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HomeMy WebLinkAboutDocumentation_Regular_Tab 08D_08/12/2004 � � MEMORANDUM TO: Mayor and Council FROM: Michael R. Couzzo, 7r., Village Mana e�_� __.__-�,�__`��� DATE: August 6, 2004 SUBJECT: Employee I-�ealth Care Renewal I am pleased to submit for your consideration the annual renewal of health care costs and benefits for Village employees and retirees. We have been able to negotiate with our current provider, CIGNA, a renewal of only a 5% increase when other agencies are experiencing 12%-16% increases for the upcoming year. The significant savings will assist us in providing further enhancements throughout the Village. Janis Mauer Client Manager Orlando Sales � HealthCare of Florida July 22, 2004 255 Primera Blvd Ste 264 Lake Mary, EL 32746 Telephone 407-833-3158 Mr Dan Gallagher Facsimile 407-833-3159 Janis.mauer@CIGNA.com Village of Tequesta 250 Tequesta Drive Suite 304 Tequesta, FL 33469 Re: Policy # 3150680 Dear Mr. Gallagher: Thank you for choosing Connecticut General Life Insurance Company (known hereafter as "CIGNA HealthCare") to provide the health coverage and wellness benefits for the employees and dependents of village of Tequesta. We are committed to optimizing their health care investment, and will work with you to control the total cost of the plan and improve the experience for your client. The anniversary for the CIGNA HealthCare contract is October 1, 2004. Prior to the contract anniversary, we reviewed the existing benefit structure, demographics ot the employee population, and recent financial performance of the plan to establish the appropriate renewal rates for the next plan year. Based on our discussions to date, along with a thorough review of enrollment and claim experience, we have prepared a set of recommendations for the Village of Tequesta benefit plan design to help control employer and member costs. These proposed benefit plans include out-of-pocket maximums to help protect members �inancially in the event of a catastrophic claim. I have also included a renewal rate offer based on the current plan design. You will note that our renewal rate proposal is higher for the current benefit program. This occurs when employee cost sharin� ti.e., copayment and deductible levels) does not increase proportionately with the overall increase in medical costs. I would like to take this opportunity to review this information with you in greater detail, and to present how CIGNA HealthCare can assist with the communication and implementation of a new plan. The account underwriter and I reviewed the most recent contract year data, and have determined the renewal rate for the upcoming policy year. At the current benefit level, a renewal rate increase of 5.0� would be required. The annual health care trend used to project future claims for your plan was 13.5%. Health care trend affects all consumers of health care and is not unique to your plan. The key determinants of health care trend include: • Medical services inflation • Prescription drug cost inflation • Deductible/copayment leveraging • Increased utilization • An aging population • New technology • State mandates � During this past policy year, CIGNA HealthCare has provided valuable programs that enhance the quality of care and improve the experience for you and our plan participants. These enhancements include: • myCIGNA.com, our personalized member portal where participants can not only review benefits and claims information, search for providers and order a new ID card, but also refill prescriptions and become more informed health care consumers through our decision-support tools. We have a number of enhancements planned for the coming year, including more powerful consumer decision support tools and more informative home page content. • CIGNAaccess, launched in the summer of 2003, allows Benefit Administrators to review various reports online. And it gives the group the freedom to appoint others as delegates and determine their level of access to information. Look for expanfled capabilities in 2004. • Going forward, we plan to deliver additional product and service enhancements to help you meet the evolving needs of your clients. We are looking to redefine consumer-driven health