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08-19-033 �i ,� Miami b. t sma� ~�aesaa wcs awaa�F 2(3(11 CITY COMMISSION AGENDA City Commission Meeting Meeting date: August 19, 2003 6130 Sunset Drive, South Miami, FL Next Regular Meeting Date: September 2, 2003 Phone:, (305) 663 -6340 Time: 7`:30 PM City of South Miami Ordinance No. 10 -00 -1712 requires all lobbyists before engaging in any lobbying activities to register with the City Clerk and pay an annual fee of $125.00. This applies to all persons who are retained (whether paid or not) to represent a business entity or organization to influence "City" } action. "City" action is broadly described to include the ranking and selection of professional consultants, and virtually all - legislative, quasi- judicial and administrative action. It does not apply to not - for - profit' organizations, local chamber and merchant groups, homeowner associations, or trade associations and unions. CALL TO ORDER: A. Roll Call B. Invocation° C. Pledge of Allegiance: D. Presentation(s)7:00 p.m. None ITEMS (S) FOR THE COMMISSION'S CONSIDERATION`: 1. Approval of Minutes - August 5, 2003 2. City Manager's Report REGULAR CITY COMMISSION AGENDA — August 19, 2003 1 3. City Attorney's Report PUBLIC REMARKS (5- minute limit) CONSENT 4. A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, SETTING FORTH CERTAIN POLICIES PERTAINING TO CODE COMPLIANCE AND ZONING, WHICH SHALL BE APPLICABLE TO THE SNAPPER CREEK ANNEXATION AREA UPON ANNEXATION INTO THE CITY OF SOUTH MIAMI; PROVIDING AN EFFECTIVE DATE 3/5 (Mayor Feliu) ORDINANCE (S) SECOND READING PUBLIC HEARING (S) None RESOLUTION (S)/PUBLIC HEARING (S) None RESOLUTION (S) 5 A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, RELATING TO HEALTH INSURANCE BENEFITS; AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT WITH CIGNA HEALTHCARE TO PROVIDE' GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL- TIME EMPLOYEES; PROVIDING AN EFFECTIVE DATE. 3/5 (City Manager) 6. A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, RELATING TO LEGAL I SERVICES; DIRECTING ADMINISTRATION TO INITIATE AN RFP FOR LEGAL SERVICES FOR THE CITY OF SOUTH MIAMI; PROVIDING AN EFFECTIVE DATE. 3/5 (Mayor Feliu) ORDINANCE (S) FIRST READING (S) SPEAKERS PLEASE TAKE NOTICE THAT SECTION 2-2.1(k)(2) OF THE CODE OF ORDINANCES PROVIDES THAT "ANY PERSON MAKING PERSONAL IMPERTINENT, OR SLANDEROUS REMARKS OR WHO SHALL BECOME BOISTEROUS WHILE ADDRESSING THE COMMISSION REGULAR CITY COMMISSION 2 AGENDA - August 19, 2003 , r" " -'°': ----, 7 - ..ter -`; ,. SHALL BE FORTHWITH BARRED FROM FURTHER AUDIENCE BEFORE THE COUNCIL BY THE PRESIDING OFFICER, UNLESS PERMISSION TO CONTINUE BE GRANTED BY A MAJORITY VOTE OF THE COMMISSION. COMMISSION REMARKS PURSUANT TO FLA STATUTES 286.0105,_ "THE CITY HEREBY ADVISES THE PUBLIC THAT IF A PERSON DECIDES TO APPEAL ANY DECISION MADE BY THIS BOARD, AGENCY OR COMMISSION WITH RESPECT TO ANY MATTER CONSIDERED AT ITS MEETING OR HEARING, HE OR SHE WILL NEED A'RECORD OF THE PROCEEDINGS, AND THAT FOR 3UCH.PURPOSE, AFFECTED PERSON MAY NEED TO ENSURE THAT A VERBATIM RECORD OF THE PROCEEDINGS IS MADE WHICH RECORD INCLUDES THE TESTIMONY AND EVIDENCE UPON WHICH THE APPEAL IS TO BE 'BASED. THIS NOTICE DOES NOT CONSTITUTES CONSENT BY THE CITY FOR THE INTRODUCTION OR ADMISSION OR OTHERWISE INADMISSIBLE OR IRRELEVANT 'EVIDENCE, NOR DOES IT AUTHORIZE 'CHALLENGES OR APPEALS NOT OTHERWISE ALLOWED BY LAW. I �Vl I .RESOLUTION NO. 2 3 A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF 4 THE CITY OF SOUTH MIAMI, FLORIDA, RELATING, TO 5 SNAPPER CREEK ANNEXATION; SETTING FORTH CERTAIN 6 POLICIE'S PERTAINING TO CODE COMPLIANCE AND 7 ZONING, WHICH SHALL BE APPLICABLE TO THE SNAPPER 8 CREEK ANNEXATION AREA UPON ANNEXATION INTO THE 9 CITY OF SOUTH MIAMI; PROVIDING'AN EFFECTIVE DATE. 10 11 WHEREAS, in an effort- to foster positive community 12 relations with the Snapper, Creek proposed annexation area ,13 and bring the total community together, the Commission 14 desires to take a diplomatic approach to assuring the 15 property owners in that area by setting policies pertaining 16 to code compliance and zoning. 17 18 NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY 19 COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA; 20 21 Section 1. That the policies hereinafter set forth 22 pertaining` to code compliance and zoning, shall be 23 applicable to the Snapper Creek Annexation--Area upon 24 annexation into the City of South Miami. 25 26 Section 2. That all existing construction which 27 has been properly permitted by Miami Dade County will be 28 grandfathered, in other words, will be allowed to continue 29 as is. 30 31 Section 3. That any existing construction allowed 32 by Miami Dade County Code, which did not require a permit 33 will also be grandfathered. 34 35 Section 4. That if it is determined at a future 36 date that existing construction was built without proper 37 and required permits from Miami Dade County, that 38 construction element cannot be grandfathered, and the 39 property owner shall be required to apply for an after-the- 40 fact permit from South Miami, the City will assist property 41 owners in obtaining the appropriate approvals and permits. 42 43 Section 5._ That the City of South Miami will not 44 carry out a code compliance field check or examine the 45 building permit records unless at some future date a 46 complaint is received or is necessary due to a review Additions shown by underlining and deletions shown by everstrilc xg. . ... I triggered by a remodeling or new construction permit 2 application. 3 4 Section 6. That the City will require compliance 5 with all City and zoning regulations for a new construction 6 and additions initiated after annexation. 7 8 Section 7. That the City will allow for the 9- grandfathering of certain uses authorized under the current 10 County Zoning Codes applicable to the area. 11 12 Section 8. This resolution shall take effect 13 immediately upon approval. 14 15 PASSED AND ADOPTED this day of , 16 2003. 17 18 ATTEST: APPROVED: 19 20 21 CITY CLERK MAYOR 22 23 Commission Vote: 24 READ AND APPROVED AS TO FORM: Mayor Feliu: 25- Vice Mayor Russell: 26 Commissioner Wiscombe: 27 CITY ATTORNEY Commissioner Bethel: 28 Commissioner McCrea: 29 i j Page 2 of 2 4 Source South Miami �" �'� CITE' -OF SOUTH MIAMI aaaaad INTEROFFICE MEMORANDUM INCORPORATED . �L O -2Tp TO: Honorable Mayor, Vice Mayor DATE: August 19, 2003 & City Commission FROM: Maria V. Davis ITEM No. City Manager RE: Selection of Group Health Insurance RESOLUTION A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA„ RELATING TO HEALTH INSURANCE BENEFITS AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT WITH CIGNA HEALTHCARE TO PROVIDE GROUP HEALTH INSURANCE' FOR CITY OF SOUTH MIAMI FULL -TIME EMPLOYEES PROVIDING AN EFFECTIVE DATE. BACKGROUND AND ANALYSIS The attached resolution seeks approval from the City Commission for the City Manager to sign a one -year contract with Cigna HealthCare to provide health insurance coverage for City of South Miami full time employees. We have received renewal rates from our current group health insurance carrier Neighborhood Health Partnerships and noted 'a (32) % thirty -two percent increase in premiums. The City found it necessary to seek an insurance plan that will provide quality coverage at competitive rates. The City solicited bids from several companies. Five companies which are listed below responded: BCBS CIGNA HEALTHCARE FLORIDA LEAGUE OF CITIES NEIGHBORHOOD HEALTH PLANS UNITED HEALTHCARE A review committee consisting of the Human Resources Manager, representative of the PBA, AFSCME and general employees carefully reviewed the proposals and unanimously recommended the selection of Cigna Healthcare. By selecting Cigna HealthCare, the designated Agent of Record for our health insurance benefits will be Employee Benefits Consulting Group. It is estimated that selection of a new carrier will result in projected annual savings of approximately $79,000.00 in the next fiscal year's budget, without resulting in reduced benefits for our employees. RECOMMENDATION Approval is recommended. RESOLUTION NO. A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, RELATING TO HEALTH INSURANCE BENEFITS AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT WITH CIGNA HEALTHCARE TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL -TIME EMPLOYEES PROVIDING AN EFFECTIVE DATE. WHEREAS, in order to ensure adequate health insurance for all full time City employees and their families, the City has found it necessary to seek an insurance plan that will provide quality coverage at a competitive rate; and WHEREAS, proposals for health insurance were requested and received from five (5) different' insurance companies; and WHEREAS, the companies that submitted proposals were: BCBS Cigna HealthCare Florida League of Cities Neighborhood Health Plans United HealthCare WHEREAS, the review committee consisting of the Human Resources Manager, representative of the PBA, AFSCME and general employees carefully reviewed the proposals and unanimously recommended the selection of Cigna Health Care; and WHEREAS, with the selection of the new health insurance provider -Cigna HealthCare, the designated Agent of Record will be Employee Benefits Consulting Group until contract expires or until otherwise determined by either party. NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA; Section 1. The City Manager is hereby authorized to contract with Cigna Healthcare for the city's group health insurance. Section 2. The contract shall be effective October 1, 2003 and shall be renewable on an annual basis. e Section 3. This engagement is at will and shall continue until any party terminates the engagement by giving written notice to the other party. The City shall not be charged for agent of record services. Employee Benefits Consulting Group shall be compensated by the insurer: Section 4. This resolution shall take effect immediately upon approval. PASSED AND ADOPTED this day of , 2003. ATTEST: APPROVED: CITY CLERK MAYOR Commission Vote: READ AND APPROVED AS TO FORM: Mayor Robaina: Vice Mayor Russell: Commissioner Wiscombe: CITY ATTORNEY Commissioner Bethel: Commissioner F`eliu: Page 2 of 2 1 RESOLUTION NO. 2 3 A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF 4 THE CITY OF SOUTH MIAMI, FLORIDA, RELATING TO 5 - HEALTH INSURANCE BENEFITS AUTHORIZING THE CITY 6 MANAGER TO ENTER INTO A CONTRACT WITH CIGNA ` 7 HEALTHCARE TO PROVIDE GROUP HEALTH INSURANCE 8 FOR CITY OF SOUTH MIAMI FULL -TIME EMPLOYEES 9 PROVIDING AN EFFECTIVE DATE. 10 11 WHEREAS, in order to ensure adequate health insurance for all full time City 12 employees and their families, the City has found it necessary to seek an insurance plan 13 that will provide quality coverage at a competitive' rate; and 14 15 WHEREAS, proposals for health insurance were requested and received from five 16 _(5) different insurance companies; and 17 18 WHEREAS, the companies that submitted proposals were; 19 20 BCBS 21 Cigna HealthCare 22 Florida League of Cities 23 Neighborhood Health Plans 24 United HealthCare 25 26 WHEREAS, the review committee consisting of the Human Resources Manager, 27 representative of the PBA, AFSCME and general employees carefully reviewed the 28 proposals and unanimously recommended the selection of Cigna Health Care; and 29 30 WHEREAS, with the selection of the new health insurance provider -Cigna 31 HealthCare, the designated Agent of Record will be Employee Benefits Consulting 32 Group until contract expires or until otherwise determined by either party. 33 34 NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY 35 COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA; 36 37 Section 1. The City Manager is hereby authorized to contract with Cigna 38 HealthCare for the city's group health insurance. 39 40 Section 2. The contract shall be effective October 1, 2003 and shall be 41 renewable on an annual basis. 42 43 44 45 46 .. .._ ., - l Page 2 of 2 2 3 Section 3. This engagement is at will and shall continue until any party 4 terminates the engagement by giving written notice to the other party. The City shall not 5 be charged for agent of record services. Employee, Benefits Consulting Group shall be 6 compensated by the insurer. 7 8 Section 4. This resolution shall take effect immediately upon approval. 9 10 PASSED AND ADOPTED this day of , 2003. 11 12 13 ATTEST: APPROVED: 14 15 CITY 'CLERK MAYOR 16 17 Commission Vote: 18 READ AND APPROVED AS TO FORM: Mayor Robaina: 19 Vice Mayor Russell: 20 Commissioner Wiscombe: 21 CITY ATTORNEY Commissioner Bethel: 22 Commissioner Feliu: 23 Page 2 of 2 BCBS Monthly Premium Monthly Premium 391.12 HMO 704.02 PPO 727 EMP $ 326.37 1,173.36' $ 415.29 EMP CHILD $ 602.60 $ 801.56 EMP SP $ 684.00 $ 756.99 FAMILY '$ 960.23 is 1,225.69 CIGNA (EBCG) Monthly Premium Monthly Premium 391.12 HMO (Stand Alone) 704.02 HMO /DUAL OPTION EMP $ 325.92 1,173.36' $ 325.92 EMP CHILD $ 586.65 $ 586.65 EMP SP $ 651.83 $ 651.83 FAMILY $ 977.75 $ 977.74 CIGNA (Line) Consulting) Monthly Premium Monthly Premium HMO POS Open EMP $ 335.35 $ 395.47 EMP CHILD $ 610.83 $ 711.85 EMP SP ! $ 678.70 $ 790.94 FAMILY $ 1,018.05 $ 1,186.41'- Monthly Premium POS $ 391.12 $ 704.02 $ 782.24 $ 1,173.36' Florida League of Cities Monthly Premium ,Monthly Premium 'PPO (Gold Plan). PPO(Silver Plan) EMP '$ ...473.30 $ 431.88 EMP CHILD $ 823.89 $ 751.80:" fMP SP ' '$ 887.37 $ 809.72- FAMILY ! $ 1,237.96 $ 1,129.64- fVHP Renewal Rates Monthly Premium 'Monthly Premium HMO POS EMP $ 366.33 450.00 EMP CHILD $ 659.37 $ 810.00 EMP SP ' $ 732.64 900.00 FAMILY $ 1,098.97 '< $ = 1,351.00 United Healthcare HMO /option 1 HMO /option 2 Monthly Premium Monthly Premium EMP $ 359.85 $ 355.60. EMP CHILD $ 647:75 $ 640.07 EMP SIP 719.72 $ 711.20 FAMILY 1,079.57 $ 1,066.79 HMO EMPLOYEE RATES ARE IN BOLD Monthly Premium PPO(Bronze Plan) $ 398.04 $ 692.89 $ 746.27 $, 1,041.12 1,079.57 $ 1,066.79 HMO EMPLOYEE RATES ARE IN BOLD Monthly Premium PPO(Bronze Plan) $ 398.04 $ 692.89 $ 746.27 $, 1,041.12 HMO EMPLOYEE RATES ARE IN BOLD Monthly Premium PPO(Bronze Plan) $ 398.04 $ 692.89 $ 746.27 $, 1,041.12 MO. 330 P.4/14 JUL.z5.3003 12'-50PM BLUE CROSS FTG 58�QFS$1 Rate Analysis fir CITY OF SOUTH MxAMI Coverage Effective Date :111UI12,003' Proposal Expires ;11101;12003 Division. C_ ffy OF SOUTA NUAM1 monthly l t � Far: Blue COGY Man 716 [� nt - R%..$101$23/S40 r ^ 4 -0er t �lil MCovers l a refer cc +Gild gal Ass ' vns is this sermon fpr erlditi cyl details of tlu: Deed "tan. Monthly RMS For: BlueCare NFQ LG CRP Plan 4 Rx-. 8101$251540 4-tier Rate Cavra S to � , a $705.16 Exn + S °use 5621.24 to .9-5 8989.93 Famil ote: Please refer to Pr al s Asp tiaras in this tioa far additional details ofthc sad lane . All rates, besets, end. e5"dve datos are subject Ce C� pp Val. dam wiu snot be billed All rates are subjex�t to Florida 13eparcmesat of l t of Insurance. A with the proposed rates until the rates are agproved by the Florida Deparkm� ticatiaa. check equal to dw ant mouth's prcmiwa based F M�� . I€ n t "� OF This inbrmadon is intended solely for "CITY SOUTH MIAMI" flits ix %madon does not apply to yam The rat e/ades-sbovnn, which #dare based ded is sub ect to chw5c and is not a g�,tftee of coverage. Also, 0a the tafa tion psi j hcation has been approv by HC BSFIH01, a caatract 00vWae i$ rantfective unttil ai'ter your app aid. No ag►t mange a contract bas begin isgtad and the initial gremluu� has P term ax waive any of the p=Vs rights. The 1 e oove�rage afforded by any BCBSFIHCI policy is subject to tba ter w and conditions of fhe policies as issued, SMIR NO. 330 P.5/14 iLIL.25. 2003 12. 50PM BLUE CROSS FTL Proposal .Assumptions i and revie3w caf the BCSSF/HOI Corddentiality Nctiee at�ci owl s r 1 PPlicastt hereby asks liaaat acl wle4ges that it may be liable to BCBBF/Hol aDd or agrees to abide by said Natice. A,lap eats said Notice. others should it fail to comply with •the requi This proposal assumes group size of 140 esrnplayeese calculations based upon -data tvrraished; fitd rates based upon actual enrollment . s benefits, >u geo-mia d are subject to Home E3£fsca approval Final r , Final rates are guar atLtaed for twelve (12) month, begin s 110 1 than 11l01/�0�43. f�i ero t (15 ° /a) of employees live outside the State of TWE proposal assumes no wore than. p Florida, Gt'ier grovidB st�mes that Blue Cross and Blue Sbield of Florida will be the only Qvr proposal as �s health coverage far the Gro% employees. Quote d rates a sr,=e the following Wrollment; a` Plea 716 B1ueCws Ir1F'Q LG GIB' Plan 4 Blue�Choice CQp y 75 BMPIoyer Coatn`butiOn 75 75 °, uro. Participatioa 75 %0 A Blue Cross and Blue Shield of FloriFlorida restew� will be prosenW at least 45 days before the policy annivcrsary date. utri of 30 hours 1 ' .� are those aotive fall -time en�ploye� wlr<a regulszl�' work a � F- ligible amp oy Per week lan, Pre-existing ns waived for initial enrollees oovere�d with a prior groin health p Pre-exists condltio I cent euroilees that *60us coverage, w"k no more 0= conditions are generally waived for sabseq a 63-day lapse in omlemgc Prior to they hire date. to ees over the ag. of 65 For employers with 20 or more employees, Federal lave regtutea active e p um Medicate- This F t be allowed a chorea, of coverage between' The emp y , and/or Their spouse, to ees ail select the employeeo Goverage as per• proposal assumes such awp y to acs andloz their Federal iaw requires active emp 'y For employers with 100 or more ep�Yees, a as airy t are dabled 1 allowed a choice of coverage betwep1 °yen's plea dependeasts under age 65 ft asauanes such employees all select the MPIOYef9 ooverag P and Medicare. This proposal a ees and/or their depe>adeuts who are entitled to Me& fear the first on Federal law requires active empl y o ees cove as gra�r3' p y the basis of End Stag® penal Discase,`to have the Pl Y 30 moaft of their Medicare eiigibihty. „UL.25.EO33 12;54PM BLUL- GKU55 ('IL dyv..