HomeMy WebLinkAboutDocumentation_Regular_Tab 09C_09/18/2003 �, •
MEMO
DATE: 9/16/2003
TO: MAYOR AND COUNCIL ,�
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FROM: MAItY MILES, VILLAGE CLERK ON BEI-IA3,F OF DAN GALLAGHER, HLJMAN RESOURCES
ADMINIS'I'1tATOR
RE: CIGNA HEALTHCARE GROUP BENEPITS PROPOSAL
Attached is a renewal proposal from Accordia on Ci,gna HealthCare coverage for Village
employees. The total cost of renewal for POS (Point of Service) and PPO (Preferred Provider
Option—for our retirees) is $616,093.08, lower than anticipated in the budget for Fiscal Year
2003/2004. This reflects an increase of appro�tnately 14.49% over last year's total.
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MEMO
DATE: 9/1G/2003
TO: MAYOR AND COUNCIL t; ,��1"'
FROM: MARY MILES, VIIJ.AGE CLERK ON BFIIAI,F OF DAN Gt1LLAGHER, HUMAN RESOURCES
ADMINISTR ATOR
RE: CIGNA I-IEAI,TFICARE GROUP BENEFITS PROPOSAL
Attached is a renewal proposal from Accordia on Cigna HealthCare coverage for Village
employees. The total cost of renewal for POS (Point of Service) and PPO (Preferred Provider
Option—for our retirees) is $616,093.08, lower than anticipated in the budget for Fiscal Year
2003/2004. This reflects an increase of approximately 14.49% over last year's total.
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VILLAGE t}� � �:QIJ�STA �-�°
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�QI�r�"Ty ��^.h� �
O en Access Out ofArea - Refir,ee `"
PLANS POS PPfl �
$eaefita fn I�otxvrk Out o[Netwodc Tn Pietvreric Qu1 of Nehwrk °
rn
Pl4YSIC[AN SER�7CES l009'o aRcr IOD'/o �fler
Qiiice VLdts CO-PAY - PRIIr1ARY SIO ca pay 7 �� 0 a �� S! S co a 70% E �
. Office Ytsits CO-PAY - S�ECIALIST �p � ��1 deductible Sl5 co pey e^nua! deductible
70°� aiter annual a
]RPAT[ETIT H05PITAL SERVICSS [Q09�6 afkr �uctibie 909fi eRa 7U% afla n
5140 co-pay + 5100 w pay �n�� deduetible annual deduclihle �
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OUTPATIElVT HOSPITAI. SERVICES IOOi6 aHer 70�b sfl�r 90% aRer 76`Jo aflar
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�SU eo-poy annual deductib(e mnual deductible annusl deductible
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EAIERGLHtCY ROObt SERV[CE5 ��OYo sfler 10095 after 9056 aQer 7Q� siter �
S50 co-pay S50 co-pay annual doduceible anhual deduciible m
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�RE5CRIPTION DRUG B�NEFITS 100°,4, after 100°/v a Ekr --�g
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Geaerlc SS eo-pay 1.'iA 57 capay A+lq
Brand - Form�l�rv S15 co-pay S i 5 co-pay
Brand - Nan-Formn�sry S35 co-pey N/q
4a11 Order - 90 day supP�Y 2 x co-paY 2 z ca-paY
ASH DEDUC[]BLE
adividaal f Famll�• n�z 53001 S6U0 5300/ S90Q S590/ Sl,SOa �
UT-0F POCKET �
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nditidual f Fsmlly) S 1,�00? 52,000 52,3U0/ 54,600 51,600 ! 55,440 57,506 t� 1Q,500 �
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IFETL�lEhiA)QhlU13 unlimiled SI,OOD,006 �1,Ofl0,6U0 NtA
tOTV7��i.Y RATES EM1IPLOYE£ CURRENT RENEWAL CURR�NT RENEVk�AL w
COVRT o0
mplo��ee 34! 1 Retfree �345.42 5395.51 $5 F6.95 S591.91 Correet REtiree �
mplo��eeaod sponse 13! i Retlree 5739.22 S846,40 $l,D33.88 �1,183.?9 ppQ Retes. `^'
mplo��ee nad Chi1d(ren) 10 5639.43 S731.69
mplo3 �eeaodFom(ly 15 $1,036.27 �1,186.53 51,550,83 S1,775.70
ldNTHLYTOTAI, �43 ,288.36 �49,56539 51,550.83 S1,775.7d
NU,1[.TOTAL $514,46032 5514,784.68 �18,609.46 32i,308.40
011HINED MOIVTHLY TOTAL 544,839.I9 Current �$1,341.09 �aewa!
019$[NED ANNUAL TOTAL SS38,070.28 S616,fl 43.08
' Far A¢tbot3aed Beneflls all sendcn and supplte .
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'[his summsry is not intended lo be e cmnp)ete expl�nation of benefitc of 16e proposad insluance pafisies. Actusl premiuma and benefiv wil! be determin�d hy ihe find enrollm«it �nd are wbjecl b nnduv�Tiling °�
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Uillage �� Y�equesta
�tenewal Options 1 �/O'I/2003 - 09/30/2004
L.aast Upciatn�i 07/29I2(143
�al rates re�quNre fdnal �pnaierinrN#tng aNPrav�� Current I��tes Renewal plan Alternate 1 Plan Alternate 2 Plan
F lorida IiMO �� Subsr,ribers
Fm IR oY�e _�� � 0 $ 274.42 $ - $ 31421 $ - $ 302.14 $ - $ 288.14 $ -
[�m i• Sp c� use 0 $ 587.26 $ - $ 672.41 $ - $ 646.57 $ - $ 616.fi2 $ -
L:rn lo ee •F C hildi�en ��_ 0 $ 507.67 $ � - $ 58128 $ - $ 558.94 $ - $ 533.05 $ -
����ye? �{- r ���_ _� 0 $ 823.26 $ _ - $ 942.63 $ - $ 906.41 $ - $ 864.42 $ -
f °lorida ��n �1cc�ess f�i�S �
Em la �se _ ____� 3 $ 345.42 $ 11,744.28 $ 395.51 $ 13,447.20 $ 380.31 $ 12,930.45 $ 362.69 $ 12,331.49
E nP�oY + � 13 $ 738.21 $ 9,G09.73 $ 846.40 $ 11,003.14 $ 813.87 $ 10,580.31 $ 776.17 $ 10,09022
Em lo n;e ± Cliild ren _____� 10 $ 639.03 $ 6,390.30 $ 731.69 $ 7,316.89 $ 703.57 $ 7,035.72 $ 670.98 $ 6,709.82
Empl��ee �a Par��� _ 15 $1,036.27 $ 15,544.05 $1,186.53 $ 17,797.94 $1,140.93 $ 17 114.00 $1,088.08 $ 16,32125
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1 'utal Monih� fflb�0"Prerri�ie m 72 $ 43,288.36 $ 49,565.17 $ 47,660.48 $ 45,452.78
Uiierall Managed Gare Ren�ewai hiueas�e — �5 �o �� �0 5�
Alternate Alternate
�ASi� �LJ�P� [71FFERi'cNCE� MhNfl Current Plan Plan 1 F�lan 2
F'C;P COP/4Y $ $10 1
,3PEGIALIE� f COP,AY �20 $20 �25
$250 per day
INPATIENT A[)MISSIC��I CC)WA,Y $100 $250 x 3 days
�MER�aEI�lCY ROrJJM (;Gf'�'1f $50 $75 $100
URGEI�T C;,4FiE COPAY $25 $35 $50
L�UTPATICNT SUHGERY Cf_1�AY $50 $125 $250
F'REi(;FilF'TION COF'AYS $5/$15/$35 $10/$2U/$40 $10/$20/$40
{�UT �� PUCKEI" MA:KIhNUMI $1000/$2000 $1500/$3000 $1500/$30U0
$250 per day
E�ASIC F�LdktJ I�IFFEFi�RJ�;E::� PCIS $100 $250 x 3 days
Otat af PJetwod< Flo�pik�tl Cmp�y 70% 70% 70%
Qut of PJsiworl< Coinsurance� $300 $500 $500
()ut s�f Networl< Individual De�daciible $600 $1,000 $1,000
(?ut af PJehnru►Ic Family fJetiuclible $2,000 $3,000 $3,000
(?ut pf �lehruodc individual 017F' Maximum $4,000 $6,000 $6,000
Out of Netwodc Family Cl(�f' tvlaxirnum
Village of Tequesta
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INTRO� UCTION
Thank you for allowing us the opportunity to manage your group benefits plan. Our objective is to design a program that is
affordable and offers the comprehensive care your employees have come to value. We are sure you will agree that such a plan is
found in this proposal. „
Acordia, Inc. is an insurance brokerage organization specializing in a full range of high quality insurance, employee benefits, financial
products, and services. Acordia, Inc. is also part of the Wells Fargo Group of Companies -- the fifth largest insurance broker in the
United States. Each of our clients benefit from the national contracts this affiliation brings us.
The types of services we provide our clients include: Group
Medical
401K Pension & Deferred Compensation,
, Profit Sharing Plans Universal Life,.
Keyman Insurance
• Group
Short and Long ordla Life
Term Disabilitv
Section 125,
Cancer Insurance, Commercial
Long Term Care Insurance Property & Casualty
Dental
Our mission is to explore your needs and offer customized solutions to fulfill your company's objectives. We are certain th
Village of Tequesta and Acordia will continue to benefit from a long lasting and mutually profitable business relationship.
forward to being of continuing service.
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A Welis Fargo Company
1 West Palm Beach
Irssurance • Bonding • Emplvyee Benefi[.s
OBJECTIVES
The objectives established for this proposal are as follows:
* Evaluate the present program based on employer's specifications;
* Improve on administration and service of present program coverage; and
* Where possible, improve the cash outlay of your present benefit program.
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A Wells Fargo Company
2 West Palm Beach
Inaurance • Bonding • Employee Benefits
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MEETING THE OBJECTIVES
To meet the objectives established for this proposal, we have reviewed the current benefit package of Village of Tequesta and compared it
with several insurance companies that have experience with groups of your size:
BLUE CROSS UNITED HEALTHCARE
AETNA (Declined to quote) SELF INSURED PLAN (Quote not competitive)
On the following pages we are presenting a summary of benefits from those carriers who were competitive, along with rates that were
, quoted based on your current employee census.
The proposed rates are based on census data originally submitted. Final rates will be based on actual enrollment to be effective 10/1/03.
Rates quoted herein are subject to adjustment if there is a change in the proposed effective date, the package of benefits illustrated, or the
census information used to determine final rates.
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A Wells Fargo Company
3 West Palm Beach
Irssurance • Bonding • E'mploy�ee Bersefits
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fletlree PPC) I;u[renl R�t�s " �. . Su6s Metlical pPQ Rre�ium: :
Em Io ey e_ _ 1$ 652.64 $ fi52.64
E :mpioye + Spouse 1 $ t,396.68 $ 1,396.68
E:m I�o ie + C hild ren� 0$1,207.41 $ -
E •mPlo Y ee i• F, 0 $1,957.96 $ -
(:urrent Monthl rLF'recniurm_ $ 2,Q49.32
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F�etir l?PO I �ene wat Rates i � — ..:' Subs� Medical . PPQ� Pfeanium :
E�Y�? _—� _� 1 $ 747 .27 $ 74727
Em l oye �r. S _ 1$1,59920 $ 1,:i99.20
Em lo ee + Child(ren)_� 0$1,382.48 $
Em lo ee + Famil 0$?.,241.86 $ -
Renewal Mor�thl Premfum $ 2,346.47
RENEWAL INGREAS� 14.5%
Village of Tequesta
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VILLAGE L��' TEQUESTA
COMPANY CIGNA
O en Access Out of Area O en Access O en Access
PLANS POS PPO POS POS
Benefits In Network Out of Network ln Network Out of Network [n Network Out of Network [n Network Out of Network
PHYSiC1AM1 SERVICES !00%after o 100%after lU0%aRer o
Office Visits C'O-PAY - PRIMARY $10 co- a 70% a�� 70% after 70% after 100fo aftet 7pofo after
Oftice Visits (:O-PAY - SPECIALiST p Y annual deductible $� 5 co-pay annual deductible $20 co-PaY annual deductible $� co-pay annual deductible
$20 co- a p y $25 capay
100% after �0% after annual o 0 0 70% after 100% aMr, 70% after
INYATIENT HOSPITAL SERVICF.S 90% after 70% afier 100% after
$100 co- a deductible annual deductible �250 cb-pay per annual deductible
p Y +$100 co-pay annual deductible annual deductible $250 co-pay +$250 PAU ' ` day, +$250 co-pay per day
$750 max ; $750 max.
