HomeMy WebLinkAboutResolution_81-06/07_09/13/2007RESOLUTION NO. 81-06/07
A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF
TEQUESTA, PALM BEACH COUNTY, FLORIDA, TO RENEW AONE-
YEAR CONTRACT FOR HEALTH INSURANCE WITH CIGNA
INSURANCE, IN THE APPROXIMATE AMOUNT OF $754,600.00 FOR
FY 2007/2008 WITH BUDGET ALLOCATION FROM GENERAL FUNDS,
WATER UTILITIES AND STORMWATER FUNDS, AND AUTHORIZING
THE VILLAGE MANAGER TO EXECUTE THE CONTRACT ON BEHALF
OF THE VILLAGE
WHEREAS, the Village has experienced very good levels of service with Cigna
Insurance and the employees wish to continue coverage with them at this time; and
WHEREAS, the Village has reviewed the major carriers in the market and are
satisfied that Cigna offers good value for money in respect of services offered -Exhibit
A
NOW, THEREFORE, BE IT ORDAINED BY THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS:
Section 1 Consideration is given to Resolution No. 81-06/07 to renew health
insurance coverage services with Cigna for FY 2007/08 (Contract attached at Appendix
B) and the Village Manager of the Village of Tequesta be authorized to execute renewal
on behalf of the Village.
Section 2 This Resolution shall become effective immediately upon passage.
The foregoing Resolution was offered by Vice-Mayor Watkins who moved its adoption.
The motion was seconded by Council Member Amero and upon being put to a vote, the
vote was as follows:
For Adoption Against Adoption
Mayor Jim Humpage X
Vice-Mayor Pat Watkins X
Council Member Dan Amero X
Council Member Tom Paterno X
Council Member Calvin Turnquest X
The Mayor thereupon declared the Resolution duly passed and adopted this 13 day of
September, 2007.
MAYOR OF TEQU
ATTEST:
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I~1"~TA Heal~t~i~~re
CIGNA Healthcare Group Benefits Renewal
Village of Tequesta
250 Tequesta DriveSuite 304
Tequesta, FL 33469
SIC Code: 9111
Account Number: 3150680
Total Eligible Employees: 90 Participating Subscribers: 87
Employer Contributions: Employee Contributions: 100%
Dependent Contributions: 75%
Waiting Period: 30 days
Eligibility Definition: Active Employees working 40 hrs
Note: The Quoted rates aze subject to final Underwriting approval and, as noted below, aze subject
to change in the event of changes in benefits selected or changes in the risk factors upon which the
Quoted Rates are based. In addition, state law may require regulatory approval of rates. If
required regulatory approval has not been obtained on the proposed effective date, the healthplan
shall use rates that are consistent with its then currently approved rating methodology and the
quoted rates shall be effective immediately on the date for which they are approved for use. The
Quoted Rates are guaranteed while the Group Service Agreement remains in effect until the next
anniversary date, unless enrollment changes by ] 5% in which case the CIGNA Companies may
change the Quoted Rate.
Proposal # 161883 Page 1 of 19 7/23/07
CIG~I'~TA Hc~,1t~i~~re
Proposed Benefits
Product: CIGNA Healthcare Network POS Open Access
Situs State: FL Effective Date: 10/01/2007
Category Description In Network Out of Network
Medical Benefits Network (POS) Copay (Open Access)
Modular Medical Management Program PHS+
PCP Office Visit Copay $]0
Specialist Office Visit Copay $20
Plan Coinsurance 70%
Hospital IP Copay -Per Admit $200
Hospital IP Deductible -Per Admit $400
Hospital IP Copay Per Day NA
Hospital IP Deductible -Per Day NA
Hospital IP - Number of Copays Per Admission NA
Hospital IP - Number of Deductibles Per Admission NA
Maximum Reimbursable Charge Option 1 - 80th
percentile Incl
NSP & Bill Neg
Plan Deductible -Individual $0 $300
Plan Deductible -Family $0 $600
Out of Pocket Maximum -Individual $1,000 $2,000
Out of Pocket Maximum -Family $2,000 $4,000
Ded/OOP Max Accumulator Standard: One Standard: One
Way Way Accumulation
Accumulation
OOP Max Copay Includes Copays
OOP Max Ded Excl Ded Excl Ded
Lifetime Maximum Unlimited $1,000,000
Annual Maximum NA
Outpatient Facility Copay $l00
Outpatient Facility Deductible $200
Emergency Room Copay $75 $75
Urgent Care Copay $35 $35
Other Health Facility IP Maximum Days 60 60
Home Health Care Copay $0
Home Health Care Maximum Days 60 60
Durable Medical Equipment Included Excluded
Durable Medical Equipment Maximum $3,500 NA
External Prosthetic Appliances Included Excluded
External Prosthetic Appliances Deductible $200
External Prosthetic Appliances Maximum $1,000 NA
Proposal # 161883 Page 2 of 19 7/23/07
~IG~TA H~~,1t~.i~.re
Proposed Benefits
Product: CIGNA Healthcare Network POS Open Access
Situs State: FL Effective Date: 10/01/2007
Category Description
Medical Benefits Network (POS) Copay (Open Access)
Chiro
Short Term Rehab Copay
Chiro Copay
Short Term Rehab and Chiro Combined Maximum
Days
Short Term Rehab Maximum Days
Self-Referred Chiro Maximum Amount
Self-Referred Chiro Maximum Days
Infertility Treatment Standard Coverage
Infertility Opt 1 -Diagnoses/Corrective procedures
Infertility Opt 2 -Opt 1 plus Invitro, GIFT, ZIFT, etc.