care, introduce modular plan and benefit designs, and expand our medical management capabilities. We look forward to working with you to select a plan design that best fits your strategy for the future. I will contact you shortly to review any questions you may have and select a time to meet and review these options. We at CIGNA HealthCare value our relationship with you and look forward to proving we are Experts Who Care As always, please call me if you have any questions or if I may be of assistance to you. Sincerely, �� ���� . Janis Mauer Cc: Acordia �IGl'�TA. Healt�i��are CIGNA HealthCare Group Benefits Proposal Village of Tequesta 250 Tequesta DriveSuite 304 Tequesta, FL 33469 10/1/2004 Renewal SIF SIC Code : 9111 Group Contact : Dan Gallagher Account Number : 3150680 Sales Contact: Laurie Mandell — S FL Office Total Eligible Employees: 75 Participating Subscribers : 74 Employer Contributions : Employee Contribution : 100% Dependent Contribution: 75% Waiting Period : 30 days Eligibility Definition : Active Employees working 30 hrs Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are 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 15% in which case the CIGNA Companies may change the Quoted Rate. 1-102ZM011-SIF-1 Revisionl 1 of 15 07/22/04 Village of Tequesta �IG1�TA►. Hea1t1�.��.re Proposed Benefits Product: CIGNA HealthCare Network POS Open Access (Network/Network POSOA) Situs State: FL Effective Date: 10/Ol/2004 Benefits Summarv Category Description In Netrvork Out of Network Medical Benefts Modular Medical Management Program Benefit Option PCP Office Visit Copay $10 Specialist Office Visit Copay $20 Plan Coinsurance 70% Hospital IP - Per Admit Copay $100 Hospital IP Deductible - Per Admit $100 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 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 Way Standard: One Way Accumulation Accumulation OOP Max Copay Includes MRI/PET/CAT OOP Max Ded Exci Ded Excl Ded Lifetime Maximum Unlimited $1,000,000 Annual Maximum NA Outpatient Facility Copay $50 Outpatient Facility Deductible $0 Emergency Room Copay $50 $50 Urgent Care Copay $25 $25 Other Health Facility IP Maximum Days 60 60 Home Health Care Copay $0 Horr►e 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 Chiro Misc Benefits Included Included Short Term Rehab Copay $20 Chiro Copay $20 Short Term Rehab and Chiro Combined Maximum 60 6U Visits Short Term Rehab Maximum Visits NA NA Self-Referred Chiro Maximum Amount 1-102ZM011-SIF-1 Revisionl 2 of 15 07/22/04 Village of Tequesta �IG1v.�►. Health��.re Proposed Benefits Product: CIGNA HealthCare Network POS Open Access (Network/Network POSOA) Situs State: FL Effective Date: 10/O1/2004 Benefits Summary (Cont.� Category Description In Network Out of Network Medical Benefits (Cont.) Self-Referred Chiro Maximum Visits NA Infertility Treatment Standard Coverage Not Covered Not Covered Infertility Optl - Diagnoses/Corrective procedures Excluded Infertility Opt 2- Opt 1 plus Invitro, GIFT, ZIFT Excluded Infertility Opt 2- Lifetime Maximum Amount NA MRI, CT PET Scans Copay $50 Non-Surgical TMJ Excluded PCL Included Medicare COB: Retirees >=65 Admin Option NA Well Aware Program (Diabetes, Asthma, Low Back) Included Well Aware Program (Cardiac) Included Well Aware Program (COPD) Included Guest Privileges Included 24 Hour Health Info Line Included Healthy Babies Included Healthy Rewards Included Life Source Organ Transplant Network Included Language Line Included Transition of Care Included Well Being Newsletter Included CIGNA Health Advisor Benefit Option 1-102ZM011-SIF-1 Revisionl 3 of 15 07/22/04 Village of Tequesta �I+G1�TA H��.t�.i�a�re Proposed Benefits Product: CIGNA HealthCare Network POS Open Access (Network/Network POSOA) : Situs State: FL Effective Date: 10/Ol/2004 Benefits Summary (Cont.) Category Description In Network Out of Network Pharmacy Benetits CIGNA PharmacyPlus 3-Tier Copay Plan Buy Up Option Coinsurance NA Retail - Generic Copay $5 Retail - Brand Copay $15 Retail - Non Prefened Copay $35 Mail Order - Generic Copay $10 Mail Order - Brand Copay $40 Mail Order Copay - Non-preferred $100 Retail - Individual Buy Up Option Deductible NA Retail - Family Buy Up Option Deductible NA Retail - Individuai Deductible NA Retail - Family