OUTPATIENT HOSPITALSERVICES �00%aRer 70%after 90%after 70%after 100%after 70%after 100%after 70°/a.atter
$50 co-pay annual deductible annual deductible annual deductible $125 co-pay $125 co-pay $250 w-pay '$250 co-pay
EMERGF,N('Y ROOM SF.RVICF,S 100% after ] 00% after 90% after 70% after 100% after 100% after 100% after ` 100°10 afteY
$50 co-pay $50 co-pay annual deductible annual deductible $75 co-pay $75 co-pay $100 co-pay r, $100 co-pay
PRESCRIPTIO�' DRUC BF,NF.FITS 100%after 100%after l00%after lpp%��:
Ceneric $5 co-PaY N/A $7 co-pay N/A $10 co-pay N/A $10 co-pay. N/A
Brand - Formulary $15 co-pay $15 co-pay $20 co-pay $20 co- a
PY
Brand - Non-Formulary $35 co-pay N/A $40 co-pay $40 co-pay
Mail Order - 90 day suPP�Y 2 x caPaY 2 x co Z x co 2 x co- a
CASH UEDUCTIBLE
PY _
Individual / Famil • none $300 / $600 $300 / $900 $500 / $1,500 none $500 / $1,000 ; none $500 / $},OOU ,
OI IT-OF-POCKET
Qndividual / Family) $1,000 / $2,000 $2,300 / $4,600 $1,800 / $5,400 $3,500 / $10,500 $1,500 / $3,000 $3,500 / $7,000 $I,500 / $3,000 $3,500 / $7,000
I,IFF.TIMF. MAXIMUM unlimited $1,000,000 $1,000,000 N/A unlimited $1,000,000 unlimited $1,000,000
MONTHLY RATES EMPLOYF.E Ct1RRENT RENEWAL CURRENT RENEWAL ALTERNATE 1 ALTERNATE 2
COUNT
� Employee 34 / 1 Retiree $345.42 $395.5 ] $652.64 $747.27 $380.31 $362.69
Employee and Spouse 13 / 1 Retiree $739.21 $846.40 $1,396.68 $1,599.20 $813.87 $776.17
EmployeeandChild(ren) l0 $639.03 $731.69 $1,207.41 $1,382.48 $703.57 $670.98
EmployeeandFamily is $1,036.27 $1,186.53 $1,957.96 $2,241.86 $1,140.93 $1,088.08
MONTHLY TOTAL $43 ,288.36 $49,565.39 $2,049.32 $2,346.47 $47,660.50 $45,452.67
ANNUAL TOTAL $519,460.32 $594,784.68 $24,591.84 $28,157.64 $571,926.00 $545,432.04
COMBINED MONTHL.Y TOTAI. $45 ,337.68 $51,911.86 $50,006.97 $47,799.14
COMBINED ANNUAL TOTAL $544 ,052.16 Current Renewal Alternate 1 Alternate Z
$622,942.32 $600,083.64 $573,589.68
* For Authoriaed Bene�ts all services and supplie .
This summary is not intended to be a complete explanation of benefits of the proposed insurance policies. Actual premiums and benefits will be determined by the final enrollment and are subjecf to underwriting
approval.
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VILLAGE TEQUESTA .
COMPANY BLUE CROSS - O tion 1
1351 Plan 1752 Plan 1750 Plan
PLANS PPO PPO PPO
Benefits In Network Out of Network In Network Out of Network in Network Out of Network
PHYSICIANSERVICES ` 1�%after �0%ofaliowance 100%after 50%ofallowance � � �� a���� c ��� I ��
$20 co-PaY � 5Q°�a;1kf �Uowa�ce'
Oftice Visits CO-PAY - PRIMARY aRer annuai ` $20 co pay gtteranhual �$'"�� ,, a"�r ��
Of'fice Visits CO-PAY - SPECIALIST g0% after deductible $35 capay s deduet�ble � `� �� � �� �� �
annuai deductible , � , �� ,� � ,,,���hb1�;,
r�,�,����' I�+ u �;�,��
100% after 100%after � o ` ; , �,,� "�+ �^� , �"����"�"� '" '
INPATIENT HOSPITAL SERV (CES $SOO PAD ���°�o of allowance 100/Q of allowanGe, �r �+� ������g�'$�ro�cc`
� aftec $1,750 PAD. �$i for , , atter $�1 730 P�AT3 ; t ;v; ,�'"� � � �� � (� �',AD
($1,000 for 001� , � �
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_ � , � � a �r`� r ��,fi� a ��W � °�'� � ° rti�.
100% after 100% of allowance 1 Q0"/o after t Op% ofalloWan�e1 �� ��/o c�f al�qwanC�rj.
OUTPATIENT HOSPITAL SERVICES ,. ° "' P
$I50 co-pay after $350 capay '$150 capay after $350: cu-pay � A,� ' y � M�'�3� �„�
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o '' � o � '' ; ^ �', � u ' �^ � � ����'��" P �, a ,����� � � � �
80% after 60% of allowance 1,00% after 1q0°!o of allowance' .„
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EMERCENCY ROOM SERVICES � �O�f� � 'C�¢ o�'ailawance� �
$100 cv-pay after $100 co-pay 5,150 Capay • aiter $3S4 co- "��% � ` � " ° " ' ''` �«� ` ,
, PaY �' �� ��et` �3QQ c� ;
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PRESCRIPTION DRL�G BENEFITS 100% after 100% after ;.a��;}(,�(y+�>`�a��� �, �,� � a� r
Generic � �, ' °� u; �� ' ,,, � � : i, �
$7 co $7 co-pay ? , �" $? capay �
Brand - ForroularY $20 co � �N//1 $20 ctr a�� N/A " �� ��
P Y ` ,SZ(f co-pay ` N/A
Brand - i�on-Furmulary $35 co $35 co-PaY �$3S co pay ;
�1ail Order - 90 day supply 2 x ca 2 x co !.,, , Z x e�-pa� ��,' ,` �,
�, r r , . ,
CASH DF.DIiCTI131_E
Indicidual/ Famil .) �50O / $1,SUQ $250 / $750 $1,000/$3ttl00 " � �one ' ' $3U0 / �i ,�
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OUT-OF-NOCKET ° `
(tndividuai / Fairiily�} � $3,000�/� $9,000 �' � ' $� 000 f $95000 � "� � � $2,500 / $7,SOQ
[.IFETIME MAaI�IUM � �$S,�Q0,000 �� � � $S,OOO,OUO ,, : ' . . $5,006,000 ���, �;
MON1'HLY RATES �MPLOYEE pROPOSED PROPOSED PKOPOSED
COUNT
Employee 34! 1 Retiree $284.20 $312.60 $347.30
Employee and 5pouse 13 / 1 Retiree $632.50 $695.50 $772.90
Employee and Child(ren) 10 $549.90 $$11.80 $671.40
Employee and Family is $898.10 $994.80 $1,096.90
MONTHLY TOTAL $37,772.50 $41,7 i 8.00 $46,143.60
ANNIJAL TOTAL $453 ,27�.00 $5��,61 f).00 $553,723.20
CIGNA
COMBINED MONTHI.Y TOTAL $45,337.68 $51,911
COMBiNED ANNUAL TOTAL $544,052.16 Current $622�942.32 Renewal
This summary is not intended to be a complete explanation of benefits of the proposed insurance policies. Actual premiums and benefits will be determined by the final enrollment and are subject to undenvriting
approval.
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VILLAGE TEQUESTA
COMPANY BLUE CROSS - O tion 9
1351 Plan 1552 Plan 1754 Plan
PLANS PPO PPO PPO
Beilefits In Network Out of Network In Network Out of Network In Network Out of Network
� PHYSIC;IAN SERV ICES 100% after o i 6 ��� �9 �"" a� x� k�, `�R ��,s,h� �d� �r� �k '
60 /o of allowance �, x t�Qp'�/ afl�e�� ��r+ (�►� b� �p�yariC� I �'
Office Vi5its CU-PAY - PRIMARY $20 co-pay t, � ,, �� ! ��„ � e , ,: ,
after annual �+ I I I
� 80% after '.� „ $1,S �ct�-pa�,�q� �, r, ��` � �t��t$��
Office Visits CO-PAY - SPEC[ALIST deductible ' �� � �� � �'�'�� ����j�r ��� I �
�� � 3Q �u
annual deductible � ��E � � � , ,�,,,�� +� k,� ���� , ��� xx, �
° o ' " ,'1(JQ%dsft4�y�+��,�� �f,��x �;� ���<<� ;�� c
100 /o after �"�` . ��"i
INPATIENTHOSPiTAI.SERViCES 100%ofallowance 'a .�� s ��,�q�'�q�'
� � $500 PAD �e t^ �� ��5fl� �kl1��i +��< � o K a, �
after$1,750PAD ,� � � 6 �k� � �g�$����p�
($1,OOU for O0A) ; �$� ���i�'�" ��1�' � s �, t,t �, � �ra�F���, . �M� r `
s � � ° 8 t � f f "�� �-'� � �an ���k�t, �� '� ° e
OUTPATIF.NT HOSPITALSERVICES 100%after � ]00°/aofailowance 100�a�er�,���".��s '��►,p�d'`',t� � , i ' �'I�
$150 co-PaY after $350 co pay ;�YM' $1�R���X° ��` ��5,�3�� �; I �I
� .��' ��'F,Kb,�7� �ou a�� , �s 1Y. ,�y�pN � .F�7
. i4! i 5f xr:"�� 1 f a"a�� � �'^ "�'1 � U � ° !� �v�4� '�'�r� r
80% after 60% of allowance ' r` r8ba/o � r
EMERCENCY ROOM SERVICF,S �� � , �I' ��
$100 co-pay after $100 co pay ns�' $�aqd,CC��ay ¢; ' �c'�1,(I����
•,w� r � � � '�' af Fb/, �' ��r :S,r 4 @F n�.
PRESCRIPT101VDRLJGBENEFITS 100%after h�� li�(�of��� ;,� �Y��4y�,'ww��� a,y� ; �
� ` , �. a M� " �+ ��ti� w, ,��
Generic $7 co ; $7 ' a�' t y,�y��h������ a
Brand - Formular `' � �`�'�`"�'�£��� � r `�'r'"`+�� x
Y $20 co- a N/A ±; r+ � ���
P Y , �,h�� 20 GckpBy Y ,„a �� '�,��� �.��31�`��
�� Q.
Brand - Non-Formulary $35 co- a "_� ''``` �` � 3''��� �` � � ��'���o��.� �
Y pP Y 2 x co d� �'� ��7�t?�Qi'P�� � t s. ,5�y ���++��� I �
Mail Order - 90 da su 1
CASH DEDUCTIBLE $500! $1,500 ,� 4�� ^���,�,�, $���$j�#�����'��������?�
Individual / Famil �,� --
OUT-OF-POCKET � i �T�, N �; � r �sx��, b ,� , � ta '�,��^�,�� i'
(IndividuallFamily) $3,000/$9,000 �,iJ � g ,,{,� ��'�'���„
,�
LIFETIME MAXIMUM ;; ` ; w: �� , �$yfppp,pp¢,"`',��'�vr �r .4'�;t`�,�;.
