite 319 Ashburn, VA 20148 Phone (571) 252-1810 Fax (571) 252-1401 17_GCA_LCSB IMPORTANT INFORMATION ABOUT ENROLLMENT According to our records, you will soon be eligible for Medicare. In order to continue retiree health insurance and prescription drug coverage through Loudoun County Public Schools (LCPS), you will need to enroll in Medicare Part A and Part B and the Cigna Medicare Surround and Cigna-HealthSpring (PDP) plan. Cigna-HealthSpring Rx (PDP) is a Medicare Prescription Drug (Part D) plan. This enrollment will automatically cancel your enrollment in any different Medicare Prescription Drug (Part D) plan or a Medicare Advantage plan you may be enrolled in. Please call Employee Health, Wellness and Benefits at 571-252-1810 if you think you might be enrolled in a different Medicare Prescription Drug plan or a Medicare Advantage plan. Welcome to Cigna Medicare Surround, a Medicare Supplement and Cigna-HealthSpring Rx (PDP), a Medicare prescription drug plan that works for you. Cigna s plan includes personalized service and virtually no paperwork. What is Cigna Medicare Surround? Cigna Medicare Surround is an indemnity medical plan that helps pay some of the health care costs that Medicare does not cover, such as your Medicare Part A and B deductibles and coinsurance. With the Cigna Medicare Surround plan you have the freedom to choose any health care provider that accepts Medicare. Once you are enrolled in the Cigna Medicare Surround indemnity medical plan, you will receive a Cigna indemnity medical identification (ID) card. You should present your red white and blue Medicare card (primary coverage) along with this new Cigna card (secondary coverage) when you receive care. The back of the Cigna ID card has the address for submitting claims along with the toll-free telephone number for Cigna Customer Service. What is Cigna-HealthSpring Rx (PDP)? Cigna-HealthSpring Rx (PDP) is a national Medicare Part D drug plan offered by Cigna HealthCare with: no deductible, no coverage gap, over 60,000 retail and mail order pharmacies nationwide, expansive drug list Savings through the Healthy Rewards program. What do I need to know as a member of Cigna Medicare Surround and Cigna-HealthSpring Rx (PDP)? This mailing includes important information about Cigna Medicare Surround and Cigna-HealthSpring Rx (PDP) and the coverage it offers, including a summary of benefits document and drug list. Please review this information carefully and keep it for future reference. If you want to be enrolled in this Medicare Supplement and Medicare prescription drug plan, complete the enclosed LCPS Retiree Health Insurance Enrollment/Change Form and return it to Employee Health, Wellness and Benefits along with a copy of your Medicare A&B card. INT_17_50861

Once you are a member of Cigna Medicare Surround and Cigna-HealthSpring Rx (PDP), you have the right to appeal plan decisions about payment or services if you disagree. When you get them, be sure to read the Evidence of Coverage documents from Cigna Medicare Surround and Cigna-HealthSpring Rx (PDP) to know which rules you must follow to receive coverage with this Medicare Supplement and Medicare prescription drug plan. Cigna-HealthSpring Rx (PDP) is a Medicare drug plan and is in addition to your coverage under Medicare Part A or Part B. Your enrollment in Cigna-HealthSpring Rx (PDP) doesn t affect your coverage under Medicare Part A or Part B. It is your responsibility to inform Cigna-HealthSpring Rx (PDP) of any prescription drug coverage that you have or may get in the future. You can be in only one Medicare prescription drug plan at a time. If you are currently in a Medicare prescription drug plan, your enrollment in Cigna-HealthSpring Rx (PDP) will end that enrollment. Enrollment in Cigna-HealthSpring Rx (PDP) is generally for the entire year. By joining this Medicare prescription drug plan, you acknowledge that Cigna-HealthSpring Rx (PDP) will release your information to Medicare and other plans