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▪ If you or your dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP)
coverage and you request enrollment within 60 days after that coverage ends; or
▪ If you or your dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with
respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such
assistance.

Note: The 60-day period for requesting enrollment applies only in these last two listed circumstances relating to

Medicaid and state CHIP. As described above, a 30-day period applies to most special enrollments.

As stated earlier in this notice, a special enrollment opportunity may be available in the future if you or your dependents lose other
coverage. This special enrollment opportunity will not be available when other coverage ends, however, unless you provide a
written statement now explaining the reason that you are declining coverage for yourself or your dependent(s). Failing to accurately
complete and return this form for each person for whom you are declining coverage may eliminate this special enrollment
opportunity for the person(s) for whom a statement is not completed, even if other coverage is currently in effect and is later lost. In
addition, unless you indicate in the statement that you are declining coverage because other coverage is in effect, you may not have
this special enrollment opportunity for the person(s) covered by the statement. (See the paragraphs above, however, regarding
enrollment in the event of marriage, birth, adoption, placement for adoption, loss of eligibility for Medicaid or a state CHIP, and
gaining eligibility for a state premium assistance subsidy through Medicaid or a state CHIP.)

To request special enrollment or obtain more information, contact your Human Resources department.

Women’s Health and Cancer Rights Act Notice
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer
Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage 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.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits
provided under this plan. Therefore, deductibles and coinsurance apply.

If you would like more information on WHCRA benefits, contact your Human Resources department.

Patient Protection Disclosure
You do not need prior authorization from Cigna 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, contact Cigna Customer Service at 800-244-6244,
or visit www.mycigna.com

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOU MAY OBTAIN A COPY OF THE PLAN’S NOTICE OF PRIVACY PRACTICES,
WHICH DESCRIBES THE WAYS THAT THE PLAN USES AND DISCLOSES YOUR PROTECTED HEALTH
INFORMATION.
Castlerock Asset Management’s Health and Welfare Plan (the “Plan”) provides health benefits to eligible employees of Castlerock
(the “Company”) and their eligible dependents as described in the summary plan description(s) for the Plan. The Plan creates,
receives, uses, maintains and discloses health information about participating employees and dependents in the course of providing
these health benefits. The Plan is required by law to provide notice to participants of the Plan’s duties and privacy practices with