$5,000,000
MONTHLY RATES EMPLOYEE pROPOSED PROPOSED PROPOSED
COUNT
Employee 34 / 1 Retiree $301.58 $315.16 $348.26
Employee and Spouse 13 / 1 Retiree $676.36 $706.92 $781.18
Employee and Child(ren) 10 $588.74 $623.96 $693.02
Empioyee and Family i5 $970.20 $1,022.71 $1,133.68
MONTHLY TOTAL $40,464.74 $42,507.73 $47,061.02
ANNUAL TOTAL $485,576.88 $510,092.76 $564,732.24
° CIGNA
COMBINED MONTHLY TOTAL $45 $51�911.86
COMBINED ANNUAI, TOTAL $544,052 Current $622 ,942.32 Renewal
This summary is not intended to be a complete explanation ofbenefits of the proposed insurance policies. Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting
approval.
8
.,
. . . , ;,. -... . ,,:..�,. , �.�,. �
VILLAGE TEQUESTA ,
COMPANY BLUE CROSS - O tion 11
1151 Plan 1351 Plan 1552 Plan 1752 Plan 1750 Plan
, PLANS PPO PPO PPO PPO PPO
Benefits ln Network Out of Network In Network Out of Network In Network Out of Network ln Network Out of Network In Network Out of Networ
PHYSICIANSERVICES 80%after 60%pf 100%after � 60°loof ;. 60%of > Sp%of.:.
i �
100% after �, i '100% after
Office Visits CO-PAY - PRIMARY annual allowance after $20, capay � aUawa�ce after alipwance after allawance after.
o , : $1 S co=PaY �. $2U cq-P?Y
Office Visits CO-PAY - SPE('IALIST deductible : annual ' �� 80%after� ' annual annual.` .' ".annual '
` $30 co-pa� , , �35 co
ded'uctible . arnnual �aeductibie .. 8ed`uct�ble , � �deduGtible : � deductible' i
I 00"/c after 1 OU% of 100%o after 100% of 100°lo aiier !. 1 QQ% of 100% after 100% of �,���'� � T; �������'t�'�
IVPATIF.NT NUSPITAL SERV7CES < s� , � � �a, r r�
$750 PAD allowance after $500 PAD `' allowance after '` $500 PAn ' allqwance atter $500 PAD alicnvance atter ,„� �� � all j o'uitatt�e �f1er
($1,250 OOA) $2,OOU PAD ($I,OOD OOA) $1,750 PAI) . ($1,000 dOA) $1;750 PAp ($1,Q00 OOA) " $1,75Q PAD �$$�1�/�), :�,$�,�� P,4b '
l 00% after 100% of ] 00% after , 100%0 of ?. ,r` 100% of a 100% of '��'� rn`���� � rys �;,4'" �ppy6 8f ''"
OUTPATIE:N'I' HOSPITALSF:R�`IC'GS 100�/aafter 100%after �1 �a� i��� , fh'
$200 co- a ailowance after allowance after � , allowance,after allowance affer � r� aila�nr�e �
p Y p y '$ i S0 co-pay :' $350 co- a' � i 50 ca: pay $1 SO co- a r r a�
$400 co- a A Y �$350 co- a P, Y $# p� �PaY �� i
p Y $350 co-pay � fi,� .5 �(�p Cap�';`
HQ% af'ttv fi�% of' a'c 60°l0 of o �, 60% of a 1.00% of :;�� r����` ,��'"�`�hi ��', c� �"'�'` ��y ,
80%atter - 8�/o after ' 100%after �1�1?!'��fteK <' ���� of ti,
F.ME;RGFN(`l' ROOM SER\'IC'F,S allowance after allowance after ° r allowance after all.owance affer � a�jpq•���aft�t
$ I OU co= a
� Y $l0U co-pay $100 co pay $100 co a $100 co-pay $150 co-pay `"�a{�d�p �payr , ,
P Y. . $iQ0 co $350 co-pay a l�� ��. � �,w ,� $�Jq�CO #�aYx:
, �a'� : �� ,��+ti �
PRES("RIPTION I)KI�G BENEFITS 100%afie� 100%after '.- 100%after 1U0%after rxdE1°/y�`ter' `�� ea,��tti
Generie , *� k;�`t �
�7 co $7 co-pay i $7 capay ; $7 co `v ' � � ��� , � ,
� �d"A�Y 4 q�,�, � � , y ,,
BranJ - F'ormulary $20 cc�-pay N/A $20 co-Pay , N/A • '$20 eo,pay N/A ,: $20 co-pay N/A $20 y{ ' � �' ^ ° "���`'��T/Af �
Brand - Nnn-Formufary $35 co $35 co- 2 ' u '` �"�`� � u ��� " �� '
P Y" $35 co-paY $35 ca ��S Co�pay t
11ai1 Order - 90 day suppiy 3� x ci�- a � � ` �� '` �� �, � � i � " � J
P�' 2 x eo-paY 2 x co�ay 2 x co f,2 ���y ;; ��g��. ',r i �; ;",
CASH UF.DUCTIBLE. $1.,000 / $3,000 $500 / $1,500. �r ,�" "'" t�;
Individual / Famil • $500 / $1;500 $250 / $750 $1,000! $3,000 , ,, nohp � � $SQba/�1,' $pp'',
� � � � � , � � �1?q,° �e � � �
Ol`T'-OF-POCKET �;
(Individual / Famil,y} �4.00U / $12,000 ! $3,OQ0 /:$9,Q00 `' $3,OOQ / $9 000 $3,000 / $9,Q00 �'� :'�$��$QQ �'�$7�,�bp, �'
� :. . �. ... � I /ry � k � �h �1 {
1.IFE:TIMEMAXIMltN1 ;$5,000,(300 $5,000,000 `;$5,000,000 $S,OOO,OUO ^��'��'� '.,�,
hto!v7'Ht RA 'res EMPI, pKOPOSED YROPOSED PKOPOSED PROPOSED PROPOSED
C'OUNT
Employee 34 / 1 Retiree $270.50 $285.60 $298.50 $314.00 $349.00
Employee and Spouse 13 / 1 Retiree $602.00 $635.50 $664.20 $698.80 $776.60
Employee and Child(ren) 10 $525.00 $552.50 $585.70 $614.70 $674.50
Employee and Family 15 $856.40 $902.40 $951.40 $999.40 $1,102.10
MONTHLY TOTAL $35,991.50 $37,954.00 $39,874.30 $41,91120 $46,363.90
ANNUAL TOTAL $431,898.00 $455,448.00 $478,491.60 $502,934.40 $556,366.80
CIGNA
OMBINED MONTHLY TOTAL $45 ,337.68 $51,911
COMBINED ANNUAL TOTAL $544 ,052.16 Current $622 Renewal
This summary is not intended to e a complete explanation o benefits o the propose insurance policies. Actual premiums and benefits will be determined by the final enrollment and are subject to underwTiting
approval.
9
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VILLAGE TEQUESTA •
COMPANY BLUE CROSS - O tion 12
1351 Plan 1551 Plan 1755 Plan
PLANS PPO PPO PPO
Benefits In Network Out of Network In Network Out of Network in Network Out of Network
� 100"/a after � � �� � �� ,,4'�5�:'
PHYSICIAN SERV ICES 60% of allowance , 1QA'./o aftt7: ' a 60% af al�owance
Of6ce Visits CO-PAY - PRIMARY $20 eo=pay , � , '
80% after after annual `�1S Co pa� , �tter aniiugl � ., �`; r
OTfice Visits CO-PAY - SPECIALIST deductible $30 ca a c�eductible ,,„r' � ��"
�� t r i �,
annual deductible �, P �'�, ��,�
100°!o after 1 QO°/p �fter ' 100% o�allowance ��
INPATIENTHOSPITALSERVICES $500PAD �00%ofallowance � �� ���:
''$400 PAI) ; ,��.; � PR � , •
($1,000 OOA after $1;750 PAD � after $1,2QO PAD ' ° �
) ($8U0 QOA� �� :
v ,: � � ,,'
100% after ' 100% of.allowance I UO°10 after `� 1 Q0"/a of allowance ��'+� �''
OUTPATIENT HOSPITAL SERVICES , �,
$ I50 co-pay after $350 eo-pay ;�10U ecs pay , after $3Q4 capa� �' � � � " `
`� h, � �����.
k wl th
80% aRer 60% of allowance i 9U"/o after ' 6Q'�o of allowance �„ ,����"�'��
EMERCENCY ROOM SERViC'ES \ � ���
$] 00 co-pay after $100 co-pay : $1 UO co pay � aftCr $T 00 Capax �r
��. p ��, ,, ��'
PRESCRIPTION DRUG BENEFITS 100%after iQ0%atter , i �r
� A , �,„
Generic $7 co-PaY $7 ca a � ` `. �� �����3.���'
P Y : r °. . �t�� � ���, � :
Brand - FormularY � $20 co-pay � N/A $2�p c4 pay '� � �' NfA', � '� " ., � � � ��� � �
i: ,
R �� `
Brand - Non-Formulary $35 co-pay $35 co }�ay '� ; , r �; "
:`
� ,
` �w�w
Mail Order - 90 day suppl,y ��� 2 x c�� a � � �y .: , ��` � , �"�
P Y 2 k co ' x � h
CASH DEDLICTlBLE
$500✓$I,S00 $5001$1 500 ` .' ` �'y�'
Individual / Famil ; `" r ,;
OUT-OF-POCKET `� ' �;� ;
r: .
$3,000 / $9.000 $2 / $7,500 � �
(Individual / Family) F v ��,� f ,;
' � �k. i
LIFETIME MAXIMUM � �� $S,OtSO � , • �"�$5,000,000 ! ,.-� �� � �� �
. , ,.�.,w:,.
MONTHLY RATES EMPLOYEE pROPOSED PROPOSED PROPOSED
COUNT
Employee 34 / i Retiree $301.90 $331.18 $350.91
Employee and Spouse 13/1 Retiree $677.64 $743.19 $787.43
Employee and Child(ren) 10 $589.91 $640.94 $69832
Employee and Family 15 $972.75 $1,060.80 $1,143.23
MONTHLY TOTAL $40,543.81 $44,317.36 $47,437.52
ANNl1AL TOTAI $486 ,525.72 $531 ,8�8.32 $569 ,250.24
CTGNA �
COMBINED MONTHI.Y TOTAL $45 $51
COMBINED ANNUAL TOTAL $544 ,052.16 CuCrent $622 ,942,32 Renewal
This summary is not intended to be a complete explanaticm of benefits of the proposed insurance policies. Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting
approval.