as is necessary for treatment, payment and health care operations. You also acknowledge that Cigna-HealthSpring Rx (PDP) will release your information, including your prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. You will receive a Cigna-HealthSpring Rx (PDP) ID card in the mail. You will need to use the new ID card when you go to the pharmacy. You should use Cigna-HealthSpring Rx (PDP) network pharmacies to fill your prescriptions. If you use an out-of-network pharmacy and there is not an emergency, Cigna-HealthSpring Rx (PDP) may not pay for your prescriptions. You can find network pharmacies in your area by looking in your pharmacy directory that you will receive once you are enrolled or by calling customer service at the number below. Ready to enroll? To enroll in this Medicare health plan, complete the enclosed LCPS Retiree Health Insurance Enrollment/Change Form and return it to Employee Health, Wellness and Benefits along with a copy of your Medicare A&B card. What happens if I don t want to join Cigna Medicare Surround and Cigna-HealthSpring Rx (PDP)? You are not required to be enrolled in Cigna Medicare Surround and Cigna-HealthSpring Rx (PDP) as your Medicare Supplement and Medicare prescription drug plan. If you do not wish to be enrolled, complete the enclosed Retiree Health Insurance Enrollment/Change form and choose, I do not wish to enroll/i wish to cancel my coverage in the LCPS retiree health insurance and submit the form to: Loudoun County Public Schools Employee Health, Wellness and Benefits 21000 Education Court, Suite 319 Ashburn, VA 20148 Phone: 571-252-1810 Mon-Fri 8a-5p Upon receipt, we will end your retiree health care for you and any covered dependents. PLEASE REMEMBER: If you cancel your participation in the LCPS Retiree Health Insurance, you will not be able to re-enroll through Loudoun County Public Schools at any point in the future. You can also decide to join a different Medicare prescription drug plan. You can call 1-800-MEDICARE (1-800-633-4227) 24 hours per day, 7 days per week for help in learning how. TTY users should call 1-877-486-2048. 17_GCA_LCSB INT_17_50861

What if I want to leave Cigna-HealthSpring Rx (PDP)? Medicare limits when you can make changes to your coverage. You may leave this plan only at certain times of the year or under certain special circumstances. To leave the plan, call Employee Health, Wellness and Benefits at 571-252-1810, or call 1-800-MEDICARE. Cigna-HealthSpring Rx (PDP) serves a specific area. If you move out of the area that Cigna-HealthSpring Rx (PDP) serves, you need to notify Employee Health, Wellness and Benefits at 571-252-1810 so you can disenroll and find a new plan in your area. Our service area includes the continental United States, Hawaii, Alaska and the District of Columbia; it also includes Puerto Rico and the U.S. Virgin Islands. Keep in mind that if you leave our plan and don t have or get other Medicare prescription drug coverage or creditable coverage (as good as Medicare s), you may have to pay a late enrollment penalty in addition to your premium for Medicare prescription drug coverage in the future. The Cost of your Plan See the enclosed Loudoun County Public Schools Monthly Retiree Health Insurance Rates schedules. Have more questions? Visit the Employee Health, Wellness and Benefits website at www.lcps.org/administration/business & Financial Services/ Employee Health, Wellness and Benefits/Retiree Information or contact Employee Health, Wellness and Benefits at 571-252-1810. Need Help? Our Cigna Medicare Surround Customer Service Associates are available to assist you 24 hours a day, 7 days a week. For medical questions, please call 1-800-244-6224. If you have any questions about the pharmacy plan, Cigna-HealthSpring Rx (PDP), its benefits and features, simply call Cigna-HealthSpring Rx (PDP) Customer Service Team Monday through Friday at 1-800-558-9562, 8 a.m. 8 p.m., local time. (Between October 1 and February 14, you can reach us seven days a week.) TTY/TDD users, please call 711. This information is available for free in other languages. Please call our customer service number at 1-800-558-9562 (TTY 711), Monday through Friday at 1-800-558-9562, 8 a.m. 8 p.m., local time. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al 1-800-558-9562, servicio al Cliente siete días de la semana, de 8am a 8pm. Los usuarios de TTY deben llamar al 711. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring Rx (PDP) is a Medicare Prescription Drug plan (PDP) with a Medicare contract. Enrollment in Cigna-HealthSpring depends on contract renewal. 17_GCA_LCSB INT_17_50861

LOUDOUN COUNTY PUBLIC SCHOOLS DEPARTMENT OF BUSINESS & FINANCIAL SERVICES EMPLOYEE HEALTH, WELLNESS & BENEFITS DIVISION 21000 Education Court, Suite #319 Ashburn, VA 20148 Phone (571) 252-1810 Fax (571) 252-1401 RETIREE HEALTH INSURANCE ENROLLMENT/CHANGE FORM 1. Retiree Information EFFECTIVE DATE Retiree Name Date of Birth (month/day/year) Retiree Mailing Address (if P.O. Box, also provide residential address) Retiree Social Security Number and PID City, State, Zip Home Phone Number Email Address Alternate Phone Number 2. Electing or Canceling Your Coverage (select one) Option 1: I do NOT wish to enroll/i want to cancel my coverage in the LCPS retiree health insurance. Initials Option 2: Select Coverage Level Retiree Only Retiree + Spouse Retiree + Child Family (3 or more) Select Your Plan (Non-Medicare Eligible Retirees) CIGNA (POS) CIGNA (OAP) *All non-medicare eligible individuals under your coverage must have the same plan. Select Your Plan (Medicare Eligible Retirees) Cigna Medicare Surround plus Cigna- HealthSpring Rx * All Medicare eligible individuals must enroll in Medicare Part A&B and the Cigna Medicare Surround plus Cigna-HealthSpring Rx to maintain coverage through LCPS. 3. List Your Dependents and Select Plan Add Remove Change Continue Relationship to Retiree Name Social Security Number Date of Birth (month/day/year) Select Plan *(See Section 2 for details) POS OAP Cigna Medicare 4. Medicare Coverage - Attach a copy of Medicare Part A&B for any Medicare eligible participants. Retirees and their dependents must elect Medicare Part A&B when they become eligible in order to maintain LCPS coverage. Please attach a copy of your Medicare card to this form, if applicable. **The reverse side of this form must be signed in order for elections/changes to be processed** Cat#876012a

Certification As a participant in the Health Benefits Plan, I certify that I understand: I have applied for or canceled membership in the above mentioned health plan for myself and for any eligible dependents listed. I agree, for myself and for any eligible dependents listed, to abide by the rules and regulations of the health plan. The information provided above is true and correct to the best of my knowledge. If I have applied for spousal or dependent health insurance coverage, the dependents listed on my enrollment form are my legal spouse and/or child(ren) under the age of 26 and, if this is a new election, I agree to provide the necessary documentation verifying this relationship. I must notify Employee Health, Wellness and Benefits within 30 days of any change in status which would cause any of my covered dependents to cease to be eligible for benefits under the health, dental and vision plans. These changes include, but are not limited to, death of a dependent, divorce or reaching the policy age limit. If I fail to notify Employee Health, Wellness and Benefits by filing the appropriate termination and/or change forms, I will be responsible for any claims, and/or premiums paid on behalf of any individual who ceased to be eligible for benefits under the policy. It is my responsibility to keep informed of any changes to the plan that might affect me or my dependent(s) eligibility. At retirement I may not elect to add dependents for any reason. However, I may elect to decrease or cancel coverage on myself