�3a r. iry 1{ RIUBUO” BhwSbWd otpladda • + Z°uw �w�oe ww�enw'' • Kom HeLkh' Care , ,540 $2 $2 * Sbm d Nuraing FaOOity Day, $2,540 I�ow Prot u Food Products l' h SiQ $2,500 • cd Cardiac, lvdOr Sjdach, and MusagC Tes and gp Lifedm MjLdmtmx Per Imured $5,00b,000 • Total Sub ce i?�Y CITE ad Treats 2,�d0 (41dmt, ©utp 't or =y combi iCA) S7,500 Hospice Benefit ADDMO1YAL PSNEFTIS ` Accident care Nikes will l)e paid Aocilde�t Care subject to S•Y oOPSY► deduc ble and gainmMee provisims of the pram. Not C®VCCPd. C covered at 100°!o of .Allowed Amomit. mammo m Screening Senices Covered for all umbers, wburnity gealt i -1 o=*dnodon, ham, Traungaunt Services kKIW, cornea and bone mWOW - traasplaats, BiVh to ago 15,1 S visits, deducible �*deyl Cif Care waived. Covered aarvioes for as Wdt ('age 17 Waftesa Bone& (Adults) and over) mdude an annual s� related. welimss Srvices up to a cgendar yew' m , of 8150. 'j a reni Cs are na subject to ft Calendar "Year DO&actible, but are seat to the applicable 00POPUM Or Ooinsa =ce r0Wn ibility. Utitlgel V16ion and' bming 99=1u are rat cc. M=m do not accumulate to fb& oetwdda you BlueChoice FFCI Physician COPY Ply Dcsiga sue.. NO.-30 P.11/14 JUL.255.2003 12154PM BLUE CROSS FTL �arlle�oB6 � of F10 Bluescript Rota Fbargmq Ptogram $10 GGPay r PrefecTed Qemwlc Dugs $ 25 r• Y P refMod Brand Drags $ 40 cppay e xon preferred Dry pa�yr►o�tth • MsI z► Supply Cowtod - • Graf' Con1 Pdya and 17evice1 Mail Grder.lPbaxmac' Program $ 20 cogaY a preferred Gencria DMV s 50 coPtY . prelmTed BmdDrMgs s gq c pay s Ikon Pmfw'ed Dm,gs go da maxim= Cow . Graf C4mgmcpvts end IIMIIes IMLGill=y tl and of the Cowered *rough a p Deg dont Cbildreu �endar year in which ag wed; as fibraugh of the calerm YOU is which age 25 is aUajwd,if 1) dqxnd0i covered eciployet. ,fryr sulart living is fife =Vera pmpwee rbold,, or 2) d 'Von aa • s rk p' e l �' ee for full -Mime or paGtnae Covered after 12 PrO43 fisting C " D' l�enefidt are gbject to the p�oVis1016� is a vmm ' of b *.Ik and not a coattaet. . ,� Pya pros des tovorage for a ben This bmltatlaas set garbh in it1�e mo►steY ear tlbdac4"b'le TOT. eQ� �� exelaslons and t bavu►g to sail y a caV= l edam states, the inmed P Sicisn office 6awxc D To verify a, provider's dpedaih' o parCiow a PPtI p1iYs most recce olrta n the 1004 Cw Qf f kA e� ibifi Y to sdset and v Y a provider's aetv�ork may co , it s the weeds sole r F provider Mrse , .. lion eCatus at tTmr tmle sGrVl�IOeB r B1ueChaioe PPG Pbysicien COPY Pisa' "�k.+ ,•.s..a.„ rar^p:- *- '9G�. ..s ""= "",;,f4T .u:. ;? rv. r,.,: , . ..i"— ';:'T'.f F,..,..erg.''" i5'rv�"'SSF jUL.25.20e3 12,55PM BLUE CROSS FTL NO. 31313 F. 12/14 BLIJFIGARE FOR LARGE GROUPS PLAN 13EN .FIT HIGHLIGHTS from or arranged by your hi01- Primary Cars Physician. Care must be received Corr To YOU 13ENIFITE physician 0111110e SMlcee ; • Primary Care Physician office servioeb si 0 capay per visit $10 copay per visit • Farticiped ng Specialist office services self -rafOrral to participating GYN $1 p =pay peat visit • one annual for w6111man exarrt► 'these Office 6000611 may include: pesdtatric and wesil•baby cars . periodic health "union and in, MLmizations ■ otoor diagnog a 59tvlces ■ Health education amt tanning,' counseling 0 ly planning, prOfassional nutritional, and medical s isal serv, loesj _ Vtsiori and hearing screening ■ Family planning serviOes ■ In- o4fioe surgM Additional i"vices (Clfk* yr Oulipaftnt Feollikyi No Allergy lasting $5 copay per vish Allergy injeCtiory, including serum -. • . Outpatient physical, speech, audiac and $S copay per visit occupational therapies No ccpaY , Diagnostic lab and X-ray Mospltal Servieaas (Inpadord Vacuity) No copay Room and board Theses Inpattesrd hospital "IVINS may "I'Adet AnesthMI& use of opemong and recovery rooms, e oxygen, drugs, and rnodioatrOns eat units Intensive Care Unit acid other spec Lr pMW and physical, speech, ■ Inpatibl'►t eech, cardiac and , occupatlonail ftrapeas hi*WRW or Ambufateory surgical Contar (Outpatient Faculty) No oc�pay s Outpatient surgical services; may include; Artogthesla, use of operating and reroverY rooms, oxygen, drugs and medication, including: Hoq taal or surgical 0enter Surgeon's fees ; CNtpd@nt laboratory, X-my, and ether tests eluacwe is offered by MOMM OPIDMI, The 14110 from Biwa 0=1 end slue Shield or Florida Iftn 4 F.W. S1pC JUL. 25.2003 12: MFM BLUE CROSS FTL NO-330 F.13/14 BLUE. RE FOR LARGE GROUPS 4 Kai 13EN FIT E'IlGHUGHTS COST TO YOU BSNSFtTS Emergency services M"Phai) $50 copay per visit Us® of emergency rooms and emergency servioss at pa 61pating hospitals $50 oopey per �ftk Use of emergency rooms and emergency services O*Ids f., senris:a area or at non- pardoipating hospitals Maternitlt Services • Primary Cara Physician trice servioss office services •,initll D9 visit only $10 oopay Nooc y Participating Specialist . Carftd Muse Midwife or Midwife No Wpay Inpatient hospital Mrvivas No adpay . Birthing center sdrvices Dehavloral kiatlh Servicae Mental Health 481`9 y per visit calendar year . outpatlent visits - 20 per ye No oopay • inpatient facility - 30 days per calendar year Pariial hospi WIMMgon (a partial days for t inpatient day) No copay substance Dep enoV outpatient vialts - 2D per calendar YOW $15 copay per visit Inpatient hospitalization (detcaYflOWOn only+} No copay infer IKY 5ervlrea' $10 oopay per visit . Primary Owe Physician $10 copsy per visit . Pa rdcipating gpso dot Specild SwIc" No copay . Hospice caro . Skilled nursing facility - 90 days per cpiendat year No copy No cmPey . Home haaM oar@ n scary) Ambulance (medically No o No copay Durable Medical equipment No copaY Prosthetics and orthodcs ®IueCAM Fla" Plsrmaoy Program FiMI phn When precbed by a p ardc � tn g Ph)6I an $10,00 geeia $25.00 grand and filled at a participating pharmacy $4Q.00twln- preferred ((includes Oral ptivae) Malt preier Pharmacy • For your convenience, a so-day supply of $Moo generic maintenance medlMation is avallable through the mail $90.00 non - preferred (inciud : oral cOntraceplives) $1;500 per Member McAmurn out-01-15001M $3,000 per family Plea 4 Rey. SN►9 JUL.25.2003 12t56PM BLUE CROSS F7L No. 3-30 F.14/14 SLUECAPA FOR LARGE GROUPS PLAN 4 SENEFr r HIGHUGHT3 SALE& EXCLusloNS AND LIMITATIONS 1 i is a altial lisiiryg of services that are exciar €►fro m c+�varage under this agree lease refer The fo low P only 1f, and t�► the e>�rit the suah �dusi+art is permitted under IgtN, Far a compit�te 1't;3tittg p to the Muter P00110y. • All servloes not sAecifically listed in the soheduie f benefits o�edor i tany rider or Wclorsern��t, unless such sa ws are sPc"ally required �'y + Elewve cosm@pc surgery; + Hearing aids or eyeglasses, dental care, or oral apPfiances; Physical for insuranos, Dowsing, school, or recreational purposes; Elective' abadti; Woticere oompensation + pr soription drugs (unless included through ElueCare "; and • Coiriplementary'and Alternative, Healing Methods (CAM). The c o eints @ire the respartsibil'Ity of Me Member and must be paid to the provider at the torte seevice is �ndere6. S it should became necessary, a grievance <procedurs is available: to all Members a$ detailed in the Master Policy. at A xisting cond�ion lim ikmian applies far, ftae who do not have prsvious creditable eoMera9e enrollment: pl ease rotor to the Master Patioy► for details. s a� desa►ctian et the many your Primary Can Physician. This au�mn+IY It � p Iy !ill T►eelth tale asnrkme must de provides w euthvriaad eYYa td Blue Gras end Blue SHBId hI Fiodda, e TMN b2 MS t we 91tro�cross SLjNWWV n+n iots and services eovsred by "Ih t)ppeni, Inc " Gros and Blue Shield of Piodds, If& an h*P se see Nlealg t+otlay groups of 61 or mom empap++e. Howth C ptta++e, ate aeaarlption of b+nerhs end mouclone, pbe and lNu+ shiatd Meod0cm Thh dare not canedtu+a a contract !'� a camp 8901 sixim SR" he terms proved. Pim 4 Acv. 5!44 sVr i�,' .. -?... " .. , ,� n..- .; :,;;; •rt TUL.z5.c063 12:SHPM BLUE Cp.CSB FTL 9$427881 � S MwMMd armada privacy Notice 8 Haab FWw To our Customers: fle.at Blue Cross and Blue `Shield elf Florida and meal% options, Inc, know that the way we conduct our business offers the To that omer's respect and trust. our customers are our reason h� �,► �,�rrnatlon should be kept Odn�doniial. opportunity to earn our cult � that ihslr non- public personal fuanc�l cuetamess have the right to Privacy u. about our priva�CY policy f irti your right to privacy is not n6w. However, nevu laws now require that we notify You Our belie y gomoerning: What kind of personal information we collect about you and how we obtain it How we use your personal information you ws rele to ot�+er ccrnpan�s What kind of personal inforrnalion about y How we protect your personal information our non- public financial and health This Privacy Not'in is provided to help you better understand haw we moor Ct Y We rotsct your non- pubi'ec personal financial and hezasih information in this manner avail after our customer. information. P , relationship with you has ended.• Please feel free to to to this latter, however, 0 you should hire any questions at ut r privacy p MG p our Member You do not need reply u ctrl cont" us at the Customer Service phone number shown on y contact us. If you are one of our members Your Sales RBpresenta#ive. identification Card, if you are one of our 3roup customers you car► reach us though y Wt�t Kind Of P"MOral Information Co We Golle dt And HOW 00 we Obtadn R? r individual our narng► address, phone nurnbar, social secut number, date and 'Ihs erss�nal information we obtain depends on the product �' service you have and.whether those'are group products or services. Generally, the information includes y , it could also Include as habits, and injury dates. e slex, height and weight, occupation,' salary, transonal information, health habits, general place of birth, mg , and warp history' information, bJiling preferences, t nsfrc cry rnforntaiic�t+ Most of the information we collect is provided by you, but we may also coflect personal inforrrtiatlan about You from several ether sources, depending on the nature of the prcdaact or service. We obtain personal information about you from the followring souMs' dad us, or an affil 2rCs, on an application for insuranos or other sees, . Information you Provided your transactions with other entitles; . information you provided us, or an affil ate, about yo dad us; . trormaton your physlclan or other health care practitioner prove e Information your employer provides us; urohased from us or our affiliates, s Information we maintain about you from other products ar eervicas you A . information received from other sources. JUI.. Z5. @03 12` 53PM BLUE: CROSS F i L How Day We Uee Your personal lnforMati*n? � irrl Igt116r1t and �rillnistE,'r th3 prodUOt OF We use your personal information to porfarmen9aotions and furictiarts ner�ssary t11Br it. @tC.1(iLe servios you purohased from Us, Thew functions include enrollm��ci din any of tou attiar products fa serve' . On occasion, be also use your personal information to tleter�rr►irie if you m gib, your personal information is used for reporting or other functions required or permitted by law. What rjrid Of Rersand Infer atfon toarut You We Sham? .. a f a �i ii tth bu`s inses we may share an �r of the information we caallect ab�oyfi theeirsi¢omn�o�w�$a'� abou# out oother ar° ie &, however, � �u� osr and financial services affiliates, we may d'rsoiase`ar7y { t of information we share with others is limited fo what Wei sa disclose any tithe irdormati n�we collect about and the ameuri service you have with us, or as Otherwise permuted or required or law erg if in qi$ future we expand our business to include ' d above) iro �ypanies that perform marketing or other services on our faehalf, including srlmtnietrative services you (as describe ) or to other t9na�cia! irts�titutians with wham we have joint marketing agreern personal to affiliates or roan -milli s for stivlaesothat n rights. outside the scope of what Is l�m►i under sharing your per the law, we will issue new privaW notices to all our customers sxplein�ng ktow Do We pmWot your Information? 6eatraiic, and procedures 9uerdi: to protect your $ iced I ou.aree �e We o. We establish yaur We maintain physipal, a procedure) administer tits products and S91v Ya au. We personal Information to the 60rd races�ry fidentlellty agreements with contrasted parties jhat receive nnfanneiticn to thoSi� employees Qys whams nee know Information can restrict access to your non - public personas financial and health to administer the product or service you purchased from tie. FF^pum?`;q JUL.25 2003 12�53PM BLUE CROSS FTL Bl B dd u�Croaa Summary of B1ueChaice PPP Physfchm Copaymut Benefit aluoChokv , PPO Pbyddm Copsy Plait 716 Deductibles: Individual Calendar Year Doduo0le $300 Family Calondsr Year De&4dbla $900 • Hosphel Per Admission Deducdble FPO Hospitals — Non -PPO Hospitals $300 • 8mergmoy Room Per Visit Deductible $0 (All Hospkals) NOT& The calendar year deductible is waived for Independeof Cli;ioal Labaratoty Services. 7be HOVital per Admission Da&ucdble and the Emalmey Roam. Per Visit Deductible are in & diti0n to the Calendar Year Dedualible: Coinemsee Pacezttsge Payable by RCBN: • PPO Providen — Allowed Amount 80% • No*nO Providaa — Allowed AmwW 70°le - Amhalanoo Servicas Maximum Out of Pocket Coivxvranc@ Responsibility per Calendar Year. mvidw Cow== Limit A2,000 Famay Cow Limit 56,000 NOTE. a re :;z,,,,m Out of Pocket Coiastymwe Ragx=ibf * Limits do of bdude ate► deductibles, oopsymWo, my benefrt penalty reductima, ncm- covm1d dwges or any charges in vxA ss of the Allowed Amount. ties Serv& PPO Famwftys clans $15 Copay (Family Pracdoe, om=al Pra&lce, Imemal Mod acne; or Pediatstes) 0 Otbe r PPO Prary dcrs $25 Copsy - Allergy hiecdom W PPO Pmwi&n) $5 Cvpray Noh-PPO Providers Calendar Year Deductible and C.oit►sursaoe NOTE: Durable Medical Bquipmeo - Proathedost and O:t]aades are odt subjCCt to tbG Copayrat roVim=at, but ate a*act to Ilm iadsvidoal Calendar Year DeductKe stuff Coinsurance respou'biiity. Calendar Year Dfaximnms Per Inured a Mental Health Servlm: — Iupexient days/visits or 30 combbiation of i ent and Partial Haspiiu}i zati= days - Outpatient visits 20 - Blucchoice PPO Physician copy Flan Design cam isirr� SLR s Fb of C1�A+ E4CJ J;LT -Tj ASS TH 07P'1'>��'Ig, NC. T,0 f� r L:13I' FWOT TY iioetior►s 10 YOU for ®, subrnit app your for Woes; and and with'Fvit knowiadg ttoatiori on behalf ei ya d their It VOtunta�►i5►' and sudmit an aP rtaining your employs THE sm loy s and their dspex +ss� a or 9 Ou (nay Comb flnanclai Infdrmatu�� 7HSr,Ct7N)=ii�i�iALn As your P cortaln health WM TO SARA C TMrdp► Alp E"MNTS transrnissian to SCS�FlH� decj�� jo awdcs �aH DEERE DYEES AN iications Will �►1Pti A R p •� I F ;ikAp TD' E ! ENiPt- ARE REGARi Ei� obliPatians thoss ' EFiHf3i r confidentiality depaWallts. and as IEGAi ND' pl9UCIF uA� ROC with notice of YO HEA►1,'6M AND Fp�IANCtRL tNPDIaWIATiDN rair�des YP nptlan ikons• 1D T4 gppEGUAFstD iNFC�ATI S¢1HDl P s andlar emp►aYr aPP T1AL ANC PR0PRIE4ARY, ® em your orli+� 9 iFlog" Don lnotuded in P► its employees IN retai�i to health and financial inform cotleot enmilment appl►oeticr�s Frip , ,�� may then rateas$ use appf►cations to i3G8SF/HQ�t for proce Subject to apploble la atf a your �mpiaY a �d c { ate a group aPP a.r,t far anY licati would urposes. t�aticn related to an snroitrnertit aPp P ►cet►ons in strict ce�idence and shall not use guoh in�� a in�onnatton anizatian must mWnteln ail enrollment nailY de Itillabis heolFh , dit n a nfi ration d the lrtidlrridusl to such Your org nrallrnar►L No personally' �dhaUt tins Pncr wrtaen author , and 911 heath Or financial information Your or s other f an a leted enrollment aPplrca�ans, whale Wity aRhor t 1 ► ►30Sa tai a I ►cations, to only MOB 11f its ®mpiojda be d�dpsed to any, ss to the comp en�zatlo enrPlim PP pe appi� cna to BCBSF1Hal. disdosed. Your crg wr inoluded in otiose ro er transmission of th tc, derh+ Pram, s ficr tie P P BLE FEC?ERAL. STATE, AND pantr�butn raiaied to and new EI.PPi -lCA URT,1►GENCY, OR lniorm$ on is directly AFL �IARENT AND NY AU'T140Rt�d FINANCIAL SIJAL COMPLY! W1� ANY a� Willa ORgER FEKEEPi 4 DF HEALI AND ?R -lat RATION YOUR DRG�AN1ZATi Ofd R GULAT101H NL 1iA il)LING AN[ 61�1KS VifS RUl- .