• l�
, ... .,
., .. _. ,,
. ,, , ,: . . . , . „ ,., ,
VILLAGE TEQUESTA -
COMPANY CIGNA UNITED HEALTHCARE
O en Access Out of Area O en Access - ECP4 Plan Out of Area en Access - 899T Plan
PLANS POS PPO POS �PPO POS
Benefits In Network Out of Network in Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
PHYSICIANSERVICF.S ]00%after 100%after 100%'.aRer 70%Of 100%atter o 70%of
70% after 70% aRer allow.ance ,, 7b%o afteC ; � 00 /o after
ffice Visits CO-PAY - PRIMARY $10 co- a allowance
Office Visits CO-PAY - SPECIALIST $20 co-pay annual deductible $�5 co-pay annual deductibl $� co-pay afterannual "�IS Go-pay annuai deduct�ble $�S co-pay after annual
P Y $ I S co-PaY $15 co i$13 co- a
deductible p y $15 co-pay deductible
� 70% of
I 00% after �0% after annual 90 o�a a �� 70 /o of 100% after �
INPATIENTHOSPITALSERVICES deductible 90%after 70%after allowanee 90%aHer ;70%after ;� allowance
$100 co- a annual aR�r annual annuat deduct�bl annual deduchble $250 Y after annual
p y +$100 co- a annual deductible annual deductibl per da ,
P Y deductible ` deductible $1 max.
deductible
70% of 7p% of
100% after 70% aRer 90% after 70% after �0% after allowance 9(W/o after . 70% at�er 100% after allowance
OUTPATIENT HOSP17'AL SERVICES annual
$50 co-pay annual deductible annual deductible annual deductibl aRer annual annual deductible annual deductible $200 co-pay after annual
deductible
deductible deductible
EMERGF,YCYROOMSERVICES 100%after 100%after 90%after 70%after 100%after 100%after 100°,/oafter '100%alter „' ]00%after 100%after
$50 co-pay $50 co-pay annual deductible annual deductibl $100 co-pay $100 co-pay $SO co-pay $50 co-pay ` $]00 co-pay $100 co-pay
PRESCRIPTIO;VDRUGBENEFITS 100%after 100%after 100%after 100%after 100°/aafter
Ceneric $5 co-pay NiA $7 co-pay N/A $S co-pay N/A $10 co-pay N/A $10 co-pay N/A
Rrand - Formulary Q15 co-pay $15 co-pay $25 co-pay $�5 co- a
P Y $30 co-pay
Brand - Non-Formulary $35 co-pay N/A $40 eo-pay $30 co-pay $50 ca-pay
Mail Order - 90 day supply 2 x co-pay 2 x co-pay 2.5 x co- a "
P Y 2 x co-pay 2.5 x co-PaY
CASH DEDUCTIBLE
Individual / Famil none $300 / $600 $300 / $900 $500 / $1,500 $250 / $500, $500 / $1,000 `$250 / $500 $500 / $1,000' none $500 / $1,000
OI.IT-OF-POCKET
(Individual / Famil��) $1,000 / $2,000 $2,300 ! $4,GU0 $1,800 / $5,400 $3,500 / $10,500 $2,250 / $4,500 $3,500 / $7,000 $2;250 / $4,500 $2,500 / $5,000 $1,500 / $3,000 $3,500 / $7,000
LIFF,TIME MAXIMUM unlimited $1,0OO,OUO $1,000,000 N/A $2,000,000 unlimited $I,000,000 none $2,000,000
MONTHLY RATES EMPLOYEE CURRENT RENEWAL CURRENT RENEWAL PROPOSED ARIZONA PROPOSED
COIINT
Employee 34 / 1 Retiree $345.42 $395.51 $652.64 $747.27 $371.33 $617.80 $381.17
EmployeeandSpouse 13/1Retiree $739.21 $846.40 $1,396.68 $1,599.20 $794.65 $1,322.09 $815.71
EmployeeandChild(ren) 10 $639.03 $731.69 $1,207.41 $1,382.48 $686.96 $1,142.93 $705.17
Employee and Family t 5 $1,036.27 $1,186.53 $1,957.96 $2,241.86 $1,113.99 $1,853.40 $1,143.52
MONTHLYTOTAL $43,288.36 $49,565.39 $2,049.32 $2,346.47 $46,535.12 $1,939.89 $47,768.51
ANNUALTUTAL $519,46032 $594,784.68 $24,591.84 $28,157.64 $558,421.44 $23,278.68 $573,222.12
COMBINED MONTHLY TOTAL $45,337 $51�911.g6 $4g�47S.01 $49,�08.40
OMBINED ANNUAL TOTAL $544 �052.16 Current $622 �94232 Renewal
$581,700.12 $596 500.80
* For Aut�l orized Benetits all, services and si .
1 h �s summary is not mtended to be a complete explanation of benefits of the proposed insurance policies. Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting
approval.
11 ••
,�
.�
�=: "
x fi _ . . _ - _ - _ - -
c� ' � " -
This is a summary of5enejtts foryour POS Cper: Access CoDayplan. Service speciitc mazimums accum:�lale in orie �firectio�:
(in-network will accumulate to our-oj=neiwork). Liletime mczrimums, our-ofpocket maxin:ums mrd/orplan deductibles do not
cross accumulate. All in-nehvork services »rust be perjornred oy tlte Prin:ar}� Care Pl�vsicia�r (PCP,1 or the in-nenvork Specialist
or approved by the ioca! Healthplan. CIGN�4 .°/iarmaer plan declucribles, out-of-pocket ma,;in:ums, copays and annual
maximunis do not integrate with :he employer medical program.
C�GIYA �eal�hC`are.l3en�fitS`ummu�y
� x� _ � ; ; A ���Irab e of �'�questa �` r '� ,
� : E � � ;
..� ��� � z,�� � .PO�' Open Acc�ss Copa,y Plr�n k� Y
, � � y � � _ 3 � � � � '�E .
� �'�� r - ^' �- g _:x � # L� � Al��r��#e .Pltzn 1 � � � ; Kt f ����e..
ra,__ _ �.� r, _-_ . �,- - S Fl - 2 r �- � '�x
..5' � §, :��.'�"E,
i � � o
• o �� er e ••,
i etimeMaximum nlimited I,OOQ,000
oinsurance Levels 100°•0 0°io of Reasonable and Customary
'ote: All services will be
overed at a 100°'o coinsurance
level; with or without applicable
o avs
Contrac! Year 13eductible
Individual one S00 per person
Family iLiaximum lone 1,000 pe; family
A re�ate es
es
nnual Out-of-Pocket Maximtim
Includes Coinsurance . ot Appficable es
I»cludes Deda�ctitile N 0
Includes Copavs Inpatient Faciliry and Outpatient Inpatient Fac;tit�� and Outpatient
aciiity capays only aci]iry deductibles apply
._ Individual �1,500 per rson �;
pe ,000 per person
Family Maximun: 3,000 per family 6,000 per family
Age egate es es
Does No� Apply To opays not listed above and plan I�*ion-compliance penalties,
I �eductibies eductible or charges in excess of
i ,
I I easoriatiic anu Custcirrtary �
��nce the Qut-of-?ocket �enefits for �ecident or sickness
vta ;imum is reache�l, inpatient �excluding mentai heaitn, alcohot,
acilitv copays (including r.d dn�g abuse benefits) are vaid at
H/SA) and outpatient facility I 00%, once an individual's out-of-
o avs wili no lonaer be reauired ocket has been reached
utomatic.tteinstatement ot Apnlicabie
�ciBF Sviiaii�Gi;S vi ✓Gi1f iicali}l.
E:ii�LiA rieai€is€.:a=� Page 2b
- � � s � � 0 � ' B � � � �
Pl�ysiciaii's Scrnices
P7'lfllUl:V Cnre 1'l�t�.srciun's Offrcc ri,ri� tio chargc aftcr S 10 per off icc 7U% aftcr dcductiblc
visit copay
Spec:olrn Cu�•e Pl�ysiciun's O fce G'i.sir No charge after �20 per office 7Q"/� after deduciibic
Q(Tce y'isrts isit copay
Corrst�han! anc! XcJerru! Pliysician's Services
Surge,�� Perjonned hi �he Plrysician's Office No chargc aftcr per officc visit 70% aftcr dcductibic
ooay
A!lerg}� Ti•eatn�enl//njectia:s o charge after either the office 70% after deductible
isit copay or the actuai charge,
vhichcve; is less
A!lerav Serum (dispense� by 1/re pJ�i�sician in the No charge ' i0°io after deductible
o �ce)
Preventive Care
� Routine Prevenlive Care.• LVell-Baby, R`e!1-Child, o charge after per office visit tn-network coverage only
_ Adult anci 6Ve11-Won:an (in�lttding inrnuulrzations) op2y
Inimwtizarions No charee
outine Mammograms, PSA, PAP Smear o charge 0% nfter deductible
applies to a�ry placQ af service) IVote: The associated wellness ote: The associated wellness
.xam is subiect to the office visit cam is not covered
o a �
econd Opi�rio�ts o charge ar"ter speciaiist �20 per 70°�o after deductible
(Seivices will be rovidetf on a vo(tsnta • basisJ ffice visit copav
- utpatient Pre-,qdmission Tesring
_. Prin�ary Care Plivsiciaa's Ojfice Visi! No charge if only x-ray and/or lab 70% after deductible
services; � 10 per office visit
• ooay if other office visit services
;- Isa provided.
• Specialist Plrysician's Offrce Visit o charge if only x-ray and/or lab 70% after deductibie
ervices; specialist $20 per office
- �isit copay if other office visit
: I cPryirPS 2�SQ r ^.iOY!d?!�.
Oz�rpatie::t Hospi:�! Facility �lVo charge for r-ra_yrlab if billed 7Q% after deductible
I
uY � Scp8i3iC �liiNaiiBili �i2�il65tiC�
I facility such as a hospital
No ch2rge
/ndependent X-rav aad/or Lab l•acili��� 70% after deductible
�fia jrutient !iu�pitai - Faciiiy ServicYS ivo charge 3iier z2�G per 7�7°% after a?SG per;�dmission
� dmission copay eductibie and plan deductible
I Senii-Private Roone and Board Limited to the semi-private Limited to the semi-private rate
egotiated rate
Frivate Rooni �Limiied to the semi-private ILimiied to ihe semi-privaie rate
e2otiated rate
Soecia! Cm•e Units (ICU/CCU,1 Limited to the ne¢otiated rate Limited to the ICU/CCU dailv rate
�G�apatient Facilitp Services tvo char�e after �125 per vi�it �7Q% after $125 per visit deductible
� Clf?cYQlliis �v0lTi, R2CvYc1"y% nOOIYI, �i'OCei �OGi]i � copay
and ,Trcat�rten! R.oa�r I I
xoatteru Hosnita[ Phusccia�r's i�isit.c,'�'n�ts�rliarinrts INo charee h0% after deductible
� ��ii@i Sviiii%Oi�S fOi l%OUi ri@a{tti.�
Cac���ca?cr�:e Page Z7
;a �:� t �x� e a , e . .
npa�ie�rt Ilosprra! Proj essional Serrices No charge � 70",b after deductible
Sru;��con
Ructrvlogis�
Pa1linlo�ist
An c�sN�c�.rioln ��Lc1
fultipleSurgrcal Rcduclion Not Applicablc Multiplc surgcrics performcd
uring onc opc.atin� scssion result
in paymcnt rcduction of SO;o to thc
urgcry of icsser chargc. Thc most
xpensivc procedure is paid as any
ther surqcry.
Orrtpatis�rt Professio�ral Services : o cnarge 70% aftcr deductible
Surgeon
Raclioiogist �
- Palholooist
�. AiieslhesioloQrs!
mergency and Urger►1 C'are Sen�ices
_ Plrysician 's Ojfrce o charge after $10 per office o charge aftcr $! 0 per office visit
isit copay opay **
- Hospilal Emerge�rcy Roon� o charge after �75 per visit o charge after $75 per visit
opay** (Copay waived if opay*"
admittedl
- Urgen� Care Facilily o�� o�,�n�,r;e,�� r-a�u�r� ivo charge after �3�. per visit No charoc after �35 per visit
opay** (Copay waived i� copay**
Anrbulance dmitted) **
l ivo charge o charge**
--- x* !f not a true emergency, **If not a true emergency,
.. ' ervices are not covered �ealthplan approval is required for
overage at the plan's OON
`"-' oinsurance level
T;'° i�patieni Services at Otlier Healtla Care Facilities (No charQe 70% after deductible
Includes Skil[ed Ni�rsing Facilily, Re/rabilitation �
Hospital a�ed Sub-,4cute Facilities I
60 days maximum per contract year
No prior hosaitalization reQUired i I I
"aooratory a►rd kadioiogy ,5ervicQs
Rln'Is, CAT Scans and PET Scuns �ir(o charae after S50 per procedure �70°io after deductible
No1e: tlie cop�t• appli�s ai a pe�- pr•ocedsu•e basis, �or� opay u I
a�ty place of service
• Associate� aircilfr�ry �{it�rges ure,t�hject to �he
applicaoie place oj service coinsurance level, place o I (
service copav �zndior p�an deductiGie je.g. injections, ' I
clve, eic.J
01her Labora�on� und Radioloo Services:
Oi�[pntien! tiospita! Faci[ity 'o charge 70° o afte: deductible
lr:de^er.de;r; :Y-rav a;�c� :;r Lab Facilr:;: ^:o c�ar2� 7�;�c afte� deduc:i�!e
� x
.'�`�Ri1 �G;:�.'" ��l:.��inr { pC fCjrrr f?$��tf).
