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Res. No. 108-05-12087RESOLUTION NO.108-05-12087 A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI,FLORIDA,AUTHORIZING THE CITY MANAGER TO RENEW THE CONTRACT WITH AVMED HEALTHCARE TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL TIME EMPLOYEES;PROVIDING AN EFFECTIVE DATE. WHEREAS,the City's Agent of Record received the health insurance renewal rates forAv Med wherein thecarrier proposed a fifteen percent (15%)increase in premiums;and WHEREAS,the Agent of Record recommended thatwe review all insurance carriers thatare currently onthe market to ensure thatweare being offered the most competitive rates;and WHEREAS,the Agent of Record solicited bids from eight(8)companies;onlyfour(4)ofthose companiesprovidinguswithaproposal;and WHEREAS,a Review Committee consisting of representatives from AFSCME,PBA,Human Resources and general employees reviewed the proposals and compared the insurance companies'rates, benefitplandesigns,network of providersandhospitals;and WHEREAS,after careful review,the Committee recommended renewing withAvMedHealth Care;and WHEREAS,withthe selection of AvMedHealthCare,the designated Agent of Record is Employee Benefits Consulting Group until contract expiration or until otherwise determined byeither party. NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI,FLORIDA,THAT; Section 1.The contract,whichis attached tothis resolution as exhibit 1,shall be effective October 1,2005 and shall be renewable onan annual basis. Section 2.This engagement isatwillandshall continue until either party terminates the engagementbygivingwrittennoticetotheotherparty.TheCityshallnotbechargedforagent of record services;EmployeeBenefits Consulting Groupshallbecompensatedbytheinsurer. Section 3.This resolution shall take effect immediately upon approval. PASSED AND ADOPTED this /(o 7day of (J^LLO^J^\2005. I TEST: TY CLERK READ AND APPROVED AS TO FORM: APPROVED: Commission Vote: Mayor Mary Scott Russell: Vice Mayor Velma Palmer: Commissioner Randy G.Wiscombe:yea Commissioner Marie Birts-Cooper:Yea Commissioner Craig Z.Sherar:Yea 5-0 Yea Yea CITY OF SOUTH MIAMI INTEROFFICE MEMORANDUM TO:Honorable Mayor,ViceMayor &City Commission FROM:Maria V.Davis City Manager "Z^ DATE:August 16,2005 Re:Renewal of Av Med Health Insurance South Miami All-AmericaCity W 2001 RESOLUTION A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI,FLORIDA,AUTHORIZING THE CITY MANAGER TO RENEW THE CONTRACT WITH AVMED HEALTHCARE TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL TIME EMPLOYEES PROVIDING AN EFFECTIVE DATE. REQUEST Theattachedresolutionseeksapproval from theCity Commission fortheCityManagertorenewaone- year contract with Av Med Health Care to provide health insurance coverage fortheCityof South Miami's full time employees. BACKGROUND Wehavereceivedrenewalratesfromourcurrentgrouphealthinsurancecarrier,AvMed,whereinthereis a fifteen percent (15%)increasein premiums.TheAgent of Record recommended thatweseekoutbids fromothercarrierstoensurethatwearebeingofferedcompetitiverates.OurAgent of Recordsolicited bidsfromeightcompanies.Bidswere received fromthefollowingcompanies:Aetna,AvMed,Humana and United Health Care. The Committee -which consisted of representatives from AFSCME,PBA,Human Resources Department and general employees -analyzed each plan,specifically reviewing the following areas:rates,benefit plan design(i.e.co-payments and deductibles)and network of providers and hospitals. Although Humanapresentedthelowestbid ($296.16 per employee per month),AvMed's($332.40per employeepermonth)benefitsweremuchmoreadvantageoustothe City's employeesincomparison.It wasalsonotedthatchangingfromonecarriertoanotherwouldmakeithardertofindcompanieswilling tobidonthe City's healthinsuranceinthefuture,asalreadyindicatedbyonlyfour of eightcompanies requestedtobidactuallysubmitting proposals.BelowwehavelistedthemajorcomparisonsbetweenAv Med and Humana: AVMED HUMANA 1. 2. 3. 4. 5. 6. 7. Specialist Office Visit Inpatient Hospital Outpatient Surgery Mental Hlth./Sub.Abuse Rx Drugs Mail Order Rx $10 co-pay no co-pay no co-pay no co-pay $7/$20/$35 2times co-pay $20 co-pay $100 co-pay/day upto $300/admission $100 co-pay $100 co-pay/day upto $300/admission $10/$20/$40 3 times co-pay Provider Directory-In comparison toAvMed,Humana hasa limited network of Primary Care Physicians and Specialists. Page Two Health Insurance Resolution 08/16/05 We alsonotedthat Av MedreceivedhigherscoresfromtheFlorida Agency forHealthCare Administration (AHCA)incomparisontoHumana.TheState of FloridameasuredeachHMOinthe following categories: a)Overall plan satisfaction b)Easeingettingtoseeaspecialist c)Easeingetting needed care,tests,or treatment d)Howwellproviders communicate withmembers e)Gettinghelpfrom customer service Based onallthe information reviewed,the Committee recommended renewing with AvMed HealthCare. RECOMMENDATION Approval oftheresolutionis recommended. TABLE OF CONTENTS I.Executive Summary II.Proposed Medical Rates III.HMOBenefitComparison IV.POS Benefit Comparison V.Appendix Employee Benefits Consulting Group Proposal Responses Vendor Name Aetna AvMed Blue Cross/Blue Shield CIGNA HealthCare Humana Neighborhood Health Partnership United HealthCare Vista Response Submitteda proposal. Submitteda proposal. Declinedtoquote. Declinedto quote. Submitted a proposal. Declinedto quote. Submitted a proposal. Declined toquote. EmployeeBenefitsConsulting Group Executive Summary Attachedisouranalysis of the medical proposalsthatwereceivedonbehalf of theCity of SouthMiami.Weapproachedthe following vendorsinregardstothisproject: Aetna Humana Av Med(incumbent)Neighborhood Health Partnership Blue Cross/Blue Shield United HealthCare CIGNA Vista Wewere successful inreducingtheAvMed premium increase to 15.2%forthe upcoming planyear(assumingho changes with thecurrentbenefit structure).AvMedhasthe following municipalities asclients:City of FortLauderdale,MiamiDadeCounty,Village ofBal Harbour,and the Village of Key Biscayne. The15.2%increase fromAvMedisfavorablein comparison totherenewalsthat the City of South Miami has received over thelast3 years: 2002:40%increase -Blue Cross/Blue Shield 2003:32%increase-Neighborhood HealthPartnership 2004:40%increase -CIGNA Aetna,Humana,andUnitedHealthCaresubmittedproposals.Theproposalfrom Humana is competitive fromafinancial standpoint;however thefollowingissues warrant consideration:. 1)The physician network withHumanawould create asignificantamount of disruption.Many employees would havetochangetheirPrimaryCarePhysician and Specialists ifHumana wasselected. 2)ThebenefitswithHumanaarenotas"rich"incomparisontoAvMed. 3)AvMedreceivedhigher scores fromthe Florida AgencyforHealthCare Administration (AHCA)incomparisontoHumana.TheState ofFlorida measured eachHMOinthefollowingcategories: a)Overall plansatisfaction b)Ease ingettingtoseeaspecialist c)Ease ingettingneededcare,tests,or treatment d)How wellproviders communicate with members e)Getting helpfromcustomer service The proposed rates with United HealthCare are 21.7%above the current cost structure with AvMed.From a plan design standpoint the United HealthCare plans are "Open Access"(i.e.members can receive services from a specialist without a referral from a Primary Care Physician).United HealthCare has the largest network of providers in South Florida. We appreciate the opportunity the City of South Miami has given us in regards to this project.Employee Benefits Consulting Group is prepared to assist the City of South Miami in managing healthcare costs while still mamtaining the integrity of the benefits package. HMO Employee only Employee +child(ren) Employee +spouse Employee +chlld(ren)+spouse POS Employee only Employee +child(ren) Employee+spouse Employee +child(ren)+spouse Enrollment Assumptions HMO Employeeonly Employee +child(ren) Employee +spouse Employee +child(ren)+spouse POS Employee only Employee +child(ren) Employee +spouse Employee +child(ren)+spouse AnnualPremium Costs: Relative Value Proposed Medical Rates Fully-Insured Program:10/1/05 Effective Date Current IAvlvteri) $289.04 $504.63 $560.73 $841.10 $355.91 $621.37 $690.46 $1,035.68 87 21 9 6 123 6 0 0 1 7 $588,096 100.0% Renewal (AvMeri) $332.40 $589.07 $654.55 $981.83 $378.25 $660.39 $733.81 $1,100.72 87 21 9 6 123 6 0 0 1 7 $677,297 115.2% Pagel Aetna $351.68 $654.12 $735.01 $1,040.97 $396.54 $737.57 $828.77 $1,173.76 87 21 9 6 123 6 0 0 I 7 $728,959 124.0% Humana $296.16 $518.29 $574.56 $861.84 $323.81 $566.69 $628.21 $942.33 87 21 9 6 123 6 0 0 1 7 $598,527 101.8% United HealthCam $344.24 $654.06 $722.92 $1,032.74 $362.12 $688.04 $760.47 $1,086.38 87 21 9 6 123 6 0 0 1 7 $715,752 121.7% Employee Beneflts Consulting Group IsaPCP/Gatekeeperrequired? Deductible Coinsurance Out-of-Pocket Maximum Office Visit PrimaryCarePhysician Specialist Inpatient Hospital Outpatient Surgery AvMed Network Yes None 100% $1,500/person; $3,000/family $10copay/visit $10copay/visit Nocopay No copay HMO Benefit Comparison 10/1/05 Effective Date Aetna Network Yes None 100% $1,500/person; $3,000/family $10copay/visit $10copay/visit No copay No copay Emergency Room $75copay/visit(1)$75 copay/visit (1)If the hospital is outside of the Av Med network a$100 copay/visit will apply. Pagel Humana .Network Yes None 100% $1,500/person; $3,000/family $10copay/visit $20copay/visit $100copay/day upto $300/admission $100copay/visit $75copay/visit United HealthCare Network No None 100% No maximum $15copay/visit $15copay/visit Nocopay Nocopay $75copay/visit AvMed Mental Health Network Inpatient Nocopay (limit of30 days/year) Outpatient $25copay/visit (limit of20 visits/year) Substance Abuse Inpatient No copay (coverage only provided foracute detoxification) Outpatient $50copay/week (limit of6 weeks/year) Rx Drugs (30 day supply) Generic Brand -Formulary Brand -Non Formulary Self Injectables Rx Drugs (90 day supply) Generic Brand -Formulary Brand -Non Formulary $7copay $20copay $35copay $75copay $14 copay $40 copay $70 copay HMO BenefitComparison 10/1/05 Effective Date Aetna Network Nocopay (limit of30 days/year) $25copay/visit (limit of20 visits/year) No copay (limitof30 days/year) $10copay/visit (limit of30 visits/year) $10 copay $20copay $35copay incl.above $20 copay $40 copay $70 copay Page2 Humana Network $100copay/day upto $300/admission (limit of31 days/year) $20copay/visit (limit of20 visits/year) $100copay/day up to $300/admission (coverageonlyprovided for acute detoxification) No copay (benefit maximum of $35/visit and alimit of44 visits per lifetime) $10copay $20copay $40copay 25%copay $30 copay $60 copay $120 copay United HealthCare Network Nocopay (limit of30 days/year) $15 copay/individual visit $10 copay/group visit (limit of30 visits/year) No copay (limit of30days/year) $15 copay/individual visit $10copay/groupvisit (limit of30 visits/year) $10 copay $30copay $50copay incl.above $25 copay $75 copay $125 copay IsaPCP/Gatekeeper required? Deductible Coinsurance Out-of-Pocket Maximum (excludes deductible) Office Visit Primary Care Physician Specialist Inpatient Hospital OutpatientSurgery Emergency Room (*)Subject tothe plan deductible. Point-of-Service Benefit Comparison 10/1/05 Effective Date Av Med Network Non-Network Yes No None 100% $1,500/person; $3,000/family $10copay/visit $10 copay/visit Nocopay Nocopay $75copay/visit $500/person; $1,500/family 70% •$3,000/person; $6.000/family 70%' 70%' 70%' 70%* $100 copay/visit Pagel Network Yes None 100% $1,500/person; $3,000/famiIy $10copay/visit $10copay/visit Nocopay Nocopay $100copay/visit Aetna Non-Netwnrk No $500/person; $1,500/family 70% $3,000/person; $6,000/family 70%' 70%' 70%* 70%' $100 copay/visit Mental Health Inpatient Outpatient Substance Abuse Inpatient Outpatient Rx Drugs (30 day supply) Generic Brand -Formulary Brand -Non Formulary Self Injectables Rx Drugs (90 day supply) Generic Brand -Formulary Brand -Non Formulary (*)Subject tothe plan deductible. Point-of-Service Benefit Comparison 10/1/05 Effective Date Av Med Network Non-Network No copay |70%* (limit of30 days/year) $25 copay/visit 70%' (limit of20 visits/year) Nocopay 7qo/0< (coverageonly provided for acute detoxification) $50copay/week 70%' (limit of6 weeks/year) $7copay $20copay $35copay $75copay $14 copay $40copay $70copay Not covered Not covered Not covered Not covered Not covered Not covered Not covered Page 2 Network Aetna Non-Network No copay |70%' (limit of30 days/year) $25copay/visit 70%' (limit of20 visits/year) Nocopay 7o<>/0< (limit of30 days/year) $10copay/visit 70%* (limit of30 visits/year) $10copay $20copay $35copay incl.above $20copay $40copay $70copay Not covered Not covered Not covered Not covered Not covered Not covered Not covered IsaPCP/Gatekeeperrequired? Deductible Coinsurance Out-of-Pocket Maximum (excludesdeductible) Office Visit Primary Care Physician Specialist Inpatient Hospital OutpatientSurgery Emergency Room (*)Subjecttotheplan deductible. Point-of-Service Benefit Comparison 10/1/05 Effective Date Humana Network Non-Network Yes No None 100% $1,500/person; $3,000/family $10 copay/visit No copay $200copay/admission Nocopay $50copay/visit $400/person; $800/family 70% $2,500/person; $5,000/family 70%* 70%* 70%' 70%' $50copay/visit Page 3 United HealthCare Network Non-Network No None 100% No maximum $15 copay/visit $15 copay/visit Nocopay Nocopay $75 copay/visit No $1,500/person; $3,000/family 70% $3,000/person; $6,000/family 70%' 70%' 70%' 70%' $75 copay/visit Mental Health Inpatient Outpatient Substance Abuse Inpatient Outpatient Rx Drugs (30 day supply) Generic Brand -Formulary Brand -Non Formulary SelfInjectables Rx Drugs (90 daysupply) Generic Brand -Formulary Brand -Non Formulary (*)Subjecttotheplan deductible. Point-of-Service Benefit Comparison 10/1/05 Effective Date Humana Network Non-Network $200 copay/admission |70%* (limit of30 days/year) $10 copay/visit 70%' (limit of20 visits/year) $200copay/admission Nocopay 7qo/0 (benefit maximum of $35/visit and a limit of44 visits per lifetime) $10copay $20copay $40copay 25%copay $30 copay $60copay $120copay 70%' Not covered Not covered Not covered Not covered Not covered Not covered Not covered Page 4 United HealthCare Network Non-Network No copay |70%* (limit of30 days/year) $15 copay/individual visit 70%' $10 copay/group visit (limit of30 visits/year) Nocopay 70%' (limit of30days/year) $15 copay/individual visit 70%' $10copay/groupvisit (limit of30 visits/year) $10copay $30copay $50copay incl.above $25copay $75copay $125 copay Not covered Not covered Not covered Not covered Not covered Not covered Not covered p u 11 i.1.11 a 1 y FLORIDA Plan 75 Option 001 Preventive Care PhysicianServices (Visits to specialists must be authorizedbyyour primary care physician). Hospital Services Prescription Drugs Other Medical Services Copayment Limits Lifetime Maximum Mental and Nervous Disorders (1) Routinephysicalexams Well-child care Well-woman exam (may self-refer to OB/GYN) •Primary care physician office visits (includes diagnostic lab and X-ray,office surgery,allergy testing,speech and hearing exams, vision screening exams,breast cancer screening treatment) (Hearing exams and vision screening exams cover children through age18.) •Specialist office visits (includes same items asprimary care physician office visit) •Allergy treatmentsand materials •Immunizations •Emergencyroomvisits •Outpatient surgical care (includes ambulatory surgical center and hospitaloutpatient) •Inpatient physician visits (while member is confined in a hospital) •Prenatal care (office visit copayment applies to first visit only) •Diabetestreatment,including self-management training Inpatient care (semiprivate room,ancillary services) Outpatientnonsurgicalcare Outpatient surgical care (includes ambulatory surgical center) Preadmission testing Otherinpatientsuppliesand services Hospital emergency services Seeattacheddrug rider,if applicable Diabetic supplies (30-day supply per copayment) Skilled nursing facility (up to W0 days per calendar year) Homehealthcare (upto60 visits per calendar year) Ambulance Durable medical equipment •Diabetes equipment i Private duty nursing [inpatient or outpatient) <Hospice services (inpatient or outpatient) •Spine and back disorders (limited to20 visits per calendar year) •Shortterm physical,speech,hearing and occupational therapy (limited to60 visits combined per calendar year) Individual Family Physicianservices Partial hospitalization Inpatient services (maximum of31 days percalendar year) Plan paysforservicesprovidedorarrangedbyyour PARTICIPATING primary care physician 100%after $10 copaymentper visit to primary care physician or $20copaymentper visit to specialist 100%after$10 copayment pervisit 100%after$20copaymentper visit 100% 100%after$10copaymentper visit toprimarycare physician or $20copaymentpervisitto specialist 100%after $100 copaymentperdayforfirstthreedays 100%after $50 copayment 100%after $100 copayment 100% 100%after $75 copayment per occurrence Subject tothe applicable prescription drug copayment.If prescription drugcoverageisnot included,thena$5 Level One/$15 Level Two/$30 Level Three copayment appliesperitem (baseduponan Rx3 Drug List). 100% 100%after $10 copayment pervisit 100%after $20 copayment pervisit $1,500 $3,000 Unlimited 100% 100%aftera $100 copaymentperdayforthefirstthreedays HumanaHMO isahealthplan that enablesyoutotake advantage ofcare arranged bythe primary care physician you select from the network of participating providers. Your personal physician provides your primary care,referring you to specialists when appropriate. FL-10233-HH 2/04 Plan 75 Option 001 Planpaysfor services provided or arranged by your PARTICIPATING primary care physician Mental and Nervous Disorders (1)(confd) •Outpatient services (maximum of20 visits per calendar year)100%after$20copaymentpervisit Alcoholism and Drug Abuse Services (1) •Detoxification -Inpatient 100%after $100 copaymentperdayforthefirstthreedays -Outpatient -Physician services for detoxification only 100% •Outpatientvisits (lifetime maximum 44 visits)100%upto$35pervisit vlost medical services mustbe provided or arranged ay your participating primary care physician.Only emergency services,or urgent services received while Dirt oftheservicearea,arecovered when providedby lonparticipating providers or facilities. Participating primarycareandspecialist physicians andotherprovidersin Humana's networks are nol the agents,employees or partners of Humana oranyofitsaffiliatesor subsidiaries.Theyare independent contractors. Humanais not aprovider of medicalservices. Limitations and Exclusions IThis isa partial andsummarizedlist of limitations wd exclusions.Yourgroup may have specific limitations and exclusions not included on this list. Please checkyourCertificateforthis complete listing.TheCertificateisthe document upon whichbenefitpayment will bedetermined. ••less stated otherwise,no coverage willbe provided for jn account of thefollowing situations: Elastic,cosmeticorreconstructivesurgery,exceptas specified inthe Group Plan. 2.Any service,supply or treatment connected with custodial care. 3.Purchase or rental of supplies ofcommon household use. 4.Investigational or experimental procedures or treatment methods. 5.Care for military service connected disabilities forwhichthememberis legally entitledto services andforwhich facilities are reasonably available to the member. FL-10233-HH 2/04 Humana does not endorse or control the clinical judgement or treatment recommendations made by the physidansor other providers listed in network directories or otherwise selected by you. To be covered,expenses must bemedically necessary andspecifiedascovered.Please see your Certificate for more information onmedical necessity and other specific plan benefits. 6.Any service,supply,care or treatment provided tothe member without the authorization of hisor her primary care physician,unless thememberis receiving emergency services as outlined inthe Schedule of Emergency Coverage at nonparticipating providers. 7.Rehabilitativeservices,unlesswedeterminethatthe members conditioncanbe significantly improvedby our provision of such services. 8.Drugsor medicines,prescription or nonprescription, provided tothememberwhileheor she isnot hospital-confined,unless otherwise covered byan outpatient prescription drug rider attached tothe GroupPlan. 9.Infertility counseling,testing and treatment services, sex change services,or reversal of elective sterilization. 10.Careandtreatment of theteethorperiodontium, unless otherwise specified inthe Group Plan. 11.Elective abortion. 12.Eye refraction,the purchase or fitting of hearing aids, eyeglasses,contact lenses or advice on their care,except as specified inthe Group Plan or otherwise provided bya vision care rider attached tothe Group Plan. j?HUMANA, 1 >»Guidance when youneedit most Offered by Humana Medical Plan,Inc 1)Anycopaymentsforthetreatmentofmentaland nervous disorders or alcoholism anddrugabuse servicesdonotapplytowardcopaymentlimit Tlie amount of benefit provided depends upon the plan selected. Premiums will vary according totheselection made. For general questions about theplan,contact your benefits administrator. 13.Any care,treatment,servicesorsuppliesreceived outside of theservice area,unlessotherwisespecified intheGroupPlan. 14.Any treatmenttoreduceobesityincluding,butnot limitedto,surgical procedures. 15.Sicknessorinjuryforwhichthemember refuses to accepttherecommended care and treatment ofhisor herphysicianwhen: a.thephysicianbelievesthatno professionally acceptable alternative exists;and b.wehavegiventhememberwrittennoticethatwe will onlyprovidethe physicians recommended care andtreatmentThememberhastherightto appeal adecision ofthisnaturebyusingthe Grievance Procedure outlinedintheGroup Plan. 16.Servicesand supplies for treatment of temporomandibularjoint disorder ordysfunction (TMJ)and craniomandibular jaw disorders (CMJ) whicharerecognizedasdental procedures.This includes,but is not limited to,theextraction of teeth andthe application of orthodontic devices and splints. LG/SG How the Rx4 structure works Coverage at participating pharmacies Level One -$10,Level Two -$20,Level Three -$40,Level Four -;25% Covered prescription drugs are assigned to one offour different levels with corresponding copayment amounts.The levels areorganized as follows: •Level One:lowest copayment for low cost generic and brand-name drugs. •Level Two:higher copayment for higher cost generic and brand-name drugs. •Level Three:higher copayment than Level Two for higher cost,mostly brand-name drugs that may have generic or brand-name alternatives on Levels OneorTwo. •Level Four:highest copayment for high-technology drugs (certain brand-name drugs,biotechnology drugs and self-administered injectable medications). Prescription drug products,or classes ofcertain prescription drug products,are generally reviewed on an ongoing basis by a Humana Pharmacy and Therapeutics committee which is composed of physicians and pharmacists.Drugs are reviewed for safety,effectiveness and cost-effectiveness prior to assignment or a change in assignment to one ofthe levels.Coverage ofa prescription drug or placement of the drug within alevel are subject to change throughout the year.In the event drugs are moved to categories with higher member cost,advance notice is provided based on past usage.Always discuss prescription drugs with your physician to determine appropriateness or clinical effectiveness with respect to you or any specific illness. Check our Website or contact Customer Service for the most up-to-date information about the Drug List. Some drugs in all levels may be subject to dispensing limitations,based on age,gender,duration or quantity. Additionally,some drugs may need prior authorization in order to be covered.In these cases,your physician shouldcontactHumana Clinical Pharmacy Reviewat 1-800-555-CLIN (2546). Members can visit Humana's Website,www.humana.com,toobtain information abouttheir prescription drug and corresponding benefits and for possible lower cost alternatives,or they can call Humana's Customer Service with questions or to request a partial Humana Rx4 Drug List by mail. For a complete listing of participating pharmacies,please refer to our Website or your participating provider directory._^____ When you present your membership card at a participating pharmacy,you are required to make a copayment for each prescription based on the current assigned level ofthe drug. Drugs assigned to:Copayment per prescription or refill Level One:$10 Level Two:$20 Level Three:$40 Level Four:25%*ofthe total required payment tothe dispensing pharmacy per prescription or refill. •The total maximum out-of-pocket copayment costs for drugs in Level Fouris limited to $2,500 per calendar year,permember. •If the dispensing pharmacy's charge is less than the corresponding copayment,you will only be responsible for the lower amount. •Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates. •If you use a nonparticipating pharmacy,there is no coverage,except for prescriptions required during an emergency for treatment of an emergency medical condition. There are no claim forms to file if you use a participating pharmacy and present your membership card with each prescription. Coverage Your coverage includes the following: specifics •A 30-day supply or the amount prescribed,whichever is less,for each prescription or refill. •Contraceptives. •Certain self-administered injectable drugs and related supplies approved by Humana. •Certain drugs,medicines or medications that,under federal or state law,may be dispensed only by prescription from a physician. Mail-order For your convenience,you may receive a maximum 90-day supply per prescription or refill through the benefit mail (maximum 30-day supply for self-administered injectable,drugs).The same requirements apply when purchasing medications through a participating mail-order pharmacy as apply when purchasing in person at a pharmacy.Members can call Customer Service or visit our Website for more information, includingmail-order forms. GN-12278-HH 5/05 Definition •Drug List:a list ofprescription drugs,medicines,medications and supplies specified by Humana.This list of terms identifies drugs as Level One,Level Two,Level Three or Level Four and indicates applicable dispensing limits and/or any prior authorization requirements.