- CERNI pER IN RELA'�t�N Ta A LpEit: AND ON LOCAL E.A p EY 1!T HEReUN PLY �Y1Ti'I REGULA 01 N RE i1E' P �, ,pT10NSr INCt.UdINt3 wltOUT NL YOUR ORGANI7 �P► RON gH RI I-It TMI�NT QF RMi�A TiC� pR11S OR PRIVATE AND i� CAI-�Y sENSI�t EP► INFD OF EHRpLLaEN OF ENROLL�AEN'T APi�i -IL RE RAC pEC RECEIPT OF1 PR!'PARATii9N TION RELATING TO REC>.fnNG -THE DISC AGENT PtECOR�S, �IFbRtAA G P PSYCHOLOGICAL OR PE�Oi�IA'i'RiC EvAWATI A6S'ED URDU, N O DRiG AU1iSls LiISITATION pI GpHDL AN HIS/ TE:R?INt3 REyUL'[lS AND Included in W Rp DEI,►Clf, corrfldetlal HdL Qf1 DRUG R . health and financial infor formation m on °ern n ALfaO of pare in Praectirtig ubi►Cpe, and pemo it uses to prevent disolosu+a, P whioh a re$ganabie busrti a eel and Your ar ntzgoon shall use the trot- $ less than the siandarrd t cgre ranch training to Its-employ s�ri� the enroilrnet tlard of cam mease Wa as wait as pan Icular derived frombht In no event shall that eta c.. dwialky nnat�on, her awn c�'sdenUsi tnfahersnce, to proper r info teaiing his or eneral ad would use In pro rocedures to assure 4 gOBSFIHOt and youretz9tion. maintain pat-1 as and p , between measures for tints rnaterdi• tarrningon of the tr0tual relatlonship The provisiats of this Wics shall surety w.,. EBCG Employee Benefits Consulting Group TW Jeanette Errizo promos Gene Wnon pax: 305-865.3877 S (In--I, cover sheet) _ Date: $193103. Phanw Roc CIGNA HealthCere ce Jeanette; Attadhed are the proposed mtca %ith CIGNA HealihCare. In addition, pleeae sign the attachad coed ".cal que4onnaire and fax t aak�to ray attention (per eu ihe� are inn large on-going it the Claims. um Of the page)- This ;ust verif ss that, to thy. , beSt of au � ThsnRs, Game Baynon f f ,2525 orange Jive, $uise 703 a Davie, FL 333301 Ph {854j 47� 3-1x34 Fax t95a) 7 3 0144 d� �'4'eb: hftpw vwWabog.not -rfw-, T -F,nw 4bin g,) t, ttrS6 'ON 3NOHd -)Ni dnCun 0053 wc'u W BuLployee senorita Consulting Group Augot 12, ?003 Ms. Jeanette Enrizo Humm Resource Depatnent City of South Miami 6130 Sunset Drive' South Mia►r 4 Florida, 33143 Re: CiGNA ijealthCaxe Proposal Dewar Jeanette: Hue are CIGNA HealthC=_,s proposed rates under a "Dual Caption" scenWia, Monthly HM-0 Rates Employee only $325.92 Employee + child(ren) $586.65 Employee + spouse $651.83 Employee + child(reri) + spouse $977.74 F?S Employee only $191.12 Employee + ch ,d(r ) $704.02 Employee + spouse $782,24 Employee + child(re n) + spousc $1,173.36 Jemette, please call me if you have any questions or concerns after reviewing this letter. I look ,rorwwd to discussing this in further detail. Sincerely. Gene Bayron Principal 12525 orange Drive, Suite 703 * Davie, F"loridtt 33330 Phone' (954) 473710:34 • Fax: (954) 473 -01.45 • Weis: 1•,ttp. //www.ebcg,11Ct Fd Wd8S:90 P®a? ET '6ny 9bti0 Ettp t?S5 : 'ON BNOHd oNj dnodo Mew : WOJd Employee Benefits Consulting Group July 30, 2003 Ms. Jeanette Enrizo Human Resource Manager City of South Miami 6130 Sunset Drive South Miami, Florida, 33143 Re: CIGNA HealthCare Dear Jeanette. Enclosed is a copy of the fax that I sent to your attention on 7/29/03. In addition, I have included updated provider directories' for CIGNA HealthCare. As you will note, CIGNA HealthCare has included two addendums: ■ - Listing of Primary Care Physicians that have been added since the provider directory was produced (1/17/03). ■ Listing of physicians that are associated with the University of Miami. These physicians are network providers in CIGNA HealthCare's HMO and Point -of- Service network. CIGNA HealthCare has a comprehensive network of providers around the South Miami area. Using the zip code' of City Hall (33143) here are the number of Primary Care Physicians within a 5 and 10 mile radius: 5 mile radius of City Hall 207 10 mile radius of City Hall 404 *) Primary Care Physicians include: Family Practice, General Practice, Internal Medicine, and Pediatrics. These figures can be validated by accessing CIGNA HealthCare's web site: www.cipa.com. 12525 Orange Drive, Suite 703 • Davie, Florida 33330 Phone: (954) 473 -1034 • Fax: (954) 473- 0146 • Web: http: / /www.ebcg.net Jeanette, please call me if you have any questions or concerns. - I look forward ' to IE34C4G� Employee Benefits Consulting Group July. 29 2003 Ms. Jeanette Enrizo Human Resource Manager City of South Miami 6130 Sunset Drive South Miami, Florida, 33143 Re: CIGNA HealthCare Proposal Dear Jeanette: Attached is the revised proposal from CIGNA HealthCare. As you will note, _ CIGNA HealthCare has proposed two options: Option #1; Standalone HMO Option #2: Dual Option (HMO and Point -of- Service) Under both scenarios the City of South Miami would realize a significant premium savings in comparison to the Neighborhood' Health Partnership renewal. Jeanette, please call me after you have an opportunity to review this information. I look forward to discussing this in further detail. Sincerely, Gene'Baynon Principal 12525 Orange Drive, Suite 703 Davie, Florida 33330 Phone: (9541473-1034 • Fax: (9541'.473 -0146 • Web: httn: J /www_ebcg.nPt Fm �> mmmm'p m mmmml mmmmp mmmrn :, v= 3333c 3333lC) 3333 3333�C) o o o-0 0 0 3 65766 ' 0 0 0 0 K m v o l< l< l< � 0 0 l< l< l< l CD �c < <c < -0 l< %<%cl< M py FD m m m m m p m m m m 0 m 0 m '* CO m m m 0 m 0 0 p m m m m 0 0 m 0 0 c 3 + ++ o + +`+ o D + ++ o ++ t o m ;K -0 =-,< 7"t3 S Q� `� Q C d - 0. 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N N N <N o.aaa D a �D a �D Q ° i O4 - rdO b L July 29, 2003 V " Jeanette Enrizo Human Resource Department 6130 Sunset Drive South Miami, FL 33143 RE: Notice Of Bid Invitation City Of South Miami Bid No. 072103 Dear Jeanette, Please accept this bid on the City of South Miami's health insurance from Linel Consulting, LLC (Linel). The bid attached has comparables of the existing plan design. Linel will provide the enrollment with bilingual staff and will provide your HR department with HIPAA training at no charge. HIPAA training is required for your department per the federal regulation. Linel's training will take place on a quarterly basis and consist of awareness, materials, plan design, implementation, and maintenance. Thank you for the opportunity to bid on the City of South Miami's health in nce. Sincerely, 3 Kevin N. Fine, MHA 1 G� �a LE%L CONSULTING, LLC 3132 DAY AVENUE MIAMI, FL 33133 PIT 305- 362 -4417, M. 305- 232 -3463 This is a summary of benefits for your HMO Copay plan. All in- network services must be performed by the Primary Care Pharmacy deductibles, out -of- pocket Physician (PCP), referred by the PCP or approved by the local Healthplan. CIGNA plan and annual maximums do not integrate with the employer medical program. maximums, copays m A i BENEFIT HIGHLIGHTS IN-NETWORK i etime Maximum nlimited Coinsurance Levels 100% ote: All services will be covered at 100% coinsurance level; with or without applic able cop a s Contract Year Deductible Individual one Family Maximum one A e ate es nnualOut of- Pocket Maximum Includes Coinsurance of Applicable Includes Deductible npatient Facility and Outpatient Facility copays only Includes Copays $2,000 per person Individual $4,000 per family Family Maximum Aggregate es opays not listed above and plan deductibles Does Not Apply To Benefits for accident or sickn ess (excluding mental nce the Out -of- Pocket Maximum is reached, inpatient facility health, alcohol, and drug abuse benefits) are paid at copays (including MH /SA) and outpatient facility copays will no 100 %, once an individual's out -of- pocket has been onger be required reached. of A licable utomatic Reinstatement Physician Is Services Primary Care Physician's Office visit o charge after $10 per office visit copay Specialty Care. Physician's Once Visit o charge'after specialist $10 per office visit copay' Office Visits Consultant and Referral Physician's Services Surgery Performed In the Physician's Ojfice o charge after per office visit copay o charge after either the office visit copay or the actual charge, Allergy Treatment /Injections hichever is less Allergy Serum' (dispensed by the physician in the o charge o ice) reventive Care Routine Preventive Care: Well -Baby, Well - Child, Adult o charge after per office visit copay and Well -Woman (including immunizations) Immunizations o charge outine Mammograms, PSA, PAP Smear o charge The wellness exam is subject to the office visit (Applies to anyplace of service) iote. associated co a econd o charge after specialist $10 per office visit copay Opinions' (Services will be provided on a volunta basis Better solutions for your health.sM CIGNA HeaithCare ✓."�",. ^""."'� .,, ...�' ^. m.. .h „a , ,1;. fi -,x =` ice, ”' 3, r,- i',.'}' ."'�'s#1- ?li�',„-°2'LT,'v�r' ^ °:�.`+�tn�'3,, ?.e. ,Y"r ,FSF,1r.d,' ». 't..s'.: �a;Y BENEFIT HIGHLIGHTS IN-NETWORK utpadent Pre- Admission Testing o charge if only x -ray and /or lab services; $10 per office visit copay Primary Care Physician's Office Visit if other office visit services also provided. Specialist Physician's Office Visit o charge if only x -ray and /or lab services; specialist $10 per office �i�i? copay ifothcr office visit services also provided. o charge for x- ray/lab if billed by a separate outpatient diagnostic Outpatient HospitalFacility acility such as a hospital Inde endent X -ra and/or Lab Facility o' charge npatient Hospital - Facility Services o charge , imited to the semi - private negotiated rate Semi- Private Room and Board " imited to the semi- private negotiated rate Private Room S ecial Care Units (ICU /CCU) invited to the negotiated rate Outpatient Facility Services o charge Operating Room, Recovery Room, Procedure Room and Treatment Room anent Hos ital Ph sician's lrsitslConsultations o charge n npatient Hospital Professional Services o charge Surgeon Radiologist Pathologist Aiol!gist of Applicable 'cauction ofeal Services o charge ist ist iol mergency and Urgent Care Services charge after $l0 per office visit copay Physician's Office Hospital Emergency Room o charge after $50 per visit copay ** ( Copay waived if admitted) o charge after $25 per visit copay ** ( Copay waived if admitted) Urgent Care Facility or Outpatient Facility Ambulance ` . o charge ** ** If not a true em-r-1 services are not covered npatient Services at Other Health Care Facilities o charge Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub -Acute Facilities ote: If plan includes an inpatient hospital copay, the copay does not 60 days maximum per calendar year apply. No prior hospitalization required Laboratory and Radiology Services MRls, CAT Scans and PET Scans o charge Note: the copay applies, on a per procedure basis, for any place of service Note :: associated ancillary charges are subject to the applicable place of service copay and/or plan deductible (e.g. injections, dye, etc) Other Laboratory and Radiology Services: Outpatient Hospital Facility o charge Inde endent X -ra and/or Lab Facili o char e Better solutions for your health.sM CIGNA Healthcare S Better solutions for your health.sM BENEFIT HIGHLIGHTS IN-NETWORK CIGNA Healthcare Outpatient Short -Term Rehabilitative Therapy and o charge after $10 per visit copay, 60 visits combined maximum Chiropractic Services per contract year Includes: Cardiac rehab, Physical Therapy Speech Therapy Occupational Therapy Chiropractic Therapy (includes `Chiro ractors) Home Health Care ' o charge Maximum: 60 days per contract year with a 16 hour per day limit ospice Inpatient Services o charge Note: If plan includes an inpatient hospital' copay, the copay does not apply. p Out atient Services o charge Bereavement Counseling Services Provided as part of Hospice Care o charge Services Provided b Mental Health Professional Covered under Mental Health benefit Maternity Care Services Initial Visit to Confirm Pregnancy o charge after per office visit copay All subsequent Prenatal Visits, Postnatal Visits and o charge Delivery Delivery (Inpatient Hospital, Birthing Center) ' o char e , Abortion Includes elective and non - elective procedures Office Visit o charge after per office visit copay. Inpatient Facility o charge, Outpatient Surgical Facility I o charge Ph sician's Services o charge Family Planning' Services Office Visit (tests, counseling) o charge after per office visit copay Surgical Sterilization Procedures for Vasectomy /Tuba Note: Charges billed by a separate outpatient diagnostic facility will Ligation (excludes reversals) a covered under the plan's Laboratory and Radiology benefit Inpatient Facility '1 o charge, Outpatient Facility o charge Physician's Services o charge Better solutions for your health.sM BENEFIT HIGHLIGHTS IN-NETWORK nfertlity Treatment olot !Covered ervices not covered include: • Testing performed specifically to determine the cause of infertility. Treatment and/or procedures performed specifically to restore fertility(e.g. procedures to correct an infertility condition). • Artificial means of becoming pregnant are (e.g. Artificial Insemination, In- vitro, GIFT, ZIFT, etc). ote: Coverage will be provided for the treatment of an nderlying medical condition up to the point an infertility ondition is diagnosed. Services will be covered as any ther illness. Organ Transplant ncludes all medically appropriate, non - experimental ransplants Office Visit No charge after specialist $10 per office visit copay . Inpatient Facility o charge Inpatient Physician's Services o charge $10,000 per transplant/per lifetime maximum (only available when Travel Maximum sing a Lifesource Facility)' arable Medical Equipment o charge ote: services accumulate to the plan's Lifetime Maximum 3,500 maximum per contract year Prosthetic Appliances o charge after $200 EPA deductible $1,000 maximum per contract year rvices accumulate to the Ian 's Li etime Maximum are o charges made fora continuous course of dental t started within six months of an injury to sound, [Phician's eeth. ' o charge after per office visit copay sicians Ofce tient Facility o charge patient surgical Facility o charge sieian's Services o char e and Non - surgical TMJ Provided on I a limited, case by case, basis. Always excludes and orthodontic treatment. Subject to medical appliances necessity. Physician's Office No charge after specialist $10 per office visit copay; No charge for - ray/lab' if billed by a separate outpatient diagnostic facility such as hospital Inpatient Facility No charge Outpatient Facility o charge Ph sician's Services o charge outine Foot Disorders of Covered Better solutions for your health.sM CIGNA HealthCare , �,• .. ,. _ � „yam -�� .� .--=.. � ;��- ,...��., ,� -�,�� . .,�., BENEFIT HIGHLIGHTS • Prescription Drugs CIGNA PharmacyPlus Retail Drug Program 7 per 30 -day supply for generic drugs 25 per 30-day supply for preferred brand -name drugs Genrr c Pooh, broentive Formulary Plan $50 per 30 -day supply for non - preferred brand -name drugs Includes oral contraceptives and con trace tive devices In-Network Pharmacy Deductible (Mail Order Excluded) ` one In-Network Pharmacy Out of Pocket Maximum (Mail None ' Order Excluded) CIGNA Tel -Drug Mail Order Drug Program $14 per 90 -day supply for generic drugs 50 per 90 -day supply for preferred brand -name drugs Generic Push, Incentive Formulary Plan $100 per 90 -day supply for non - preferred brand -name drugs ncludes oral contraceptives and contraceptive devices Mental Health and Substance Abuse Rehabilitative' Services Inpatient Mental Health Services No charge after $75 per day copay 20 days maximum per Member per Contract Year includes Substance Abuse Rehabilitation days Outpatient Individual? Mental Health Services 20 visits maximum per Member per Contract Year o charge after $35 per visit copay Outpatient Mental Health Group Therapy 40 visits maximum per Member per Contract year No charge after $15 per session copay includes Substance Abuse Rehabilitation visits Inp aicia Substance Abuse Rehabilitation Services 20 days maximum per Member per Contract Year o charge after $75 per day copay includes Mental Health days Outpatient Individual Substance Abuse Rehabilitation Services 20 visits maximum per Member per Contract year No charge after $15 per visit copay for the first 2 visits and $35 per visit thereafter Outpatient Group Substance Abuse Rehabilitation Services 40 visits maximum per Member per Contract Year No charge after $15 per visit copay includes Mental Health visits re- Existin Condition Limitation of Applicable re Admission Certification- Continued 'Stay Review Coordinated by PCP re uired' or all Inpatient Admissions) Case Management oordinated by Healthpian. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health; incident has precipitated a need or rehabilitation or additional health care support. The program strives to attain abalance between quality and cost- effective care hile maximizing the patient's quality of life. Benefit Exclusions (by way of example but not limited to); I . Your plan provides coverage for medically necessary services. Your plan does not provide coverage for the following except as required bylaw: 2. Services that are not medically necessary, except specifically outlined preventive care; 3. Charges which the person is not legally required to pay; Better solutions for your health.SM CIGNA HealthCare 4. Charges made by a hospital owned by or performing services for the U.S. government if the charges are directly related to a sickness or injury connected to military service; 5. Custodial services not intended primarily to treat a specific injury or sickness, or any education or training; 6. Experimental or investigational procedures and treatments; 7. Cosmetic surgery or therapy performed to improve self esteem unless: (a) a person receives an injury which results in bodily damage requiring surgery; (b) it qualifies as reconstructive surgery performed on a person following surgery, and both the surgery and the recons jcti : u j,.Ta -:ire essential and medically necessary; (c); it qualifies as reconstructive surgery following a mastectomy, including surgery and reconstruction of the other breast to achieve symmetry. 8. Reports, evaluations, examinations, or hospitalizations not required for health reasons, such as employment, insurance or government licenses and court ordered forensic or custodial evaluations. 9. Treatment of the teeth or periodontium unless such expenses are incurred for. (a) charges made for a continuous course of dental treatment started within six months of an injury to sound natural teeth; (b) charges made by a Hospital for Bed and Board or Necessary Services and Supplies; or (c) charges made by the outpatient; department of a Hospital in connection with surgery., 10. Reversal of voluntary ' sterilization procedures, and certain infertility services; 11. Transsexual surgery and related services; 12. Treatment for erectile dysfunction. However, penile implants are covered when an established medical condition is the cause of erectile dysfunction; 13. Therapy to improve general physical condition; 14. Personal or comfort items such as personal care kits, television, and telephone rental in hospitals; 15. Eyeglasses, hearing aids or examinations and prescription fitting, except as provided in the Certificate; 16. Certain internal or external prostheses, or replacement of external prostheses due to wear and tear, loss, theft or destruction; 17. Surgical treatment for correction of refractive errors, including radial keratotomy; 18. Prescription and non - prescription drugs, except as provided in the benefits section of the Certificate; 19. Routine foot care; 20. Amniocentesis, ultrasound, or any other procedures requested solely for sex determination of a fetus, unless medically necessary to determine the existence of a sex - linked genetic disorder; 21. Any injury resulting from, or in the course of, any employment for wage or profit; 22. Any sickness` which` is covered =under any workers' compensation or similar law. 23. Charges for over the counter disposable or consumable supplies, including orthotic devices. 