�I�u� ?-iralrn��r,• Page �8
: a► � . a �, 0 . � s � � • e � + era
�Otupalicru S/tort-Ternr Rehahili�alive Therapy axu No char�c aftcr spccialist �20 per �70°o aRcr dcductibic, �iU visits per
�Cliiropracric Sen�iccs ��isit copay, GU visits combincd ontract ycar
�aximum per contract ycar
Includcs:
Cardiac rchab
Physicai Tncraoy
Spcccn Thcrapy
Occupational Thcrapy
Chiropractic Thera v(inciudcs Chiro ractors)
ome Healtk Care No charge . 70% after deductible
Maximum: 0 days per contract year with a 0 days per year; reduced b�� any
� 16 hour a dav limit in-nctwork visits
ospice No cfiarge In-network coverage oniy
s •� lnpatient Services
4-.'
ote: If plan includes an inpatient
ospitai copay, the copay does not
pply.
_ - Ou[nafierr! Services , �o charQe
Bereavernent Cou�rseli�rg In-nctwork coverage only
Services Provicfed as part of Hosprce Care o char�e
Services Provicied bv Mental Nealth Projessiona! overed under Mental Health
"' benefit
arerrriry Care Services
�;;, lirilia! Visit to Confirnt Pregna�acy o charge after per office visit
' �op3y 70% after deductible
Yi
'- ° Al! sz�bseauen� Pre�ra�al �isi[s, Posuratal Visits a,rd No charge 74°io after deductible
Delivery
Delivery (litpatie�rl Hospilal, Birlhi�io Cei:ter) o charge after $2�0 per 70% after $250 per admission
_ �dmission r��ay eductible 2n� plan c�ed�±ctible
�
I e r.,....;c:: I I
" ncludes efecrive aird non-e!eclive procedur�s
OJfce d'isit Ne �harge afte: per �ffice visit �7Q°io after dedu�t�ble
co�ay.
l��patienl Faciliq� o charae after �250 per 0°io after T�?50 per admission
dmission copay eductible and olan deductible
_._ Uutpatient Suroical Facilitv '��Jo chargs after $12� per visit �70% after $1 �5 per visi[ deductible
I copay
_ � Fhysician's• Se-vices �ivu char�e I�Ciu aii2" uBt�iUCii�iB i
_ �+��� � r. •• r� r c� r� ii n c� n r r'r� lf `rs rd�f
uc�cr ov�'u'uCi �.� Tvi jfOU� u�a�t: �.
' Page 29
�iisi'�irt :iL2ii�'!�1::
- s .� i� ° � �' � � .� , •� • �8 �.
Faniil�� Plan�ri�rg Srrvice.r :
Qfjice Vi.crr (tests, ca��r.�•elin�,�) �No chargc after per office visit 70"/� after deductibie
opay
Sur�icnl Slerrlizalin�r Procedr�re.r fnr
Va.rec�on{��/Trrbal l,r�n�rn�r (c:rr.luries rci�eisnls) Notc: Chargcs billcd by a scparatc
utpaticnt diaenostic facility will
- c covered undcr the plan's
Laboratory and Radiology bcnefit
hrpatie�tt racility o chargc aftcr �250 per 70% aftcr 5250 per admission
dmission copay educiiblc and ptan dcductiblc
Ou��atren! Facilily No chargc aftcr S i 2� per visit 70% after � 125 per visit deductibie
- opay
Plrvsician's Services o charQe • 0% after deductibie
nfertiliry Ti•carnieru ot Covered ot Covcrcd
c:: ervices not covered inclucie:
Testing performed specifically to determine 1he cause
�. of i�rferiilily.
Treatmeiu and/or procedures performed speciTcally
� to restore fer(ili{i� ("e.g. procedures [o correct an
inferlilily conditionJ.
Arti�cial nlea�:s ojbeconii�rg preg�eant are ("e.g.
_ Artificial /i:sentina�ia�, I�t-��ilro, GIFT, ZIFT, e1cJ.
ote: Coverage will be provided tlle treaurie�tl ojari
uider/ving medica( condiliar up to tlre poirtl an i�tfertility
ondilior: is diagnosed. Services will be coverec� as aity
"'�• [her il/ness. �
#� Organ Trmrsp[ant
(n-network coveraee only
ncl:rdes a!1 medically appropriate, non-experiiuenla!
:'.;' ransplants
±_> Office Visit , o charge after specialist $20 per
ffice visit copay
f _, Inp¢tient Facility 'o charge after $250 per
:;°`` dmissic,n cop2y
_ inpatient Physicim:'s Services o charge I
" � C `��"'�""'� jjj1fO � 131�J,UUU DET ti3fI5D13fIVbC� No[ covered
Lifecime maximum {oniy
available when using a Lifesource
• .F2C:! 1 T." )
trrable �Yledicttf Eqr�ipme�rt No charge In-network cover2ge only
3,500 maximum per contract I
_ ote: Services acce�nu{/ate to the plan 's Lifetime ear
fr_ximun:
xterrral Prostlreticrlpplia�rcr�s No charge after $ZOG EPA In-net�vori: cove;age oniy I
- �leductible I
l A�JO maxim4m per contract I
ote: Ser accunttela[e to the lan ; Lifelime .h4aximun ear
���� �E�( .SUlU:`.'L: I S n . � y vv r i r 3 °8�I h..iiYi
CIrNt� xe«�ltta�arc
P�ge 30
: � � .1 Ci' ' e � : � � e . .
Jexla! �are � � � $ '�'
.rnuferl !a chni�;es nrncre jnr u coirli�rtrotrs cn�n:se oj�ieir�n! �
rcnlmtnt .rlarfer/ �t�Nliin si.r nu�rilh.s r�ju�i injur� lo s��und,
+a�m•a! tee!!�. - .
1'lii�siciuir'r Of�cc� o chargc aflcr per officc visit I70:o aftcr dcductiblc
opay �
����a,;�„r r-a�,i,�v No chargc after $250 per '70°/a aftcr �25U pc: admission
dmission copay cductiblc and plan dcduciibic
Ourpa�ie,rt suroica! Facilirp o chargc after 512� per visit 70% aftcr $124 per visit dcductiblc
Plrysician's Services opay
o char�e 7�% aftcr deductibie
urgicaf and Non-surgical i MJ In-nctwork covcragc only
rovided on a Iintited, case by case, basis. Always exdu��
pplimrces and orlhodoirlrc lrealn�e�it. Subject to nredica!
recessit v.
z _ _ Plrvsician's Ojfrce No charge after specialist S20 per
ffice visit copay; No charge for
-ray/lab if billed by a separate
utpatient diagnostic ;aciliry such -
s a hospi[al
Inpatien� Facility o charge after 5250 per
dmission copay,
- Oulpalient Facili[y o charge after Sl?� per visit
- opay
Physicia�r's Services 'o char e
outine Foot Disorders : ot Covered Not Covercd
Vision Care
In-network coverage only
�'�� Eye Exam everv. /? nionths. �10 per office visit c�pay
Eve Glasses/Contacr Lenses no� covered
rescript�o�r Drugs
:'' ClGNA Pl�arrnacyPlces Retai! D�zrg Program 10 per 30-day supply for generic In-network coverage only ,
`' rugs
Ceneric Push, Incentive Fonnufary Plan 20 per 30-day supply for
s='_? referred brand-name drugs
ncludes ora! con�raceptives and catlraceptive devices $40 per 30-day supply for non-
I preferred brand-name druas �
°i�armaevueuucrible(IVIailOrderExcluclerl) I None �� `
'one
- plsa: macy Out of Pocket iLl�crimum �Mail urder INone �
c/uded) f None
I
CIGNr1 Te.-Drrrg �1�uij Oraer Iirug f�rogram � Z� per 90-day supply for generic f n-nenvonc �overage oniy
• 'rugs
veneric Ptts{t, Irrcentive Fo;;r::ilary Pian �» per 90-day suppiy for
referred hrand-nzme dn!js �
Incfudes ora! contrccep�ives and con[raceptive devices 11 � per 90-day supply for non-
reierred brand-name dru s �
�(-''L:�'r'�S:.�l�.ltf�nc �nr in. i�i-.j�
� ..� y�Jf r"lEarcir.
CY�11IA �IealthGare Pr�ge 3 :
: .� E"�e' si "st C'Je g + ��p i p .� p ' � � � � .
uhsrance Ahuse De�oxrfrcntion Services o char�c aftcr 52�0 per !n-nctwori: covcragc oni}'
lnnnlicnt � dmission copaY,
�enta! Ncalt/i anrlSuhstance Ahuse Rrhahrfi�ari��e
cr��iccs In-Nctworh Only
lnpntreu[ Men�ul llenllh ,Sc�r•vices No chargc aftcr $50 per day copay
'S dvt;s �naxir�l�un per �Lfemhe;• per• C�onlracl
}'car rncludes Subs�airce Abr�se Relrabilr�ation
daYs
Oulpatient lirdividi�n/ Mental Healdl Services
10 visits n�arimun� per A�fember per Con[ract o charge aftcr �30 per visit
Year ^opay
Outpatie�rl Menta! Heal[ii Group Therapy In-Nctwork Only
�0 vrsils maxinr�ur� per Member per Co�rlroc[ . o charge aftc; $1 � per scssion
year inch�des Substance Abuse Reliabilitation opay
- vrsits
== lnpatient S:�bslance Abuse Rehabililation Services
25 days marinnun per Member per Cvntraci � o char�e after ��Q per day copay In-Network Oniy
.;�• }'car indudes �eii[a! Hea11h days
Outparie�tt l�:dii�idi�al Substa»ce ,9buse Rel�abilitation
- Services
'0 visits maximum per M�ntber per Co�rtracl �'o charge after $15 per visit !n-Network Only
year opay for the first 2 visits and $30
cr visit thercafter
Ou�patrent Grocrp Substance Abuse Rehabilitatio�r
Services
_ 40 visits nraxinrt�m per Member per Con[ract o charge after S15 per visit In-Ne:work Only
�`- Year includes �Ylenta! Health visits �CO av
�__ .
- re-Existi�rg �o�rditiorr Limitatiorr (pCL) �ot Applicable Applies to ar.y injury or sickness
for which a person receives
- reatment, incurs expenses or
� receives a diagnosis from a
hysician during the 90 days before
he earlier of the date a person
_ begins an eligibility waiting period
r becarnes insured fur these I
I I benefits. Coverage for the nre- '
_ I existing condition is exciuded untu
ne year of the member being
I continuously insurzd and;or is
atisfying a waiting period.
i
Usuailv the P�L is waived for the
initia( eroup, but if not, the insured
ill receive credit for any portion
of the PCL �vaiting period that was
atisfied under the previous plan if
hey are enrolled in the subsequenc
lan within G3 days (or the
• pplicab!e :imeframe req�i:�d pe,
I � taie iawi. j
r - uciici JVfUIJI i'vi yvi.ii i caif{'1.���
PQ�'� j.-��
�i� ie'es ;ii:ii i C.3�Fc.°C
,
: � � " st�i • g e • � @ � ,�,
Pre-Ad�riission Certificarrair-Contiiu�ed Sra�• Reriew ICoordinatcd by PCP Mandatory: Employce is
(reqr�ircrl nl1 hipa�ic�i1 Atlnris.clar.$) csponsiblc for contacting thc
Hcalthplan
Pcnaltics for nor-compliancc: $SQO
cnalty appiicd to hospital inpaticnt
, nargcs for failure to contact
Hcalthplan to prcccrtify admission.