Deductible NA OOP - Individual Maximum NA NA OOP - Family Maximum NA NA Ded & 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 Insulin Covered Insulin Needles & Syringes Covered Glucose Test Strips Covered Lancets Covered Prenatal Vitamins Covered Clinical Management Program Enhanced Enh. - Benefit Exclusion Selected Enh. - Intensive Appropriateness of Use Selected Enh. - Utilization and Unit Cost Management Selected Generic Push Included Formulary Incentive Prescriber Panel Open 1-102ZM011-SIF-1 Revisionl 4 of 15 07/22/04 Village of Tequesta �CI�1vA He�,�.t�l��re Proposed Benefits Product: CTGNA HealthCare Network POS Open Access (Network/Network POSOA} Situs State: FL Effective Date: 10/O1/2004 Benefits Summar�(Cont.) Category Description In Network Out of Network 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 $15 Outpatient SA visits 3-20 Copay $30 SA Outpatient Max Number of Visits 20 Group Therapy Outpatient Copay $15 Group Therapy MH/SA Combined Maximum Visits 40 MH/SA OON Buy-up Option Excluded Description In Network Vision Benefits Low Plus Eye Exam Copay $10 Eye Exam Frequency (months) 12 Hardware Not Covered __ _ _ _ 1-102ZM011-SIF-1 Revisionl 5 of 15 07/22/04 Village of Tequesta �I�NA Healt�i+��.re Proposed Medical Rates Site ID : FL 816 C& D Grou Descri tion : FIN OA POS Rates Tier Inforce Rate ent Rate Wal Change% Subscribers Members Employee 9 9 $395.51 $415.29 5.0% Emp + Spouse 3 6 $846.40 $888.72 Emp + 3 9 $731.69 $768.27 Child ren Emp + Family 4 15 $1,186.53 $1,245.86 Total 19 39 1-102ZM011-SIF-1 Revisionl 6 of 15 07/22/04 Village of Tequesta �I�1"�TA� Healt�i��.re Proposed Benefits Product: CIGNA HealthCare POS Open Access (HMO/POSOA) Situs 5tate: FL Effective Date: 10/O1/2004 Benefits Summarv Category Description In Network Out of Network Medical Benefits Modular Medical Management Program Benefit Option Coinsurance 7�% PCP Office Visit Copay v$10 Specialist Office Visit Copay � $20 , Hospital IP - Per Admit Copay �$100 Hospital IP Deductible - Per Admit $100 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 Plan Deductible — Individual $0 $300 Plan Deductible — Family $0 $600 Out of Pocket Maximum — Individual ,-- $1,000 $2,000 Out of Pocket Maximum — Family v$2,000 $4,000 Lifetime Maximum � Unlimited $1,000,000 Annual Maximum NA Outpatient Facility Copay � $50 Outpatient Facility Deductible $0 Emergency Room Copay '' $50 Urgent Care Copay r $25 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 v$3,500 EPA Inciuded External Prosthetic Appliances Deductible �$200 External Prosthetic Appliances Maximum �$1,000 Chiro Included Short Term Rehab Copay V$20 Chiro Copay y $20 NA Short Term Rehab and Chiro Combined Maximum v 6Q NA Visits Short Term Rehab Maximum Visits NA 60 Self-Referred Chiro Maximum Amount Self-Referred Chiro Maximum Visits NA MRI, CT PET Scans Copay �$50 1-lO2ZM011-SIF-1 Revisionl 7 of 15 07/22/04 Village of Tequesta �IGl'�TA. He�1.t�i��r� Proposed Benefits Product: CIGNA HealthCare POS Open Access (HMO/POSOA) Situs State: FL Effective Date: 10/01/2004 Benefits Summarv (Cont.) Category Description In Network Out of Network Medical Benefits (Cont.) PCL Excluded Excluded Infertility Excluded Non-Surgical TMJ Excluded Medicare COB: Retirees >=65 Admin Option NA Robust Reporting Package Excluded 24 Hour Health Info Line Included Well Aware Program (Diabetes, Asthma, Low Back) Included Well Aware Program (Cardiac) Included Well Aware Program (COPD) Included Well Being Newsletter Included Heaithy Babies Included Healthy Rewards Included Life Source Organ Transplant Network Included Guest Privileges Included Language Line Inciuded Drugstore.Com Included Transition of Care Included CIGNA Health Advisor Benefit Option _ _ __ _ _ _. _ __ 1-102ZM011-SIF-1 Revisionl 8 of 15 07/22/04 Village of Tequesta �I�-1tiTA He�1t�i��e Proposed Benefits Product: CIGNA HealthCare POS Open Access (HMO/POSOA) : Situs State: FL Effective Date: 10/O1/2004 Benefits Summar�(Cont.,� Category Description In Network Pharmacy Bene£ts $5/$15/$35 Copay — Generic $5 Copay — Brand $15 Non-Preferred Copay $35 Mai( Order — Generic Copay $10 Mail Order — Brand Copay $40 Mail Order Copay - Non-preferred $100 Retail — Individual Deductible $0 Retail - Family Deductibie $0 OOP - Individual