Infertility Opt 2 -Lifetime Maximum Amount
Bariatric Services
Bariatric Surgery -Lifetime Maximum Amount
Health Advisor
MRI, CT PET Scans Copay
Non-Surgical TMJ
PCL
Medicare COB: Retirees >=65 Admin Option
Well Aware Program (Diabetes, Asthma, Low Back)
Well Aware Program (Cardiac)
Well Aware Program (COPD)
Well Aware Program (Weight Complications)
Well Aware Program (Targeted Conditions)
Well Aware Program (Depression Management)
Wellness Program (Healthy Steps to Weight Loss)
Guest Privileges
24 Hour Health Info Line
Healthy Babies
Healthy Rewards
Life Source Organ Transplant Network
Language Line
Transition of Care
Well Being Newsletter
CIGNA Health Advisor
In Network Out of Network
Included
$20
$20
20
NA
NA
NA
Not Covered
Excluded
Excluded
NA
Excluded
NA
Excluded
$50
Excluded
NA
Included
Included
Included
Included
Included
Included
Excluded
Included
Included
Included
Included
Included
Included
Included
Included
Excluded
Included
20
NA
Not Covered
$0
Included
Proposal # 161883 Page 3 of 19 7/23/07
~CIG-NA H~a1t~.i~.re
Proposed Benefits
Product: CIGNA Healthcare Network POS Open Access
Situs State: FL Effective Date: 10/01/2007
Category Description In Network Out of Network
Pharmacy Benefits CIGNA Pharmacy 3-Tier Copay
Plan Coinsurance NA
Retail -Generic Copay $5
Retail -Brand Copay $15
Retail -Non Preferred Copay $35
Mail Order -Generic Copay $]0
Mail Order -Brand Copay $40
Mail Order Copay -Non-preferred $100
Retail -Individual Deductible NA NA
Retail -Family Deductible NA NA
Annual -Individual Maximum NA NA
Annual -Family Maximum NA NA
OOP -Individual Maximum NA NA
OOP -Family Maximum NA NA
Standard Preventive Drugs Subject to Deductible NO
Ded, Annual Max, OOP Max Apply to MOD Do Not Apply
to MOD
MOD Program No Mandatory
Maintenance Drug List NA
Oral Contraceptives/Devices Covered
Lifestyle Drugs Not Covered
Oral Fertility Drugs Not Covered
Smoking Cessation Not Covered
Smoking Cessation Subject to Deductible NO
Non-Prenatal Vitamins Covered
Non-Prenatal Vitamins Subject to Deductible NO
Anti-Obesity & Anorexiants Not Covered
Anti-Obesity & Anorexiants Subject to Deductible NO
Self-Administered Injectables Covered
Optional Injectables Buy-Up Not Covered
Insulin Covered
Insulin Needles & Syringes Covered
Glucose Test Strips Covered
Lancets Covered
Prenatal Vitamins Covered
Step Therapy Included
Clinical Management Program Basic
Proposal # 161883 Page 4 of 19 7/23/07
CIGl'~TA H~~1t~.i~~r~
Proposed Benefiis
Product: CIGNA Healthcare Network POS Open Access
Situs State: FL Effective Date: 10/01/2007
Category Description In Network Out of Network
Pharmacy Benefits CIGNA Pharmacy 3-Tier Copay
Enh. -Benefit Exclusion Not Selected
Enh. -Intensive Appropriateness of Use Not Selected
Enh. -Utilization and Unit Cost Management Not Selected
Generic Push Included
Formulary Incentive
Prescriber Panel Open
MH/SA Benefits Option 4 -High (POS)
Inpatient Per Day Copay $50
Inpatient Max Number of Days MH/SA Combined 25
MH Outpatient Copay 1 to 20 Visits $30
MH Outpatient Max Number of Visits 20
Outpatient SA visits 1-2 Copay $IS
Outpatient SA visits 3-20 Copay $30
SA Outpatient Max Number of Visits 20
Group Therapy Outpatient Copay $15
Group Therapy M WSA Combined Maximum Visits 40
MH/SA OON Buy-up Option
Vision Benefits Low Plus
Eye Exam Copay $10