(This list is subject to change.) •Copayment:the amount to be paid by die member toward the cost ofeach separate prescription or refill ofa covered drugwhen dispensed bya pharmacy. •Participating pharmacy:a pharmacy that has signed a direct agreement with us as an independent contractor or has been designated by us as an independent contractor to provide services to all coveredpersons •Nonparticipating pharmacy:a pharmacy that has not been designated by us to provide services to covered persons.^ Limitations and Unless specifically stated otherwise,no coverage is provided for the following: exclusions •Any drug prescribed for a sickness or bodily injury not covered under the master group contract. •Any drug,medicine or medication labeled "Caution-Limited by Federal Law to Investigational Use"or any experimental drug,medicine or medication,even though a charge is made to you. •Anorectic or any drug used for the purpose of weight control. •Any drug used for cosmetic purposes,including but not limited to: -Tretinoin,e.g.Retin A,except ifyou are under the age of 45 or are diagnosed as having adult acne; -Dermatologicals orhair growth stimulants;or -Pigmenting or de-pigmenting agents,e.g.Solaquin. •Anydrugor medicine that is: -Lawfully obtainable without a prescription (over the counter drugs),except insulin;or -Available in prescription strength without a prescription. •Abortifacients (drugs usedtoinduce abortions). •Infertility services including medications. •Any drug prescribed for impotence and/or sexual dysfunction,e.g.Viagra. •Any drug for which prior authorization is required,as determined by us,and not obtained. •Any service,supply or therapy to eliminate or reduce a dependency on,or addiction to tobacco and tobacco products,including but not limited to nicotine wididrawal therapies,programs,services or medications. •Treatment for onychomycosis (nail fungus). •Any portion ofa prescription or refill that exceeds a 30-day supply (or a 90-day supply for a prescription or refill thatis received fromamailorder pharmacy). •Legend drugs which are not recommended and not deemed necessary by a health care practitioner. •Prescriptions filled at a non-network pharmacy except for prescriptions required during an emergency. (Unless specifically listed on this benefit summary.) This is only a partial list of limitations and exclusions.Please refer tothe certificate of coverage forcomplete details regarding prescription drug coverage. HUMANA. Guidance when you need it most Humana Plans are offered by the Family ofInsurance and Health Plan Companies including Humana Employers Healdi Plan of Georgia,Inc.,Humana Medical Plan,Inc.,Humana Health Plan,Inc.,Humana Health Benefit Plan of Louisiana,Inc.. Humana Health Plan of Ohio,Inc.Humana Health Plans ofPuerto Rico.Inc.,Humana Wisconsin Health Organization Insurance Corporation,or Humana Health Plan of Texas,Inc.-A Health Maintenance Organization. Our HealthBenefitPlanshave limitations and exclusions. GN-12278-HH 5/05 HumanaHMO ii m 11 i ,CI.i •m •w;•_-•:UCD.Cl I l< FLORIDA Plan 25,Option 40 Planpaysforservices provided or arranged byyour participating primarycare physician Preventive Care Physician Services Hospital Services Outpatient Services Prescription Drugs Other Medical Services Routine physical exams (limited toone examper calendar year) •Well-child care •Well-woman care (1) 100%aftera $10 primarycare/ pediatrician copayment per visit (other specialists covered in full) 100%aftera$10primarycare/ pediatrician copaymentper visit (other specialists covered in full) Office visits in conjunction with a sickness 100%after a $10 primary care/ or injury pediatrician copayment per visit Outpatient physician care (other specialists covered in full) <Diagnostic labtestingand X-rays >Emergencyroom visits i Surgery performed ina physician's office >Allergy tests/serum Inpatient care (semiprivate room and ancillary services) Ancillaryservices Preadmission testing Emergency room Outpatientsurgical Outpatientnonsurgical See attached riderifapplicable •Durablemedical equipment (2) i Skilled nursing facility (limited to 100 days perlifetime)(2) i Ambulance i Therapy (includes occupational,physical andspeech therapy;must be determined byprimary care physician that the member's condition canimprove significantly within 60 days ofthe date therapy begins.)(2) Home health care (2) 100%after $200 copayment per admission 100% 100%after$50 copayment pervisit (waived if admitted) 100% 100% 100%after$10copaymentpervisit Planpaysforservicesnotprovidedor arranged by your participating primary care physician Not covered 70%afternonparticipatingdeductible 70%after nonparticipating deductible 70%afternonparticipatingdeductible 100% 100%after$50copaymentper visit (waivedifadmitted) 70%after nonparticipating deductible 70%afternonparticipatingdeductible 70%after nonparticipating deductible Hospice Services Deductible Out-Of-Pocket Maximum Lifetime Maximum Benefit Mental Health Services 100%upto$5,000inpatientandoutpatientcombined maximum Individual $0 Family (two times the individual amount)$0 Individual $1,500 Family (two times the individual amount)$3,000 Inpatient facility (limited to30daysper calendaryear)(3) Inpatientprofessional services Outpatient (maximum of20 visits per calendaryear) Unlimited 100%after $200 copayment peradmission 100% 100%after $10 copayment pervisit $400 $300 $2,500 $5,000 $1,000,000 70%after deductible 70%after deductible 70%after deductible HumanaPOS allows youtoseek care from any provider withouta referral.Care received from or arranged by your participating primary care physician will be covered ata higher benefit level. FL-10011-HH 4/04 Plan 25,Option 40 Planpays for services provided or arranged by your participating primary carephysician Plan pays for services not provided or arranged by your participating primary care physician Alcohoj and Drug Abuse •Inpatient facility (3)100%after$200copayment peradmission 70%after deductible •Inpatient professional services •Outpatient (detox) 100%70%after deductible •Outpatient (excluding detox)(limitedtoa lifetime maximum of 44 visits) 100%nottoexceed$35pervisit 70%after deductible (notto exceed $35 pervisit) Payments •Plan benefitsare paid basedon maximum allowable fees,asdefinedinyour Certificate.Participating providers agreetoaccept maximum allowable feesaspaidin full. For services rendered by nonparticipating providers, thememberis responsible foramountsexceeding maximumallowablefees,asdefinedinyour Certificate.Emergency services,orurgent services receivedwhile out of the servicearea,arecoveredat the referred level. Participatingprimarycareandspecialist physiciansandotherprovidersinHumana's networks are neJ the agents,employees or partnersofHumanaorany of itsaffiliatesor Limitations and Exclusions Thisisapartialand summarized list of limitations andexclusions.Your group may havespecific limitations and exclusions not included on this list. PleasecheckyourCertificateforthis complete *isting.TneCertificateisthe document uponwhich enefitpayment wOl be determined. Jnless stated otherwise,no coverage willbeprovidedfor thefollowing situations. 1.Plastic,cosmeticorreconstructivesurgery,except as specified intheGroup Plan. 2.Any service,supply or treatment connected with custodial care. 3.Purchase or rental ofsupplies ofcommon household use. 4.Investigational or experimental procedures or treatment methods. 5.Care for military service connected disabilities for whichthe member is legally entidedto services and forwhich facilities are reasonably available to the member. 6.Any service,supply,care or treatment provided to the member without the authorization ofhisor CR0304 FL-10011-HH 4/04 subsidiaries.They are independent contractors. Humanais not a provider of medicalservices. Humana does not endorse or control the clinical judgement or treatment recommendations made bytinephysiciansor other providerslistedin network directories or otherwise selected by you. Tobe covered,expenses must bemedically necessaryand specified ascovered.Pleasesee yourCertificateformore information onmedical necessity and other specificplan benefits. (1)Insureds may serkefer toa participating specialist foranannual OB/GYN examandforanymedically necessary follow-up careidentified attheannual 10. 11. 12. her participating primary care physician,unless the memberis receiving emergency services or unless such services havebeen expressly authorized under theterms of thisGroup Plan. Rehabilitative services,unlesswe determine that the member'sconditioncanbe significantly improvedby our provision ofsuch services. Drugsor medicines,prescription or nonprescription, provided tothememberwhileheorsheisnot hospital-confined,unless otherwise covered byan outpatient prescription drugrider attached tothe GroupPlan. In-vitro fertilization,sexchangeservices or reversal of elective sterilization. Careandtreatment of theteethorperiodontium, unless otherwise specified inthe Group Plan. Elective abortion,exceptas specified inthe GroupPlan. Eye refiacdon,die purchase or fitting of hearing aids, eyeglasses,contact lenses or advice ontheircare, except as specified inthe Group Plan or otherwise provided bya vision care rider attached tothe Group Plan. HUMANA. >*Guidance when you need it most Offeredandinsuredby Humana Medical Plan,Inc visitLimitedtooneexamperinsuredper benefit year. (2)Failure topreauthorizemayresultin financial penaltyordenialofpayment. (3)Servicesrequirepriorapprovalofplanor designee.Expensesdonotapplytoward out-of-podcet maximum. The amount of benefit provided depends upon the plan selected. Premiums willvaryaccording tothe selection made. For general questions about theplan,contact your benefits administrator. 13. 14. 15. 16. Any care,treatment,servicesor supplies received outside oftheservice area,unlessotherwise specified intheGroupPlan. Anytreatmenttoreduceobesity,including,butnot limited to,surgical procedures. Sicknessorinjuryforwhich die member refuses to accepttherecommended care and treatment ofhisor herphysicianwhen: a.the physician believesthatno professionally acceptablealternativeexists;and b.wehavegiven die member writtennoticethat wewillonlyprovidethe physicians recommended care and treatment.The member hastherighttoappeala decision of this nature byusingtheGrievance Procedure outlinedin theGroupPlan. Servicesandsupplies for treatment of temporomandibular joint disorder or dysfunction (TMJ)and craniomandibular jaw disorders (CMJ) whicharerecognizedasdental procedures.This includes,but is not limited to,theextraction of teeth andthe application of orthodontic devices and splints. H UllVd n &P OS RX 4 Prescription Drug Coverage Level One -$10,Level Two-$20,Level Three -$40,Level Four -25% How the Rx4 structure works Coverage at participating pharmacies Nonparticipating pharmacy coverage GN-12195-HH 5/05 Covered prescription drugs are assigned to one of four different levels with corresponding copayment amounts.The levelsareorganized as follows: •Level One:lowest copayment forlow cost generic andbrand-name drugs. •LevelTwo:higher copayment for higher cost generic and brand-name drugs. •Level Three:higher copayment than Level Two for higher cost,mosdy brand-name drugs that may have generic or brand-name alternatives on Levels Oneor Two. •Level Four:highest copayment for high-technology drugs (certain brand-name drugs,biotechnology drugs and self-administered injectable medicarions). Prescription drug products,or classes of certain prescription drug products,are generally reviewed on an ongoing basis by a Humana Pharmacy and Therapeutics committee which is composed of physicians and pharmacists.Drugs are reviewed for safety,effectiveness and cost-effectiveness prior to assignment ora change in assignment to one of the levels.Coverage ofa prescription drug or placement of the drug within a level are subject to change throughout the year.In the event drugs are moved to categories with higher member cost,advance notice is provided based on past usage.Always discuss prescription drugs with your physician to determine appropriateness or clinical effectiveness with respect to you or any specific illness. CheckourWebsiteorcontactCustomerServiceforthemost up-to-date information aboutthe Drug List. Some drugs in all levels may be subject to dispensing limitations,based on age,gender,duration or quantity. Additionally,some drugs may need prior authorization in order tobe covered.In these cases,your physician shouldcontact Humana Clinical PharmacyReviewat 1-800-555-CLIN (2546). Members canvisit Humana's Website,www.hurnana.com,to obtain information abouttheirprescription drug and corresponding benefits and for possible lower cost alternatives,orthey can call Humana's Customer Service with questions orto request a partial Humana Po:4 Drug List by mail. Fora complete listing of participating pharmacies,please refer toour Website or your participating providerdirectory. When you present your membership card ata participating pharmacy,you