24. Charges in excess of reasonable and customary limitations; 25. Charges for medical and surgical services intended primarily for the treatment or control of obesity which are not Medically Necessary. Excluded services' include, but are not limited to, weight reduction procedures designed to restrict your ability to assimilate food, such as gastric bypass; gas tric balloons, jaw wiring, stomach stapling and jejunal; bypass. 26. Certain Durable Medical Equipment (DME). 27. Non- medical4ancillary services, including but not limited to vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, work hardening, driving safety and services, training, educational therapy or other non - medical ancillary services for learning disabilities, developmental delays, autism or mental retardation. 28. Cosmetics, dietary supplements, health and beauty aids, and nutritional formulae. This chart summarizes the benefit plan you requested; it has not been adjusted to reflect state benefit mandates. A complete description of the terms of the coverage, exclusions and limitations, including legislated benefits (if applicable), will be provided in your Certificate or Summary Plan Description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "CIGNA HealthCare " refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel- -Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. "CIGNA Tel -Drug" refers to Tel-Drug, Inc. and Tel -Drug of Pennsylvania, L.L.C., which are also operating subsidiaries of CIGNA Corporation. Better solutions for your health.sM CIGNA HealthCare BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Lifetime Maximum Unlimited IS1,000,000 Coinsurance Levels ` 100% 0 70% of Reasonable and Customary Note: All services will be covered at a 100% coinsurance level; with or without applicable copays Contract Year Deductible Individual None $500 per person Family Maximum None 1,000 per family Aggregate es Yes nnual Out-of-Pocket Maximum Includes Coinsurance of Applicable Yes Includes Deductible No No Includes Copays Inpatient Facility and Outpatient Inpatient Facility and Outpatient Facility copays only Facility deductibles apply Individual $2,000 per person $4,000 per person Family Maximum $4,000 per family $8,000 per family Aggregate Yes Yes Does Not Apply To Copays not listed above and plan on- compliance penalties, deductibles eductible or charges in excess of Reasonable and Customary Once the Out -of- Pocket Benefits for accident or sickness Maximum is reached, inpatient excluding mental health, alcohol, facility copays (including and drug abuse benefits) are paid at H /SA) and outpatient facility 100 %, once an individual's out-of- copays will no longer be required pocket has, been reached Putomatic Reinstatement Fot Applicable BENEFIT HIGHLIGHTS O. O. Physician's Services Primary Care Physician's Office visit No charge after $10 per office 70 % after deductible visit copay Specialty Care Physician's Office Visit No charge after $10 per office 70% after deductible Office Visits visit copay Consultant and Referral Physician's Services Surgery Performed In the Physician's Office No charge after per office visit 70 % after deductible copay Allergy Treatment /Injections No charge after either the office 70 % after deductible visit copay or the actual charge, whichever is less Allergy Serum (dispensed by the physician in the No charge 0% after deductible of c e ) ' Preventive Care Routine Preventive Carer Well -Baby, Well - Child, No charge after per office visit In-network coverage only Adult and Well -Woman (including immunizations) copay Immunizations No charge Routine Mammograms, PSA, PAP Smear No charge 0 %o after deductible applies to anyplace of service) Note: The associated wellness Note: The associated wellness exam is subject to the office visit exam is not covered copay Second Opinions No charge after specialist $10 per 700/o after deductible (Services will be provided on a voluntary basis) office visit copay Outpatient Pre - Admission Testing Primary Care Physician's Office Visit No charge if only x -ray and/or lab 70 % after deductible services; $10 per office visit copay if other office visit services also provided. Specialist Physician's Office Visit No charge if only x -ray and/or lab 0% after deductible services; specialist$10 per office visit copay if other office visit ervices also provided. Outpatient Hospital Facility No charge for x- ray/lab if billed 0 %o after deductible by a separate outpatient diagnostic facility such as a hospital No charge Independent X-ray and/or Lab Facility 0 %o after` deductible Inpatient Hospital - Facility Services No charge 70 % after plan deductible Semi- Private Room and Board Limited to the semi- private Limited to the semi - private rate negotiated rate Private Room Limited to the semi - private Limited to the semi = private rate negotiated rate Special Care Units ICU /CCU Limited to the negotiated rate Limited to the ICU /CCU daily rate Outpatient Facility Services o charge 70 % after deductible Operating Room, Recovery Room, Procedure Room and Treatment Room Inpatient Hospital Physician Is risits/Consultations INo charge 70 %o after deductible BENEFIT IIIGHLIGHTS TN-NETWORK O. Inpatient Hospital Professional Services No charge'' 70% after deductible Surgeon Radiologist Pathologist Anesthesiologist Multiple Surgiral Reduction of Applicable _ ultiple surgeries: performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any ther surgery. Outpatient Professional Services No charge 70% after deductible Surgeon Radiologist Pathologist Anesthesiologist Emergency and Urgent Care Services Physician's Office No charge after $10 per office No charge after $10 per office visit `visit copay copay ** Hospital Emergency Room No charge after $50 per visit No charge after $50 per visit copay** (Copay waived if copay** . admitted) Urgent Care Facility or Outpatient Facility No charge after $25 per visit No charge, after $25 per visit copay*,* (Copay waived if 'opay * *, admitted) Ambulance No charge ** No charge ** ** If not a true emergency, * *If not a true emergency, services are not covered healthplan approval is required for overage at the plan's OON coinsurance level Inpatient Services at Other Health Care Facilities No charge' 0% after deductible Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub -Acute Facilities 60 days maximum per contract year No prior hospitalization required Laboratory and Radiology Services MRls, CAT Scans and PET Scans No charge 0% after deductible Note: the copay applies on a per procedure basis, for anyplace ofservice Associated ancillary charges are subject to the applicable place of service coinsurance level, place o service copay and/or plan deductible (e.g. injections, dye, etc.) Other Laboratory and Radiology Services: Outpatient Hospital Facility o charge 70% after deductible Independent X-ray and/or Lab Facility o charge 0% after deductible C •' OUT-OF-NETWORK Outpatient Short -Term Rehabilitative Therapy and No charge after specialist $10 per 70% after deductible, 60 visits per Chiropractic Services visit copay, 60 visits combined contract year maximum per contract year Includes::; Cardiac rehab Physical Therapy Speech Therapy Occupational: Therapy Chiropractic Thera y includes Chiropractors Nome Health Care No charge 70% after deductible Maximum: 60 days per contract year with a 40 days per year; reduced by any 16 hour a day limit in- network visits Hospice No charge n-network coverage only Inpatient Services Note: If plan includes an inpatient hospital copay, the copay does not pply. Out' atient Services No charge Bereavement Counseling In-network coverage only Services Provided as part of Hospice Care No charge Services Provided by Mental Health Professional Covered under Mental Health benefit Maternity Care Services Initial Visit to Confirm Pregnancy No charge after per office visit copay 70% after deductible All subsequent Prenatal Visits, Postnatal Visits and No charge 0% after deductible' Delivery Delivery (Inpatient Hospital, Birthing Center) No charge 70% after plan deductible bortion Includes elective and non - elective procedures Office Visit No charge after per office visit 70% after deductible copay: Inpatient Facility No charge 70% after plan deductible Outpatient Surgical Facility No charge 70% after deductible Physician's Services No charge 70% after deductible Family Planning Services Office Visit (tests, counseling No charge after per office visit 70% after deductible copay Surgical Sterilization Procedures for Vasectomy/Tubal Ligation (excludes reversals) Note: Charges billed by a separate outpatient diagnostic facility will be covered under the plan's Laboratory and Radiology benefit Inpatient Facility No charge 70% after plan deductible Outpatient Facility No charge 70% after deductible Physician's Services o charge 0% after deductible BENEFIT HIGHLIGHTS IN-NETWORK • O' nfertility Treatment `' of Covered of Covered Services not covered include: , • Testing performed specifically to determine the cause of infertility. • Treatment and/or procedures performed specifically t o restor`e fertility (e.g. procedures to correct aan infertility condition). • Artificial means of becoming pregnant are (e.g. " Artificial Insemination, . In-vitro, GIFT ZIFT, etc). ote: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any Cher illness.' Organ Transplant In-network coverage only Includes all medically appropriate, non - experimental transplants Office Visit No charge after specialist $10 per ffice visit copay Inpatient Facility No charge Inpatient Physician's Services No charge Travel Maximum $10,000 per transplant/per Not covered Lifetime maximum (only available when using a Lifesource Facility) Durable Medical Equipment No charge In-network coverage only 3,500 maximum per contract ote: Services accumulate to the plan's Lifetime year Maximum External Prosthetic Appliances No charge after $200 EPA In-network coverage only deductible 1,000 maximum per contract Note: Services accumulate to the plan's Lifetime Maximu year Dental Care Limited to charges made for a continuous course of dental reatment started within six months of an injury to sound, aturalteeth: Physician's Office No charge after per office visit 70 % after deductible copay Inpatient Facility No charge 70% after plan deductible Outpatient surgical Facility No charge 0% after deductible Physician's Services No charge 70 % after deductible urgical and Non - surgical TMJ In-network coverage only Provided on a limited, case by case, basis. Always exclude appliances and orthodontic treatment. Subject to medical necessity. Physician's Office No charge after specialist $10 per office visit copay; No charge for - ray/lab if billed by separate outpatient diagnostic facility such as a hospital Inpatient Facility No charge Outpatient Facility No charge Ph sician's Services No charge [Routine Foot Disorders Not Covered Not Covered BENEFIT HIGHLIGH-TS IN-NETWORK OUT-OF-NETWORK rescription Drugs CIGNA PharmacyPlus Retail Drug Program S7 per 30 -day supply for generic In-network coverage only rugs Generic Push, Incentive Formulary Plan $25 per 30 -day supply for referred brand -name drugs Includes oral contraceptives and contraceptive devices'' 50 per 30 -day supply for non - referred brand -name drugs Pharmacy Deductible (Mail Order Excluded) None None Pharmacy Out of Pocket Maximum '(Mail Order None one Excluded) CIGNA Tel -Drug Mail Order Drug Program $14 per 90 -day supply for generic In-network coverage only rugs Generic Push, Incentive Formulary Plan 50 per 90 -day supply for referred brand -name drugs Includes oral contraceptives and contraceptive devices $100 per 90 -day supply for non - referred brand -name drugs ubstance Abuse Detoxification Services No charge In-network coverage only Inpatient Mental Health and Substance Abuse Rehabilitative Services In-Network Only Inpatient Mental Health Services No charge after $75 per day copay 20 days maximum per Member per Contract Year includes Substance Abuse Rehabilitation days Outpatient Individual Mental Health Services 20 visits maximum per Member per Contract No charge after $35 per visit Year, copay Outpatient Mental Health Group Therapy In-Network Only 40 visits maximum per Member per Contract No charge after $15 per session year includes Substance Abuse Rehabilitation copay visits Inpatient Substance Abuse Rehabilitation Services 20 days maximum per Member per Contract No charge after $75 per day copay In-Network Only Year includes Mental Health days Outpatient Individual Substance Abuse Rehabilitation Services 20 visits maximum per Member per Contract No charge after $15 per visit- In-Network Only year copay for the first 2 visits and $35 per visit thereafter Outpatient Group Substance Abuse Rehabilitation Services 40 visits maximum per Member per Contract lNo charge after $15 per visit n- Network Only Year includes Mental Health visits 1copay BENEFIT HIGHLIGHTS IN-NETWORK •. re- Existing Condition Limitation (PCL) Not Applicable Applies to any injury or sickness or which a person receives treatment, incurs expenses or receives a diagnosis from a _ physician during the 90 clays before ` he earlier of the date a person begins an eligibility waiting period or becomes insured for these benefits. Coverage for the pre- existing condition is excluded until one year of the member being continuously insured and/or is satisfying a waiting period. Usually the PCL is waived for the initial group, but if not, the insured' will receive credit for any portion of the PCL' waiting, period that was satisfied under the previous plan if they are enrolled in the subsequent plan within 63 days (or the applicable timeframe required per state law). Pre-Admission Certification- Continued Stay Review Coordinated by PCP Mandatory: Employee is (required for all Inpatient Admissions), esponsible'for contacting the Healthplan Penalties for non - compliance: $500 penalty applied to hospital inpatient charges for failure to contact Healthplan to precertify admission.' enefits are denied for any admission reviewed; by Healthplan d' not certified. Benefits are denied for any dditional days not certified by the ealth lan. Case Management Coordinated by Healthplan. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to ttain a balance between quality and cost- effective care while aximizing the atient's quality of life. Benefit Exclusions (by way of example but not limited to): Your plan provides coverage for medically necessary services. Your plan does not provide coverage for the following except as required by law: I. Services that are not medically necessary, except specifically outlined preventive care; Better solutions for your health.sm CIGNA Healthcare t 2-_Charges which the person is not legally required to pay; IfCharges made by a hospital owned by or performing services for the U.S. government if the charges are directly related to a - sickness or injury connected to military service; 4. Custodial services not intended primarily to treat a specific injury or sickness, or any education or training; 5. Experimental or investigational procedures and treatments; 6. Cosmetic surgery or therapy performed to improve self esteem unless: (a) a person receives an injury which results in bodily damage requiring surgery; (b) it qualifies as reconstructive surgery performed on a person following surgery, and both the surgery and the'rccunsinactive surgery are essential and medicallynecessary;_(c) it qualifies as reconstructive surgery following a mastectomy, including surgery and reconstruction of the other breast to achieve symmetry. 7. Reports, evaluations, examinations, or hospitalizations not required for health reasons, such as employment,` insurance or government licenses and court ordered forensic or custodial evaluations. S. Treatment of the teeth or periodontium, unless such expenses are incurred for: (a) charges made for a continuous course of dental treatment started within six months of an injury to sound natural teeth; (b) charges made by a Hospital for Bed and Board' or Necessary Services and Supplies; or (c) charges made .by the outpatient department of a Hospital in connection with surgery. 9. Reversal of voluntary sterilization procedures, and certain infertility services; 10. Transsexual surgery and related' services; 11. Treatment for erectile dysfunction. However, penile implants are covered when an established medical condition is the cause of erectile dysfunction; 12. Therapy to improve general physical condition;'' 13. Personal or comfort items such as personal care kits, television, and telephone rental in hospitals; 14. Eyeglasses, hearing aids or examinations and prescription fitting, except as provided in the Certificate; 15. Certain internal or external prostheses, or replacement of external prostheses due to wear and tear, loss, theft or destruction; 16. Surgical treatment for correction of refractive errors, including radial keratotomy; 17.' Prescription and non - prescription drugs, except as provided in the benefits section of the Certificate; 18. Routine foot care; 19. Amniocentesis, ultrasound, or any other, procedures requested solely for sex determination of a fetus, unless medically necessary to determine the existence of a sex - linked generic disorder; 20. Any injury resulting from, or in the course of, any employment for wage or profit 21. Any sickness which is covered under any workers' compensation or similar law. 22. Charges for over rite counter disposable or consumable supplies, including orthotic devices. 