Eye Exam Frequency (months) 12
Hardware Not Covered
Benefit Exceptions:
Network POS OA -Massachusetts -Infertility Option 2 is included
Excluded
Proposal # 161883 Page 5 of 19 7/23/07
~IGNA Healt~i~~.rc
Group Description: FL816A (ALL ACTIVE EMPLOYEE'S) FL816C (ALL ACTIVE EMPLOYEE'S, ALL
COBRA EMPLOYEE'S) FL8l6D (ALL ACTIVE EMPLOYEE'S)
Tier Inforce
Subscribers Members Current
Rate Renewal
Rate Monthly
Premium
Change
EMP 44 $422.30 $464.33 $20,430.52 9.95
EMP+SPOUSE 9 $903.71 $993.66 $8,942.94 9.95%
EMP+CH[LD(REN) 12 $781.23 $858.99 $10,307.88 9.95
EMP+FAMILY 18 $1,266.88 $1,392.98 $25,073.64 9.95
Total 83 160 $64,754.98
Proposal # 161883 Page 6 of 19 7/23/07
~IGl\TA Hea1t~~C~re
Proposed Benef is
Product: CIGNA Healthcare POS Open Access
Situs State: FL Effective Date: 10/01/2007
Category Description In Network Out of Network
Medical Benefits POS OA Copay
Modular Medical Management Program PHS+
Coinsurance 70%
PCP Office Visit Copay $10
Specialist Office Visit Copay $20
Hospital IP Copay -Per Admit $200
Hospital IP Deductible -Per Admit $400
Hospital IP Copay Per Day NA
Hospital IP Deductible -Per Day NA
Hospital IP -Number of Copays Per Admission NA
Hospital IP - Number of Deductibles Per Admission NA
Maximum Reimbursable Charge Option I - 70th
percentile Incl
NSP & Bill Neg
Plan Deductible -Individual $0 $300
Plan Deductible -Family $0 $600
Out of Pocket Maximum -Individual $1,000 $2,000
Out of Pocket Maximum -Family $2,000 $4,000
OOP Max Copays Includes Copays
Lifetime Maximum Unlimited $1,000,000
Annual Maximum NA
Outpatient Facility Copay $100
Outpatient Facility Deductible $200
Emergency Room Copay $75
Urgent Care Copay $35
Skilled Nursing Facility Copay $0
Skilled Nursing Facility Maximum Days 60 60
Home Health Care Copay $0
Home Health Care Maximum Days 60 40
DME Included
Durable Medical Equipment Maximum $3,500
EPA Included
External Prosthetic Appliances Deductible $200
External Prosthetic Appliances Maximum $1,000
Chiro Included
Short Tenn Rehab Copay $20
Chiro Copay $20 NA
Proposal # 161883 Page 7 of 19 7/23/07
~IGl'~TA H~~,1t~i~~.r~
Proposed Benefits
Product: CIGNA Healthcare POS Open Access
Situs State: FL Effective Date: 10/01/2007
Category Description
Medical Benefits POS OA Copay
Short Term Rehab and Chiro Combined Maximum
Days
Short Term Rehab Maximum Days
Self-Referred Chiro Maximum Amount
Self-Referred Chiro Maximum Days
MRI, CT PET Scans Copay
PCL Admin Option
Infertility
Bariatric Services
Bariatric Surgery -Lifetime Maximum Amount
Health Advisor
Non-Surgical TMJ
Medicaze COB: Retirees >=65 Admin Option
Robust Reporting Package Employer Features
24 Hour Health Info Line
Well Aware Program (Diabetes, Asthma, Low Back)
Well Aware Program (Cazdiac)
Well Aware Program (COPD)
Well Aware Program (Weight Complications)
Well Aware Program (Targeted Conditions)
Well Aware Program (Depression Management)
Wellness Program (Healthy Steps to Weight Loss)
Well Being Newsletter
Healthy Babies
Healthy Rewards
Life Source Organ Transplant Network
Guest Privileges
Language Line
Drugstore.Com
Transition of Caze
CIGNA Health Advisor
Pharmacy Benefits $5/$l5/$35
Copay -Generic
Copay -Brand
Copay -Non-Preferred
In Network Out of Network
20 NA
NA
NA
NA
$50
Excluded
Excluded
Excluded
NA
Excluded
Excluded
NA
Excluded
Included
Excluded
Excluded
Excluded
