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CONNECTICUT

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 .. 8 DENTAL BENEFITS .. 10 VISION CARE BENEFITS .. 14 HEARING CARE BENEFITS .. 15 DEFINED TERMS .. 16 PLAN EXCLUSIONS .. 20 HOW TO FILE A CLAIM .. 23 COORDINATION OF BENEFITS .. 24 THIRD PARTY RECOVERY PROVISION .. 25 FUNDING THE PLAN AND PAYMENT OF BENEFITS .. 26 GENERAL PLAN INFORMATION .. 27 Rev 11-2-2017 INTRODUCTION Your (our) health benefits plan provided by the CONNECTICUT Teachers' Retirement Board contains four separate sections.

(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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