23.' Charges in excess of reasonable and customary limitations; 24. Charges for medical and surgical services intended primarily for the treatment or control of obesity which are not Medically Necessary. Excluded services include, but are not limited to, weight reduction procedures designed to restrict your ability to assimilate food, such as gastric bypass, gastric balloons, jaw wiring, stomach stapling and jejunal bypass. 25. Certain Durable Medical Equipment (DME). 26. Non- medical ancillary services,; including but not limited to vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, work hardening, driving safety and services, training, educational therapy or other non- medical ancillary services for learning disabilities, developmental delays, autism or mental retardation. 27. Cosmetics, dietary supplements; health and beauty aids, and nutritional formulae. This chart summarizes the benefit plan you requested; it has not been adjusted to reflect state benefit mandates. A complete description of the terms of the coverage, exclusions and limitations, including legislated' benefits (if applicable),, will be provided in your Certificate or Summary Plan Description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "CIGNA HealthCare " refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA, Corporation. These subsidiaries' include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel -Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. "CIGNA Tel- Drug" refers to Tel -Drug, Inc. and Tel -Drug of Pennsylvania, L.L.C., which are also operating subsidiaries of CIGNA Corporation. Better solutions for your health.slvr CIGNA Healthcare Florida Municipal Insurance Trust mk - Nts- OR Ilk". . :n Z .�,..Fa's". >m p,m,. :y.'itsY,r a ,...,,,c'..a",a - .w'Mw ,. Calendar Year Deductible: Individual 0 $500 Family 0 $1,500 Maximum Out of Pocket: Individual $2,000 $3,000 Family $4,000 $6,000 Lifetime Maximum $1,000,000 $1,000,000 ��a�'C r " `,�y. �"'' }� x"' ✓ �� ■ - 1��r`! � lV. r ��yy�,` `� .0 r d'`�� i �-? y;� "` ♦ Inpatient $100.00 Co -Pay per Day for $500:00 Co -Pay, then 50% of Services days 1 -5, hen 70 % reasonable charges Of `covered expenses after deductible ♦ Outpatient $100.00 Co -Pay, then 70 %° $100.00 Co -Pay, then 50% of Services of covered expenses reasonable charges after deductible ♦ Emergency Room $100.00 Co -Pay, then 100% $100.00 Co -Pay, then 100% Services of covered expenses of reasonable charges u+ � • Preventative Care $30.00 Co- Pay ** Not .Covered • Routine Services $30.00 Co -Pay ** 50% of reasonable charges • Well Child Care $30.00 Co -Pay ** 50% of reasonable charges; • Specialty Care $30.00 Co -Pay ** 50% of reasonable charges • OB /GYN Care $30.00 Co- Pay ** 50% of reasonable charges • Allergy Injections $30.00 Co- Pay ** 50% of reasonable charges • Surgical Expense 70% 50 % of reasonable charges • Maternity Care $30.00 Co -Pay, 50% of reasonable charges 1 n Visit, then 100% * *Co -Pay applies to office visit charge only - all other In Network in office services paid at 70% _. MBF RC -MS09B REV 10101 a1z, Florida Municipal Insurance Trust Other Health dare Services In Network' Out of Network ♦ Prescription Drugs $10.00 Generic Wholesale Price, less 13 %, (Express Scriptsjg $20.00 Preferred Brand less In Network Co -Pay $35.00 Non Preferred Brand ♦ Mental & Nervous' Disorder .v • In atient Services $100.00 Co -Pay, $500.00 Co Pay, then (39 days per calendar year maximum) then 70% 50 %° of reasonable charges • Outpatient Services '' $30.00 Co -Pay, 50% of reasonable charges $1,000 calendar year maximum then 100% $50.00 per visit maximum ♦ Alcohol and Drug Dependency • Individual Visit $30.00 Co -Pay 50% of reasonable charges lifetime maximum then 70 °!° 12,000 35.00 per visit maximum (44 outpatient visits Lifetime maximum) ♦ Hos Ice Care 70% 50% of reasonable charges e6 month maximum care) $6,000 lifetime maximum ♦ Home Health Care 70% 50% of reasonable charges $1,000 calendar year maximum ♦ Physical Therapy 0% $2,000 calendar year maximum 50% of reasonable charges ♦ Skilled Nursing Facility 70% 50% of reasonable charges (60 days per, year maximum) ♦ Chiropractic Services $30.00 Co -Pay, 50% of reasonable charges then 70% ` $40.00 per visit maximum ♦ Routine X -Rays, Lab Tests, 70% 50% of reasonable charges Diagnostic Services r All surgical procedures over $500.00 must be pre - authorized. Failure to obtain a pre- authorization will result in a denial of benefits. ❖ All emergency and non - emergency hospital stays must be pre- certified. Failure to obtain pre - certification will result in a 200% penalty. •- All Out of Network Benefits are covered at 50% of reasonable and customary charges, after the calendar year deductible has been met. All deductibles do not apply toward the annual maximum out of pocket expenses. -y Co-Pays do not apply to the annual maximum out of pocket expenses. 4P The hospital Co-Pay for Out of Network confinement due to an emergency does not apply. A All charges exceeding reasonable charges are patient responsibility. = (This is intended as a Summary of Benefits and does not include all of the benefits, limitations, and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.) MBF FLC -MS09B REV 10101 Florida Municipal Insurance Trust Major Plan Benefit 1n Network Out of Network Calendar Year Deductible: Individual " Q $500 Family 0 $1,500 Maximum Out of Pocket: Individual $1,500 $2,500 - Family $3,000 $5,000 Lifetime Maximum $1,000,000 $1,000,000 Hospital Services` ♦ Inpatient $250.00 Co -Pay; then 80% $500.00 Co-Pay, then 60% of Services of covered expenses reasonable charges after deductible ♦ Outpatient $100.00 Co -Pay, then 80% $100.00 Co -Pay, then 60% of of covered expenses reasonable charges after deductible ♦ Emergency Room $100.00 Co -Pay, then 100% $100.00 Co -Pay, then 100% Services of covered expenses of reasonable charges Ph siciara Services Y • Preventative Care $25.00 Co- Pay ** Not Covered • Routine Services $25.00 Co- Pay * * 60% of reasonable charges • Well Child Care $25.00 Co- Pay ** 60 % of reasonable charges • Specialty Care $25.00 Co- Pay ** 60 % of reasonable charges • OB /GYN Care $25.00 Co- Pay ** 60% of reasonable charges • Allergy Injections $25.00 Co -Pay ** 60% of reasonable charges • Surgical Expense 80% 60% of reasonable charges • Maternity Care $25.00 Co -Pay, 60 % of reasonable charges 1 51 Visit, then 100% * *Co- Pay applies to office visit charge only - all other In Network in office services paid at 80% MSF FLC- MS09S. REV 10/011 Florida Municipal Insurance Trust Other Health Care Services in Network Out of Network ♦ Prescription Drugs $10.00 Generic Wholesale Price, less 13 %, (Express Scripts) $20.00 Preferred Brand less In Network Co -Pay $35.00 Non Preferred Brand ♦ Mental & Nervous Disorder • Inpatient Services $100.00 Co -Pay, $500.00 Co -Pay, then (30 days per calendar year maximum) then 80% 60% of reasonable charges • outpatient Services $25.00 Co -Pay, 60% of reasonable charges $p1,000 calendar year maximum then 100%,. $50.00 per visit maximum ♦ Alcohol and Drug Dependency • Individual Visit $25.00 Co -Pay. 60% of reasonable, charges $2,000 lifetime maximum then 80% $35.00 per visit maximum (44 outpatient visits lifetime maximum) ♦ Hospice Care 80 %° 60% of reasonable charges (61 month maximum care) $6,000 lifetime maximum ♦ Home Health Care 80% 60% of reasonable charges $1,000 calendar year maximum ♦ Physical Therapy 80% 60% of reasonable charges $2,000 calendar year maximum ♦ Skilled Nursing Facility 80% 60% of reasonable charges (60 days per year maximum) ♦ Chiropractic Services $25.00 Co -Pay, 60% of Treasonable charges then 80% $40.00 per visit maximum ♦ Routine X -Rays, Lab Tests, 80% 60% of covered charges Diagnostic Services All surgical procedures over $500.00 must be pre - authorized. Failure to obtain a pre- authorization will result in a denial of benefits. All emergency and non - emergency hospital stays must be pre- certified. Failure to obtain pre - certification will result in a 20% penalty. o� All Out of Network Benefits are covered at 60% of reasonable and customary charges, after the calendar year deductible has been met. e All deductibles do not apply toward the annual maximum out of pocket expenses. t- Co-Pays do not apply to the annual maximum out of pocket expenses. 4- The hospital Co -Pay for Out of Network confinement due loan emergency does not apply. 4, All charges exceeding reasonable charges are patient responsibility. (This is intended as a summary of Benefits and does not include all of the benefits, limitations, and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.) MBF FLC MS09S REV 10/01 -. l . f i S Florida Municipal Insurance Trust Calendar Year Deductible: Individual 0 $300 Family 0 = $900 Maximum Out of Pocket: Individual $1,000 $2,000 Family $2,000 $4,000 Lifetime Maximum $1,000,000 $1,000,000 r ♦ Inpatient $100.00 Co -Pay, then 90% $500.00 Co -Pay, then 70% of Services of covered expenses reasonable charges after deductible ♦ Outpatient $100.00 Co -Pay, then 90% $100.00 Co -Pay, then 70% of Services of covered expenses reasonable charges after deductible ♦ Emergency Room $100.00 Co -Pay, then 100% $100.00 Co -Pay, then 100% Services ' of covered expenses of reasonable charges Physician ery ces r • Preventative Care $20.00 Co- Pay ** Not Covered • Routine Services $20.00 Co- Pay ** 70% of reasonable charges • - Well Child Care $20.00 Co- Pay ** 70% of reasonable charges • Specialty Care $20.00 Co- Pay ** 70% of reasonable charges • OB /GYN Care $20.00 Co- Pay ** 70% of reasonable charges • Allergy Injections $20.00 Co- Pay ** 70% of reasonable charges • Surgical Expense 90% 70% of reasonable charges • Maternity Care $20.00 Co -Pay, 70% of reasonable charges 1st Visit, then 100 %° * *Co -Pay applies to office visit charge only - all other In Network in office services paid at 90% - MBF FLC-MS090 REV 10101 .. :. - Florida Municipal Insurance Trust Other Health Care Services In Network Out of Network ♦ Prescription Drugs $10.00 Generic Wholesale Price, less 13%, (Express Scripts) $20.00 Preferred Brand less In Network Co -Pay $35.00 Non Preferred Brand ♦ Mental & Nervous Disorder • Inpatient Services $100.00 Co-Pay, $500.00 Co -Pay, then (30 days per calendar year maximum) then 90% 70 % of reasonable charges • Outpatient Services $20.00 Co -Pay, 70% of reasonable charges $1,000 calendar year maximum then 100% $50.00 per visit maximum ♦ Alcohol and Drug Dependency • Individual Visit $20.00 Co -Pay 70% of reasonable charges $2,000 lifetime maximum then 90% $35.00 per visit maximum (44 outpatient visits lifetime maximum) r ♦ Hospice Care 90% 70% of reasonable charges (6 month maximum care) $6,000 lifetime maximum ♦ - Horne Health Care 90% 70% of reasonable charges $1,000 calendar year maximum ♦ Physical Therapy 90 % 70% of reasonable charges $2,000 calendar year maximum Skilled Nursing Facility 90% 70% of reasonable` charges (60 days per year maximum) ♦ Chiropractic Services $20.00 Co -Pay, 70% of reasonable charges then >90% $40.00 per visit maximum ♦ Routine X -Rays, Lab Tests, 90% 70% of reasonable charges Diagnostic Services r _ -All surgical procedures over $500.00 must be pre - authorized. Failure to obtain a pre - authorization will result in a denial of benefits. All emergency and non- emergency hospital stays must be pre- certified. Failure to obtain pre-certification will result in a 20% penalty. All Out of Network Benefits are covered at 70% of reasonable and customary charges, after the calendar year deductible has been met. All deductibles do not apply toward the annual maximum out of pocket expenses. Co -Pays do not apply to the annual maximum out of pocket expenses. The hospital Co-Pay for Out of Network confinement due to an emergency does not apply. S All charges exceeding reasonable charges are patient responsibility' I, ' (This is intended as a' Summary of Benefits and does not include all of the benefits, limitations, and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.) MBF FCC MS09G REv imi LORIDA LEAGUE OF UITIES, INC. AIFK PuBLYC )DISK SERVICES July 18, 2003 Administration/ Marketing, El Risk Control City of South Miami Jeanette Enrizo ❑ Underwriting 6130 Sunset Drive Property & Casualty South Miami, FL 33143 Health Post Office Box 530065 125 East Colonial Drive Orlando, FL 32853 -0065 Re: RFP - Group Health Insurance 800- 445 -6248 407- 425 -9142 Dear Ms. Enrizo: Suncom 344 - 0725 Fax 407 -425 -9378 We appreciate the opportunity to provide you with this proposal of insurance for Health Claims employee benefits. Medical coverage has been proposed on a Point of Service Post Office Box 538140 (POS) managed care basis through the Florida Municipal Insurance Trust, a non -` Orlando, FL 32853 -8140 profit, non- accessible, group - pooled program. 800 - 756 -3042 407- 245 -0725 The Trust also provides dental and short -term disability benefits and a prescription Suncom 344 -0725 drug card Ian. Fax 407 -425 -9378 g P ❑ Workers' The Trust offers First Health to provide a statewide managed care network for its Compensation Claims participants. These Comprehensive networks of doctors and hospitals are available Post Office Box 538135 in most regions. Orlando, FL 32853-8135 800- 756 -3042 4077245 -0725 All rates quoted are guaranteed for sixty (60) days from the date of the proposal. Suncom 344 =0725 ° The rates include costs of administration, reinsurance and estimated claims costs. Fax 407-425-'9378 Monthly, quarterly and annual loss reports are provided at no additional charge. ❑ Property & Liability We welcome the opportunity to further discuss our proposal and should you have Claims Post Office Box 538135 any questions, please contact me at 1- 800 -445- 6248. Orlando, FL' 32853 =5135 800- 756 =3042 Sincerely, 407- 245 =0725 Suncom 344 =0725 Fax 407- 425 -9378. Chuck Wilde Marketing Representative CWfjr Enclosure n® FLORIDA LEAGUE OF CATIES, INC& PI Buc RISK SERVICES Administration/ PROPOSAL OF INSURANCE Marketing FOR p Risk Control Underwriting CITY OF SOUTH MIAMI Property & Casualty Health Post Office Box 530065 125 East Colonial Drive Effective Date: 10/01/2003 Orlando, FL 32853 -0065 800 - 445 -.6248 407- 425 -9142 Suncom 344 - 0725 Fax 407- 425 -9378 Provided by lid Health Claims Florida Municipal Insurance Trust _ Post Office Box 538140 Orlando, FL 32853 -8140 800- 756 - 3042 407- 245 -0725 Suncom 344 - 0725 Fax 407- 425 -9378 ❑ Workers' Administered by: Compensation Claims Post Office Box 538135 The Florida League of Cities, Inc. Orlando, FL 32853 -8135 PUBLIC RISK SERVICES 800- 756 -3042 P.O. 'Box 530065 407- 245 -0725 Orlando, FL 32853 -0065 Suncom 344 -0725 Fax 407- 425 - .9378 407. -425 -9142 or Toll Free 1- 800 =445 -6248 ❑ Property & Liability Claims Post Office Box 538135 Orlando, FL 32853 -8135 July 18, 2003 800- 756 - 3042 407 - 245 -0725 Suncom 344 -0725 Fax 407- 425 -9378 7±1 .1. _ AR.__._S_5�,1 CROUP DENTAL SCHEDULE OF BENEFITS FLORIDA MUNICIPAL INSURANCE TRUST G'FNFRAL DENTAL AR B N FIT 0JJ :JQF1 TIC CARE RENEE Lifetime Maximum Benefit - Unlimited Lifetime'Maximilu mn Benefit - $1,000 per individual. Calendar Year Maximum Benefit - $1,000 per individual SUMMARY OF GENERAL CARE SERVICES'' 1. Examinations and recall services, check -ups and SUMMARY OF ORTHODONTIC CARE 1. Diagnostic procedures cleaning of teeth 2. Appliances for tooth guidance and control of 2. Palliative treatment harmful habits 3. Endodontic treatment 3. Retention appliances 4. Space maintainer 4. Comprehensive treatment with fixed and 5. X -rays removable appliances for correction of 6. Oral surgery malocclusion in permanent, primary and 7. Periodontal treatment mixed dentition 8. Normal' extraction of teeth 5., Orthodontic treatment must be completed 9. Silver and synthetic permanent fillings, crowns prior to attainment of age 19. and jackets 10. Fixed bridges consisting of crowns or jackets 11. Dentures and removable bridges DFQI JrTIR1 F $50 per individual per calendar year. LIEFTIME DEDI I .TIB E $50 per individual. GINS IRANC F Plan pays 80% of first $1,250 of eligible CQlNSLJRANQF Plan pays 50% of first $2,000 of eligible expenses per calendar year. expenses per individual in their lifetime. D NTA ` RAT FS (PER MONTH) STAND ALONE - (Without Health) Employee Dental $28.91 Employee Dental $32.30 Dependent Dental &425Q Dependent Dental $47S0 Family Dental $71.41 Family Dental $79.90 Dental coverage written in the Florida Municipal insurance Trust is subject to a 25 % participation of those employees quoted. *** This summary was designed only to give you a brief description of benefits provided and does not include all of the provisions, limitations or exclusions In the policies. In an actual claim situation, the policy provisions, limitations, exclusions will apply. If this outline disagrees with the Plan Document in any way, the Plan Document will govern. FLORIDA MUNICIPAL INSURANCE TRUST DENTAL BENEFIT PLAN SUMMARY Reasonable and customary limits will apply to all covered eligible expenses: rU NFRAi DENTAL CARE Calendar Year Maximum ... ......... ..... .......