Maximum NA OOP - Family Maximum NA Oral Contraceptives Covered Contraceptive Devices Covered Lifestyle Drugs Not Covered Insulin Needles & Syringes Covered Glucose Test Strips/Lancets Covered Prenatal Vitamins Covered Oral Fertility Drugs Not Covered Insulin Covered Generic Push Included Formulary Incentive Prescriber Panel Open Description Tn Network Out of Network MH/SA Benefits Option 4- High (PO5) 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 $15 Outpatient SA visits 3-20 Copay $30 SA Outpatient Max Number of Visits 20 Group Therapy Outpatient Copay $15 Group Therapy MH/SA Combined Maximum Visits 40 MH/SA OON Buy-up Option Excluded _ _ _ 1-102ZM011-SIF-1 Revisionl 9 of 15 07/22/04 Village of Tequesta �IG1�T.�i He�lth�are P�oposed Bene�ts : Product: CIGNA HealthCare POS Open Access (HMO/POSOA) Situs State: FL Effective Date: 10/Ol/2004 . Benefits Summary,�Cont.� Category Description In Network Vision Benefits Low Plus Eye Exam Copay $10 Eye Exam Frequency (months) 12 Hardware Not Covered _ ____ _ _ 1-102ZM011-SIF-1 Revisionl 10 of 15 07/22/04 Village of Tequesta CIGN� He�.t�.��re P�oposed Medical Rates Site ID : FL 816A & C Grou Descri tion : FL OA POS Rates Tier Inforce Rate ent Rate Wal Change% Subscribers Members Employee 31 31 $395.51 $415.29 5.0% Emp + Spouse 10 20 $846.40 $888.72 Emp + 7 19 $731.69 $768.27 Child ren Emp + Family 7 23 $1,186.53 $1,245.86 Total 55 93 _ _ __ _ _ 1-102ZM011-SIF-1 Revisionl 11 of 15 07/22/04 Village of Tequesta �IG1vA� He�1t�Z��re Medical History Information For i�illage of Tequesta 1. Have there been any claims over $10,000 in the last 12 months? 2. Has any employee missed more than 10 consecutive days in the last 12 months due to illness or in'u ? 3. Are there an em lo ees with on oin disabilities? 4. Have any individuals been diagnosed, received treatrnent, or are currently receiving treatment for any of the following conditions in the past three years: Alcohol/Drug abuse, Cancer, Diabetes, Heart Conditions, Immune System Disorders, Kidney Ailments, Liver Diseases, Lung Conditions, Obesity, Organ Trans lants? No known medical conditions exist _ 1-102ZM011-SIF-1 Revisionl 12 of 15 07/22/04 Village of Tequesta CIG1'�IA. He�1t�i��,r� Underwriting Contingencies For Village of Tequesta *The rates are guaranteed for a period of 12 months while the contract remains in force. *The employer contributes at least 50% toward the total cost of the plan. *No seasonal employees are covered under this plan. *The current waiting period is 30 days. *This quote assumes all employees are located in the network area, and that all employees are only eligible for the product offerings specified. *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. *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. *There is a minimum participation of 50% required. This will be based on the total eligible employees, identified as 75 employees. *If a decision is not reached within 60 days from the date the rates and/or fees set forth herein are received, then Connecticut General Life Insurance Company and its affiliated companies and entities (collectively, "CIGNA") reserves the right to revise said rates and/or fees. *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. *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. *No Medicare eligible retirees are covered under this plan. *Medical History Information is accurate to the best of your knowledge *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. __ 1-102ZM011-SIF-1 Revisionl 13 of 15 07/22/04 Village of Tequesta �I�NA He�.1t�i��,re Underwriting Contingencies For Village of Tequesta (cont.) *For HMO or POS members located in Arizona, Florida, North Carolina and Texas and for Indemnity, PPO or Network accounts sitused in those locations, the following procedures will be excluded beginning with effective dates on or after January 1, 2004: Bariatric Surgery (Gastric Bypass and Related Services), AbdominoplastylPanniculectomy (elimination of redundant skin of the abdomen), Breast Reduction, Erectile Dysfunction, and Varicose Vein Treatment. Any such procedures performed on or after January 1, 2004, will not be covered. *Out of Network benefit maximums are reduced by In-Network utilization. *Urgent Care is subject to plan deductible