E3enefits are denied for any
dmission rcvicwed by Hcalthplan
• nd not eertified.
r: _ 8enetits are dcnicd for any
dditional days not certified by the
l,tr'.
Health lan.
Case Ma�ru;eineu� oordinated by Healthplan. This is a service designated to provide
ssistance to a patient who is at risk of developing medical
omplexities or for whom a health incident has precipitaced a nced for
= ehabilitation or additional health care support. The program scrives ro
ttain a balance be[ween quality and cost-effectivc care whilc
aximizing the atienPs oualitv of lifc.
__ Benefit �Exclusions (by way af example but not di%:ited to):
Your plan provides coverage for medically necessary services.l'our plan does not provide coverage for the following except as
required by law:
:�::; l. Services that are not medi�ally nec�ssary, except specifically outli7ed preventive care;
=• 2. Charges which the person is not legally required to pay;
3. Cfiarges made by a hospital owned by or performing services for the U.S. government if the charges are directly related to a
_ sickness or injury connected to military service;
-. 4. Custodial services not intended primarily to treat a specific injury or sickness, or any education or training;
° �. Experimental or investigational procedures and trsatments;
�. Cosr�eti� surgcry u� ii�e� perfurmeu to improve selCesteem uniess: (aj a person receives aij in,jury wnich resuits in oodiiy
_ damage requiring surgery; (b} it qualifies as reconstructive surgery performed on a person following surgery, and both the
surgery and the reconstructive surgery are essential and medically necessary; (cl it qualifies as reconstructive surgery
r"oilowing a mastecromy, inciudine surgery and reconstruction of rhe other breast te achieve symmetry•.
i. Reports, evaluations, examinations, or hospitalizations not required for health reasons, such as employment insurance or
gov�mment licenses and courc ordered forensic or custodial evaluations.
8. Treatment of the tee;h or periodontium, unfess suc� expenses are incurred for: (a) churges made fcr a continuous course of
dentai Treatment siarted � :-ithin six m�n;ns of an injury ta scund na:uraE teeth; (b} c5arges made by a nospiiai ior Bed ana
Board or Necessary Services and Suppiies; or (c) cnarges made by the ouipa[ieni department oi a Hospitaf in connection
with sur'ery.
9. Reversal of voluntary sterilization procedures, and certain infertility services;
10. Transsexual surgery and reiaied services;
_ 1 1. Treatment for erectile dysfunction. However, penile implants are covered when an established medica! condiiion is the
ca�se of erectile dysfunctior:;
12. Therapy ro improve genera! phys:cal conditio^:
13. Personal or comfort items such as personal care kits, television, and telephone rental in hospitals;
14. Eveelasses hearing aids or examinations anel prescription fitting, except as provided in the Ce:
t�. Certain intemal or external prosth °ses, er replace ot extema? prosth due to �.vear an� tear, I�ss, th�ft or d°struction;
�. iU. �U��IC�!! `ll'�1:I:IC'ItL ( COfT�CiI011 CI i°iFaC.tVB �°.� inc�udine i3413i KPi3[OLOiiIV:
I/, YTeSCCI�TIQII Zilll [1() �r1�OC PV .^,C�L 8c nrQy:C��� !!: :�!° �`���F�� ���!'.Q:l Of tl�;e Car-[it�r�t��
r ,
` � ; +' c, u c. SA�
�E��i SO�tiiiOrS fvf t%Oiii �iEa�u�.
- Page 33
C�Gl�� :Hes��hCare
1 S. Routinc foot carc;
19. Amnioccntcsis, ultrasound, or any o�hcr procedures rcqucstcd =oic!4� (or scx dctcrmination of a �ctus, unlcss mcdically
ncccssary to dctcrminc thc cxistcncc of a scx-linkcd gcnctic disordcr;
20. Any injury resulting from, or in thc coursc of, any cmploymcnt for w�gc or profit;
21. Any sickncss which is covcrcd undcr any �vorkcrs' compcnsation or simiiar law.
32. Ch�rgcs ibr ovcr thc counicr disposablc or consumablc supplics, including onhotic dcviccs.
23. Chargcs in cxcess ot'rcasonablc and cusromary limitations;
` 2�. Chargcs for mcdicai and surgical scrvices intcndcd primariiy for thc trcatmcnt or control of obcsity which arc not Mcdically
tvecessary. Excluded scrvices include, but arc not limited to, wcight reduction procedures designed to restrict your ability to
assimilate food, such as gastric bypass, gastric balloons, jaw wiring, stomach stapling and jcjunal bypass.
25. Certain Durabie tvtedical Equipment (rJME).
2G. Non-mcdical ancillary services, including but not limited to vocational rchabilitation, bchavioral training, biofcedback,
neurofecdback, hypnosis, sleep therapy, employment counseling, back school, work hardening, driving safety and scrviccs,
training, educational thcrapy or other non-mcdical ancillary services for learning disabilities, dcvelopmcntal dclays, autism
or mental retardation. '
27. Cosmetics, dietary� suoplemcnts, health and bcauty aids, and nutritional formulae.
This chart summarizes the bencfit pian you requested; it has not bcen adjusted to reflect state benefit mandates. A complete
description of the terms of the coverage, exclusions and limitations, including legislated benefits (if anplicable), will be provided
in your Certificate or Summary Plan Description.
Beuefrts are insured and/or acfntinrstered by Connectictd Genera! Lije hrsurance Conrpar�v.
"C/GNA Heal�/iCare" ; e�e; s to various opera[iirg subsi�liaries ojClGNA Corpo�•atio��. Producu mid services are provided by
these subsidiarres and riot by C1GNA Corporation. Tfiese s:�bsidraries include Connec[icut Genera! Life /nsurance Cartpan,y, �
�-, CIGNA Visiou Care, /nc., Tel-Dnig, Inc. and irs aJftliates, CIGNA Behavioral Hea(th, /�tc., Ltlracorp, and HMO or service
k company subsicliaries of CIGNA Health Cornoratiai mtd CIGN.4 Deirtal Neafth, Inc. "CIGNA Te!-Drug" reiers to Tel-Dru,g, Inc.
and Tel-Drug ojPennsylvania, L.L.C., whicli are also operalrng suosidiaries of CIGNA Corporation.
,��'�:.:
�:
�: l
� J1Yl
\I' �c ici Sv�i.itiOrS fOi yOUi iica�i�
_. Pa�e 34
C. tN�::�::Z�::u,.�
Tl�is is n suntnrnn� n�n�ne%rl.r ��nrir POS Open :lecess C'npm• pinn. Seri�r�e spc�rific ma.rinr«nrs accumtrlale in �ne di�•ec'linn
(in-rtc�r�rork �rill nc�u�nnlure !o rn�t-o; nel�rork). I,i(elime �na.tintw�is, orrl-n/-por.6e ma.�inrums apd/or pian derlurlin/e tin no�
cvn.�_s uca�nlirlrrte. iill in-nr�it�vrk ser•vice.s ni�rst be pe��ormerl hi� �/�e /'ri�narr C�ure Pln.�sicirnr (PC'/') ur tl�e in-ilrnvnrk ,Speciulis�
u,• npprrn•rrl hi• rl�c incnl /lcallliniui�. C'1GN;1 Phnrmuc�• plun ricdut7ihlc.s, ntrt-n�pnckc 11I[1.YNli1!l7Lti, CO�)C1llS CIA(I Ulltll![II
u�a.rinn�nrs do nor inrc�;rme wi�h dre en�ployer nret�ical progrnnr.
+C�GN�9. .��alth�are Ben��� Sumr,�a�-y
6�illage o� f' �'eques�sa
I'(1S �pen �cce�s �`opr�y �'lan
;:: Alts�nate Plaaz 2
: � M °0�! : 1 +r�'C • t •••
i(etime Maximiun Unlimited �1,Q00,000
Caif+surance Leveis 100% 70% of Reasonabie and Customary
ote: All services will be
_ overed at a 100% coinsurance
level; with or without applicable
opa �s
Cattracr Year Deductible
: lndividual None 500 per person
Famify �blaximu�r� None �,000 per family
.4 re,gare Yes 'es
nnua! Out-oj-Pocket ,tifasinuun
- lncludes Coinsurance ot Applicable es
' Includes Deductible o 0
/�icludes Copavs 3npatient Facility and Outpatient [npatient Facility and Outpatient
Faciiity co�ays oniy acility deductibles apply
/iidividtral 1,�00 per person 3,000 per person
Fanuiy Maxintum 3,000 per family 6,000 per family
Aggregate es es
: Does Not Appfy To Copays not listed above and plan � on-compliance penalties,
' � �iCui3CCi1"i�ES a 2tiilCiivlZ vi Cii2i �ES iit ZXC255 �i I
� Reasonaoie and Customary �
�nce the Out-of-Pockec Beneirts for accident or sickness
Maximum is reache�, inpatient excluding mentzl heal:h, alcohol,
facility copays (including nd drug abuse benefits) are paid at
MHlSA) and outpatient faciiity IIUO%, ance ar individuai`s out-af-
,co a�s will no Ioneer be re uired ocket has been reached
• utv�r�afic Reinstatemene �ivot A plicaolc
� �Ir�i in �i �r ' ci 1 SM
�,:. �ef:er s�,u�i�r,s ,,,; �o�, ,n�a,tn.`
� PaQe 41
i IGNt�H�aitt�Care `
: 1 ° 1 �1! � •' � • �0;
lfysicia�i's Seruices j �
Priniar�� Curc P �„�,�,��«r,� :,� ������� ri.��rr No chargc aftcr S 15 per officc 70"/o aftcr dcductiblc
isit copay
- .Spccinlrr Cnrc Plii:cicinfi's Qj�cc VLsi� , o chargc aRcr �25 per officc 70% aftcr dcductiblc
Uj�r.e Visi�s isit copay
Cars�drani and Rej erral Physicia�r's Services
Surger�� Per fornred !n tl�e Plivsician's Ojfrce No charge after per office visit 70% after deductiblc
. opay
�tl/erg� Treaurrent/lnjectio�rs No cnarge after cither the office 70% after deductible
isit copayor the actual charge,
nichever is less
Allergv Serum (dispensed by the plivsicinn iir tlre o charge ' 70°/a after deductiblc
o(rce)
reventive Care
``� Routine Preve�rlive Care: We(!-3aby, Well-Chitd, o charge after per office visit (n-network covera2e oniy
a::-
Adcdt and Well-Wouiai (inclerdiitg immuniza[ions) opay
- l�nmunizatiars No charee
ourr�te Mamnrogranrs, PS.A, F,4P Smear No charge 70% after deductible
applies ro any place ojservice) hote: Thc associated wellness `ote: The associated wellness
xam is subject to the office visit xam is not covered
ooav �
econd Opinions No charge aiter specialist �35 per 70°io after deductible
(Services 3vi11 be rovided at a volttnlurv basis) ffice visit co av
Outpatient Pre-Admission Testing
=�'�- Primary Care Pl�ysicion's Ojfice i�isit No charge if only x-ray and/or lab 70% after deductibie
k' :--
services; $ I S per office visit
�_,: opay if other office visit services
Iso provided.
`:�� Specialisl Physicimi's OJfrce t'isit o charge if only x-ray and/or lab 70°% aftes deductible
ervices; specialist �25 per office
isit copay if other office visit
- ervices also provided.