$1,000 Deductible- .............................. ................. $50 calendar year After the deductible has been met, unless otherwise stated, the following coinsurance will apply: This plan will pay 100% preventative services, not subject to the calendar year deductible, as follows: 1. Oral examinations 2. Dental X-rays (Bitewings,twice per calendar year, Full Mouth or Panoramic once every 2 Years) 3. Fluoride application (for dependents under age 15) 4. Prophylaxis This plan will pay 80% for basic dental services as follows: 1. Emergency treatment for pain 2. Space maintainers 3. Dental X -rays 4. Biopsies of oral tissue 5. Pulp vitality tests 6. Fillings 7. Extractions 8. Oral Surgery 9. Endodontics 10. Periodontics This plan will pay 50% for dental restorations and specialty services as follows: 1. Inlays, onlays 2 Crowns 3. Bridges, dentures SCHEM11 F QF ORTHMONTI B NFFIT (applies only to eligible dependents under age 19). Lifetime maximum (per person) $1;000 Lifetime deductible $50 per person Covered eligible expenses are payable after the deductible at 50 %. 1. Diagnostic procedures. 2. Appliances for tooth guidance and control of harmful habits. 3. Retention Appliances. 4. Comprehensive treatment with fixed and removable appliances for correction of malocclusion in permanent, primary and mixed dentition. These summaries are designed only to give you a brief description of the benefits provided and does not include all of the provisions, limitations or exclusions in the policies. In an actual claim situation, the policy provisions, limitations, exclusions will apply. If this outline disagrees with the Plan Document in any way, the Plan Document will govern. CLAIM ADMINIATRATOR• Florlda League of Cities, Inc. Claims Center P.O. Box 538135 (407) 245 -0725 Orlando, FL 32853 -8135 (800) 756 -3042 GROUP VISION VISION SERVICE PLAN SCHEDULE OF BENEFITS A deductible amount of $10.00 is required for any service(s) rendered payable out of pocket by the eligible person to the panel doctor at the time of service. GOV R D FXP NS S VISION EXAMINATION The primary purpose of the Vision Service Plan is to provide for professional vision examination and care. This examination comprises an analysis of the vision functions, including the prescription and supply of glasses where indicated NS S AND FRAMES A. LENSES - The VSP Panel Doctor will order the proper lenses from a VSP approved laboratory. VSP provides any necessary lenses, including single vision, bifocal, trifocal or other more complex and expensive lenses, when necessary for the patient's visual welfare. This assures the finest American- made lenses and quality workmanship. The doctor verifies the accuracy of the finished lenses. B. FRAMES - The patient is assisted in the selection of frames. VSP provides a wide selection of quality frames. Because of the cosmetic nature of frames and the rapidly changing styles, VSP has a limit on the cost of the frames provided, under the program. The limit is designed to cover 'a majority of frames in current use. Patients who select frames that exceed the limit are required to pay the additional wholesale cost, plus a modest additional fee. C. MEDICALLY NECESSARY CONTACT LENSES - Contact lenses are allowed under the program in any of these instances provided prior approval is obtained from VSP by your doctor with documentation. 1) Following cataract surgery. 2) When visual acuity cannot be corrected to 20/70 in the better eye except by use of contact lenses. 3) Anisometropia,of greater than 350 diopters and asthenopia or diplopia, with spectacles. 4) Keratoconus diagnosis where contact lenses is the treatment of choice. 5) Monocular aphakia and/or binocular aphakia where the doctor certifies medically necessary contact lenses are necessary for safety and rehabilitation to an occupational productive life. All five (5) categories of "medically necessary" contacts are subject to coordination of benefits with the medical insurance carriers. VSP will provide the contacts or glasses, but not both. D. COSMETIC CONTACT LENSES - When cosmetic contact lenses are selected, an indemnity allowance will be made in lieu of all other services. HOW OFTEN SERVICES AR AVAILABLE A. A VISION EXAMINATION - is available to each covered person every 12 months. B. LENSES -Art mf- :usable every 12 months when required. C. FRAMES - Are available every 24 months. LIMITATIONS EXTRA COST - The plan is designed to cover visual needs rather than elective materials. If any of the following are selected and the VSP doctor does not receive prior authorization,' there will be an extra charge: a) Oversized lenses b) A frame costing more than plan allowance C) Tinted or photochromic lenses (other than Pink 1 and 2) d) Coated lenses e) No-line bifocals (blended type) and progressive lenses f)' Cosmetic Faceting g) Other cosmetic items. ITEMS NOT COVERED: a) Orthoptics or vision training b) Subnormal vision aids c) Aniseikonia lenses d) Two pair of glasses in lieu of bifocals e) Plano (non- prescription) lenses f) Cosmetic contact lenses. Replacement or repair of lost or broken lenses and frames, except at normal intervals. Medical or surgical treatment of the eyes. Services or materials provided as a result of any Workers' Compensation Law, or similar legislation, or obtained through or required by any government agency or program whether Federal, State or any subdivision thereof. Any eye examination required by an employer as a condition of employment, unless agreed upon in writing by VSP and included in the original contract. QUAL C HOI .F .OV RA , Eligible persons not wishing to secure - services from a Vision Service Plan Doctor may secure services from a non- participating doctor and submit bills for reimbursement. The amounts reimbursed are limited and may not cover the full charges. I i E 1 �IRI ITY Each group electing vision care must maintain their vision care coverage for a minimum of one year from the time of inception. All employees and dependents who meet the eligibility requirements of their enrolled group are covered for vision care benefits Neither employees nor dependents have the right to individually select vision care coverage. Requirements' for participation are: a) 100% of all city employees, or b) 100% of all City employees carrying any coverages with EMIT. PREMIUM RATES: Employee $ 5.74 Dependent IL43 Family Total $14.17 tom. C\ vi N N en O 00 ri to 00 y d 00 N r M Q V1 \O. � W dN' ''d' a N 00 d'�-i �.. M 000 C M [- C tn C kn 64 64 Hi 64 69 69 69 -: cl _ a s a w a a a bbbb a t7OoC7C7 � a •C,4 000 N OC N N O ON M CL+ W M 00 [� � M C M �O N en CI- cq cV r- 41 � N N te) � 0 l- en cq 69 a :� 69 69 6H 6N4 69 QNl O O C7 C7 C7 C7 v, �, v, v, 0 O V M a\ O l� 01 00 N O -R. M N 0 M M 00 M w P w ON O� ~ Vl M 00 W) in :.CD �-' Uj` O d M. 0�0 ONp �,. d' 00 l- N a, o snsA� ss O. o' o sssys4� ryszsdsIs \ a \ a a N 00 N DD .--i w r+ N C\ ^" N 01 N f" - O V3 o v ° ej o tu o U r+n U + U W�Tl W W o+ m o i 00 tn e� 4 cn N O� N eq Ge - N y z 4 O. M M a�A7CG, ti O 7 N �. \C A 64 69., � � h v Is a� cj ts ? �00 y � 00 � i �� .. 00 Cq .:� O. O q C � � a _ �1 ti p ri w _ • an + + � W W � � � � Q � v� ,� e� '" � PC RM T V M l(1 00 M E-: 0�0 00 O N O r,� O M O 00 M C V V1 n+ t� r m 10 N C) r CI M O M o0 a, N. r 64 M 't y O O, v1 l- O N 64 69 N W) 69 64 N FA 69 69 '. 69 M r .0 N M N N v1 O V1 �p ,r N 00 O\ C� h 00 00 In r- M M N "' i � . N.. h dam' ^ MV..�.��i inl1 .�-+ N:� 00 V1 0 N �+ t+ GS b9 b4~ 6�46R 69.. -i 646464 b 6s 1 •o j V + i + O 0 www _a I 08/07/2003 14 :39 308- 687 -2499 SUSAN REDDING PAGE 0+1 Z002 08/07/2002 ti;U FAX 4"bobod 1 0 rshp crry OF SOUTH MAW ,skip #W5557 R iscd 8/7/03 ENO Fos P1 I Medical P18n $1Q $10 office Viatco -p a rct so $0 atimt(;0P&YC t presc*tiou Co- payment $7 $7 ( MW.*c $25' 525 ptef 'ed Brad Nw.VwftredB=d 200,10 All Designakd Sclf ink ectsbles out ofNetworL. Deduodble 70130 Cokwu'ancG Pcrce�tge 53,E Mani=a oat -of Poch time Deduotible W/10 Cowu=ce Percentage $1,00() Maximum out -of pwket # At Dedu(tbie and W-0f pooke mw=t€ we two times per family. BD� 5557 X55! , .? $ 356.33 5 450 1.` EMployee WY $ ` 752.64 $ 900 1; Bnvlqw + Spon.s $ `+559.3? $ 810 ' +G'wm(rw) $1,098,97 $1,35L!! Employee ± Family RXW }i,eeepted By' Date: -.-�- ride; nA I 03/07/2003 14: 39 305 --667 -2499 SUSAN REDDING PAGE 02 08/07/200.1 1 -1.52 FAX �OQ3 t ° &alffi h, CM07SOUTHWOR RMWAL ACCEPTANCE — ALTIERNATIVF, MEFIT P'AN A GROUP O B0957 Revd 817103 BMW FLAN MIGM_ Medical Pin HMO PO$ P1 I ;s offoe visit co psya=t $10 $10 Inpatiitast Co- psyyment $250 $25t! r rescription Co- payment $7 $7 Gene $ preferred Brand $25 $25 l�aa- preferred Brand $44 All Desipgbd Self- injectAbles 20% 20/0 t of NaWork Wo Deductible 70130 cuhuUsauce Percentage w $3,000 M xiM= Oat -of -Fo t p'pQ: 13 none �edticttble c0i O �sumot 90 /I Pero tage 901100 maim= U'ut4f pocket ,x,1;1 ?e&cdble and Lout -of JPecket mounts are tWo tlMPs PC *300- RTC. ZWA.L RATES EpnCTrVE 101MM TO 91.I0/04; 005557 H Employer. Only $ 354.24 $ 435.1 FMployee + Spouse $ 708.46 $ 871. , Employee + Child(rcaa) $ 837.61 $ 784.11 aployoo + Fatal}► $1,062.70 81,306, Title; . r,.- :.- ,.- x*m- ,!"°'T^sn•'+r' - ,� -.-;;- m"A'k 5�`T!t 08/07/2008 14:39 305- 667 -2499 SUSAN RENDING PAGE 03 0004 08r4S7r2oQ3 1,1x52 FAX ` od Health ip. ,`fit Ole 1SGUTS MUM RENENVAL ACCEPTANCE -- AL TERNAT BENERT Pik S GROUP muss7: Revieed 817903 BENZ= PLAN BtMGN 11�ed vel Ply y3 mo 0 f5 Visit Co- payment $14 81 i rope mt C symedt $250 $250 Pre 'i cap -p ynnat 514 X10 Ciao $30 $30 Free rred $sand &5 Non- prefered l�r ct 20% es 20- 411 'ted f -" 'actabl % out ofNaiie mk: Deductble 70930 Cotsmneo Percentage ; $3,000 lIMuan - of -Pvckt PPD: e DcdWdb10 90Y10 Coiasumca $ 1,000 Msxtn n taut- of- Pboket All DeducOle and Out�of- Pocket mounts are two timae Pa f&uli RMWA.LL RATES EFTECTNE Rolljo3 To 9M/04: 1Y $ 343.62 $ 422. ! S 68712 S 845.!1 EuV17fle + spouse $ 618"49 S 760. 4 Ein&Yft + C�d(reo $1,030,83 $1,267'. ; givloyee + Fwrffly Rato Accepted By: Dates .v i i i i 08/07/2003 14:39 305- 667 -2499 SUSAN REDDING PAGE 04 x{005, 08/07/2003 1). "33 PAX irer Crry OF SOUT11 YaA1V C GROUP #BQ5557 weed 81710 Br+ sTr YJrl7rL, DMC*N: "Cal x'19:1 Emo Pos Pl ; ' 3 f3�t®'vietc ptymeut W $ I ent C"symeat $5 0 $250 pCg ep Ca In"It $10 slo Ckaoric S3 pY'C Bt''l7d Q . NonVdamd Bmd 9 845 AU Dempated Solf-qeatables 200, out of Nate+ )c * $500 tt%lc 70/30 CoinS=00 vammup $3,000 N,[o r m OLt o -r FPi?t none Deduottble 90/10 CojWU=Q6 An Drduct-ble and out-of-Pookot amounts im two limes Par fadly. VjMEWAL RAM EVTBCTrVE 1011103 TO 9/300. OB05S57 HI OB 55= ; .1. 2. $327.35 $ 42 ftplayae y r 1�uvloyw+ $594.29 $ 76o I9 $mpkyee+ d(TW) $582.0 $ 760. 9 gtayee ,+-'l�esnly $982.0 $1,267. i RaW Accepted By: Irate: .--.- °'1"At1e: .psi .�.�, 08/07/2093 .11439. .305-667-2499 SUSAN REDDING PAGE 05 08/07/9003 1 1:63 Fib ZOOS ,4 Ne�'hborhood Hea M OF SOUTH MOM MWA .ACCErj`ZC 1K A M?T�Yg' ]�! +1itl '��IJ£'+rBidC rJi f . GROUP #8415557 Reviged X103 REMIT PLAN DESIGN: 0f$ae v'at Ca raymC7at $ $500 0 5 �1 $5 bpadent co-paym pm5miption Co payrMt 910 $10 G=Cric $30 $34 prdwr*dB=d r5 NCO- preferred Brand AM Dee1wSted Self wftbles 00/a Glut of Nei ark: $500 Deductible 70130 Co�suraace MWAL RATES MECTWE I01ittl3 TO 91IM10A. #B15557 11 .E� $327.35 $ 361. amplayee Only $ 723.1 ! Employee + spouse $654.69 1 $589.21 $ 651 ; ftildyee +child( $982.04 $1F085. i 1 MP + Few' Rates Accepted BY: 10�e: N "Ii�1ea ,s^'3,. 08107/2003 14 :39 365 -667 -2499 SUSAN REDDING PAGE 06 08/07/2003 11.55 VAX e ftod H ealkk ip CrM 0;? SOMA 4>RaUP MOV Rvdwd DIi M PLAN DESIGN' sot e1A, E I ct IS Mvd ad Plan l O POS PZ l Office visit Ca•p &Yam $5 So bxpadentCo-paymmt presmipfien $10 S7 Generic X30 50 Pre xed grand $ Non fe1. grand All bedgmud tijeotab'1es 200om 20% Oct ofNdwc&p * 9500 amble 70/30 Coinsumoe Foraeatot $3,404 r,ao �iible 90110 Cohmmum Pereentw, . * $1,000 out-of-Pocket i w I3educ xble JMd -af Pocet wwouatg tvM times Pw hmi1y. REMWAL RATESUMME 1011103 To 900/04; 47 Zi ',..? 481; Employet WY $654.69 $ 963.;' Bnplcry►ee + spouse $589.21 $ 867,_; Employee+CbLd(=) Z %�'ee �Par�►�'1y Rates Accepted BY-' - Title., r'?a;! 0810712003 14:39 305 -667 -2499 SUSAN REDDING PAGE 07 08/0712005 11:58 -FAX I N mw, 4 1W r "OWL' cm 0# soum WIMM WMWAL ACCMAXCE —,PL ' ATit "N"IT PLAN GROUP #BOM7 ided 8/7103 YJLMW PLAY DESIGN'. LEA CLOW bfixhcg Ply 990 Office Vat Co-payment $15 speciav Visit CowPLYMent $25 t Mpir al Co- paYM60 X2$0 per day up to 5 day a t ptescr#60n comet $10 Ckneric RdwedBrand S35 $35 'Narrpr0fcrred Btud All DesiPaWd Self injectableg : 20% Additional CO- payraMts t8 Z30 siu' ery atzan ur$a7+;, per d< e Y Ou iat Radoka9y S20 pex via at Cu4ntint Thw4d Emergency Room 31011 per visit Ambuhnro $50 per oce ncc $25 pis visit ` imember �taauz0 toy pot 3`OC! Q Y 'UnW.4L RATES ZFnCIM IWJI03 To 9130/04: 557 H E=Piore 401y $291.5 $583,1a 1oi' $p0 $524.79 gsioyac1d(x+cn) $674,67 Etloy+ + psualy Raw Acaepbea>Y: Ti Dates �-- ft 06"07/2003 14,39 305- 667 -2499 SUSAN REDDING RAGE 08 08/07/2003 11:54 FAQ =iodUnho Health 0Jr S0uTS; WAL,&C CF, — ALTMATM GROUP O13t 57 set 8!7103 .T PLA241DEgrG ', gut, +cl� � id bae&csl pion $14i affice Visit Co- payment so 09 C ent Prwipfion Co -pay eat S7 Chic FrchrredBmd Non - prayer Brea �5 All T edpated SW-in) W61105 out of Notvv lc $500 L?edt�"b1e 70/30 Coisluratxc+cFtaSe 3, 1+ atau ih�t a£POCImt lam: ono Deacle 90110 Coia=my SLOW Moiram Out Pvu1 k * All cdu�tzNo ad 0Ut,0 -?00J t Zmount�a are two thTm f` l+. 'SAL RATES UnCIVE 1011105 TO 950104: . B0555 , c 481. IL by" $ 953, 11UVL'm + spowe S 867• lOj[GEf + Family PAW Aceepted B'• I Twit'. DRAW i asr•�lzroua i5:�a r�.ax , gjUUl Ndghborhood Health Paroffiership May 21, 2003 City ofSowhMi=i Attar: J=Ott* Ems► onset Drive South Miami, FL 33143 RE., GR.0L1P #B05557 RENEWAL RATES EFl~`BCT["V'E QCTQFBEFL 1, 2003 Dear Me, Enrm; : u leased to provide your businoss with group hallih iv=a Ic tbro gh arketm as p . Z M � is erYenc f 0i the o' able , put our Sv � e toeing to l�saghborhood'liealtb pa�ri.up. We apprecat b g F health insurance business to work far you and your =100Yee2• Our mlual review of your mcdW plans indicates t"d we must adjust your prcrna � ►c. Tiwe adjustmWAS are due to coed u dy is =sling health care oasts aAd 411=61 of swi ca a. They may ratleat changes in the composition of your work force. F'ffeetive with your 00 ib er 1, 2003 billing, your premitud rates wall be w follows: . #805557 H #305557 T �` POS� Employee Only $ 371.96 $ 457.3$ Employee + spouse $ 743.91 $ 914.75 Fhployoo, + Chit reap} 3 669.52 S 923.27 L Employee Iza Y � 1 , 72 a 5 To control your benefit ;costs you IM WMt to make b=14 Gha EN at this t L W x ►e options to aarisuler are plans with higher deduotible% other comsunce levels, or add tia; al mana=ged care features. if YOU mre iateaasted in miAdng benefit changes, plea have Your age, It .anted us prior to the and of your renewal date. The prescription drug benefit is changing to a 4- tier co- payment structuro,`wbkh wit b effective with your plan renewal. A nm 40 tier for designated self- iuject blew has been adc k. in Jane 7600 Corporate Center orive • Miami, fiorida 33126 -7216 pb Bmx0256sa • Miarel, fladda 33102.56 ,,m ... 8.,.< z;; r•,.. .r,;: � _ are vvd TY Q5l21�2QO3 15,41 FA8 I*alffi b acl it. ho aff OF souTri MLOU ;MMWAL ACCZPTANCII C1 Our # 'S5T' MXVT PLAN DrMC V' Md0 P08 FIs[:. "old Flan $14 1° $0 offiot visit co- payoent $41 aPct n ��'aaC°' ya`eat $7 $7 $25 $25 Fro d PO $40 Non -i+ 20% tat Sal€ jactobito 201!0 Out oM k, $500 1e 70130 perch * $3,004 i Fockat PFO-. Ron ie 90110 t nseaaucc Pie $1,000 Maxig:u�a Otit.of�aobt All Dcduatfble and 00-of PAxt ammmu tai two times P h=oy. • iii"fo aims== to a caum',�ti of 7, for 1 mouth RENEWAL L R&'TE$ UnCffg 161il03'TO g301Q4: 55? $ 371.96 8 45738 Er*wce Only $ 74391 $ 914.75 EnVle + soun $ 66452 BMPIWM + Ch0frcn} $1,115.89 $1,372.14 �II Pmployoc + Family tes As=pW DIU% lop N, Tlt1G: j ate Center Drive M4iam4, FloMa 33426 -1216 7600 Corpor pa 3=025580 •' Miami, fiorida 331D2 -5 Q Qua . FINANCIAL EXHIBITS - MEDI PAGE 1 Medical Plan Design and Rate Proposal for City of South Miami Based upon the information provided and our analysis of your organization, UnitedRealthcare - Florida is pleased to oize tug f '.'.. ,- ing medical fiand = plan for an effec�ve date no later than October 1; 2003. OPTION L• BGNB Site(s): National Excl. OO R Choice Plus * Platform: Prime Plan Offering: Single Option In Network Benefits: $l5 o.v. /$250x2ded/ 90 % coin/$2,000x2 max.00P Out Network Benefits: $500x2/ -70% coin/$3000x2 max.00P Pharmacy Benefits $10/30/50; 2.5x for M.O. Assumed Proposed z __- EnroIlment iA Employee 92 $367.20 5 ri Employee +Spouse 7 $734.41 i Employee + Child(ren) 14 $660.47 Lo � Employee +Family 24_ $1,101.61 Q q� Monthly Premium' $74,616 -7- Annual Premium $895,392 Z (° OPTION H: BGOB Site(s): National - Excl. OW Choice Plus * Platform: Prime Plan Offering. Single Option In Network Benefits: $20 o.v. /$250x2de8/ 90% coin/$2,00W max.00P Out of Network Benefits: $500x2170% coin/$3000x2 max.00P Pharmacy Benefits $10/30/50; 2.5x for M.O. Assumed ` oposed Enrollment Rates Employee 92 $362.86 �� (,Po Employee + Spouse 7 $725..72 Employee + Child(ren) 14 $653.14 (640- 0 Employee + Family 24 $1,088.57 Monthly Premium yil.,�'� Annual Premium $884,793 'f ° Quote Assumptions: ✓ �" - Rates are guaranteed for 12 months for the contract period of 10/1/03 through 9/30/04. - UnitedHealtheare is the only carrier offered. - UnitedHealthcare reserves the right to adjust the rates if the enrollment at issue varies by +/_ 10% from the submitte Quote is subject to final underwriting which may have conditions. Additional paperwork and/or information may lr Employer contributes a minimum of 75% toward the employee only rates and 0% toward the dependent rates. - Requires a minimum participation level of 75 %. - Preliminary rates are subject to an employer form approval process which may include a telephone interview. Quote assumes no out of area or retiree lives. - Unless otherwise stated, this offer replaces and renders all previous offers null and void Quote is contingent on employer contributions being 75% per ee on eff date *High level benefit summary. Please see your plan summary for more detailed benefit description. P.0312 JUL -21 -2003 10 :31 nitedHost1theare Choice PuS -"w!