and coinsurance if inember is out of area. *Emergencies are always covered In-Network provided that the situation meets CIGNA HealthCare's standard definition of an Emergency. *All covered Out-of-Network services are subject to plan deductible and coinsurance. *Blended rates apply to current sites only. New members added to the existing sites during the year are covered under the existing blended rate. *Any new sites added during the year, regardless of inembership size, must be priced and quoted by Underwriting according to the site specific demographics. *CIGNA HealthCare reserves the right to re-blend the quoted rates, if one or more of the quoted sites A) Withdraws prior to the effective date of the account, or B) Cancels during the policy year. *CIGNA HealthCare Companies reserve the right to adjust the quoted rate(s) including blended rate(s) if A) One or more of the quoted sites withdraws prior to the effective date or terminates during the contract term, or B) At any time following enrollment the distribution of covered participants by site would cause the blended rate(s) to vary by 5% or more. *CIGNA HealthCare is the exclusive provider of healthcare coverage to your employees. 1-102ZM011-SIF-1 Revisionl 14 of 15 07/22/04 Village of Tequesta CI�1\TA Hea�.t�i�are Underwriting Contingencies For Village of Tequesta (cont.) The CIGNA 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 avaitable 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, Tel-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 Date Client Name Title . _ _ _ 1-102ZM011-SIF-1 Revisionl 15 of 15 07/22/04 Village of Tequesta �I�-1'�TT.�. �--���t�.����� CIGNA HealthCare Group Benefits Proposal : Village of Tequesta 250 Tequesta DriveSuite 304 Tequesta, FL 334b9 PPO Benefits SIF 10f1/2Q04 SIC Code : 9111 Group Contact : Dan Gallagher Account Number : 3150680 Sales Contact: Janis Mauer for Laurie Mandell — S FL Office Total Eligible Employees: 74 Participating Subscribers : 0 in PPO membership Employer Contributions : Employee Contribution : 100% Dependent Contribution: 75% Waiting Period : 30 days Eligibility Definition : Active Employees working 30 hrs Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are 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 ra.tes. 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 sha11 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 ne�ct anniversary date, unless enrollment changes by 15% in which case the CIGNA Companies may change the Quoted Rate. 1-102ZM011-SIF-1 Revision2 1 of 7 07128/04 Village of Tequesta �T��T.�. J�Ie�.t�.�.��tar� Proposed Bene�ts Product: CIGNA HealthCare PP4 Situs State: FL Effective Date: 10/Ol/2004 Benefits Summarv Category Description In Network Out of Network Medical Benefits Inpatient Coinstuance 90 % �p Outpatient Coinsurance 90% 70% PCP Copay $15 Hospital IP Deductible - Per Day NA NA Hospital IP Deductible - Per Admit NA NA Out of Pocket Maximum - Individual $1,500 $3>� Out of Pocket Maximum - Family $4,500 $9,000 Emergency Room Deductible NA NA MRI, CT PET Scans Copay $0 $0 Plan Deductible - Individual $300 $500 Plan Deductible - Family $900 $1,� Lifetime Maximum $1,000,000 D� Excluded Chiro Excluded Non-Surgical TMJ Excluded EPA Excluded PCL Excluded Infertility Excluded 2� �, Excluded Extended Freventive Care Excluded Transition of Care Excluded 1-102ZM011-SIF-1 Revision2 2 of 7 07/28/04 Village of Tequesta �I��T� �������� P�oposed Benefits Product: CIGNA HealthCare PPO Situs State: FL Effective Date: 10/Ol/2004 Benefits Summa , (r�! ,Cont.� Category Description In Network Out of Network Pharmacy Benefits RzPRIlVIE TwaTier Copay (PPO) Phannacy Coinsurance 60% Copay - Generic $7 NA Copay - Brand $15 NA Mail Order - Generic Copay $14 Mail Order - Brand Copay $30 Drug Deductible NA $100 Oral Contraceptives Not Covered Contraceptive Devices Not Covered Insulin Needles & Syringes Covered Glucose Test Strips/Lancets Covered Prenatal Vitamins Covered Vitaxnins Not Covered Smoking Cessatiun Not Covered ix►jectable Drugs Not Covered Oral Fertility Drugs Not Covered Insulin Covered No Mandatory Generic Excluded Mandatory Generic Excluded MD Dispense as Written Excluded Formulary Open Open Network Match % 95% MH/SA Benefits {Mental Health - Alcohol & Drug Abuse} Inpatient Coinsurance 80% 60% Outpatient Coinsurance NA 50% Outpatient Copay $25 Inpatient Deductible - Per Admit NA NA Inpatient Deductible - Per Day NA NA Inpatient Cal Year Max Days 30 30 Inpatient Lifetime Max Days NA NA Outpatient Cal Year Max Days 60 60 Outpatient Lifetime Max Days NA NA Vision Benefits None __ _ 1-102ZM011-SIF-1 Revision2 3 of 7 07/28/04 Village of Tequesta �I�-NA H��.