are required to make a copayment for each prescription based onthecurrent assigned level ofthedrug. Drugsassignedto:Copayment per prescription orrefill Level One:$10 Level Two:$20 Level Three:$40 LevelFour:25%*ofthetotalrequiredpaymenttothedispensingpharmacyper prescription or refill. •Thetotalmaximumout-of-pocketcopayment costs fordrugsinLevelFourislimitedto$2,500per calendaryear,permember. •Ifthe dispensing pharmacy's charge is less than the corresponding copayment,you will only be responsible for the lower amount. •Your copayments for covered prescription drugs are made onaper prescription or refill basis and will not change ifHumana receives any retrospective volume discounts or prescription drug rebates. Therearenoclaimformsto file ifyouusea participating pharmacyandpresentyour membership card with each prescription. You may also purchase prescribed medications from a nonparticipating pharmacy.You will be required to pay for your prescriptions according tothe following rule. •You pay 100percentofthe dispensing pharmacy's charges. -Youfilea claim form with Humana (addressisonthe back of ID card). -Claim ispaidat70 percent ofthe dispensing pharmacy's charges,aftertheyare first reduced bythe applicable copayment. •Your copayments for covered prescription drugs are made onaper prescription or refill basis and will not changeifHumana receives any retrospective volume discounts orprescriptiondrug rebates. Coverage specifics Mail-order benefit Definition of terms Limitations and exclusions Yourcoverageincludesthefollowing: •A30-daysupplyortheamount prescribed,whichever is less,foreachprescriptionor refill. •Contraceptives. •Certain self-administered injectabledrugsandrelated supplies approvedbyHumana. •Certaindrugs,medicinesor medications that,under federal orstate law,maybedispensedonlyby prescriptionfroma physician. Foryour convenience,youmay receive amaximum 90-day supplyperprescriptionorrefillthroughthe mail(maximum30-day supply for self-administered injectable drugs).Thesame requirements apply when purchasing medications througha participating mail-orderpharmacyasapplywhen purchasing inpersonata pharmacy.MemberscancallCustomerServiceorvisitourWebsiteformoreinformation, includingmail-orderforms. •Drug List:alistof prescription drugs,medicines,medications and supplies specified byus.Thislist identifies drugsas Level One,Level Two,Level Threeor Level Fourand indicates applicable dispensing limits and/or any prior authorization requirements.(Thislistissubjectto change.) •Copayment:theamounttobepaidbythemembertowardthecostofeach separate prescriptionor refill of acovereddrugwhen dispensed bya pharmacy. •Nonparticipatingpharmacy:apharmacythathasnotbeendesignatedbyustoprovide services to coveredpersons •Participating pharmacy:a pharmacy that has signed adirectagreementwithusasanindependent contractororhasbeen designated byusasanindependentcontractortoprovide services toall coveredpersons. Unless specifically stated otherwise,no coverage is provided forthe following: •Anydrug prescribed fora sickness orbodilyinjurynotcoveredunderthemastergroupcontract. •Anydrug,medicineormedicationlabeled"Caution-LimitedbyFederalLawto Investigational Use"orany experimentaldrug,medicineor medication,eventhoughachargeismadetoyou. •Anorecticoranydrugusedforthepurposeofweightcontrol. •Anydrugusedforcosmeticpurposes,includingbutnotlimitedto: -Tretinoin,e.g.Retin A,exceptifyouareundertheageof45orarediagnosedashavingadultacne; -Dermatologicals orhairgrowth stimulants;or -Pigmentingorde-pigmenting agents,e.g.Solaquin. •Anydrugormedicinethatis: -Lawfully obtainable withouta prescription (over thecounterdrugs),exceptinsulin;or -Available inprescriptionstrengthwithoutaprescription. •Abortifacients(drugsusedtoinduce abortions). •Infertility services including medications. •Anydrug prescribed for impotence and/or sexual dysfunction,e.g.Viagra. •Anydrugforwhichprior authorization is required,as determinedbyus,andnotobtained •Any service,supply or therapy to eliminate or reduce a dependency on,or addiction to tobacco and tobacco products,including butnot limited to nicotine withdrawal therapies,programs,services or medications. •Treatment foronychomycosis(nailfungus). •Anyportionofa prescription or refill that exceeds a 30-day supply (ora 90-day supply fora prescription or refillthatisreceivedfromamailorderpharmacy). •Legend drugs whicharenot recommended andnotdeemed necessary byahealth care practitioner. •Prescriptions filled atanon-network pharmacy exceptfor prescriptions requiredduringan emergency. (Unless specifically listedonthisbenefit summary.) This is only apartiallist of limitations and exclusions.Pleasereferto the Certificate of Coveragefor complete detailsregarding prescription drugcoverage. HUMANA. Guidance when you need it most Humana Plans are offered bythe Family of Insurance and Health Plan Companies including Humana Medical Plan,Inc., Humana Employers Health Plan of Georgia,Inc.,Humana Health Plan,Inc.,Humana Health Benefit Plan of Louisiana,Inc., HumanaHealthPlan of Ohio,Inc.,HumanaHealthPlans of PuertoRico,Inc.,HumanaWisconsinHealthOrganizationInsurance Corporation,or Humana Health Plan ofTexas,Inc.-A Health Maintenance Organization or insured by Humana Health Insurance Company of Horida,Inc.,Humana Health Plan Inc.,Humana Health Benefit Plan of Louisiana,Inc.,Humana Insurance Company, Humana Insurance Company of Kentucky,or Humana Insurance ofPuertoRico,Inc. Our Health Benefit Plans have limitations and exclusions. GN-12195-HH 5/05 HumanaPOS YOUR BENEFITS UnitedHealthcare Choice Plan S56 Choice plan gives vou the freedom to see any Physician or other health care professional from our Network,including specialists,without a referral.With this plan,youwill receive the highest level of benefits when you seek care from a network physician,facility or other health care professional.In addition,you do not have to worry about any claim forms or bills. Some ofthe Important Benefits of Your Plan: You have access to a Network of physicians,facilities and other health care professionals,including specialists,without designating a Primary Physician or obtaininga referral. Benefits are available for office visits and hospital care,aswell as inpatient and outpatientsurgery. Care CoordinationSM services are available to help identify and prevent delays in care for thosewhomightneed specialized help. FLLEMS5602 Emergencies arecoveredanywhereinthe world. Pap smears are covered.• Prenatal care is covered. Routinecheck-upsare covered. Childhood immunizations are covered. Mammogramsarecovered. Visionand hearing screenings are covered. Choice Benefits Summary Types ofCoverage ThisBenefitSummary is intended onlyto highlight your Benefits and should not berelied upon to fully determine coverage.Thisbenefitplanmaynotcover all of your health'care expenses.Morecomplete descriptions of Benefits and the terms underwhich theyare provided are contained intheCertificate of Coverage thatyouwill receive uponenrolling inthe Plan. IfthisBenefitSummary conflicts inanywaywiththe Policy issued to your employer,thePolicy shall prevail. Terms thatarecapitalized intheBenefit Summary are defined inthe Certificate ofCoverage. Benefits are payable for Covered Health Services provided byorunder the direction of your Network physician. ♦Prior Notification is required for certain services. 1.Ambulance Services-Emergency only 2.Dental Services -Accident only Durable Medical Equipment Benefits forDurableMedicalEquipmentare limited to $2,500 percalendar year.Limitsdonot apply to Durable Medical Equipment classified as diabetic equipment or supppies. 4.EmergencyHealthServices 5.EyeExaminations Refractive eye examinations arelimitedtoone every other calendar year from a Network Provider. 6.Home Health Care Benefits arelimitedto60visitsfor skilled care servicesper calendar year. 7.HospiceCare Benefitsarelimitedto360daysduringtheentire period of time aCovered Person iscovered under thePolicy. 8.Hospital-InpatientStay 9.Injections Received ina Physician's Office 10.Maternity Services 11.Outpatient Surgery,Diagnostic andTherapeutic Services OutpatientSurgery Outpatient Diagnostic Services Outpatient Diagnostic/Therapeutic Services -CT Scans,Pet Scans,MRI andNuclear Medicine Outpatient Therapeutic Treatments 12.Physician'sOfficeServices Covered Health Services for preventive medical care. CoveredHealthServicesforthediagnosisand treatment ofa Sickness orInjuryreceived ina Physician'soffice. 13.ProfessionalFeesforSurgicalandMedical Services 14.Prosthetic Devices Benefitsforprosthetic devicesarelimitedto $2,500percalendaryear. 15.Reconstructive Procedures NetworkBenefits/Copayment Amounts Annual Deductible:NoAnnualDeductible. Out-of-Pocket Maximum:$2,500 per Covered Person,per calendar year,not toexceed $5,000 for all Covered Personsinafamily. Maximum Policy Benefit:No Maximum Policy Benefit. Ground Transportation:NoCopayment Air Transportation:0%of Eligible Expenses ♦Same as 8,11,12and13 •Prior notification is required before follow-up treatment begins. No Copayment $150pervisit $15pervisit No Copayment No Copayment $500perInpatientStay $15pervisit Same as 8,11,12 and13 NoCopayment applies to Physician office visits for prenatal care after the first visit $250per surgical procedure Forlaband radiology/Xray.NoCopayment $250pertest No Copayment $15 per visit except that the Copayment for a Specialist Physician office visit is $25.NoCopayment applies whenaPhysician charge isnot assessed. $15 per visit except that the Copayment for a Specialist Physician office visit is $25.NoCopayment applies whenaPhysiciancharge isnot assessed. No Copayment No Copayment Same as 8,11,12,Band 14 Types ofCoverage 16.Rehabilitation Services -Outpatient Therapy Benefits are limited as follows:20 visits of physicaltherapy,20visits ofoccupationaltherapy, 20visitsofspeechtherapy;20visits ofpulmonary rehabilitation;and36 visits of cardiac rehabilitation percalendaryear. YOUR BENEFITS NetworkBenefits/•Copayment Amounts $15 pervisit 17.Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Benefitsarelimitedto60dayspercalendaryear. NoCopayment 18.Transplantation Services ♦Same as8 and 13 19.UrgentCare Center Services $50pervisit Additional Benefits BonesorJointsoftheJawandFacial Region Same as 8,11,12 and13 ChildHealthSupervision Services Same as 11,12 and13 Cleft Lip/Cleft Palate Treatment Same as 8,11,12,13,and16 Dental Procedures -Anesthesia and Hospitalization Same as 8,11,and13 Diabetes Treatment Same as 3,11,12 and13 Mammography No Copayment Mastectomy Same as 8,11,12 and13 $15perindividual visit;$10pergroupvisitMentalHealthandSubstanceAbuseServices- Outpatient MustreceivepriorauthorizationthroughtheMental Health/Substance AbuseDesignee.Benefits are limitedto30visitspercalendaryear. Mental Health and Substance Abuse Services - Inpatient and Intermediate MustreceivepriorauthorizationthroughtheMental Health/Substance AbuseDesignee.Benefits are limitedto30dayspercalendaryear. Osteoporosis Treatment Prescription andNon-PrescriptionEnteral Formulas BenefitsforlowproteinfoodproductsforCovered Persons through age24arelimitedto$2,500per calendaryear. Spinal Treatment Benefitsincludediagnosisandrelatedservicesandare limitedtoonevisitandtreatmentperday.Benefitsare limitedto24visitspercalendaryear. $500perInpatientStay Same as 11,12 and13 No Copayment $15pervisit Exclusions Except as may be specifically provided in Section 1of the Certificate ofCoverage (COC)or through a Rider tothePolicy,the following are notcovered: A.Alternative Treatments Acupressure;hypnotism;rolfing;massage therapy,aromatherapy,acupuncture:and other forms of alternative treatment. B.Comfort or Convenience Personal comfort or convenience items orservices such as television;telephone;barber or beauty service;guest service;supplies,equipment and similar incidental services and supplies for personal comfort including air conditioners,air purifiers and filters,batteries and battery chargers, dehumidifiers and humidifiers;devices orcomputers toassist incommunication and speech. C.Dental Except as specifically described as covered in Section 1ofthe COC under the headings Denial Services -Accident only and Cleft Up/Cleft Palate Treatment,dental services are excluded.There is no coverage for services provided for the prevention,diagnosis,and treatment ofthe teeth or gums (including extraction,restoration,and replacement ofteeth and services to improve dental clinical outcomes).Dental implants and dental braces are excluded.Dental x-rays,supplies and appliances and aU associated expenses arising out ofsuch dental services (including hospitalizations and anesthesia) are excluded,except as might otherwise be required for transplant preparation,initiadon of immunosuppressives,the direct treatment ofacute traumatic Injury,cancer,or cleft palate,or as described inSection 1ofthe COC under the heading ofDenial Procedures •Anesthesia and Hospitalization.Treatment for congenitally missing,rnalpositioncd,or super numerary teeth is excluded,even ifpart ofaCongenital Anomaly except inconnection with cleft lip or cleft palate D.Drugs Prescription drug products