Included
Included
Included
Excluded
Included
Included
Included
Included
Included
Included
Included
Included
Excluded
NA
$0
Excluded
$5
$15
$35
Proposal # 161883 Page 8 of 19 7/23/07
IGl'~TA He~1t~i~~re
Proposed Benefiis
Product: CIGNA Healthcare POS Open Access
Sites State: FL Effective Date: 10/01/2007
Category Description
Pharmacy Benefits $5/$15/$35
Mail Order -Generic Copay
Mail Order -Brand Copay
Mail Order Copay -Non-preferred
Retail -Individual Deductible
Retail -Family Deductible
OOP -Individual Maximum
OOP -Family Maximum
Oral Contraceptives
Contraceptive Devices
Lifestyle Drugs
Insulin Needles & Syringes
Glucose Test Strips/Lancets
Prenatal Vitamins
Step Therapy
Oral Fertility Drugs Covered Expenses
Insulin
Generic Push
Formulary
Prescriber Panel
MH/SA Benefits Option 4 -High (POS)
Inpatient Per Day Copay
Inpatient Max Number of Days MH/SA Combined
MH Outpatient Copay 1 to 20 Visits
MH Outpatient Max Number of Visits
Outpatient SA visits 1-2 Copay
Outpatient SA visits 3-20 Copay
SA Outpatient Max Number of Visits
Group Therapy Outpatient Copay
Group Therapy MH/SA Combined Maximum Visits
MH/SA OON Buy-up Option
Vision Benefits Low Plus
Eye Exam Copay
Eye Exam Frequency (months)
In Network Out of Network
$]0
$40
$100
$0
$0
NA
NA
Covered
Covered
Not Covered
Covered
Covered
Covered
Included
Not Covered
Covered
Included
Incentive
Open
$50
25
$30
20
$IS
$30
20
$IS
40
$10
12
Excluded
Proposal # 161883 Page 9 of 19 7/23/07
IGl'~TA He~,1t~i~~re
Proposed Benefiis
Product: CIGNA Healthcare POS Open Access
Situs State: FL
Category
Vision Benefits
Effective Date: 10/01/2007
Description
In Network
Out of Network
Low Plus
Hardware
Benefit Exceptions:
Not Covered
Proposal # 161883 Page 10 of 19 7/23/07
IG1'~TA H~~.1t~i~.re
Group Description: FL816B (ALL ACTIVE EMPLOYEE'S) FL816C (ALL ACTIVE EMPLOYEE'S)
Tier Inforce
Subscribers Members Current
Rate Renewal
Rate Monthly
Premium
Change
EMP 2 $422.30 $464.33 $928.66 9.95
EMP + SPOUSE 0 $903.71 $993.66 $0.00 9.95
EMP+CHILD(REN) 0 $78].23 $858.99 $0.00 9.95
EMP+FAMILY 0 $1,266.88 $1,392.98 $0.00 9.95%
Total 2 2 $928.66
Proposal # 161883 Page 1 I of 19 7/23/07
IGNA H~~.t~i~.re
Proposed Benefits
Product: CIGNA Healthcare PPO
Situs State: FL Effective Date: 10/01/2007
Category Description In Network Out of Network
Medical Benefits Trans PPO Copay
Modular Medical Management Program PHS+
Office Visit Copay NA
Primary Care Copay $15
Specialty Care Copay $15
Coinsurance 90% 70%
Hospital IP Copay -Per Admit NA
Hospital IP Deductible -Per Admit NA
Hospital IP Copay Per Day NA
Hospital IP Deductible -Per Day NA
Maximum Reimbursable Charge Option 1 - 80th
percentile Incl
NSP & Bill Neg
Collective Deductible/OOP Admin Option NO NO
Combined Medical/Pharmacy Deductible/OOP Admin NO NO
Option
Annual Individual Plan Deductible $300 $500
Annual Family Plan Deductible $900 $1,000
Deduct Accumulator Cross Cross
Accumulation Accumulation
OOP -Individual Maximum Amount $1,500 $3,000
OOP -Family Maximum Amount $4,500 $9,000
OOP Max -Accumulator Cross Cross
Accumulation Accumulation
OOP Max Ded Excl Ded Excl Ded
OOP Max Copays Excl Copays Excl Copays
Lifetime Maximum Amount $1,000,000
Lifetime Maximum -Annual Reinstatement Amount NA
Outpatient Facility Copay NA
Outpatient Facility Deductible NA
Emergency Room Copay NA