or my dependent(s). This is an irrevocable election. I and/or my dependents must elect Medicare Part A&B when eligible, in order to maintain coverage under an LCPS plan. If Medicare Part A&B are not elected coverage through LCPS will be canceled. Non-payment of health insurance premium for longer than 60 days will result in an irrevocable cancellation of my health insurance plan. This authorization will be effective for this plan year and subsequent years, unless modified by completion and acceptance of a new Retiree Health Insurance Enrollment/Change Form. Retiree Signature Date Rev: 10.2016

LOUDOUN COUNTY PUBLIC SCHOOLS DEPARTMENT OF BUSINESS & FINANCIAL SERVICES EMPLOYEE HEALTH, WELLNESS & BENEFITS 21000 Education Court, Suite #319 Ashburn, VA 20148 Phone (571) 252-1810 Fax (571) 252-1401 IMPORTANT NOTICES RELATED TO YOUR CIGNA MEDICARE SURROUND PLAN This notice contains important information you should read before you enroll in Cigna Medicare Surround. If you have any questions about this information, please contact Employee Health, Wellness and Benefits. Protection of your confidential information Cigna is committed to maintaining the confidentiality of your health information. They have established policies and safeguards to protect oral, written and electronic information across their organization. Information about Cigna privacy practices Cigna s notice of privacy practices is given to everyone enrolling in a medical insurance policy. Individuals covered under self-insured medical plans will receive notices from their plan sponsor and can obtain a copy of Cigna s notice by calling their customer service team. Release of confidential information Cigna will not use or disclose your confidential information for any purpose other than the purposes permitted by the HIPAA Privacy Rule without your written authorization. For example, they will not supply confidential information to another company for its marketing purposes or to a potential plan sponsor with whom you are seeking employment unless you authorize it. Access to your medical records You may ask to inspect or to obtain a copy of your confidential information that is included in certain records Cigna maintains. They may charge you copying and mailing costs. Under limited circumstances, they may deny you access to a portion of your records. Instructions on how to obtain a copy of your records will be included in the privacy notice you receive from Cigna or your plan sponsor after you enroll. Information to plan sponsors Cigna may disclose your confidential information to your plan sponsor or to a company acting on your plan sponsor s behalf so that it can monitor, audit and otherwise administer the health plan in which you participate. Your plan sponsor is not permitted to use the confidential information we disclose for any purpose other than administering your health plan. Women s Health and Cancer Rights Act (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain coverage under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related coverage, it will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. This coverage will be provided subject to the same deductibles and coinsurance or copays applicable to other medical and surgical benefits provided under this plan as shown in the Summary of Benefits. If you would like more information on WHCRA benefits, call Cigna s customer service team at 1-800-Cigna24 (1-800-244-6224).