for outpatient use that are filled byaprescription order or refill.Self- injectablc medications except as described in Section 1ofthe COC under the heading ofDiabetes Treatment.Non-injeettiblc medications given inaPhysician's office except as required in an Emergency.Over-the-counter drugs and treatments. E.Experimental,Investigational orUnproven Services Experimental,investigational or Unproven Services are excluded,except (a)bone marrow transplants and (b)medically appropriate medications prescribed for the treatment ofcancer,for aparticular indication,ifthat drug isrecognized for the treatment ofthat indication in astandard referencecompendiumorrecommendedinmedicalliterature.The fact that an Experimental.Investigational or Unproven Service,treatment,device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits ifthe procedure is considered to be Experimental, Investigational orUnproven inthe treatment ofthat particular condition. F.Foot Care Routine foot care (including the cutting or removal ofcorns and calluses);nail trimming,cutting,or debriding;hygienic and preventive maintenance foot care;treatment offlat feet or subluxation ofthe foot;shoe orthotics. GMedicalSuppliesandAppliances Devices used specifically as safety items or to affect performance primarily in sports-related activities. Prescribed or noii-prescribed medical supplies and disposable supplies including but not limited to elastic stockings,ace bandages,ostomy supplies,gauze and dressings.Orthotic appliances that straighten or re-shape abody part (including cranial banding and some types ofbraces).Tubings and masks are not coveredexcept when used with Durable Medical Equipment as described inSection 1 ofthe COC. EL Mental Health/Substance Abuse Services performed inconnection with conditions not classified in the current edition ofthe Diagnostic and Statistical Manual ofthe American Psychiatric Association.Services that extend beyond the period necessary for short-term evaluation,diagnosis,treatment,or crisis intervention. Mental Health treatment of insomnia and other sleep disorders,neurological disorders,and other disorders withaknown physical basis. Treatment ofconduct and impulse control disorders,personality disorders,paraphilias and other Mental Illnesses that will not substantially improve beyond thecurrent level of functioning,orthat are not subject to favorable modification or management according to prevailing national standards of clinical practice,as reasonably determined bythe Mental Health/Substance Abuse Designee. Services utilizing methadone treatment as maintenance,L.A.A.M.(1-Alpha-Acetyl-Mcthadol). Cyclazoeine,or their equivalents.Treatment provided in connection with or to comply with involuntary commitments,police detentions and other similar arrangements,unless authorized by the Mental Health/Substance Abuse Designee.Residential treatment services.Services orsupplies that in the reasonable judgment ofthe Mental Health/Substance Abuse Designee are not*for example, consistent with certain national standards orprofessional research further described inSection 2ofthe COC. I.Nutrition Megavitamin and nutrition based therapy;nutritional counseling for either individuals or groups. Enteral feedings and other nutritional and electrolyte supplements,including infant formula and donor breast milk,except as described inSection 1ofthe COC under the heading Prescription and Non prescription Enteral Formulas. United HealthCare Insurance Company J.Physical Appearance Cosmetic Procedures including,butnot limited to,pharmacological regimens;nutritional procedures or treatments;salabrasion,cbemosurgery and other such skin abrasion procedures associated with the removal of scars,tattoos,and/or which are performed as atreatment for acne.Replacement ofan existing breast implant isexcluded if the earlier breast implant was aCosmetic Procedure. (Replacement ofan existing breast implant is considered reconstructive ifthe initial breast implant followed mastectomy.)Physical conditioning programs such as athletic training,bodybuilding, exercise,fitness,flexibility,and diversion orgeneral motivation.Weight loss programs for medical and non-medical reasons.Wigs,regardless ofthereason for thehair loss. K.Providers Services performed byaprovider with your same legal residence or who is afamily member by birth or marriage,including spouse,brother,sister,parent or child.This includes any service the provider may perform on himself or herself.Services provided at a free-standing or Hospital-based diagnostic facility without an order written bya Physician or other provider as further described inSection 2of theCOC (this exclusion does notapply to mammography testing). L.Reproduction Health services and associated expenses for infertility treatments.Surrogate parenting.The reversal of voluntarysterilization. M.Services Provided under Another Plan Health services for which other coverage is paid under arrangements required by federal,state orlocal law.This includes,butisnotlimited to,coverage paid by workers'compensation,no-fcult automobile insurance,orsimilar legislation.Health services for treatment ofmilitary service-related disabilities, when you are legally entitled toother coverage and facilities are reasonably available toyou.Health serviceswhileonactivemilitaryduty. N.Transplants Health services for organ ortissue transplants are excluded,except those specified as covered in Section 1of the COC.Anysolid organ transplant that is performed asatreatment for cancer.Health services connected withtheremoval ofan organ or tissue from youfor purposes ofa transplant to another person.Health services for transplants involving mechanical oranimal organs.Transplant services that are notperformed ata Designated Facility.Anymultiple organ transplant not listed as a CoveredHealthServiceinSection1 oftheCOC. O.Travel Health services provided ina foreign country,unless required as Emergency Health Services. Travel ortransportation expenses,even though prescribed bya Physician.Some travel expenses related to covered transplantation services maybe reimbursed atourdiscretion. P.Vision and Hearing Purchase cost ofeyeglasses,contact lenses,orhearing aids.Fitting charge for hearing aids,eye glasses orcontact lenses.Eye exercise therapy.Surgery that is intended toallow you tosee better without glasses orother vision correction including radial keratotomy,laser,and other retractive eye surgery. Q.Other Exclusions Health services and supplies that donotmeetthedefinition ofa Covered Health Service -see definition in Section 10 ofthe COC. Physical,psychiatric orpsychological examinations,testing,vaccinations,immunizations or treatments otherwise covered underthe Policy,whensuchservicesare:(1)inquired solelyfor purposes ofcareer,education,sports or camp,travel,employment,insurance,marriage or adoption; (2)relating tojudicial oradministrative proceedings ororders;(3)conducted for purposes ofmedical research;or(4)toobtainor maintain alicenseofanytype. Health services received asa result ofwaroranyactof war,whether declared orundeclared orcaused during servicein the armed forces ofany country. Health services received afterthe date yourcoverage under thePolicyends,including health services for medical conditions arising prior tothedate yourcoverage under the Policy ends. Health services for which youhave nolegal responsibility to pay,or for which a charge would not ordinarily be made inthe absence of coverage under the Policy. Charges inexcess of Eligible Expenses orinexcess ofanyspecified limitation. Services for theevaluation andtreatment of temporomandibular joint syndrome (TMJ),whether the services areconsidered tobe medical or dental in nature,exceptas described in Section 1oftheCOC under the heading Bones orJoints of the Jaw and Facial Region.Surgical treatment and non-surgical treatment ofobesity(including morbidobesity). Surgical treatment and non-surgical treatment of obesity (including morbid obesity). Growth hormone therapy;sextransformation operations;treatment ofbenign gynecomastia (abnormal breast enlargement inmales);medical and surgical treatment of excessive sweating (hyperhidrosis); medical and surgical treatment for snoring,except when provided aspart of treatment for documented obstructive sleep apnea.Oral appliances for snoring.Custodial care;domiciliary care;private duty nursing;respitecare;restcures. Psychosurgery.Speech therapy except asrequired for treatment ofa speech impediment orspeech dysfunction thatresults from Injury,stroke,cleft lip/cleft palateor Congenital Anomaly. This summary ofBenefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage.This plan may not cover all your health care expenses.Please refer to theCertificateofCoverageforacompleteIbtingofservices,limitations,exclusions and adescription ofail the terms and conditions ofcoverage.Ifthis descnpUon conflicts in any way with the Certificate of Coverage,the Certificate of Coverage prevails.Terms that are capitalized in the Benefit Summary are defined in the Certificate ofCoverage.213-1157 0604 021 BS Che —FLLEMS5602 YOUR BENEFITS UnitedHealthcare Pharmacy Management Program Plan 023 UnitedHealthcare's pharmacy management program provides clinical pharmacy services that promote choice,accessibility and value.The program offers a broad network of pharmacies (more than 56,000 nationwide)to provide convenient accessto medications. While mostpharmacies participate inournetwork,youshould check first.Callyour pharmacist or visit our online pharmacy service at www.myuhc.com.The online service offers you home delivery of prescriptions,abilitytoviewpersonalbenefit coverage,access health andwellbeing information,andeven location of network retail neighborhood pharmacies byzip code. Copayment per Prescription Order or Refill Your Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug Product All Prescription Drug Products onthe Prescription Drug List are assigned to Tier 1,Tier2or Tier 3.Please access www.myuhc.com through the Internet,or call the Customer Service number onyourID card to determine tier status. For a single Copayment,you mayreceive a Prescription Drug Product upto the stated supply limit.Some products are subject to additional supply limits.You are responsible for paying the lower of the applicable Copayment orthe retail Network Pharmacy's Usual and Customary Charge,orthe lower oftheapplicable Copayment orthe Home Delivery Pharmacy's Prescription Drug Cost Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug Product meets the definition ofa Covered Health Service and isnotExperimental,Investigational orUnproven. Retail Network HomeDelivery Network Pharmacy Pharmacy Foruptoa 31 daysupplyForuptoa90daysupply Tier 1 $10 $25 Tier 2 $30 $75 Tier3 $50 $125 FLNPP02304 United HealthCare Insurance Company OtherImportantCostSharing Information Annual Drug Deductible No Annual DrugDeductible Out-of-Pocket Drug Maximum No Out-of-Pocket DrugMaximum Exclusions Exclusionsfrom coverage listed inthe Certificate apply also to this Rider. In addition,the following exclusions apply: Outpatient Prescription Drug Products obtained from a non-Network Pharmacy. Coverage for Prescription Drug Products forthe amount dispensed (days supply or quantity limit)which exceeds the supply limit. Prescription DrugProducts dispensed outsidetheUnited States,except as requiredforEmergencytreatment. Drugs which are prescribed,dispensed or intended foruse while youare aninpatient ina Hospital,Skilled Nursing Facility,or Alternate Facility. Experimental,Investigational or Unproven Services and medications; medications usedforexperimentalindicationsand/ordosage regimens determined byustobe experimental,investigational or unproven. Prescription Drug Products furnished bythe local,stateor federal government Any Prescription Drug Product totheextent payment or benefits are provided or available from the local,stateor federal government (for example,Medicare)whether ornot payment or benefits are received,exceptasotherwiseprovidedbylaw. Prescription Drug Products forany condition,Injury,Sickness or mental illness arisingoutof,orinthecourseof,employment forwhich benefits are available underany workers'compensation laworothersimilarlaws, whetherornotaclaimforsuchbenefitsismadeorpaymentorbenefits are received. Anyproduct dispensed forthe purpose of appetite suppression and other weightlossproducts. A specialty medication Prescription DrugProduct (suchas immunizations andallergyserum)which,duetoits characteristics as determined byus,musttypicallybe administered or supervised bya qualified provider or licensed/certified health professional inan outpatient setting.ThisexclusiondoesnotapplytoDepoProveraand other injectable drugsusedfor contraception. DurableMedicalEquipment.Prescribed andnon-prescribedoutpatient supplies,otherthanthediabeticsuppliesandinhalerspacers specifically stated as covered. Generalvitamins,exceptthefollowingwhichrequireaPrescription OrderorRefill:prenatalvitamins,vitaminswithfluoride,andsingle entityvitamins. Unitdosepackaging of PrescriptionDrugProducts. Medicationsusedforcosmeticpurposes. PrescriptionDrugProducts,includingNewPrescriptionDrugProductsor newdosageforms,thataredeterminedtonotbeaCoveredHealth Service. PrescriptionDrugProductsasa replacement forapreviouslydispensed PrescriptionDrugProductthatwaslost,stolen,brokenordestroyed. PrescriptionDrugProductswhenprescribedtotreatinfertility. Drugsavailable over-the-counter thatdonotrequirea Prescription Order orRefillbyfederalorstatelawbeforebeingdispensed.AnyPrescription DrugProductthatistherapeuticallyequivalenttoanover-the-counter drug.PrescriptionDrugProductsthatarecomprised of componentsthat areavailablein over-the-counter formor equivalent PrescriptionDrugProductsforsmokingcessation. Compoundeddrugsthatdonotcontainatleastoneingredientthat requiresaPrescriptionOrderorRefill.Compoundeddrugsthatcontainat leastoneingredientthatrequiresaPrescriptionOrderorRefillare assignedtoTier3. NewPrescriptionDrugProducts and/or newdosageformsuntilthedate theyarereviewedbyourPrescriptionDrugListManagementCommittee. Growthhormone therapy forchildrenwithfamilialshortstature(short staturebasedupon heredity and not caused bya diagnosed medical condition). This summary of Benefits is intended onlyto highlight yourBenefits for outpatient Prescription Drug Products and should notbe relied uponto determine coverage.Yourplan maynotcover allyouroutpatient prescription drag expenses.Please refer toyourOutpatient Prescription Drug Rider and theCertificate ofCoverage for acomplete listing of services,limitations,exclusions and adescription ofalltheterms and conditions of coverage.If thisdescription conflicts inanywaywiththeOutpatient Prescription Drug Rider ortheCertificate ofCoverage,theOutpatient Prescription Drag Rider and Certificate ofCoverage prevail.Capitalized terms intheBenefit Summary are defined intheOutpatient Prescription Drug Rider and/or Certificate ofCoverage. 