Emergency Room Deductible NA
Urgent Care Copay NA
Urgent Care Deductible NA
Other Health Care Facility IP Maximum Days 60
Lab/Radiology Standard Coverage Plan Ded/Coins Plan Ded/Coins
MRI, CT PET Scans Copay $0 $0
Proposal # 161883 Page 12 of 19 7/23/07
~I~TA H~~t~i~~.re
Proposed Benefits
Product: CIGNA Healthcare PPO
Situs State: FL Effective Date: 10/01/2007
Category Description In Network Out of Network
Medical Benefits Trans PPO Copay
Lab/Radiology Mid-Point Coins Option Coinsurance NA NA
Home Health Care Maximum Days Unlimited
Durable Medical Equipment Included Cvrd-Ded/Coins
Durable Medical Equipment Maximum Amount Unlimited
External Prosthetic Appliances Included Cvrd-Ded/Coins
External Prosthetic Appliances Deductible $0
External Prosthetic Appliances Maximum Amount Unlimited
Short Term Rehab and Chiro Combined Maximum 60
Days
Short Term Rehab Maximum Days NA
Chiropractic Caze Maximum Amount NA
Chiropractic Caze Maximum Days NA
Infertility Treatment Standard Coverage Not Covered Not Covered
Infertility Opt 1 -Diagnoses/Corrective procedures Excluded
Infertility Opt 1 -Diagnoses/Corrective procedure Not Covered
Infertility Opt 2 -Opt 1 plus Invitro, GIFT, ZIFT, etc. Excluded
Infertility Opt 2 - Opt I plus Invitro, GIFT, ZIFT Not Covered
Infertility Opt 2 -Lifetime Maximum Amount NA
Bariatric Services Excluded
Bariatric Surgery -Lifetime Maximum Amount NA
Preventive Care -Children thru Age 2 Included Not Covered
Preventive Care Opt 2 -Annual Physicals Age 3+ Excluded Not Covered
Preventive Care Opt 2 -Immunizations Excluded
Preventive Caze Opt 2 - Calendaz Yeaz Benefit NA
Maximum Amount
Organ Transplant Included Not Covered
Health Advisor Excluded
Routine Foot Care Buy-up Excluded Not Covered
Routine Foot Care Separate Buy-up Coinsurance NA
Routine Foot Care -Cal Yr Buy-up Benefit Maximum NA NA
Amount
Non-Surgical TMJ Included Included
PCL Included Included
PAC/CSR -Standard IP AdmiUCase Management UR Included
Program
PAC/CSR IP Non Compliance Penalty Amount $750
Proposal # 161883 Page I3 of 19 7/23/07
CIGNA.. H~a1t~.i~~.re
Proposed Benefits
Product: CIGNA Healthcare PPO
Situs State: FL Effective Date: 10/01/2007
Category Description In Network Out of Network
Medical Benefits Trans PPO Copay
PAC/CSR IP Non Compliance Penalty Percent 50%
Medicare COB: Retirees >=65 Admin Option NA
Medicare COB Type None
Percent of Medicare Eligible NA
Well Aware Program (Diabetes) Included
Well Aware Program (Cardiac) Included
Well Aware Program (Asthma) Included
Well Aware Program (Low Back Pain) Included
Well Aware Program (COPD) Included
Well Aware Program (Weight Complications) Included
Well Aware Program (Targeted Conditions) Included
Well Aware Program (Depression Management) Included
Wellness Program (Healthy Steps to Weight Loss) Excluded
24HIL Included
Healthy Babies Included
Healthy Rewards Included
LifeSource Organ Transplant Network Transplant Included
Program
Language Line Included
Transition of Care Included
Case Management Included
Provider Channeling Included
Away From Home Care Included
Drugstore.Com Included
CIGNA Health Advisor Excluded
Pharmacy Benefits CIGNA Pharmacy 2-Tier Copay
Plan Coinsurance 40%
Retail -Generic Copay $7
Retail -Brand Copay $15
Mail Order -Generic Copay $14
Mail Order -Brand Copay $30
Retail -Individual Deductible NA $100