- 'lain . CPS As part of our commitment to keeping ou in control of your health care decisions, our Choice Plus plan 'ves you the freedom to see any doctor, in the Urnxted�arlthcare Choke network, in.clud�ng specialists, without a referral. You can even visit any out --of- network physician and still enjoy your benefits with somewhat higher deductibles and copayments. With our Choice Plus plan, the vast majority of your health care needs are covered with little or no out -of- pocket costs When you visit a network doctor or facility. Plus, when you visit network doctors and hospitals, there aren't any claim forms or bills to worry about. Some of the Important Benefits of Our Choice Plus Plan for Covered Services: Visit any doctor in the Choice network in your Prenatal' care is included. area, including specialists, without designating a Routine check -ups axe included. pH=ry physician. Visit any network hospital in your area, Childhood immunizations are provided. You can choose to seek services outside our Manimogmm are included network, aormlly at a higher copaymect and/or Pap smears 'arc included. deductible. Vision and hearing - screenings are cavered.` Emergencies are covered anywhere in the world. see Can Covzdination , services are available to Benefits are available Sur office visits and help identify and prevent delays is care for those hospital care, as well as inpatient and outpatient who night need specialised help, surge y, when covered health services are provided. i P.04/12 SUL -21 -2003 10:32 Choice Fins Bene„ fits Summary -- Plan EG.P Types of Ci>veraga Network Benefits / Non- Network Benefits / Copayrll at Am ants Copayznent Azoa�lats Thin sewftt suan� is intended only to WA g Annual Dedutfiblez X50 twent!" year, not to exceed Annual DW%Cttbie: 5500 Per! Covered Person per your 8mft and should not be failed apoe to fidlp $500 SEra11 C WnW POMM in a farnlly' 0sbnd� year; cart tt+txeeed S1,000 for ell Coveted dt tcrulifte wMage. Thin Ilmolit plan may not ova alt Perms in a SMAY of your hmm care expeasca adore complete doeripCoos of Amcfits and the ferma anger WW& oot-ot- Poelax 1Kt tvM S2.o00 per Covo,ed Pon,,., 0.W paeW Maximnna: S3,a00 pc Owned they are provided art contained in 60 CorBfiento of Pa cele"a r not to exceed $4,000 for etl Covered Parent per calendar ycer, scot to exceed 56,000 fo r Coverage that yon via nWve upon erlratllsg en the Persons in a `wily. The Gur-of- Pocket Maximum dons all Covered ftus is a faun'$. The Oats Plan. not include the Aawal Deductible. Pocket mmenva does nor include the Amma1' If this Benefit rstunmay conflict; in any way with the Polly fastrcd to yaw employer, +die policy shall prevail. CapaymMItS for sum- Cavaeed Heahh Service; will never PedneftlL Cepayments for come Covered Health $ere = Terns that arc capitalized in the beae5t summary are apply to the 0"f- Pocket Maxirtmtn as apeeificd 'm sped!ASection I of9taC= defined in the Certsicatt afCovamg% Section lof9w COC Maximum porlay Benefit: $7,000.000 per We-wk heatds care ;erviee3 under this benefit plan are Maximum Policy Bmofim $4,000,000 per Covered Posen combined Maximum Policy Done& Covered Pezaon tinged Maximum Policy covrard only when pr w dal, arranged or authorized by Beneft. a Network Physician. 'Prior Notification is rngored fbf certain services. I. Ambulance services- zMageney only Ground 'out 5100 pauanspott Csound T:asu;poriation: 5100par transport As• Tnwpo GdoaM00 pert:mVwt Air TrenapoxtaficUM00 patamspore' L Dental Services- Accident unaEyv Same as & 11, it and 13 •30%of Migrble Exptntacs RPsiornodfication b requited before follow-up ImMent begin; 3. lynrnbk Medical Egcdpment 1046 oflrTfgibic 6asea K305f►ofbk E�enses a d� a r ai►at the con is Combioed Network and Non tdctwerk Benefits for nPorts• snore than $1,000. n $1, Durable Medical lqupnaent are limited to $2,500 gar calendar peer. Limits do act apply to DotablC Medical SquipmentelassifiW as dial c equilfow or Sapp. 4. L c geney 13e i Services S1o0 per vwtt -! $700 ps Visit *Marnofifictation is required ifresub in an Irlpati2ln $hp. : S. Eye R an cations S20 per visk', RoSacd, eye a+taminetions ale limited m one every otba 30%or6iignbb Expense; Bye amofinadtms ibr sefoactiw errors we not calcndaryesr from a Rpntiae N i" Networkptovider. covered. 6. " Some Hesltb Care 7tt'9i 0f Eligibic Expenses -30% afffi la R—sea Combined Network and NwAs. work Benefits are Umbod to 60 visits for skilled care aetwieas par oelcodaryear. 7. Hospke Can 10%ofnow 1:ap=M :0°h 715gible Expeam Combined Network ad Non - Network Btnieiits arc iimited to 180 days &wing are actin period of situ a Owland'?a*=is covered under the Percy. _ L El aldtal- h*:ientSny 1O- AOW-MetVMO •30g5ofElfgibreExpenses, P. Injeeftsis Reoeeved in a Physician's Me SZO pro visit 3096 Per rAtcaoa 10. Maternity'Serviaes V . Same as $,11,12 and 13 No Copay erg applies to PhyMen ofte vift for "Sane as 8.11,12 and i3 - Notifeeatian is rapped iflnpatiea Stay exceeds Preaata! me after the first visit 48hoom bNowing anousnal vaginal delivery or 96 hours following a casataen seetiian'delivay, 11.0utpaticnt Surgay, D'ngpoS& and ThcrapOft IM% of Elipbie Expense; 30%— � % Some" 12. rhylk"Ift's Me Servieq 320 per vigil . 30'Yv of IIigbffi Expgl6Ca No Bwsehtl; for pnvmdve case 13. PmIeatiaaat Fees for Surgical sad 10% of Eligible Expel 30°h of fit }a Services 14. Proo tosle Devicee 10°h of Eligark ExpOnses oR of &rove Ezpenset Comblaed Notm& mud Non- Network Benefits for prosthetic devices arc limited to Woo Par CalendtiQ' year P.05/12 JUL -21 -2003 1032 Types of Coverage Network Benefits / Non-Network Benefits / Copayment Amounts, Copayment Amounts 15. itecanstrnedve Prt cda>•es Same a 8.11,12,13 and 14 ~ 'Same m 8.11.12.13 and 14 1G Iiehmbilirmtiaen Serriaaea -0�a400t Ther'mpy S20 per visit 3Wl. ad Eli 'bte Expenses !h CouNmed Numpi : and Non.Nemrodc Sts era Iiaiitad as foRow� 20 visits efAwad rhW . 20 visits of -6mv kxd ommy ; 20 visits of mmc* ._ y vdm of pu6ionry rn/+aIRB man yPxd _ a vuim of 0--m am maubirwgon per dcndafyarar. 17. Skilled Naeslt+g FaadRWANIP26" Rebabrmdon ]0%-ofEligible Eatp ma 50'!- ofEligibk Emmms 7*00ty ServGers Combined Netavor'k and Non- Network 8e-ft set limited to 60 days per eskadsr year•: CraRgAW RdW 52400 tim stayi10 18 Services YOU or yawNetwoik PSysieiaa must ucdfy to whce the Eeaefits possrba7hy of a uanspF�t arises 19. uraestt Care Cufmir SWIMPF �— 535 Par visit 30% of Elipblc Expenses Additional $.enefits Bones orJoint4 "of the Jaw and Facild Re008 Same u or 11. u dad 13 "30°do of Eligible ChRd But* SuPWvhiaa Se:rvim 520 per visit; 30°.6 of eligible Expemtw Cleft Up/OakPdate TimMent Smw as 8,11,1& 13 and io '30%af�l:hoblE-1,00% Aenml proaWo t - Aaesdwka and Hosplm�ie oa Same as 8.11 sad ] 8 30 '0 0[ Eligble E> Wiluts Treatment same as 3,11.12 ma 13 30Yo ofEEigibk PXpensea 1VFammageapby No CopaymaR NoCopsymmt l�aateetromy Sams as161It 12 and 13 •30°I- ofls'lig+bkEapcoses NimW Heaft and S*stst-ce Abase Serf-s -- 830 par individvel vim, $20 per group visit No 13enefim Mum receive prior mtharividon ft=O tlse Metes[ HaSlWSubsmm Abase Designed 13aaad'ns are Timited to 30 visits parr ealasft year Mmtm1 Hmtdt and f- nbstaaax Abase Serviax - 10°� of Eligible 5901100 No ]3eaefits lnpa5ent and L►eermodiabs Mast receive prior mu tmindaaa thm* the MOW Hea18r/ &&mum Abase Desisnea 8encfsra we rma%od- tom days peresleadar year Ostsopore kTrreatment : Same ae 11,12 dad 11' Erapemes Preseeiplion and Non- Preaa�rtian Enterml Fam TOR GrEugible E�cPares 3090 of Eliinbls &ate Smelts for law prawk food products for Coveted Persaae dvmgh w 24 am Emired to S2,500 1W Calend3TyesE i P.06/12 JUL -21 -2003 10 :32 Exciadans United HeaithCaxe Insumnee Company 5xcepT as tlyny bs spedfualiypmviddt is Secigm 1 of your Cestifiealn of Coverage (COC) of Orraagh ssoaerd Ot'seu6, tame, asd7or w)neh Sfc psrfamed iB a trx+maeut for acne. Repfeeemeas dad a Rips to Oil PcHey, am Mlaw ft am act covered. c Wn kww bWIW is ezelubi fft,e aaHer broast implantwit m Coamesc Proeedere, A. Alternstbt Treatmats (Itepbme- otan existing bract implant ip Considered moomRuctive if ft initial breast implant Ata yrn Met; bypeotint roifirc malmage therapy; aroma thoRrW, acuponorma; and add forms of i awadmPFitolbmy.) Abemattrs Trumnod. Phys)cd aandidani rspWrar 6 such as adaletie aaiaing, bodybaidm& cKwim fimess, flexibility, R. Comfort or CoUvoultace cad aver -in or general modvatime. Weigttt Joss pm3mm6 for medical and twornatflog roasoas. W11% t l'BOOa) acral`Otf or corrvepit�s rterrr pr &cruces s11C1d Ss tekv)smn; uiepkaei bfubcr orbeAMSy nlxMgu Of do seaw for tM bait lom .. oorviCC:gaCtLegrVm mpim4 minapmcat and aitMbwmaldratpt :samcrSMd"gel fprpaMAI conalho including air aooMonmL & purifiers and Leases. bandrict and battery abargem dehumidifiers LProwif n Seeulo�speefonruW by a provider with your alder kFrt r lifttb or wk is a farft member bybirfh cad harnidifiees devices or aompuurs to asdu In eommmncatioe and speech. or a carmA admiring spovK brother, Sias,. poem w Chu& This iaelAm tray service Car provider C. DeOW '- s aw peellwata ea biurswor k nit bW% t as speaificagy aeptclbod as covesoal •n 1 ef=aaar'COC Coder dre Mcedmgs Dpamd L. 1hproductles S-ico;- Aaeidwt Only xtd Cleft LipaVot Maw TiGC2sxow, a^+sal ecrvim arc excluded. That )a Nolds agaicas and awaiaded UPC" for huksaw want 'cox no dovemge for servieep Peace for Ow wwaswca, aposs and rm unce orft lent, or gems Wrogateparegd* The ro"wl ofvolumst r ttWaz aace. (including amwave. Mies lion. and rapbrcement of todh and servion to improve deatd odirded AR. Services Provided ender Another Plan aue:am,4 DoaW impb=and dears) bram am excluded. Dw al x -ra^ aglplias and appliaaeca and neew survival; for which ow wvwraae it paid under aamrgarnom romdrod by feda X ante orloul ail aaani*W expeaset Sdaleg our Of ands deem) services CmdadmFksPualrzniam and s+>eWresla) low, ateloding but ram Hodtud to edvotege paid by workea' oompematian, oa -milli automobile are axclAK encilr U adgbi vift iaa be mWir fl for MOSS peepmotioA initiation Of inmmaaw, orsdmipr tun .: aremnoOtlpptessives, dtc ciaaettreatoroat of aeaerrarmaatie inpltrry. career, or clef plate at as deserhKd m Section 1 mrycur= tardw the had-at Dual Procadwrx - Ana dhask And Reat& services for umema do f �rationy sarvixydawd dim, IWO. wban yOP ary logslly endded tb AosAsUratins. iromew for o6agtolmBy mdtsin& molpositioaed. or sapern uwW Ux* ss othwesvarol faudimep are rmsoaably Svailable to you. HaS1>b ser4iCes whim an callus rmlitary cxekied, -0 ifpmt off Cmrg dW Aooumly weeps in *wmMcdQG witb cleft Hp or deft palate, draw' D.1?ritgti Prescription dtugprodttcts for pakpatidut use Oros nee Flied dry a proscription urea orsefdl Sd)f- l't .''t:anvial rte Raddr see A= far argan ortiuva; lomsplaats aft mdude4 OMW thane spar d Is covered in Sbadian I pfyourCOC Arty ON organ taataphm flier iF 0ertbamed oc a,tn cruse to earner. b+jeowbk medptiws swept a desadbed in Scdios I ofyotr COC under ae beating orDiaberes Twotmeot. flan- WinoblCmrAicatim s Iii" in a Physician's office except as requitrcd in an Mrs salio s cor asaw with OR se MS of on organ or WMw ft em you forpuTew of a w ospimt Smwgmey. Over- 9autommr dregs and aemoensg, to anmhcr person. Hem servicel tar OW301AW or a ma oegamc. F.xper[Oleneal, investigationstl or Linproven Sert+res Tgrogaw t saxvldea iklt are act petfas aedat s DwI rated Facility. Ara• mdtiple own Una;p =not Sa ul tavestigatiaod orl)raptotw:ra Swv)ceS aK excluded. pseept (a }boat palrbwuonspitehtt beled as n Covered Haft Sdr N in Sestina 1 oftbe COG and (b) medically apptpWxft madlwdioa p1mmul e:d For ere uaom+me of signer, for a pardoew indiaatioe, iEB+at dug It w agniaad forgo teaotenew all at in"00 in a 34000 nefererex Q. Travel Heap aatvicas peoxidcd io it forage tonne. umleas rertoicaa as PmerRdaay Haaltb SeNreca. compesd;um err recptnmvidedia medical iitegrgnC, lire Set Baas en Ea perba>aftld, IavastigAtlDml or TnNd or baangw sedoo expsews. s sa Oeeugh p vwabod by a Ph "wL Some travel amocums fob" tloprwnea Savke.laostrout. dr%4w orpba ersoftical regimen it t,c only ■arrllSblo vuhr4M for a to oaverad Ormplsotation somias may be rokft reed at err dberod pssfiotallr CW&60 "11 Rd result in Bearefias ifgx amore is abnd&Md lobo fsu sebaenstt. P. vESion and Reflrfng hvCn*ujmW or vnFw es in Ihd w aaoeat of dra pwd cdw Condition. p_hM OW OrWc glades. moat leMps, orkami us oift Frniag d wgp ter karisg aids. eye $lassos F. Foot Cnre w COMA t lmms. lire rxrmiw t,exapy. SMVVg OWL is inrsndod to alaw you to we blew whhoud Rodin Via cue (mdofmg the cumin; or a aw* of corns and eaHaas); add tritmma& eoarns, err onoor or Warr YWN amaw iOn Waning meld ipa mwtonly. laser, and ad w refisetme cyc surgery. debtift. hySicolt and pivueadw ando mum foot care. Method of fier fen or aublwwdce of the Q. Odw Emans ors li aft grainer; and p"HO Drat do app teed m., defadiim or Cawaad tieilt, Survive -sue G. Ne f ell Supplies same APPHIMI es Me" in gwe" le ofymr COG Druids; sued spea rely k wtoy item; art* Snout perlbmumae peimmily is spbetsaeh boo wimm. plrysieddt psych)auic`or psya,otpg ra) eammado*h twain& voae)netibus, inmaoumttotn Or ucataeeots PmMII eel or aria p[esenbert reiCdiCd wppia and datrambk mgMilios crdadmg batnat fimirep m Wktw(ri aOvClaad rmdeOue PpSoGy. whao suab!setvkwa etc (I) eegnifCd Boldly forpprposeF of coca elSSlia aeoei ngs, aeclx sus o eraPPdkt grace arse ter stmt s. OrthOtie appfmoee3 that edam o% aptarls or camp, uavet. "WIW/MGL insursom toasiage of idopti °m (l) uhk toN - ligiden asm4npc a body pSat (mcluraHag some types ofl�ssdt). 75:,insaroud msslrs' era nos sauced or abrepmbatlwo proceedings or clots; (3) aondaetsd for purposes Of inedrot'cW= t; or (6) to sera¢ aptwhentmedwithDu[ ibkMeaHealEgdpmmtasdeeCrrbvdmSeeripelofyoerCpC. o)bygGcpaKOfuytype l>T. M=td HodthRinbstaleee Abuse i dle Duosaosun Hello atavices received ae a result otwar or coy arxof wear, vft&a de:nlato of cmdoda nd or awmad Sera Nedu pafomv;.d in connection with condtiaas cos daaafied in rk current coldon of dafiM Bervice in Sae lmued foam s of aqy county. g sM0 3tatis6enl Mamml tl+e Amedwo Psyahietsic Assacintipe Sw&as fF& extcadbeyand r6e l Health seeviecs as civcd afier ch.. an your coverage under &a Policy suns, iueludrag6m><, Ni auxiad a ounry fur shottfeam evoluotion. Agwsis, tremmoator milia: inadVCatioa 'hCplmCtlC Of iwmms49 conditions nixing paw no dxa date yow eavmage urea tar- PC)iry ends. iarora & end elm sleep duordw . de memla. ne MI*cal disorders and Odor disorders wft* a known 1 Healda 8eeviera for widara yafa have no legal rt;8>raa> WMyIn pay, or fur wM& s obe?ec wadd ant plocel basis. Tkeattaeat of Mpud awases which v M ant miler mtiaily impsowe *and the cerroa level of w0witr bemade in o¢ abseeeeafaovemgc under the PV%W- tS dm everd thus 6 poo ltertwmi; prOVidw waive t"opaymuOtts ard/ortin Annual Dadaeeublo for a fanedoft or for Conditions soot au,jeetto favorable modifiesoon or mamgemeat SCMftr, m psuwally $coups d standerdt of psycIAMiC cam. as demmiaod by she Mental Realt lO du t non Abuse IL pulirdw beellb earvies, no Dexgra ow provided for eras beet, sevim for obit, CnapaAM" "Wor Designee, ;sbludiag pmt pet isrited z ►.cedes. and Wnbml d)sorders; pwsaaaHty diBOtdcr. Amroa) ZWVC ido we waived , Charges io axes; of Etigrble &4cases or in own of any specified IWdw m and Sarv;ow=Tmog medaadone tre mceet a am)ste awou, l.t .A,f (t- Alpisr.An elyal.l+ledradolj. Sadiaa;far4n evsltxatibn and treouaerrtbf traupommondr'btdsriorol syadromC (7MA. wdreOwr ere Gyelamck�e Ormaar cgnivnl Fteatmant pmvMoa in comectioa with onto wm V with ievaunteuy semkw am wusiowd to lu medical or deatal in matter, succor U desmw in Sxlion 1 offt COC coma t Omer. police datowibas end other sienelbr udwn auae>Qnd by tlas Mereal tador I,e beodmg boons err Sores bf the Law wad Facial R*&% tioaR dula fsmaa Abase Dx,pft Residential r Macau service. SaYicas for Ox Reatmeat of Svr*W uenmieat and oon,arAal mooranrd of obesltY Glm,bA s merhad oboBily). moult lines€ or ramotal lembh eondd ors and pown one arbrese swam and '6arnio l dependency 1; bmefg Croarda haaro" �+PY: sac transformation operations; Umbsount otbeaiga � (ndaromas services Out duo Bummps avow her; m provide dm gb n to plan. baron reft = Cox in mate:* amdioat and snagisid *W mat of oraeoave sweatiog!