041 BS RX NET FLNPP02304 H9 213-1377 0804 YOUR BENEFITS UnitedHealthcare Choice Plus Plan S59 Choice Plus plan gives you the freedom to see any Physician or other healthcareprofessionalfromour Network,including specialists, without a referral.With thisplan,you will receive the Highest level of benefits when you seek care Irom a network physician,facility or other health care professional.In addition,youdo not have to worry about any claim forms or bills. Youalso may choose to seek careoutside the Network,without a referral.However,you should know that care received from anon- network physician,facilityorotherhealthcareprofessionalmeansa higher deductible and Copayment.In addition,if you choose to seek careoutsidethe Network,UnitedHealthcare onlypaysaportion of thosechargesanditisyourresponsibilityto pay theremainder.This amount you are required topay,which eouldoe significant,does not applytotheOut-of-Pocket Maximum.Werecommendthatyouaskthe non-network physician orhealthcare professional about their billed charges before you receivecare. Some ofthe Important Benefits of Your Plan: You have access to a Network of physicians,facilitiesandotherhealthcare professionals,includingspecialists,without designatinga Primary Physician or obtaininga referral. Benefits are available for office visits and hospitalcare,aswellasinpatientand outpatientsurgery. Care CoordinationSM services are available tohelpidentifyandpreventdelaysincare forthosewho might needspecializedhelp. FLLGMS5902 Emergencies are covered anywhereinthe world. Papsmearsare covered. Prenatal care is covered. Routine check-ups arecovered. Childhood immunizations are covered. Mammograms are covered. Visionand hearing screenings arecovered. Choice Plus Benefits Summary Types ofCoverage ThisBenefitSummary is intended onlyto highlight your Benefitsandshouldnotbereliedupontofully determine coverage.Thisbenefitplanmaynotcoverall ofyourhealthcareexpenses.More complete descriptions ofBenefitsandthetermsunderwhich theyare provided are contained intheCertificateof Coverage thatyou will receiveuponenrollinginthe Plan. IfthisBenefitSummaryconflictsinanywaywith the Policy issued toyouremployer,the Policy shall prevail. TermsthatarecapitalizedintheBenefitSummaryare defined inthe Certificate ofCoverage. WhereBenefitsaresubjecttoday,visitand/ordollar limits,suchlimits applytothe combined useof Benefits whetherin-Networkor out-of-Network,exceptwhere mandatedbystatelaw. Network Benefits arepayable forCoveredHealth Services provided byor under the direction ofyour Networkphysician. ♦Prior Notification is required forcertain services. 1.Ambulance Services-Emergency only 2.Dental Services -Accident only 3.Durable Medical Equipment Network and Non-Network Benefits forDurable Medical Equipment arelimitedto$2,500per calendar year.Limitsdonotapplyto Durable Medical Equipmentclassifiedasdiabeticequipment orsupppies. 4.Emergency HealthServices 5.Eye Examinations Refractive eye examinations arelimitedtoone every other calendar year from a Network Provider. 6.Home Health Care Network and Non-Network Benefits are limited to 60visitsforskilledcareservicespercalendaryear. 7.HospiceCare Network and Non-Network Benefits are limited to 360days during theentireperiod of timea Covered PersoniscoveredunderthePolicy. 8.Hospital-Inpatient Stay 9.InjectionsReceivedinaPhysician'sOffice 10.Maternity Services 11.OutpatientSurgery,Diagnostic andTherapeutic Services OutpatientSurgery Outpatient Diagnostic Services Outpatient Diagnostic/Therapeutic Services -CT Scans,PetScans,MRI andNuclearMedicine Outpatient Therapeutic Treatments 12.Physician's Office Services CoveredHealthServicesforpreventivemedical care. CoveredHealthServicesforthediagnosisand treatment ofaSicknessorInjuryreceivedina Physician'soffice. 13.ProfessionalFeesforSurgicalandMedical Services Network Benefits /Copayment Amounts Annual Deductible:No Annual Deductible. Out-of-Pocket Maximum:$2,500 perCoveredPerson, percalendar year,nottoexceed$5,000 forall Covered Personsinafamily. MaximumPolicy Benefit:NoMaximumPolicy Benefit Ground Transportation:NoCopayment Air Transportation:0%of EligibleExpenses ♦Same as 8,11,12 and13 ♦Prior notificationis required beforefollow-up treatmentbegins. No Copayment $150pervisit $15pervisit NoCopayment No Copayment $500perInpatientStay $15pervisit Sameas 8,11,12 and13 NoCopaymentapplies to Physician officevisitsfor prenatal careafterthefirstvisit $250persurgicalprocedure Forlaband radiology/Xray:NoCopayment $250pertest No Copayment $15 pervisitexceptthatthe Copayment fora Specialist Physician officevisitis$25.NoCopaymentapplies whenaPhysicianchargeisnotassessed. $15pervisitexceptthattheCopaymentforaSpecialist Physicianofficevisitis$25.NoCopaymentapplies whenaPhysicianchargeisnot assessed. No Copayment Non-Network Benefits /Copayment Amounts Annual Deductible:$750 per Covered Personper calendaryear,nottoexceed$1,500 for all Covered Personsinafamily. Out-of-Pocket Maximum:$5,000perCoveredPerson, percalendaryear,nottoexceed$10,000 forallCovered Personsina family.TheOut-of-PocketMaximumdoes not include the Annual Deductible. Maximum Policy Benefit:$1,000,000perCovered, Person. Same as Network Benefit ♦Same as Network Benefit ♦Prior notificationisrequiredbeforefollow-up treatmentbegins. ♦40%ofEligible Expenses ♦Prior notification isrequired when thecostismore than $1,000. Same as Network Benefit ♦Notificationisrequiredif resultsinanInpatientStay. 40%of EligibleExpenses Eye Examinations forrefractiveerrorsarenot covered. ♦40%of EligibleExpenses ♦40%of Eligible Expenses ♦40%of EligibleExpenses 40%perinjection Sameas 8,11,12 and13 ♦Notification isrequired if InpatientStayexceeds48 hoursfollowinganormalvaginaldeliveryor96hours followingacesareansectiondelivery. 40%of Eligible Expenses 40%of Eligible .Expenses 40%of EligibleExpenses 40%of Eligible Expenses 40%of EligibleExpenses.NoBenefitsforpreventive care,exceptforChildHealthSupervisionServices. 40%of Eligible Expenses 40%of Eligible Expenses Types ofCoverage 14.Prosthetic Devices Network and Non-Network Benefits for prosthetic devicesarelimitedto $2,500 percalendaryear. 15.Reconstructive Procedures 16.Rehabilitation Services -Outpatient Therapy Network and Non-Network Benefits are limited as follows:20visits ofphysical therapy;20visits of occupationaltherapy;20visits ofspeechtherapy,20 visits of pulmonary rehabilitation;and36visits of cardiacrehabilitation percalendaryear. 17.SkilledNursing Facility/Inpatient Rehabilitation Facility Services Network and Non-Network Benefits are limited to 60dayspercalendaryear. Network Benefits/Copayment Amounts No Copayment Same as 8,11,12,13 and14 $15 pervisit No Copayment YOUR BENEFITS Non-NetworkBenefits/CopaymentAmounts 40%ofEligibleExpenses ♦Same as8,11,12,13 and14 40%ofEligibleExpenses ♦40%of EligibleExpenses 18.Transplantation Services ♦Same as8 and 13 No Benefits 19.UrgentCare Center Services $50pervisit 40%ofEligibleExpenses Additional Benefits Bonesor Joints of theJawandFacia]Region Same as 8,11,12 and13 ♦Same as 8,11,12 and13 ChildHealthSupervisionServices Same as 11,12 and13 Same as 11,12 and13 Cleft Lip/Cleft Palate Treatment Same as 8,11,12,13,and16 ♦Same as 8,11,12,13 and16 DentalProcedures-Anesthesia and Hospitalization Same as 8,11,and13 ♦Same as 8,11,and13 Diabetes Treatment Same as 3,11,12 and13 Same as 3,11,12 and13 Mammography NoCopayment Same as Network Benefit Mastectomy Same as 8,11,12 and13 ♦Same as 8,11,12 and13 Mental Health and Substance Abuse Services - Outpatient Mustreceivepriorauthorization throughtheMental Health/Substance AbuseDesignee.NetworkandNon- NetworkBenefitsarelimitedto30visitspercalendar year. $15perindividual visit;$10pergroupvisit Mental Health and Substance Abuse Services - Inpatient and Intermediate Mustreceivepriorauthorization throughtheMental Health/SubstanceAbuse Designee.NetworkandNon- NetworkBenefitsarelimitedto30dayspercalendar year. Osteoporosis Treatment PrescriptionandNon-PrescriptionEnteralFormulas Benefitsfor low proteinfoodproductsforCovered Persons through age24arelimitedto$2,500percalendar year. Spinal Treatment Benefitsinclude diagnosis andrelatedservicesand are limitedtoonevisitandtreatmentperday.Network and Non-NetworkBenefitsarelimitedto24visitsper calendaryear. $500perInpatientStay Same as 11,12 and13 NoCopayment $15pervisit 40%ofEligibleExpenses 40%ofEligibleExpenses Same as 11,12 and13 40%ofEligibleExpenses 40%of EligibleExpenses Exclusions Except as may bespecifically provided inSection 1ofthe Certificate ofCoverage (COC)or through a Ridertothe Policy,the following arenotcovered: A.AJternative Treatments Acupressure;hypnotism;rolling;massage therapy;aromatherapy,acupuncture;and other forms of alternative treatment. B.Comfort or Convenience Personal comfort or convenience itemsorservicessuchas television;telephone;barber or beauty service;guest service;supplies,equipment and similar incidental services and supplies for personal comfort including air conditioners,air purifiers and filters,batteries and battery chargers, dehumidifiers and humidifiers;devicesor computers toassistin communication andspeech. C.Dental Except as specifically described as covered in Section Iof the COC under the headings Dental Services -Accident only and Cleft Up/Cleft Palate Treatment,dental services are excluded.There is nocoverage for services provided for theprevention,diagnosis,and treatment of the teeth orgums (including extraction,restoration,and replacement ofteeth and services to improve dental clinical outcomes).Dental implants and dental braces arc excluded.Dental x-rays,supplies and appliances and all associated expenses arising out of such dental services (including hospitalizations and anesthesia) arc excluded,except as might otherwise be required for transplant preparation,initiation of immunosuppressives,the direct treatment of acute traumatic Injury,cancer,orcleft palate,oras described in Section 1oftheCOC under the heading of Dental Procedures -Anesthesia and Hospitalization.Treatment for congenitalry missing,malpositioned,orsuper numerary teeth is excluded,even if part ofaCongenital Anomaly except in connection with cleft liporcleft palate. D.Drugs Prescription drug products for outpatient usethat arc filled bya prescription order orrefill.Self- injectable medications except as described in Section 1of the COC under the heading ofDiabetes Treatment.Non-injectablc medications given m a Physician's office except asrequired inan Emergency.Over-the-counter drugs andtreatments. E.Experimental,Investigational or Unproven Services Experimental,Investigational orUnproven Services are excluded,except (a)bone marrow transplants and (b)medically appropriate medications prescribed for the treatment ofcancer,for a particular indication,if that drug is recognized for thetreatment of that indication ba standard reference compendium orrecommended inmedical literature.The fact that anExperimental,Investigational or Unproven Service,treatment,device orpharmacological regimen is the only available treatment for a particular condition will not result inBenefits if the procedure isconsidered tobeExperimental, Investigational orUnproven inthetreatment of that particular condition. F.Foot Care Routine foot care (including thecutting orremoval of corns and calluses);nail trimming,cutting,or debriding;hygienic and preventive maintenance foot care;treatment of flat feet orsubluxation ofthe toot;shoeorthotics. G.MedicalSuppliesand Appliances Devices used specifically as safety items orto affect performance primarily insports-related activities. Prescribed ornon-prescribed medical supplies and disposable supplies including butnot limited to elastic stockings,ace bandages,ostomy supplies,gauze and dressings.Orthotic appliances that straighten orre-shape abody part (including cranial banding and some types ofbraces).Tubings and masks are notcovered except when used withDurable Medical Equipment asdescribed in Section 1 ofthe COC. H.Mental Health/Substance Abuse Services performed inconnection with conditions not classified inthe current edition of the Diagnostic and Statistical Manual oftheAmerican Psychiatric Association.Services that extend beyond the period necessary for short-term evaluation,diagnosis,treatment orcrisis intervention. Mental Health treatment of insomnia andothersleepdisorders,neurological disorders,andother disorders withaknownphysicalbasis. Treatment of conduct and impulse control disorders,personality disorders,paraphilias and other Mental Illnesses thatwill not substantially improvebeyondthe current levelof functioning,orthat are not subject tofavorable mqdification ormanagement according to prevailing national standards of clinical practice,asreasonably determined by the Mental Health/Substance Abuse Designee. Services utilizing methadone treatment asmaintenance,LAA.M.