Retail -Family Deductible NA $200
Annual -Individual Maximum NA NA
Annual -Family Maximum NA NA
Proposal # 161883 Page 14 of 19 7/23/07
CIGNA ~-Ic~~.1t~iC~.re
Proposed Benefits
Product: CIGNA Healthcare PPO
Situs State: FL Effective Date: 10/01/2007
Category Description !n Network Out of Network
Pharmacy Benefits CIGNA Pharmacy 2-Tier Copay
OOP -Individual Maximum NA NA
OOP -Family Maximum NA NA
Standard Preventive Drugs Subject to Deductible NO
Ded, Annual Max, OOP Max Apply to MOD Do Not Apply
to MOD
MOD Program No Mandatory
Maintenance Drug List NA
Oral Contraceptives/Devices Covered
Lifestyle Drugs Covered
Oral Fertility Drugs Not Covered
Smoking Cessation Not Covered
Smoking Cessation Subject to Deductible NO
Non-Prenatal Vitamins Covered
Non-Prenatal Vitamins Subject to Deductible NO
Anti-Obesity & Anorexiants Not Covered
Anti-Obesity & Anorexiants Subject to Deductible NO
Self-Administered Injectables Covered
Optional Injectables Buy-Up Not Covered
Insulin Covered
Insulin Needles & Syringes Covered
Glucose Test Strips Covered
Lancets Covered
Prenatal Vitamins Covered
Step Therapy Included
Clinical Management Program Basic
Enh. -Benefit Exclusion Not Selected
Enh. -Intensive Appropriateness of Use Not Selected
Enh. -Utilization and Unit Cost Management Not Selected
No Mandatory Generic Included
MD Dispense as Written Generic Requirements Excluded
Formulary Open
Prescriber Panel Open
MH/SA Benefits PPO MHSA Combined
CIGNA Behavioral Health In & Outpatient
Mgmt. CAP
Proposal # 161883 Page 15 of 19 7/23/07
~IGNA. H~a1t~i~re
Proposed Benefits
Product: CIGNA Healthcare PPO
Situs State: FL Effective Date: 10/01/2007
Category Description
MH/SA Benefits PPO MHSA Combined
MH/SA Hospital IP Coinsurance
MH/SA Hospital IP -Per Admit Copay
MH/SA Hospital IP -Per Day Copay
MH/SA Hospital IP Combined Maximum Days
MH/SA Outpatient Copay
MH/SA Outpatient Coinsurance
MH/SA Intensive Outpatient Copay
MH/SA Intensive Outpatient Coinsurance
MH/SA OP & MH Group Therapy Combined
Maximum Visits
MH Grp Therapy Copay
MH Grp Therapy Coinsurance
MH/SA OP Tiered Copay Option
MH/SA OP Tier 1 Copay
MH/SA OP Tier 1 Visits (1 to ~ Maximum
MH/SA OP Tier 2 Copay
MH/SA OP Tier 2 Visits (Tier 1 Max to _) Maximum
MH/SA OP Tier 3 Copay
MH/SA OP Tier 3 Visits (Tier 2 Max to _) Maximum
Standard IP Review/Case Mgmt UR Program
OP Review/Case Mgmt Buy Up 1 UR Program
OP Review/Case Mgmt Buy Up 2 UR Program
Transition of Care (90 day period)
Vision Benefits None
Benefit Exceptions:
In Network Out of Network
90% 70%
NA NA
NA NA
30
$15
NA 50%
$50 $50
100% 50%
20
$IS
NA
Excluded
NA
NA
NA
NA
NA
NA
Included
Excluded
Excluded
Included
50%
Proposal # 161883 Page 16 of 19 7/23/07
~IGI'wTA H~~,1t~.i~r~
Group Description: AZOl1A (0003, ALL FLORIDA RETIREES) FL710E (0003, ALL FLORIDA
RETIREES) ME701F (0003, ALL FLORIDA RETIREES)
Tier lnforce Current
Subscribers Members Rate Renewal
Rate Monthly
Premium
Change
EMP 1 $632.00 $694.91 $694.91 9.95
EMP+SPOUSE 1 $1,203.76 $1,323.58 $1,323.58 9.95
EMP+CHILD(REN) 0 $1,203.76 $1,323.58 $0.00 9.95
EMP+FAM[LY 0 $1,590.89 $1,749.24 $0.00 9.95
Total 2 4 $2,018.49
Proposal # 161883 Page 17 of 19 7/23/07
SIG-ETA He~~.1t~i~~re
Underwriting Contingencies
For
Village of Tequesta
* CIGNA Healthcare is the exclusive provider of healthcare coverage to your employees.