FOR RETIREMENTS ON OR BEFORE JULY 1, 2014 Non Medicare Eligible/Under 65 Retirees select or Plan Medicare Eligible Retirees select Medicare Supplement Plan Retiree Only (Not Medicare Eligible) Retiree Cost Retiree Cost 25+ LCPS Years $19.37 $822.93 $842.30 $138.57 $822.93 $961.50 20 24 LCPS Years $183.96 $658.34 $842.30 $303.16 $658.34 $961.50 15 19 LCPS Years $513.13 $329.17 $842.30 $632.33 $329.17 $961.50 10 14 LCPS Years $677.71 $164.59 $842.30 $796.91 $164.59 $961.50 Retiree + Child (Not Medicare Eligible) Retiree Cost Retiree Cost 25+ LCPS Years $106.14 $1,089.96 $1,196.10 $275.42 $1,089.96 $1,365.38 20 24 LCPS Years $324.13 $871.97 $1,196.10 $493.41 $871.97 $1,365.38 15 19 LCPS Years $760.12 $435.98 $1,196.10 $929.40 $435.98 $1,365.38 10 14 LCPS Years $978.11 $217.99 $1,196.10 $1,147.39 $217.99 $1,365.38 Retiree + Spouse (Not Medicare Eligible) Retiree Cost Retiree Cost 25+ LCPS Years $252.67 $1,431.87 $1,684.54 $491.13 $1,431.87 $1,923.00 20 24 LCPS Years $539.05 $1,145.49 $1,684.54 $777.51 $1,145.49 $1,923.00 15 19 LCPS Years $1,111.79 $572.75 $1,684.54 $1,350.25 $572.75 $1,923.00 10 14 LCPS Years $1,398.17 $286.37 $1,684.54 $1,636.63 $286.37 $1,923.00 Family Coverage (Not Medicare Eligible) Loudoun County Public Schools Monthly Retiree Health Insurance Rates January 1, 2017 December 31, 2017 Retiree Cost Retiree Cost 25+ LCPS Years $379.03 $1,726.69 $2,105.72 $677.11 $1,726.69 $2,403.80 20 24 LCPS Years $724.36 $1,381.36 $2,105.72 $1,022.44 $1,381.36 $2,403.80 15 19 LCPS Years $1,415.04 $690.68 $2,105.72 $1,713.12 $690.68 $2,403.80 10 14 LCPS Years $1,760.38 $345.34 $2,105.72 $2,058.46 $345.34 $2,403.80 Retiree + Spouse or Child (One Medicare Eligible) Retiree Cost Retiree Cost 25+ LCPS Years $19.37 $1,317.62 $1,336.99 $138.57 $1,317.62 $1,456.19 20 24 LCPS Years $282.89 $1,054.10 $1,336.99 $402.09 $1,054.10 $1,456.19 15 19 LCPS Years $809.94 $527.05 $1,336.99 $929.14 $527.05 $1,456.19 10 14 LCPS Years $1,073.47 $263.52 $1,336.99 $1,192.67 $263.52 $1,456.19 Family Coverage (One Medicare Eligible) Retiree Cost Retiree Cost 25+ LCPS Years $274.74 $1,483.37 $1,758.11 $453.62 $1,483.37 $1,936.99 20 24 LCPS Years $571.41 $1,186.70 $1,758.11 $750.29 $1,186.70 $1,936.99 15 19 LCPS Years $1,164.76 $593.35 $1,758.11 $1,343.64 $593.35 $1,936.99 10 14 LCPS Years $1,461.44 $296.67 $1,758.11 $1,640.32 $296.67 $1,936.99

Family Coverage (Both Medicare Eligible) Retiree Cost Retiree Cost 25+ LCPS Years $170.46 $1,240.05 $1,410.51 $230.14 $1,240.05 $1,470.19 20 24 LCPS Years $418.47 $992.04 $1,410.51 $478.15 $992.04 $1,470.19 15 19 LCPS Years $914.49 $496.02 $1,410.51 $974.17 $496.02 $1,470.19 10 14 LCPS Years $1,162.50 $248.01 $1,410.51 $1,222.18 $248.01 $1,470.19 MEDICARE SUPPLEMENT PLAN Medicare Retiree Only Retiree Cost 25+ LCPS Years $0.00 $494.69 $494.69 20 24 LCPS Years $49.47 $445.22 $494.69 15 19 LCPS Years $247.34 $247.35 $494.69 10 14 LCPS Years $346.28 $148.41 $494.69 MEDICARE SUPPLEMENT PLAN Medicare Retiree + Medicare Spouse Retiree Cost 25+ LCPS Years $0.00 $989.39 $989.39 20 24 LCPS Years $98.94 $890.45 $989.39 15 19 LCPS Years $494.70 $494.69 $989.39 10 14 LCPS Years $692.57 $296.82 $989.39

Loudoun County Public Schools Retiree Health Insurance Rates January 1, 2017 December 31, 2017 FOR RETIREMENTS AFTER JULY 1, 2014 Non Medicare Eligible/Under 65 Retirees select OAP or POS Plan Medicare Eligible Retirees select Medicare Supplement Plan OAP PLAN POS PLAN Coverage Retiree Cost Retiree Cost Retiree Only (Not Medicare Eligible) $0.00 $842.30 $842.30 $119.20 $842.30 $961.50 Retiree + One (Not Medicare Eligible) $842.24 $842.30 $1,684.54 $1,080.70 $842.30 $1,923.00 Retiree + One (One Medicare Eligible) $494.69 $842.30 $1,336.99 $613.89 $842.30 $1,456.19 Family (Not Medicare Eligible) $1,263.42 $842.30 $2,105.72 $1,561.50 $842.30 $2,403.80 Family (One Medicare Eligible) $915.81 $842.30 $1,758.11 $1,094.69 $842.30 $1,936.99 Family (Both Medicare Eligible) $568.21 $842.30 $1,410.51 $627.89 $842.30 $1,470.19 MEDICARE SUPPLEMENT PLAN Coverage Retiree Cost Medicare Retiree Only $0.00 $494.69 $494.69 Medicare Retiree + Medicare Spouse $147.09 $842.30 $989.39 Important Notes: 1. Employees must have 15 cumulative years of full time LCPS service to be eligible for retiree health insurance. Policy 7 50 revised on 5/26/2015. 2. Effective 7/1/14, the amount of the LCPS monthly contribution to eligible retirees will be equl to the total premium for OAP/Employee Only coverage. 3. Future LCPS contributions will be capped at 150% of the 2014 contribution ($976.00).