(I-Alpha-Acetyl-Methadol), Cyclazoeine,ortheir equivalents.Treatment provided inconnection with ortocomply with involuntary commitments,police detentions and other similar arrangements,unless authorized bythe Mental Health/Substance AbuseDesignee.Residential treatment services.Services or supplies that in thereasonable judgment oftheMental Health/Substance Abuse Designee are not for example, consistent withcertain national standards or professional research further described in Section 2ofthe COC. I.Nutrition Megavitamin and nutrition based therapy;nutritional counseling for either individuals orgroups. Enteral feedings and other nutritional and electrolyte supplements,including infant formula and donor breast milk,except asdescribed in Section 1oftheCOC under theheading Prescription andNon prescription Enteral Formulas. United HealthCare Insurance Company J.Physical Appearance Cosmetic Procedures including,butnotlimitedto,pharmacological regimens;nutritionalprocedures or treatments;salabrasion,chemosurgeryandothersuchskin abrasion proceduresassociatedwiththe removal ofscars,tattoos,and/or whichareperformedasatreatmentfor acne.Replacementofan existingbreastimplantisexcluded if theearlierbreastimplantwasaCosmetic Procedure. (Replacement ofanexisting breast implant is considered reconstructive ifthe initial breast implant followedmastectomy.)Physical conditioningprograms suchasathletictraining,bodybuilding, exercise,fitness,flexibility,anddiversionorgeneralmotivation.Weightlossprogramsformedical andnon-medicalreasons.Wigs,regardlessofthereasonforthehairloss. K.Providers Services performed bya provider withyoursame legal residence orwhoisa family member by birth or marriage,includingspouse,brother,sister,parent or child.Thisincludesanyservicethe provider mayperform'on himself orherself.Services provided ata free-standing orHospital-based diagnostic facility withoutanorderwrittenbya Physician orotherprovider as further described in Section 2of theCOC(thisexclusiondoesnotapplyto mammography testing). L.Reproduction Healthservicesandassociatedexpensesforinfertilitytreatments.Surrogateparenting.The reversal of voluntarysterilization. M.Services Provided under Another Plan Healthservicesforwhichothercoverageispaidunderarrangementsrequiredbyfederal,stateorlocal law.Thisincludes,butisnottimited.to,coveragepaidbyworkers'compensation,no-fault automobile insurance,orsimilarlegislation.Healthservicesfor treatment ofmilitaryservice-related disabilities, whenyouorelegallyentitledtoother coverage and facilities are reasonably available toyou.Health services while onactive military duty. N.Transplants Healthservicesfororganortissuetransplantsareexcluded,exceptthosespecifiedascoveredin Section1 oftheCOC.Any solidorgantransplantthatisperformedasatreatmentfor cancer.Health servicesconnectedwiththeremoval ofanorganortissuefromyouforpurposesofa transplant to another person.Health servicesfor transplants involvingmechanical or animal organs.Any multiple organ transplant notlistedasaCoveredHealth ServiceinSection I oftheCOC. O.Travel Health servicesprovidedinaforeigncountry,unless required asEmergencyHealthServices. Travel or transportation expenses,eventhoughprescribed bya Physician.Sometravelexpenses related tocoveredtransplantation servicesmaybe reimbursed atour discretion. P.Vision and Hearing Purchase cost ofeyeglasses,contactlenses,orhearingaids.Fittingchargeforhearingaids,eye glasses or contact lenses.Eyeexercisetherapy.Surgery thatis intended toallowyoutoseebetter without glasses orothervision correction includingradial keratotomy,laser,andotherrefractive eye surgery. Q.Other Exclusions HealthservicesandsuppliesthatdonotmeetthedefinitionofaCoveredHealthService-see definition in Section 10 of the COC Physical,psychiatric or psychological examinations,testing,vaccinations,immunizationsor treatmentsotherwise covered underthePolicy,whensuchservicesare:(1)requiredsolelyfor purposes ofcareer,education,sportsorcamp,travel,employment,insurance,marriage or adoption; (2)relating to judicial or administrative proceedings or orders;(3)conducted for purposes of medical research;or(4)toobtainormaintainalicense ofany type. Healthservicesreceivedasaresult ofwaroranyactofwar,whetherdeclaredorundeclaredorcaused duringservicebthearmedforces ofanycountry. HealthservicesreceivedafterthedateyourcoverageunderthePolicyends,includinghealthservices formedicalconditionsarisingpriortothedateyourcoverageunderthePolicyends. Healthservicesfor which youhavenolegalresponsibilitytopay,orforwhichachargewouldnot ordinarilybemadeintheabsence ofcoverageunderthePolicy.In theeventthataNon-Network provider waivesCopayments and/ortheAnnualDeductible fora particular healthservice,noBenefits areprovided forthehealthserviceforwhich Copayments and/ortheAnnual Deductible arewaived. Chargesinexcess of EligibleExpensesorinexcessofanyspecifiedlimitation. Servicesfortheevaluationandtreatment of temporomandibularjointsyndrome(TMJ),whetherthe servicesareconsideredtobemedicalordentalbnature,exceptasdescribedinSection1 oftheCOC undertheheadingBonesorJoints oftheJawand Facial Region.Surgicaltreatmentand non-surgical treatment ofobesity(includingmorbidobesity). Surgical treatment andnon-surgical treatment ofobesity(including morbidobesity). Growthhormone therapy;sextransformationoperations;treatmentofbenigngynecomastia(abnormal breastenlargementinmales);medicaland surgical treatmentofexcessivesweating (hyperhidrosis); medicaland surgical treatmentforsnoring,exceptwhenprovidedaspart oftreatmentfordocumented obstructive sleep apnea.Oralappliances for snoring.Custodial care;domiciliary care;private duty nursing;respite care;restcures. Psychosurgery.Speechtherapyexceptasrequiredfortreatmentofaspeechimpedimentorspeech dysfunctionthatresultsfromInjury,stroke,cleft tip/cleft palateorCongenitalAnomaly. This summary of Benefits is intended only to highlight your Benefits and should not berelied upon to fully determine'eoverage.This plan may not cover all your health care expenses.Please refer tothe Certificate ofCoverage for a complete listing of services,limitations,exclusions and a description of alltheterms and conditions of coverage.Ifthisdescription conflicts inanywaywith theCertificate of Coverage theCertificate of Coverage prevails.Terms that are capitalized intheBenefit Summary are defined intheCertificate of Coverage. 02IBSChcPls FLLGMS5902QBE 213-1151_0604_Rev01 YOUR BENEFITS UnitedHealthcare Pharmacy Management Program Plan 023 UnitedHealthcare's pharmacy management program provides clinical pharmacy services that promote choice,accessibility and value.The program offers a broad network of pharmacies (more than 56,000 nationwide)to provide convenient access to medications. While most pharmacies participate in our network,you should check first.Call your pharmacist or visit our online pharmacy service at www.myuhc.com.The online service offers you home delivery of prescriptions,ability to view personal benefit coverage,accesshealthandwellbeinginformation,andeven location of network retail neighborhood pharmacies by zip code. CopaymentperPrescriptionOrderorRefill Your Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug Product All Prescription Drug Products onthe Prescription Drug List are assigned to Tier 1,Tier 2or Tier 3.Please access wwwtmyuhc.com through the Internet,or call the Customer Service number onyour ID card to determine tier status. For a single Copayment,you may receive a Prescription Drug Product up to the stated supply limit Some products are subject to additional supply limits.You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual and Customary Charge,or the lower ofthe applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug Product meets the definition ofa Covered Health Service and isnot Experimental,Investigational orUnproven. Retail Network HomeDeliveryNetwork Pharmacy Pharmacy Foruptoa 31 day supply Foruptoa90day supply Tierl $10 $25 Tier 2 $30 $75 Tier 3 $50 $125 FLNPP02304 United HealthCare Insurance Company Other Important Cost Sharing Information Annual Drug Deductible NoAnnualDrugDeductible Out-of-Pocket Drug Maximum NoOut-of-PocketDrugMaximum Exclusions Exclusionsfrom coverage listed in the Certificate apply also to this Rider. In addition,the following exclusions apply: Outpatient Prescription Drug Products obtained from anon-Network Pharmacy. Coverage for Prescription Drug Products for the amount dispensed (days supply or quantity limit)which exceeds the supply limit Prescription Drug Products dispensed outside the United States,except as required forEmergency treatment. Drugs which are prescribed,dispensed or intended for use while you are an inpatient in aHospital Skilled Nursing Facility,or Alternate Facility. Experimental,Investigational or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by us to be experimental,investigational or unproven. Prescription Drug Products furnished by the local,state or federal government Any Prescription Drug Product to the extent payment or benefits are provided or available from the local,state or federal government (for example,Medicare)whether or not payment or benefits are received,except as otherwise provided by law. Prescription Drug Products for any condition,Injury,Sickness or mental illness arising out of,or in the course of,employment for which benefits are available under any workers'compensation law or other similar laws, whether or not a claim for such benefits ismade orpayment orbenefits are received. Any product dispensed for the purpose of appetite suppression and other weightloss products. Aspecialty medication Prescription Drug Product (such as immunizations and allergy serum)which,due to its characteristics as determined by us,must typically be administered or supervised by a qualified provider or licensed/certified health professional in an outpatient setting.This exclusion does not apply to Depo Provera and other injectable drugs used for contraception. Durable Medical Equipment.Prescribed and non-prescribed outpatient supplies,other than the diabetic supplies and inhaler spacers specifically stated as covered General vitamins,except the following which require a Prescription Order orRefill:prenatal vitamins,vitamins with fluoride,and single entityvitamins. Unit dose packaging of Prescription Drug Products. Medications used for cosmetic purposes. Prescription Drug Products,including New Prescription Drug Products or new dosage forms,that are determined to not be a Covered Health Service. Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost,stolen,broken or destroyed. Prescription Drug Products when prescribed to treat infertility. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed.Any Prescription Drug Product that is therapeutically equivalent to an over-the-counter drug.Prescription Drug Products that are comprised ofcomponents that areavailableinover-the-counterformorequivalent Prescription Drug Products forsmoking cessation. Compounded drugs that do not contain atleast one ingredient that requires aPrescription Order or Refill Compounded drugs that contain at least one ingredient that requires a Prescription Order orRefill are assignedtoTier3. New Prescription Drug Products and/or new dosage forms until the date they are reviewed by our Prescription Drug List Management Committee. Growth hormone therapy for children with familial short stature (short stature based upon heredity and not caused bya diagnosed medical condition). ^^ofBcnen^tcndcd^^ TreS^U.^213-1377_0804 041 BS RX NET FLNPP02304 ^ Healdi Maintenance Organization Program Final Proposal for CITY OF SOUTH MIAMI Effective Date:10/1/05 Single Parent/Child(ren) Couple Family FL .