* Connecticut General may cancel the policy as of any Premium Due Date if the number of insured Employees
fails to meet the minimum required per group participation rules; or for failure to comply with any other
material plan provision relating to Employer contributions or group participation rules.
* If a decision is not reached within 60 days from the date the rates and/or fees set forth herein are received, then
Connecticut Genera] Life Insurance Company and its affiliated companies and entities (collectively, "CIGNA")
reserves the right to revise said rates and/or fees.
* If any information set forth in this form changes at any time while coverage is provided to you by CIGNA
Healthcare Companies, you must notify us within 30 days of these changes.
* If enrollment increases or decreases by 15% or more from the enrollment assumptions used in establishing the
rates and/or fees set forth herein, CIGNA reserves the right to revise said rates and/or fees.
* Medical History Information is accurate to the best of your knowledge
* No Medicare eligible retirees are covered under this plan.
* No seasonal employees are covered under this plan.
* State law may require regulatory approval of rates. If, as of their proposed effective date, regulatory approval
is not obtained, the healthplan shall use rates consistent with its then currently approved rates and the foregoing
rates shall be effective automatically upon approval.
* The CIGNA Healthcare Companies retain the right to modify the rates and benefits set forth in this quotation,
or to decline to offer coverage if any of the information upon which these rates or benefits was based changes
or is not accurate.
* The current waiting period is " 30 days".
* The employer contributes at least 50% toward the total cost of the plan.
* The rates are guaranteed for a period of 12 months while the contract remains in force.
* There is a minimum participation of 50% required. This will be based on the total eligible employees,
identified as "90".
* This quote assumes all employees are located in the network area, and that all employees are only eligible for
the product offerings specified.
Proposal # 161883 Page 18 of 19 7/23/07
CIGNA. H~~lt~~~~rc
Underwriting Contingencies
For
Village of Tequesta
The C[GNA Healthcare Companies reserve the right to change the Quoted Rates and/or Quoted Benefits or to
decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed
Effective Date indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of this
summary information form. If any of the information identified above changes either prior to the proposed
Effective Date or while coverage is in effect, you agree to notify us promptly of such change.
The "Underwriting Contingencies" set forth above shall survive execution of any insurance policy, application, etc.,
issued by Connecticut General Life Insurance Company or any other CIGNA Healthcare company, and shall
further survive the effective date of any such policies.
The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the
rates. Please review the Benefit Summary and its attachments for information about the benefits available in
your sites.
"CIGNA Healthcare" refers to various operating subsidiaries of CIGNA Corporation. Products and services are
provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General
Life Insurance Company, Te]-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or
service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.
Client Signature
Client Name \~,~~~~~~`0 FITF~~s~i~
G ~
~~v~ORI'ORq~~.
=,° .a:
_>~ SE~4L :D=
~1 ~ Y~l C'.C.J ~~-~~ = :lnlrnaPORATED:
L.Oy - ~l e. l.~~l l l ~ axrs, L.rn ~. ~`'~9~F olr F~~~:.~`~~
Proposal # 161883
Page IYo~)'t~
Q1.. a 7
Date
v- l1Q -~ C~.nC.~~C-t-
Title
7/23/07