�.��a.+���� Proposed Medical Rates Site: Group Description : PPO Rates Inforce Total Medical Pharmacy Total Tier Current Renewal Renewal Renewal Change % Subs Mem Rate Rate Rate Rate Employee 0 0 $747.27 $607.51 $177.12 $784.63 5.0% Emp + Spouse 0 0 $1,599.20 $1,300.09 $379.Q7 $1,679.16 Emp+Child(ren) 0 0 $1,382.48 $1,123.90 $327.70 $1,451.60 Emp + Family 0 0 $2,241.86 $1,822.55 $531.40 $2,353.95 Total 0 0 5ite: Group Description : PPO Rates (Retiree's)* Inforce Total Medical Pharmacy Total Tier Current Renewal Renewal Renewal Change % Subs Mem Rate Rate Rate Rate Employee 0 0 $591.91 $621.51 $0.00 $621.51 5.0% Emp + Spouse 0 0 $1,183.79 $1,242.98 $0.00 $1,183.79 Emp + Child(ren) 0 0 $0.00 $0.00 $0.00 $0.00 Emp+Farnily 0 0 $1,775.'70 $1,864.49 $0.00 $1,864.49 Total 0 0 *If Redree rates include Rx Prime, please use Rx nuxnbers in PPO boxes. __ 1-102ZM011-SIF-1 Revision2 4 of 7 07/28l04 Village of Tequesta �I�1�T�. I ��i��.�.���� Medical History Information For Vllage of Tequesta 1. Have there been any claims over $10,000 in the last 12 months? 2. Has any employee missed more than 10 consecutive days in the last 12 months due to illness or iri ury? 3. Are there an em lo ees with on oin disabilities? 4. Have any individuals been diagnosed, received treatment, or aze currently receiving treatment for any of the following conditions in the past three years: AlcohoVDrug abuse, Cancer, Diabetes, Heart Conditions, Immune System Disorders, Kidney Ailments, Liver Diseases, Lung Conditions, Obesity, Organ Trans lants? No known medical conditions exist 1-102ZM011-SIF-1 Revision2 5 of 7 47l28/04 Village of Tequesta �I�2wT.A I-�+��.����°� i�nderwriting Contitegencies For Village of Tequesta *The rates are guaranteed for a period of 12 months while the contract remains in force. *The employer contributes at least 50% taward the total cost of the plan. *No seasonal employees are covered under this plan. *The current waiting period is 30 days. *This quote assumes all employees are located in the network area, and that all employees aze only eligible for the product offerings specified. *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. *If any information set forth in this form changes at any time while coverage is provided to you by CIGNA HealthCare Companies, you must norify us within 30 days of these changes. *There is a nunimum participation of 50% required. This will be based on the total eligible employees, identified as 74 employees. *If a decision is not reached within 60 days from the date the rates and/or fees set forth herein are received, then Connecticut General Life Insurance Company and its affiliated companies and entities (collectively, "CIGNA") reserves the right to revise said rates and/or fees. *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. *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 �roup participation rules. *No Medicaze eligible retirees are covered under this plari. *Medical History Information is accurate to the best of your knowledge *State law may require regulatory approval of rates. ff, 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. _ _ __ 1-102ZM011-SIF-1 Revision2 6 of 7 07/28/04 Village of Tequesta � �T��OT.�►. �3 ��t�'��'� Underwriting Contingencies For Yillage of Tequesta (con�) *CIGNA HealthCare is the exclusive provider of healthcare coverage to your employees. The CIGNA 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 propos�l Effecrive Date indicated above, or if the quoted rates and/or fees aze 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 effe�tive 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 Corporarion. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Ina, Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. Client Signature Date Client Name Title __ 1-102ZM011-SIF-1 Revision2 7 of 7 07/28/04 Village of Tequesta