Oulpalient Nospital Facility o charge for x-ray/lab if billed 70% after deductible
i. y a separate o�.itpatient cii�gnocri�� i
I facility such as a tiospital
No charge
Mdependent ,� rav and/or- Lrb Facilit � 70°rb aiter deduciibie
npatie�:t Hospi�al - Facilit�- f� rvi^ys �?�!a char�e after �2�4 pe: day ?Q°,•o af:e: �250 per da,� ced�c,ibie
copay • nd plan deductible up to 3 cooays I
uo to 3 co�ays pe* admission er admission
Semi-Priva�e �ioon: and Board (Limited to the sPmi-private Limited to the semi-private rate
_ Inegotiated rate
. Private Roar� Limited to :he semi-private Limited te th� semi-private rate I
negotiated rate
S CCf¢I Cm'C Ur1t1S (ICU/C Limiteci to the nesotiated rate Limited to the ICU/CCU dailv rate
utpatisnt Fa�i!:t}� �err•ic�s Nc charje aite� �,'_'Su pei visit �'0°o after $250 per visit deductibie �
Operaiir:g Roon:, Recove;y Room., P; ocedure ,°,oam I opay i i
and Ti•eau»ent �ioont
n ati�ra: Hfls�itai ?levse�iar:'s �'isirsl�orzsult�da:zs i �o charae 0`;b a;ter deducdLic i
C A
� ��u�� s�ii.lsi��t:s f�, y� k.oalth..
._ n�� a�
�If�P+�s HcalthCare
q fl �f c7 :. rr e•,� o !P 9 + i'�
�rparie�u Ilo,�pitai Projessrona! Scrvrce.r No cnarge 70% afte, deductible
.S'ur�,�eon I
Xadinlogrsl
PalhoJogisl I
ArreslhesioJo,�rsl
ulliple Srrrgical Reductio�r �Not .4pplicabic Multipic surgcrics periormed
urin� onc operating scssion result
in payment reduction of 50% to the
urgery of lcsscr chargc. Thc most
xpcnsive procedurc is paid as any
thcr sur�crv.
Outparie�ir Prafessiairal Services 'o charge 70°io after deduc[ible
Surgeon
Radiulogist �
Pathologis�
A�testhesio% ist
mergency aird Urgen[ Care Services
�.:,
Pl�vsrcian's Oj�ce No charge after �IS per office o charge aftcr $1 � per office visit
isi[ copay opay "*
Hospilal Eurergerrcy Roonr o charge after �100 per visit o charge after $300 per visit
opay** (Copay waived if �opay**
dmitted)
Urgen[ Car•e Facilily or Oertpalrent Facili[y o charge aftcr �50 per visit No chargc after $�0 Fer visit
;,. ooay#� (Copay waiveci if opay**
dmitted) -
Am6ulance o charge** i o charge**
� *# !f not a true emergency, **If not a true emergency,
services are not covered ealthplan approvaf is required for
overage at the plan's OON
_ oinsurancelevel
npatie�rtServices at Otker Hea[t/: Care Facili[ies 'o cnarge �70% after cieductible
/ncludes Skilled Nzrrsing Facili[y, Reirabili[ation
Hospita! and Sub-Acu1e Facili�ies
60 days maximum per contract year
` No rior hos itaiization re uired + I
Il ��� r=:a:� »::d P,a�ia:�sy .,re; v:ces �
MRls, CA.T Scarrs and PET Scans �Jo charbe after �50 per procedure I 70°io after deductible
Nole: the copap applies on a per procedcsre basis, for copay V
any piace oj sen�ice
�sso�ia,�d anc.ill�r✓ c;rarges are sz�bjec! io i'r.e I
_ applicable place oi service coinsurance level, place o
-- . service copay aricUor plart deductibl IB.�, InIG{.LIQII.}� I
I dve, e�c.j I I
_ I � I
Other Laborcrtorv mid Kadioloo� S'ervices:
Oi�tpatien[ Hospilai Faciliiy No charge 70% after deductible I
litci'epe�fric�rl X-� �cy ai:di��r i.,a6 Fr�ciiirt� No charoe 17O�i �f[?r dec�uctibie
`' f32f�ar .$����:t,'Q."tg r� j �� u �. h? y � S•Lf
�
CIGNA?-�ea!th�ar Pa;e 43
_ .9 t� I i I�d ' Y): A 0 ° 1 0••
rdpari�nt Slrort-Ternr Reirafiiivarine i i�erart� arrd �No char��c aftcr spccialist S'_5 pc� 70'% aftcr dcductibic, GU visits per
Ci+iropraclic Scrivccs visit copay, (i0 visits combincd ontract ycar
maximum per contract ycar
(ncludcs:
Cardiac rchab
Physical Therapy
Spcech Thcrapy
Occupational Thcrapy
Chiro ractic Thcra y(includes Chiroorac,ors)
ome Heaftlr C'are o charge • 70% afte; deductible
Maximum: 0 days per contract year with a 0 days per year; reduced by any
-� i G nour a dav limit in-network visits
ospice o charge In-network eoverage only
Inpalien( Services
Note: If plan includes an inpatient
ospitai copay, the copay does not
oply.
D«t a(ie��t Services o char2e
ereavement Cowrseline �fn-network coverage only
Sen�ices Provrded as part of Hospice Carc o charee
Services Provided 6�- ,Lfen�al Healt/� Professional overed under Mentai Health
• benefit
urcrrriry Care Services
;;�� /nirial Visi1 to Confinri Pregnar,cy �o charge after per office visit
opay 70% after deductible
-- All subsequent Prenalal visits, Posrnara! G'isits and o charge 70°'o after deductible
Delivery
Delivery (l�ipatient Kospital, Birthi�ig Cen[er) o charge after �250 per day 0% after $250 per day deductible
copay nd plan deductible up to 3 copays
� to 3 coo2vs er admission er admission
s) �nr/!n!! I I I
ncludes elective and non-elective procedures
OJfice 6'isi� Ne charge after per office visit i0% after deductible
opay.
/npatienr f'ucifity o charge after �250 per day 70% after �2�0 per day deductible
copay up to 3 copays per �and pian deduciible up to 3 copays
dmission �per admission
Otrtpatier,t �urgical �'acility �o cnarge afier ���0 per visii i70% aiter �2�0 per visit deductible
opay
Pht-srcian's Seri�rces No charee 70% after deductibie
�i��P ��f i ll� C r f✓� !li � S �
�i�jy Q..i.,.! SJlJ_I_.�J:. 1�. � J J..d._�.
e Pa�e 44
CYGi+lN Health�'are
: � � �a . t r, � s�: �. t � s ;a e a , a . ,
Fanrily� Planrrir+g Seri�icrs I
O�fire Vrsr� (res�s, caursc�li,c�) No chargc aftcr per officc visit 70°�o aftcr dcductiulc
�P�Y
Srn•gicnl Slerrli�nliar PrnCCdures �2r
Vnsec.�omti�iT�nc�l! l.lg�rtrun (e.rclurlc:r rc��ersalsJ Notc: Charges billed by � scparatc
utpaticnt diagnostic facility will
uc covcrcd undcr thc plan's
Laboratory and Radiolu;y bcncfit
lirpatie,�t Fac.iliry �o chargc aftcr $?�0 pc; day 70% aftcr 5250 per day dcductiblc
opay up to 3 copays per nd plan dcductible up to 3 copays
dmission � er admission
Ourpa�ren[ Facili[y 'o charge after �250 per visit 70% after i250 per visit deductible
ooay �
Plivsician's Services : o char�e 70°% after deductibie
n(erti(itt: Treutment Not Covered Not Covcred
ervices not covered include:
<'` Testi�rg�erfornrecf specifrcally �o deterruine [!re cause
oj injerlititu.
Treatment and/or proce�tures perjormed specifica!!v
to restore jerl!lity (e.g. proce�ures !o correc! an
" irrfertilily co�iditio�t;.
�trtrfcia! n�eans ofbecomirrg pregna�rt are (e.g.
Arrif cial hisentination, In-vi�ro, G1FT, Z/FT, etc).
_ ote.• Covera�e will be provided for Ihe Ireatntent oJan
:.=; nderlying niedica! conctifion up to the point an infertility
�=' ondilion is diagnosed. Services wi(! be cnvered as anv
ther illness. "
Y., rgan Transp[aut In-nenvork coverage only
:: , ncludes al! medically appropriate, non-experimental
�;s ransplanls
OJfice Yisit tvo charge after specialist �25 per
`�"'= ffice visit copay
lnpatien[ Facilirv No charge after �250 oer day
` � jcopay up .0 3 c�pays aer I � I
I �"d��ssicr� �
/npatient Physician's Services o charge
Travel M�xinttun.. �10,000 pe� transalant/per ot covered I
Liieti�re ma;.imum (o�ly
_ vailable when usinR a Lifesource �
Facilitv) �
urabfe iv/edicai �quipment o cnarge (n-network coverage only
3,SOG maximum per contraci
'ore� Sen�rces a_rct�mt�late tn Ihe a.l!tr. 'S L��n(itpc P;,�
a_riniuni
zter�ral Prosthetic Appliarrces INo charge after 52U0 EYA In-ne:work coverage only
�deductible
_ 1,000 maximum per contract
d�te.� ierv ices accui?rc�lute fo !i:e plar: 's i.r�e:ime A�ia,ru�iun �ear , �
� �e�ier s�iurio,ns for �: our h�a,'�h. s `� r
CIGIVA Healthtare Page 45
' � b�Q a� 8 i:" • 1 3 �i'8
� enfa( CarC �
inriled io chargcs made a continirou.s cora:�e nJrleiun!
revtnren! srarr�d it�iriiin .six �rinntli.s o�"un injiu�� �o soiu�d,
rali�ral lcetli.
1 'ltysicran's Oj�ce No chargc aftcr per officc visit 7Q°io aftcr dcductibic
opay.
lnpn�ienr Fnciliti- o chargc aftcr 5250 per day 7Q"r6 after 5250 per day deductiblc
�opay up to 3 copays per nd plan dcductibic up to 3 copays
dmission cr admission
� Oulpatie�il st�rgical Facrlity o charge after �250 per visit U% aftc� $250 oer visit deductibic
opay
Phvsicia�rs Servrc.es � b charee 70% after deductible
urgical and Nan-surgical ThfJ • In-network coverage oniy
rovrded on a lintiled, case by case, basrs. ,1lways excfucfe
ppliances a�id orthodon[ic tren�me�u. Subject ro medica!
_ ; �ecessity.
Pl:ysician � OJfice o charge afte; specialist $25 per
_ ffice visit copay; No charge for
- - -ray/iab if billed by a separate
utpatient diagnostic facility such
s a hospital
lnpatient Fadlity o char�e after $250 per day
opay, up to 3 copa_ys per
` dmission
Oe�lpatient Faciiiry o charge after $250 per visit
opay
- Ph sicia�r's Services �o char e
"`'�' ouriire Foot Disorders 'at Covered at Covered
Visiori Care ln-network coverage only
-_ Eye Eaam every !2 niorrlhs. 10 per office visit copay
fi=:; Eve ClassesiContac: Genses �fot covered
��� rescriptioir Drugs
C/GNA PharmacyPlus Retail Drug Program �10 per 30-day supply for generic In-network coverage only
rugs
Generic Persh, Ince�i�ive Forniulary Plan 20 per 30-day supply for
referred brand-name drugs
I Y �nciuues orai conlraceptives anci coniracep(ive devices Ia40 per 3v suppiy for non I I
- I preferred brand-name drugs I
'" harmacy Deductibl� ("A�lai[ Order Exclucfecil 'one INone
harmacy Out of Pockel ivlaximum (!Y1'ail Gra'er ��io�z INone
xduded)
� CIGNA Tef-t7ru� t3�ai! Order Drug Program 25 per QO-day suppiy ior generic I(n-network coverage only i
'ru;s
Generic Push, h2cs�itive Forrr:ulary Pla1t 55 per 90-day s�poly for I
�preferred 'orand-name drugs
!ncludes orcr! contraceptives o��d contraceptive devices 115 per 90-day supply for non-
referred brand-name dru�s
�„� � Sh,
` �'c^.,-�ci SvfCiiivrS �vi V�7i1i ! cai�t..
