CONNECTICUT

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Rev 11-2-2017 CONNECTICUT TRB SPONSORED HEALTH PLANS PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION EFFECTIVE JANUARY 1, 2018 Rev 11-2-2017 TABLE OF CONTENTS INTRODUCTION ........................................ ........................................ ............................. 3 ELIGIBILITY, EFFECTIVE DATE, AND TERMINATION ........................................ ......... 4 SCHEDULE OF medical BENEFITS ........................................ ................................... 5 SECTION A - BASIC HOSPITAL BENEFITS ........................................ .................................. 5 SECTION B - BASIC medical BENEFITS ........................................ .................................... 6 SECTION C - MAJOR medical BENEFITS ........................................ .................................. 7 SECTION D - PRESCRIPTION DRUG BENEFITS.

(1) Medical and surgical service provided in a Physician's office, in a Medical Facility, in a patient's home or any other location, (2) Diagnostic tests,

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