$351.68 $654.12 $735.01 $1,040.97 Referred Care Primary OfficeVisit Copay:$10 Specialist Copay:$10 Outpatient(SPU)Surgery Copay:$0 Hospitalization Copay/A:$0 Bariatric Surgery:Not Covered Emergency Room Copay:$75 UrgentCare Copay:$35 MH O/P Copay:$2520v/cal RoutineEye Exam Copay:$10 Routine GYN Exam Copay:$10,lv/cal Rehab VP Copay/D:($0)30d/cal Rehab O/P Copay:$1030v/cal Prescription Copay:$10/$20/$35,30 Day Oral Contraceptives:$10/$20/$35,30 Day 31-90DaySupply:2Copays(RetailandMOD) Chiropractic Copay:$10 20v/cal DMEItemCopay:$0 Out of Pocket Limit $1500/$3000 In-Net Lifetime Maximum Benefit Unlimited The foregoingratesapplyinthe Service Area specifiedabove.Rateswill vary forotherserviceareas.. Service Area is determined by location of the subscriber's primary care doctor. Quote Conditions Assumed Dependent Eligibility Dependent children tothe end ofthe billable year inwhich he/she turns 25 or full-time students totheendofthebillable yearin which he/she turns 25.Coverage will continue far dependents who become mentally/physically handicapped prior totheendofthebillable year they reach age 25. Ratesare pending approval bystate regulators andare subject to adjustment based on regulatory determinations. These monthly quoted rates arevalid asoftheEffective Date and apply only tothebenefit level and conditions stated above and aresubject totheterms and conditions asaresetforth intheHMO's Group Master Contract and/w theCtaporateHealm Insurant Any changes inbenefit level orconditions stated above may require a change inrates.This proposal issubject tochange atany time priortothe acceptance byAETNA of employer's offer. Final Rates Please seeRating Conditions,Assumptions and Information Requests document forquote details. Health Plans AVKgED SPECIALIST'S TESTS EBUERCEKCY SERVICES «E3T/B!raEE2aATE CARE Services at participating doctors'offices include,butarenot limited to: •ROUTINEOFFICEVISITS /ANNUAL GYNVISIT WHENPERFORMED BY PRIMARY CARE PHYSICIAN •MATERNJIY-OUTPATTENT VISITS •PEDIATRIC CARE&WELL-BABY CARE •PERIODIC HEALTH EVALUATION & IMMUNIZATIONS •DIAGNOSTIC IMAGING,LABORATORY OROTHER DIAGNOSTIC SERVICES •MINOR SURGICAL PROCEDURES •VISION&HEARING EXAMINATIONS FOR CHILDREN UNDER18 OFFICE VISITS ANNUALGYN EXAMINATION WHENPERFORMED BY PARTICIPATING SPECIALIST Inpatient care at participating hospitals includes: •ROOM&BOARD-UNLIMITEDDAYS(SEMI- PRIVATE) -PHYSICIAN'S,SPECIALISTS&SURGEON'S SERVICES •ANESTHESIA,USE OF OPERATING &RECOVERY ROOMS,OXYGEN,DRUGS &MEDICATION •INTENSIVE CAREUNIT&OTHERSPECIALUNITS, GENERAL&SPECIALDUTYNURSING •LABORATORY&DIAGNOSTICIMAGING •REQUIRED SPECIAL DIETS RADIATION&INHALATIONTHERAPIES OUTPATIENT SURGERIES,INCLUDINGCARDIAC CATHETERIZATIONS AND ANGIOPLASTY CAT Scan,PETScan,MRI OTHER DIAGNOSTIC IMAGING TESTS An emergency is the sudden &unexpected onset ofa condition requiring immediate medical or surgical care. •EMERGENCYROOMAT PARTICIPATING HOSPITALS •EMERGENCY SERVICES -NON-PARTICIPATING HOSPITALS,FACILITIES,&/ORPHYSICIANS PLANMUSTBE NOTIFIED WITHIN24HOURSOF INPATTENT ADMISSION FOLLOWING EMERGENCY SERVICESORASSOONASREASONABLYPOSSIBLE. MEDICALSERVICESATAPARTICIPATING URGENT/IMMEDIATE CARE FACILITY OR SERVICES RENDERED AFTER HOURS IN YOUR PRIMARY CARE PHYSICIAN'S OFFICE MEDICALSERVICESATA NON-PARTICIPATING URGENT/IMMEDIATE CARE FACILITY cost t©mimm $1,500 INDIVIDUAL $3.000 FAMILY $10 PER VISIT $10 PER VISIT NO CHARGE NO CHARGE $25 PER TEST $10 PER TEST $75 COPAYMENT $100 COPAYMENT $40 COPAYMENT $60 COPAYMENT Health Plans Servicesatparticipatingdoctors'officesinclude,butarenot limited to: •ROUTINE OFFICE VISITS /ANNUAL GYN VISIT WHEN PERFORMED BY PRIMARY CARE PHYSICIAN •MATERNITY-OUTPATIENT VISITS •PEDIATRIC CARE &WELL-BABY CARE •PERIODIC HEALTH EVALUATION & DvlMUNIZATIONS •DIAGNOSTIC IMAGING,LABORATORY OR OTHER DIAGNOSTIC SERVICES •MINOR SURGICAL PROCEDURES •VISION &HEARING EXAMINATIONS FOR CHILDREN UNDER 18 OFFICE VISITS ANNUAL GYN EXAMINATION WHEN PERFORMED BY PARTICIPATING SPECIALIST B30SPBTAL Inpatientcareatparticipatinghospitalsincludes: •'ROOM &BOARD -UNLIMITED DAYS (SEMI- PRIVATE) •PHYSICIAN'S,SPECIALISTS &SURGEON'S SERVICES •ANESTHESIA,USEOF OPERATING &RECOVERY ROOMS,OXYGEN,DRUGS &MEDICATION •INTENSIVE CARE UNIT &OTHER SPECIAL UNITS, GENERAL &SPECIAL DUTY NURSING *LABORATORY &DIAGNOSTIC IMAGING •REQUIRED SPECIALDIETS •RADIATION &INHALATION THERAPIES TESTS URGEHTAHMEDIATE CARE OUTPATIENT SURGERIES,INCLUDING CARDIAC CATHETERIZATIONS AND ANGIOPLASTY CAT Scan,PET Scan,MRI OTHER DIAGNOSTIC IMAGING TESTS Anemergencyisthesudden&unexpectedonsetofacondition requiringimmediatemedicalorsurgicalcare. •EMERGENCY ROOM AT PARTICIPATING HOSPITALS •EMERGENCY SERVICES -NON-PARTICIPATING HOSPITALS,FACILITIES,&/OR PHYSICIANS PLAN MUST BE NOTIFIED WITHIN 24 HOURS OF INPATIENT ADMISSION FOLLOWING EMERGENCY SERVICES OR AS SOON AS REASONABLY POSSIBLE. MEDICAL SERVICES AT A PARTICIPATING URGENT/IMMEDIATE CARE FACILITY OR SERVICES RENDERED AFTER HOURS IN YOUR PRIMARY CARE PHYSICIAN'S OFFICE MEDICAL SERVICES AT A NON-PARTICIPATING URGENT/IMMEDIATE CARE FACILITY $1,500 INDIVIDUAL $3,000 FAMILY $10 PER VISIT $10 PER VISIT NO CHARGE NO CHARGE $25 PER TEST $10 PER TEST $75 COPAYMENT $100 COPAYMENT $40 COPAYMENT $60 COPAYMENT Iealth Plans CASH BOTCTIBLE LNDIVLDUAL/FAMILY OUT-OF-IhTOIVIDUAL/FAMILY SPECBALiST'S SERVICES TESTS $2,000,000 PER MEMBER REQUIRED FOR SPECIFIC COVERED SERVICES.THE PENALTY FOR NOT OBTAINING PRIOR AUTHORIZATION IS A 20%REDUCTION IN BENEFITS. Services at doctors'officesinclude,butare not limitedto: •ROUTINE OFFICE VISITS/ANNUAL GYN VISIT •MATERNITY-OUTPATIENT VISITS •PEDIATRIC CARE &WELL-CHILD CARE •DIAGNOSTIC IMAGING,LABORATORY OR OTHER DIAGNOSTIC SERVICES •MINOR SURGICAL PROCEDURES •VISION &HEARING EXAMINATIONS FOR CHILDREN UNDER 18 OFFICE VISITS Inpatientcareat hospitals includes: •ROOM&BOARD-UNLIMITEDDAYS(SEMI-PRIVATE) •PHYSICIAN'S,SPECIALISTS&SURGEON'SSERVICES •ANESTHESIA,USEOF OPERATING &RECOVERYROOMS, OXYGEN,DRUGS&MEDICATION •INTENSIVE CARE UNIT &OTHER SPECIAL UNITS, GENERAL &SPECIAL DUTY NURSING •LABORATORY &DIAGNOSTIC IMAGING •REQUIREDSPECIALDIETS •»RADIATION &INHALATION THERAPIES •OUTPATIENT SURGERIES,INCLUDING CARDIAC CATHETERIZATIONS AND ANGIOPLASTY •CAT SCAN,PETSCAN,MRI •OTHER DIAGNOSTIC IMAGING TESTS •20 OUTPATIENT VISITS (20 VISITS IS THE TOTAL NUMBER OF COVERED VISITS FOR BOTH INANDOUTOF NETWORK,COMBINED) IF MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT RIDER ISELECTED,BENEFITS ARESUBJECTTOPOSRIDER DEDUCTIBLE AND COINSURANCE ARRANGEMENTS WHEN USING NON-PARTICIPATING PROVIDERS. SPECIFIED SERVICE LIMITS ARE THE TOTAL NUMBER OF COVERED VISITS FOR BOTH IN AND OUT OF NETWORK, COMBINED. $500/$l,500 ANNUALLY $3,000/6,000 ANNUALLY ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE Benefit Summary,continued ALLERGY TREATMENTS -INJECTIONS •SKIN TESTING PHYS8CAL,SPEECH,& OCCUPATIONAL THERAPIES &REHABBLBTATBOH CENTERS •SHORT-TERMPHYSICAL,SPEECHOROCCUPATIONAL THERAPY FOR ACUTE CONDITIONS COVERAGE IS LIMITED TO24VISITS PER CALENDAR YEAR FOR ALL SERVICES COMBINED. UPTO 20 DAYS PER CONTRACT YEAR POST- HOSPITALIZATION CARE WHEN PRESCRIBED BY PHYSICIAN &AUTHORIZED BY AVMED Cardiac Rehabilitation is covered forthe following conditions: •ACUTE MYOCARDIAL INFARCTION •PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY(PTCA) •REPAIR OR REPLACEMENT OFHEART VALVE(S) •CORONARY ARTERY BYPASS GRAFT (CABG),or •HEART'TRANSPLANT COVERAGE IS LIMITED TO18VISITS PER YEAR. HEALTBB CARE•PER OCCURRENCE ORTHOTIC APPLBAftiCES PROSTBSETICDEVICES Equipment includes: •HOSPITAL BEDS •WALKERS •CRUTCHES -WHEELCHAIRS Orthotic appliances arelimitedto: •LEG,ARM,BACK,ANDNECKCUSTOM-MADE BRACES Prosthetic devices are limited to: -ARTIFICIAL LIMBS •ARTIFICIAL JOINTS •OCULAR PROSTHESES ELIGIBLEEXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLEEXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLEEXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE $20 PER VISIT BENEFITS LIMITED TO $1,500 PER CONTRACT YEAR. ELIGIBLEEXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE $50 PER EPISODE OF ILLNESS.BENEFITS LIMITED TO $500 PER CONTRACT YEAR. ELIGIBLEEXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE THIS SCHEDULE ISNOTACONTRACT.FOR SPECIFIC INFORMATION ON BENEFITS EXCLUSIONS ANDLIMITATIONSPLEASE CONSULT YOURAVMED HMO MEDICAL AND HOSPITAL SERVICE CONTRACT AND POINT-OF-SERVICE RIDER. .V-POS-500-30-3000-03 IP-3440(9/03) N Health Maintenance Organization Program Final Proposal for CITY OF SOUTH MIAMI Effective Date:10/1/05 Single Parent/Child(ren) Couple Family EL ,$351.68 $654.12 $735.01 $1,040.97 Referred Care Primary OfficeVisit Copay:$10 Specialist Copay:$10 Outpatient (SPU)Surgery Copay:$0 Hospitalization Copay/A $0 Bariatric Surgery:Not Covered Emergency Room Copay:$75 UrgentCare Copay:$35 MH O/P Copay:$25 20v/cal RoutineEyeExamCopay.$10 Routine GYN Exam Copay:$10,lv/cal Rehab I/P Copay/D:($0)30d/cal RehabO/P Copay:$10 30v/cal Prescription Copay $10/$20/$35,30 Day OralContraceptives:$10/$20/$35,30 Day 31-90 Day Supply 2 Copays (Retail and MOD) Chiropractic Copay:$10 20v/cal DMEItemCopay:$0 Out of Pocket Limit $1500/$3000 In-Net LifetimeMaximum Benefit Unlimited The foregoing rates apply in the Service Area specified above.Rates will vary for other service areas. Service Areais determined by location ofthe subscriber's primary care doctor. Quote Conditions Assumed DependentEligibility OTfuU-4in«stwientetotheendofte^Cweragewuia>ntinuefarder*ndents who become meatallv/physicalJyliaiidicqyed prior tothe end ofthe billable year fcey reach age 25. Dependent children to the end ofthe billable year inwhich he/she turns 25 Rates are pending approval by state regulators and are subject to adjustment based on regulatory deterrninations. These monthly quoted rates are valid as ofthe Effectrvc 1^and i^ty c^to the beneft levd ^ are subject tometerms and conduceas are set forfo^ Any changes in benefit level or conditions stated above may require achange in rates.This proposal is subject to change at any time prior tothe acceptance byAETNA of employer's offer. Final Rates Please see Rating Conditions,Assumptions and Information Requests document for quote details. City ofSouth Miami Human Resources Department Health Insurance Selection July 12,2005 Please select one vendor: •AvMed *Blue Cross /Blue Shield Cigna Health Care #Humana Neighborhood HealthPartnership *United Health Care "Vista o <Odtr\c\ Carol flj/nz/rn Employee Name -Please PrintEmployee Vl6'l 6 kh\CAU' South Miami AMmafcaCUr 1IIIIF Mo Declined to quote Declined to quote No Declined to quote 2001 City ofSouthMiami 6130SunsetDrive,SouthMiami,Florida33143 City ofSouth MiamiHuman Resources Department Health Insurance Selection July12,2005 Please select one vendor: AvMed Blue Cross /Blue Shield Cigna HealthCare Humana Neighborhood Health Partnership United Health Care Vista ^^ Employee Name -Please Print ^ Declined to quote Declined to quote -Mix Declined to quote South Miami fcz&xal AMmnttaCOT W 2001 City ofSouthMiami 6130 SunsetDrive,SouthMiami,Florida 33143 City ofSouth MiamiHuman Resources Department Health Insurance Selection July 12,2005 Please select one vendor: AvMed Blue Cross /Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Name -Please Print Declined toquote Declined toquote aJO Declined to quote South Miami AWtaateaHtj V 2001 City ofSouthMiami 6130 SunsetDrive,SouthMiami,Florida 33143 City ofSouthMiamiHumanResourcesDepartment Health Insurance Selection July 12,2005 Please select one vendor: AvMed Blue Cross /Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Employee Name-PleasePrint V. Declined to quote Declined to quote Declined to quote Declined to quote "mployee Si;Signature -Date (£ South Miami AD-AnmfcaCRr 'IIH' 2001 City ofSouthMiami 6130 SunsetDrive,SouthMiami,Florida 33143 City ofSouth MiamiHuman Resources Department Health Insurance Selection July 12,2005 Please select one vendor: AvMed Blue Cross /Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Employee Name-Please Print Declined to quote Declined to quote JLLb Declined to quote A/fir Declined to quote /fc^'i^Aj /fLmjAoyeeSignature -Date South Miami flD-AnwJcaCttr \iinr 2001 City ofSouthMiami 6130SunsetDrive,SouthMiami,Florida33143 City ofSouthMiamiHumanResourcesDepartment Health Insurance Selection July 12,2005 Please select one vendor: AvMed Blue Cross /Blue Shield Cigna Health Care Humana Neighborhood HealthPartnership United Health Care Vista EmployeeName-Please Print Declined to quote Declined to quote Declined to quote Declined to quote JZ,•jPm^'Md* Employee Signature -Date South Miami JtMoofcaCBr - W 2001 CityofSouthMiami 6130 Sunset Drive,SouthMiami,Florida 33143 City ofSouth MiamiHuman Resources Department Health Insurance Selection July 12,2005 Please select one vendor: AvMed Blue Cross /Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista lut«£#.>Js Employee Name -Please Print South Miami AMraateaKj W / Declined to quote Declined to quote Declined to quote Declined to quote l^7/ii/vr Employee Signature -Date 2001 City ofSouthMiami 6130 Sunset Drive,South Miami,Florida 33143