� � Page 46
���i�'e?e HL`uiftiCnlC
•� � Pt 61f� � M. � +1 8' I 0 6 O O'
�Suhstance A6use Derozifrcarion ,;ervices ,'o cnargc aRa S''�0 per day fn-net�vork covcra�;c oniy
I lnrnticn! opay, up to i copays per
� • dmission
fental I:ealth and Suhsranc�• Afiusc Rehahilitati��e
ervices In-Network Oniy
Inpalient Me�da! !/ealt/� Se,•v;ces No charec aftcr S�0 per day copay
25 da��s �nazimtuir peJ• Melliber per ('o�rfract
}'ear inclirdes Substance ,16use Reliaoilrtatial
davs
Outpat,•'en! lurlividtra! Mental t/ea/tl� Services
?0 visits nraxinrunr per Men�ber per Contract o char�e after �30 per visit
Year oPaY
Outpatient ,�len�al tlealtlr Group Tlierap)� • (n-Nctwork Only
40 visits rnasinrtuii per ,'�fen:ber per Cattracl � o char�e after � I.i per session
Year incfudes Serbslance Abuse Reliabilila�ion opay
• visrts
Inpalieir[ Substmlce Abuse Rehabililalion Services
!::-:• 'S da}cs nraainu:nt per Menrber per Coirt; ac1 o charee after �50 per day copay i n-Network Only
Year irtcli�des .Mental f/ealth days
Ou�palrenllndividua! Sudstance Abuse Rehabiliratiori
Services
20 visits ntaxinrum oer Member per Conlract o charge after � 15 per visit (n-Network Onlv
ycar opa� for the first 2 visits and �30
er visit thereaftcr
Oc�tpalieiil Graup Strbstnnce Abtue Rehabili[atio�r
Services
40 i�isits marinrunt per Member per Con(ract o charge after � 15 per visit In-Network Only
• Year incfudes Men1a! Nea![h visrts ooav
Pre-Fxisting Co�+ditiair Limitaiiorr (!'�L) ot Applicaole pplies to any injury or sickness
for which a person receives
_._ reatment, incurs expenses or
receives a diagnosis from a
- hysician during the 90 days before
�
he earfier of the date a person
egins an eli��bil�*_y waitin.� �en'od (
� � b { �� r becomes insured for these
� - '6Ci�C�iS. �u'ri.i8r �C� iii� �:.i�-
I xisting co�ditioa is excluded until
ne year oi the member being
I ontinuously insured andior is
� - atisfying a wait;r�g periad.
I Usvally?he ?CL �s svaived for the
initial group, but if not, the insured
I ill receive credit for any portion
i the FCL waitin; period that was I
atisfied under tne previous plan if
hey are enrolled in the subsequent
{ ian within ci.i daVS (or the
� i �pg!icaole timefrar.�e req L:ff? d pe!•
tate la�u;.
�"� RE%fC: SO�tiei��rS is'3f ;/Oi.ii r�F?a lth. sNr
� � Page 47
CICN.4 Iieaith€:arc
_ � � �r��� ,: s � � � o a � a ��.
re-Adntissro�r Certifrcalion S1a� Rei�ie�n ICoordlnatcd �y PCP Mandatory: Employcc is
("rcyuircti a!! Inprtiic•ir! Aduri.s.�•ions) csppnsiblc for contacting Ihc
Hcalthplan
Pcnaftics for non-compliancc: 5500
cnalty applicd to hospital inpaticnt
hargcs for faiiurc to cantact
Hcalthplan to prcccrtify admission.
Bcnefits are denied for anv
dmission reviewcd by Healthplan
� nd not certitied.
_ Benet"its are denied for any
dditional days not certified by the
Health lan.
=- Case Nfa�ragen,cur oordinated by Heaithplan. This is a service designated to provide
ssistance to a patient who is at risk of developing medical
omplexities or for whom a health incident has precipitated a need for
ehabilitation or additional health care support. The program strives to
• ttain a balance between quality and cost-cffective carc whiie
�maximizinQ the aticnt's ualit ot lifc.
_- Benefit Exctusions (by way of exa»aple hut not li�nited to):
r�-.
Your plan provides coverage for medically necessary services. Your plan does not provide covera�e for the following except as
,�•• required by iaw:
)'_ .:
;�<._ l. Services that are not medically necessary, except specifically outlined preventive care;
- 2. Charges which the person is not legally required to pay;
3. Charges made b_y a hospital owned b,y or performing services for the U.S. �overnment if the charges are directly related to a
sickness or injury connected to military service;
4. Custodial services not intended primarily to treat a specific injury or sickness, or any education or trainin�;
` 5. Experirnenixi or invesiigational procedures and treatments;
J. COSiTiCiii, su�ge�y �r tFiera�y performed to improve seir'esieem uniess: iai a person receives an iniury which resuits in bodi'ty
damage requiring surgery; (b) it q,ualifies as reconstructive sureery performed on a person following surgery, and both the
sur�ery and the reconstructive surgery are essential and medically necessary; (c) it quaiifies as reconstructive surgery
following a mas[eciomy, inc!uding surge.ry and ; econ�truction of the other breast to achieve symmetry.
7. Reports, evaluations, �:aminations, or hospitalizations not required for health reasons, such as employment, insurance or
2ovemment licenses and court ordered iorensic ur custoclial evaluations.
S. Treatmem of the teeth or pe; i�dontium, unless such expenses are incurred for. (aj charges made for a continuous course of
denta( treatment started within sir, months of an injury to soun� natural teeth; (b) charges made by a 1-iospital for 8�d ano
Board or Necessary Services and Supplies; or {cj cnarges made by the outpatient department of a 1-iospital in connection
with surQery.
9. Reversal af voluntary sterilizaiion procedures, and ceRain infer[iiiry services;
10. Transsexual sur�ery and related services;
11. Treatment for erec�ile dysfunction. Howe��er, penile implants are covered when an established medical condition is the
cause oi erectiie dvsfunction:
, 12. Therap;� [e improve �ene:a! physical condi:io�;
13. Personal or comrort items such as personal care kits, television, and telephone rental in hospitals;
14. Eyeglasses, hearing aids or examinations anci prescription fitting, except as provided in the Cer!ificate;
1�. Certain in*err.ai or e:ternal prosthese�, a.* replacement of e�t�ma; prostheses due to wear a;�d tear loss theft or destruction;
... I G. Jl�ciC=l t�-F��Ym - F .. .. O� � ..
-,• C:li Cf C^; f°^:IOi� ' T� E�TGCS� !�ClUG:h� Y�i�;31 kv:3t0LOI?lV;
17. Prec�ription an� n � n 'Y r PSCr:^ +.:on �r���s. excep: as p;ov;ded in the t;enefi:s secticn of t�e Ce;;iiicate;
: � ScL1
Be iei solcitio,�s for vour health.
CIGNA HealthC:are
Pa 48
18. Routinc foot carc;
19. ,Amnfoc��tcsi�, ultrasound, or any othc; proccdures ;cqucstcd soiciy for scx dctcrmination ota fctus, unlcss mcdically
nc�cssarv �o dcicrminc thc cxisicncc of a scx-linhcd ecnctic disordcr;
20. Any injury resulting from, or in thc coursc of, any cmpioymcnt tor wagc or profit;
21. Any sickncss �.vliich is covcrcd undcr any workcrs' comper.sa[ion or simiiar law.
�2. Chargcs for ovcr thc countcr disposabic or consumaolc supplics, including ortnutic dc��iccs.
23. Chargcs in cxccss of rcasonablc and customary limitations;
24. Charecs for mcdical and surgicai scrviccs intcndcd primarily for tlu trcatmcnt or control of obcsity which arc not �tcdically
Ncccssary. Excludcd scrviccs includc, but arc not limitcd to, weight rcduction proccdures dcsigncd to restrict your ability to
assimilatc food, such as �astric oypass, gastric balloons, jaw wiring, stomach stapling and jejunal bypass.
25. Ccrtain Durable Medical Equipment (DME).
?(. ivon-medieal ancillary services, ineluding but not limited to vocational renabilitation, behavioral training, biof cdbacic,
ncurofcedback, hypnosis, sicep therapy, employment counseiing, bac4 school, work hardcning, drivine safcty and serviccs,
trainin,�, cducational thcrapy or other non-mcdical ancillary scrvices for iearning disabili[ics, dcvelopmental delays, autisrn
or mental re�ardation. '
27. Cosme[ics, dictary supplemcnts, health and beauty aids, and nutritional formulae.
This chart summarizes the benefit plan you requested; it has not been adiusted to reflcct state benefit mandates. A ccmpletc
description of thc tcmis of thc coverage, exclusions and limitations, including legislated bcnefits (if applicablc), will be provided
in your Certificatc o� Summary Plan Description.
, Beneftcs are insured an�f/or admrnisterecf by Connecticaet General Life I�rszu•arrce Con�pany.
"C/GNA //ealt/iCure" refers Io varloces operaGitg subsidiaries ojClGNA Corporatiai. Produc:s and services are providerf by
these subsidiaries ancf not by C/GNA Corporation. These subsidiaries inch�de Connecticut General Lije lnsura�rce Conrpany,
_ CIGNA Visioii Care, /nc., Tel-Drug, Inc. arid its affiliales, ClGNA Behai�iora! Heallh, /nc.. /n[racorp, anct HMO or ser��ice
_ canpany subsidiaries of C/GNA l�fealtli Corporation and C1GNA Den�a! Health, /�rc. "CIGNA Tel-Drug:' refers 10 Te!-Dncg, l�rc.
and Tel-Dr•zrg ofPennsvlvania, L.L.C., w/�ich are a[so operatingstrbsidiaries oJCIGNA Corpora[ian.
�
��� L'�c°f!°f Snf� rt:�J17S !.�.f� �OUI� r!°��ffT.
Pr�ge 49
CI�Nr� 3ieaititLare
s
�'�"�1�� .F�e�.����a�°e �t���� ���� ���.
This pag� summarizes state-mandated modiiications oi benefit cnoices. There are additional
benefit mand�tes which are not displayed below because they do not affect benef;t choices.
I'r�mary Ca�e Physi�ian 4ffice bz�it
The office visit copayment may noi exceed �30.
Spec�alrsf �'' 1��'S1CIc'�I2 �1�ICL' Tj1,�F�
The office visit copayment may not exceed $60.
Short �tehad�al��atyv� a'he3a�sr,�r�sa�' C�aro,r�r���ie G'are
° All chiropractic care is open access, subject to a combined maximum with rehabilitation
services of eithe: 60 or 90 visits, depending upon the option selec#ed.
d'rescriptio.r.t Drugs
The Rx deductible may not exceed $200 pe: family. The Rx out-of-pocket may not e�ceed
$1,000 pe: individual and $Z,000 per family.
Emera enc� lzoom and Ur� eaat G'are ,�er��c�s
The emergency room copayment may not exceed $100.
Mental Health and Substa�c� A�iaa�e
For mental health services, the outpatient copayment may not ex�eed $30 for ar. individual
� visit or $15 for a group visit. Effective for new and renewing groups on or after 6/1/03, for
mental health services, the outpatient copayment may not exceed $4d for an individual
visit and $20 for a group visit.
.'u�fllai �IitF-t)�-1 c)c.i'[et ('1;7aXg.�2li.d�
The annual out-of-gocket ma�im�.�ms may not exceed $S,�J04 individual; $10,000
membership unit.
Gi a�2dclFi�d'rer�
Coverage is provided for the first 18 months for newborn children of covered famiiv
members. �
�i �� s��
�e�e; s�luric,~�s fo; your; edl�r.
C:IGNA HeaithGarc
Pa�ge 50