(bypwludrox0 L Nutrition mud'udFl wed eregiaad walmem for eau: ins, ercepcwks Pmvidsd ap pw ertaauama for dMinsi ed Mefiavbw n and sulaidou btavd theapy; roaM ml ctsmaading for oldrwiadrvudude Or gtoaps. Oba modw SIM ritke, OM applia ors for sow ax F.ma -A feedmat and owed accificnadand elemlyte wppastraws, ioduding iof ct formula and dont+a Shdsto�d ewe; damidTary tee; privax bury araadog reppire eSm mot cues bteasttnitkeswsptStde rbsduaSechontofyourC�CandsrlkixaaHagPreFCriDSitieaodNpa pwiscoomom *-spa. on-vta s required fortt- n—tofsspeaehhtpcdemwdorspeach presp pt)oe 5atesol poemviar d,%Am%W lkt ra & fors tetarq, wake. ClefttWcldt plow or e Cm"Ind Anou dy. J. FhydW Apptdaranet Coenetic Pepdedaa m; including. W nK 6mitel t0. Pbaraaacologiml reg6uens, mraiduaa) P*mdoras OF trenemaom urdome m, rdwornsomm and o8a¢ 90 OM *mm IM proec"s assn mold -M der This anaroery OMMefrts is intended ply m *Ai* Ytmr Benefits cot bi mlied upon to fully deteanme eawpxge Thu plea may aoi coYCt eD Your in let 1f this description the ter,rrs mid conditiaas of eovermgc er, =OLL Please refit to Stan Cfertffieata of Coverage fat i CQq)jC* lieiidg c f mmcw, limbadona, exoWisons and a of ell 7turos 8tat nro eaapitaliud is Bu Bane�it uh>msoary arc 4efinedat the description e: ro dfiets in say way witY ilrc Cexcificata otCpvet age. tIte Geitificate of Coverage prevails. C.erlificate ofC?avage. PPC -8G0 P.07/12 JUL -21 -2003 10'33 J ited a ithc re h is .Plus` -1��n E � As part of our comet ,t ant to keeling you in control of your health care decisions, our Choke Plus plan gives. you the freedom to see an doctor in the Uifited althcare Choice network, including specialists, without a referral. You can eves, visit any out -of network physician and still enjoy your benefits with somewhat higher deductibles and copayments. With our Choice Plus plan, the vast majority of your health care needs are covered with little or no out -of- pocket costs when you ,visit a network doctor or facility. Plus, when you visit network doctors and hospitals, there aren't any claim forms or bills to worry about. Some of the Important Benefits of Our Choice Plus Plan for Covered Servic s: Visit auydoctmr in the Choice network in your rerratal care is included. area, inclndiag specialists, without desigualin$, a Routine check -ups are included. primary physician Visit any. network hospital in your area Childhood � are provided You can choose to seek services outside ow Mattym4grams are included. network, nomaily at.a highest cvpayment and/Or pap smears are included dcducu'bla. Vision and heating screenings ark covered. Emergencies an covered anywhere in the world. Care Coordinations'" services are available to Benefits are available for office visits and help identify and grcvent, delays ;in care for those hospital case, as well as inpatient and outpatient who might mead specialized help. =gray, when covered health services are provided. . ;,. i'.05/12 JUL -21 -2003 10:33 Choice Pius Benefits Summwy — flan ECP4 Ty of Coverage Network Benefits ! Non - Network Benefits / Gopayment Amount _ Copayment Amounts _ - :� M A Benefit Snmta9ry U unleaded orrly to bipl+ligise Auaaat VVdnatlbtet 5250 calendar year, apt to emmed Anneal 1?odaedblat DD per Covered Person pct Yom: Bmfrtc and deer old not be volied upon to fully $500 Sarah Gomed Per°sas it" ftm4r calendar year, -Aot to arced $1,000 for all Cwmed detumfoe coverage. This benefit plan may amt cover aU Pmmms in a is m-ly. of you he" care expenses, Mofe camptete _ desetfptloas of Rmekfts And the terms under WW& OW are pr vWW are tontmaed ia'd w Cere0m* of Oat- dlocket Maxiraamt S2AW per Covered Person, calendar not to exceed $4,000 for nit Covered anm 53.DD0 d C N[aycu. Coverage BLit yon wdl read" open ea.olltng In the per Year, Persons in a family. The Out -d -Poulin Maximum d� W the PN CV4 per calendar 1. not to ly. n ()W ice per ogle not erg Covered Persons k e fs Tire Via' riot inchrdb the Ann W Dedrxablo. lod Ammi- Poekex tuiaxiaurm don n� include du,Anmia[ If this Benefit Summary conflioa in any way miith the Deducpble Pndiey issued to year employer, the Policy shall pMVML Coc'emeats t" some Covered Eiun SWWm wfll never Copaymaats for samc Covered health Savim M�� Trams that are capitalized in the &merit Summary are et'ply to the Oab d- Pocket Maximum as specified in as win never apply S o 1 ou �COC. defined in the Certificate ofCoveragc. Section lofthe CoC Network healthcare services raider lids benefit plea ape Ko mmam 'Navy Eeoefrd: $2AO0,0DD pelt Combd Mafdmum Poky $=cut: S2,OWAM per Covered Person oambined hta�eimorn Polity comed 6' when prgvidod, arranged or nut Orftd by Perso¢ eomh nmt M RII Policy Smefi4 s Notw*& fhysicirm *Prior Notification is required for certain urvicu. 1. Ambtd=m Sarvlees- EmrS=q Onty Grousd Ttanepartsdom S10D per trsnppD t Gromal Tmnaport dm $10b per troxisport Air Trtmepoltatioa 100 pertnsnaport Atr TraasporadoaSlGO per trmr,,post 2. Dental Serwims - Acditm onty Ssmc ss 8,11,12 and 13 '30% afEf omen bglemm *Pricenotificadoa is toquired before NOW.Vp treatment bcgios. 3. tDpQtabte Medksal Fgetitpmeot 1096 afEiigible 1?xpeasaa "30%of8lrgeble E.spaa+ses . Combined Netvm& and Wm Network Rembs for *me'r- Awfication is mpdmd who du case is Durable Medical Egtupmmt an limited to 32AD mare 9ma 51.000. per calendar ymr. Links de rtoc apply to Durable ieFvAod Fq+upment classified ta'diobetic c*pnneat Off bwptiea 4. t%araMmaey ROM Bank" 5200 per vctit S10p per visit Vdartodflo;% m is regoircd ifrawft in as S. WeExamtoaG01" ' $15 par Malt 80%ofEtistbk ReFreetive or eramiagdom am limited to one every other Eye examinadom for refractive ergs are not celendaryeet from a Rouaiare Nrmon Netwgrlc provider. mwered. 6. Rome Hm{tS Care 1t+96 of}}iipbk Expaasaa "30'x. of Stijoble Expmses CombiACd;Natwo* and Non- Network Szoa is are tweed to 0 visits for sinned tare servioee par :ealendorycat: T. ;Hospice Can t0 %ofF.Usibk F,p7mos "30% ofEfWMG Expmo s: Combo mLNetwork sad Nrm.Nemork Benefits are Imuted to 180 drys dmiag rfie a m period of tirnt a Covered Pereoa fs covered m dsrthe Policy. & Rpspital- lapadient5pq ID°leofEtigrbleExpcnses •309b'ofF.figriticP' V. Imlecti mtReedved is a Physician's 0911m $15 per vidt O%pertgjection f0buteralty Servleas Same ea % l l,12 aad.13 'Same as 8.11.12 sad l3 No Cop"Mart applies to Ph)"Im office visits for *Nodirmien is tt gnired iflmpaoem Stay ex M& prenatal wtc niter the firstvisit d$ aroma k filming a aomud vas mal delivery or 96 iroue %ouwmg a oeaarm semc m delivety 11.Ovtpatient swZm y, Aingm de lad Taeeapeakie 'Srx'viCa . j0%of Eligible Expenses 30% ofEiigtble Smper►sa i2. ':4fliee Set+rets - --- •�•• 30'A oflCrble Expeaaes S15 pis vreat No Doefu ferpnwmneq on 13. Profeamdwpal Fees for S q: - nerd Medical 1095 of F,ligtbte Faapenses 3095 ofMpbleExperam Servtees: 14. Prostaehc lk►fces 1036ofEiigrbkExpenses 30%od•Eligrble Fspeassa' Cambmcd Network :and Noa- Nowo;k Bm is for pradm* devk rs me limited to Woo per ca mdor P.09/12 JU- -21 -2003 10 34 Types of Covemp Network Benefits / Non: Network Benefits / _ Caplym at Amounts Copayment;Amounts 1S Retonslrsedn Peomdures Sm= as 8, 11. I2.13 std 14 •Same' ask 11.12.13 alai 14 16. Rebablkation Services- oatpa" T"" ; IS , . �' 3Q31 atEiigeble P nscs : Combined Network and N6n•Network Bmfas ors limited m fol mm 20 visits afp)gston/ Amps, 20 Viol% of ft=raff -d derma ; 20 vitsies of *etc* d- W, 20 visits of prfmmrary mhabtlimdon fiend 36 vide of O*n 6m t't?ftatGtAwonlia'oa mkr yea . bum Natedne vmmtyflap:,Gm Re6abi khri s 10% of Efigr'bie Eapatses -30% of Eftible Vxcmly S Vices Cotabmcd Von* mtid Non- Wetwgrk Benefits are BMW to do dt*ys pa Wdmdar yea4 1& Transphmt &Gu Services $2;500 per Inpstimt Stay No Benefits You or yo- NetwoAc Physician moat no* us when The pemOOtMW of a Wmaptmn Odom 14. U put true Coster Setvkes $35 per visit 30 %of Etigtble E>spaum AddztiozW Benefits Bones Or Seise of the 39- and i add Rtfon Ssme as 81 111 12 and 13 •�t1%%ot Eiigiyk Expdrses Ciu1� Hearth Sepetwision Seeviees S 5 pa visit 30OA cf Eligible RTmnsa clan 1 mc—ft Pnhsto Treatmost Same as 8,11,12.13 and 16 *30% of Eli&k FacPettsas ' Deaftd Praoadnrce- hneatimle and HospiLplDedon Sameas 8.11 sort 13 *30%ofINgibk Bq msrs Diabetes Tf=tment Su e.as 3.11,12 and 13 30% Efigtbk Fxpa�sea bb-wgn.phy No Copryment NoCopaymdrt tVlaetectorery Sam a8, 11, 12 and 3 *3096efewbit S parses Ktfftd t;ealth land Msmam Abase Same s - S2S pa individual visit; S15 per stoup visit No BOArm L?m�ePademt Mast' Mae" prior antbosization thtottgt► ft mantal E4= Abase Designee. Benefas =!Iimita:d w30visitspereslmdcrycer. ' Mescal Heattb and 3obsmnce Abase Seevmm - l0% cfEliolc Expatsss No Bed bpadzwaced aErrmedwate Must Move pryer autba dm mm l vm8h the Nkatal Hoaltld Sstbst = Abuse De 1pg Btuia% ors limited tb 30 days per cai�iaiaryeas: 4sttopoeosisTtmtment s Same as 11. "12and 13 30%vrEiigiblt F.Ma scs Prtserlpdon And Non.Presm* s Enteral iwmnla 10%ef Bligible Expenses 30%.otEligrbia Eames ' BURRIS for lost protein ±and products that Covamd Pasoan etuoush age 24 an fanned to S2-SM per a�lantdar ytar, m,r rm 07, P. 10/12 3UL -21 -2003 10:34 Exclusions United HealthCare Insurance Company F- Rtaa;Myberpeoilleallypav WInSection 'IQfyowCecfifiestofCovt vfCOC)arwtough ReptpdCmcntofm n Rider alto Ponay, ft following am not a mica, efap* brmat implant is exebrded if do Sather bmwtimpbw WAS A Cosmetic hDOWU a A. AitWMtive Treatments Mcph osaW of an adsting brevet ltttplmd is ooaeldeted sexnetnwslveff" initinl breast impinnt Awpressme; VMMO teat muting Mweye draws.. aroma dmccpy. Apwa t m am amer fern n of followed smattgomp.) Ntetuaula treaunen6 Physiod Cenddiud48 Wpm such AS athletic tminim bodybo iffing, imxracise. freneam, fimub14, S. Comfon or Convenience and diva slap wpw ai motivation. Wd* furs. proRraws &rnw 'icai and nmr.wWoA mum %wild. . l'etstmal mmfots or Cxmeenteuta iterak or Satires such M sahtv}sion; meteAhone; bmber orkaimy regardless cfd* man for the biirloss. Saoiee: gneStaoEViae; suppLa, aquipmemandsimllsrinaidmtslservieeaio +d supplies fob permnol' F- PMVAdm .: Odmet ingwaing mir atefditiemrs Off. a fiefs and fdwm Wee w anti battery ahptRCes, dehtaaidlfion Sesvteas pafba -d by a Dtoviflawith your am legd moldatce or who ie a Wily mamix* by %e VIM! hanudifieest deviots or eompweea w an" in eomonmaiwipn ad speeck or mmriaga, indha t aPww broths, atmlsr; Paemt or eiuld Tlds Inow36 m,trs.et+,iw Of, Mnhdar 9~a ��ai:9i may pe>!foaa � hmrielf x hntxell, . - Faeapt a° sp SWAY ds3errbedas CWAWW in Seat on t cry== Under fin beadiega amW I r.. Reprodt etkin Serviaes..�widpx Otelp mid Cidt Lp/Ctettlakue Tteauneet.' QoW se[Vias as exeiupeti There i6 Heetdt savieq anti Daoaiahep exveuses for bUfeesiliq•>reotmdgt, ra 0ovamgr for cervices plpt5dod forthe ptaventioa dfapwsa and tretattwat ofthe arguing Sunogatt psrart6tg The roveeml of volmauy stedlisatias GadadmgexttAdiw. se d8oa and rgplrsmen t of mah aodsetvim to i omw dwA diiiial lmptailta doter Da n d M. Servitalrevided kinder Another Pfau oamomeO. DMW and braces are esoladcd. x -mys, sMdia ad appliances and Haslet savlM hewbleh &flea oovarage is paid order w angerneats Mqua a W Galan%, state or focal an apndwA ssi mpes w iieiogoue of erA deoml asWoes fmdcdioR hospttafiaaidons andansO min} irUelodmg button BiaiiCd to wveage pelf by vvotiters* omapmrmioa nalaaumatqupbile .ace atehded, exaepr M ndgbtatbervriae be tequireG far trmpphai prepamtioa, mitiatita oP mioafnoruppmssivee dUe diraCt araimad of.eaee tramaatie 1rym7, emeer a oue palate, are daBenbed in Secdon 1 of pw CAC tmder me lraadng Dmrat Proaehreg - Anas9inpt nerd ti savlpe letatad dixibiteiee who you are lepaily mtitted to Hosplml�tiba IS eAtmeta for anngenhAltytniss ng malposi4oeed or ArtOtsau ay f9eds is other oovaagl and AmMOea w rsawtably Avanabk m you. Hoddi oevion wbne on alive mitMY onsin d, vm ffpwt of o Caogetdmi Aoottaly axe* in aannedion with clad rip ar aloft patine. dow' D. DruEe X Transplants Paerotiptioo�gDlbrq {RpaheatttsethargncfiDed a by ptcunptioo 0[da orreGtl, Seer• RNIM sevim for*" ordswe itansplsatx are excluded, except 644 gmndfied ae wvMd in irtiealabjp meQieas'ions orapt � desaibad is Setaio 1 Of 9wa Ct]C ialdor the hearnog of Diabetes Section 1 nryo„r COC. Atry coil! aggro nmUepierd antis peerOemW as a treatmCrd fortamrer. Treatment „lataa- brjagibk=amdiealimu givcm is a;Phypieian's office eftpt as regpised to at Health xwAm awmadmil With tbs mmoval of so organ ordaft from you for pm vnw of a t ow0an; 6magasey. Over thaooame dnrgp emE t+aatmentx to anottie peoxa. Roo tszvi0esfottsnrs:pleett iowlvh+8 0a1 or enlind *rpm L. UpmmentaL . or tint n %rvkt2 � � prove Trmxpb* f Vwm da me cot nerimmedax a DwipurI d Fetidly. Any mu*L- own tmagd-not ExpalmgUtal, kiveSdRetiomd a YJnpfoven Setvtcea ere excludc0, a tinge nano m nanophmts accept () lined ass Covemd AeWw Service io Seaaoa 1 of8¢ C= and pnrdetelar (bY tttedieariyapptoprwe rnedteatiens praertibad for the t wommot of enowg Gaa is.. Travel oalieoiaa, if thetticaR is reeegdzad for dx tmpu7wnt of drm iDQiostion !o o atpKdud Heal& setviews piowided is a rorelan Wrumy.aateta mp may Rmldr saV;aea euarm aresootmaended is medics% ntetaattc Ike firer tint as 8spc}maataL hwestigAtiocall or : Tmvel orfem+Ipbetatioa e>, raWnfiroatA pmreribral lay a fbycie,a>L Same tl8vel expmsea,eeratcd t%prowo Servioe, deviaa apberw aut icai rag MM it bra ony mnnxbk treammart fora cot in SO FxpanomW. to crucM iianspinntation uxtricamay be micdursed A ow discretion. patdada apedidon WM MA if the petmadme is eonmi<kratl robe P. Vi io4 And 13eaving hwettlgatiprail orlJtrptova m theapmant oftbatpatfladac eaodlnlotU Patakrse wxeof aye &am&. screw louses, orhwm$ aids. Pitting chfegc for hemingaidm. eye 0-0 F. Foot Care or wmnd Ica ft Ttiymmremlx ftM. Surgery ft is htgendad td OWW Pon to see brxta Wldmtd RoWns foal con (ieimfwgtlai *Rare alovxl of Comm and alhises): trail tabrmb& tatting err gl SM or **a vision eon vacs hrdudmgM"ksaaommy, taw. and odarre!'reetiw eye aagaty, tktaift hy&tanic and pirimAw i amtenaaem rod mr. utemod of fim: t44 or wbt a anion ofthe Q. W EtCludogE Haft merdm and ognpiiem 69 do not aw an definicon am Cvvond aloft Sarviae - see G Medreal8npp�ics a� Applisaexs definitigt in Seetica fo ofyotat DevaaS oral :peeineAuy a safay its or m af&te pmrfortoutY pdtrimrily m spoesa :eland aetividaa p va dosdone, tostgrg vacdnmioai, fuzed= M or trsalmmts Pu ibad err aen yrden3tgl medie8l snpplias aa4 disposable PopPiias inekrdrng but �tlliodkd ebrSde as bmda8a+ 9 suppllC6 mrd draratga tSrdatte essences that otherwise wvcm waor he POlicy. who such wAtas MC (1) required mlely fff pvo— of—, Atraightm0eaa- ehapaaLpdypatfinekrdin ;tomstypepofba,oaas).LtietdeU andtoslsatetrotwvaetid adoration. &pane or camp. irpval employment, ieomince. mono or adoption; (Z) reletiag to jodidtd orado&ielra itvcpccoWiugaor& nknismdamedfurparyoeetofinedlaolra =mhCOr(d)to axapt whest asmd with Dwable lvk+Saal Fqulpmeotas tlett n6di 3n Seehoe l afyma CQC cl min'or mabbin a liceaw of coy MM Ii. Meatzsl Sc111t1ffSfRbstance Abpse Sarviams pclbipmd io oaeneCStoa whh rxnditioos net elmspified m the ereeent Witio edithe 1? � pshc i H altlr'aarvias se A%d as a to nh of wr or may act ofw♦x, Wkedu r declawd orundedwed or round �� savioe;6 The ama:d of arq eaamny, and statieiau Manavt of” Anwican Pivd anic Asweiatisa saviaa mat Cadnmd b yoadTha Period aeewsuyfar slrort ism evalaadon o Mprosit, ftemmd a erish Wervmdaa. m Heah'pve ecevdafte xdate }romaovpg undertta PoCyads uelR icath eve iesamihtand other steey d'rsardees,.defaeatia, ommb8� d+sordaep mac etlivr drsordefs v,r'ds aimo'rHi a>::t�ad eandit;ama aisiogpror m we data yore eoveragt: faida die Polioy cads. phyaial basis. Haft seeviaep ror V' icb Yom tinge wo kgd mponalbliryw pmy odor thigh a charge vvotfld qer Taeaaead afMa+W lllnesaa vvhieb nataiDeramidly improve beyond the outtot love] of otdne* be tnada In dre Abunae of eovemga updertke Policy. foctioneng or foraoadidom cot sukjaet w fawrsbk mafdiitCBtio err mofutgamot according to i, In tha ovw dint &eau -NaNVd provider WA vs. Copaymmrm anWw &e Amrumt Deduahisle form CODAt md�a gOnedly uroapted stmnOAn s ofpsyabiat& acre, as ilawr lmd by the mow �aa Abuse P�� laelw seNiee aD Smre56 are ptoVYded tbrtl+e health teNlea far whieF nUeats Desigae4 6dvdiog but am loo d o, eondumt and its 12; ea tfol tfipotdae: Pessmayty 6sadee; Antnral Deducabk m waived no ppiA MW. Cbagu is oexm ofF.ligtble ExpeMCa err se exceu of any epai5ed limiufioa S-;w ubTzh* rra&&m umptaim as mabaen nM LAAhf, (1.,m 1pba•AeetyLMal6adol), Sarvica fifrtlte Cvaloliatr one sMatmem of rgMamtmdibnlat joins aYor�aaK wkaakat dte Cyelaa0aufe ortbd! attdvukrd irwtmmt pieihdal ie cammCrwn with arm apnlpiy vuirh iavpl my savieec era Masideted to be mt0idl err from% ie natma exeeptao gibed In S d;w 1 of time COC cowuia pals. Police detadioru and other similae aeao¢memp, mkss m dwftW by Mmtmt i vaderthe tmo ft Dons cr Jams of the Jaw anti Fa ial Region. 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Plew refttrto year Certificate ofCovemp for a tromp}ete Uremg of mrAt w. liodti ions, c=b ditna and a daw riptian of aB the tole imd uandidaw of covetagr:- li'dais description Conflicts in any way v t the CatiSt fa afCav%%,e, the CerdfiGO OPCovetp preVWL Tears fist we capitalised in tfio Safest t Sumiary are defrned in the Cati6cate afCowasge. max. JUL -21 -2603 1 0135 P.1112 UnitedHealthcare Pharmacy-Management" '-0 a �. an '` United ealthcare's pharmacy Management program provide - clinical harmacy services that promote choice, accessibil.i and value. The Program offers a broad network of • pharrnacles �(more, than 55,000 nationwide) to provide convenie t medications. n access to While most pharmacies .Participate in our network you should check first. Call our harmacist or visit our onl' � service at vvvvw. me pp�cy 65We -IXSt.com. The online service a�fers home delivery of prescriptions, ability' to view personal be eft coverage, access health and well bem information, and even location of network retail neighborhood pharmacies by zip code. Copayment per Prescription Order or Refill For a singly Copaymettt, you may receive a PMOlpion Drug Product up t4 the stated supply Hmk unless it is adjusted based oA the ding mjmfacd M;S packaging size, or based on supply limits, Some products are subject to additional supply limits. ' Also note that some Prescription I?rng Pradnots re* that you notify as in advance to deroernrare whcdw the PtsscrWon DmS Product now the definition of a Covered Health Service' sr d is not Bxpor M=tal, Invcsdgatignal or Us MVM Generic prescription lamd -nam Braid-name Drug Product Fftsm iption Drug Prescription Drag Product an the Prof=d ' mdW not on the Drug List* Prefimed Drag List Rctaff Network Pharmacy Ito $Sp • �� For up to a 31 day supply maul $a-dce Network $25 $75 $125 Y'harm cy For to a90 & *Our Prefetsed DMS filet selUdes t}tose drugs ami6bk to you at the most affordable cost it is one of the best ways to mascimizC Pr lore din benefits. The dru list, developed 3'� g °P� by Phy�cians and phamsaeists on our rta�iionaI Phaemacy and Therapartics s tcc, includes a wide sel=on of game sod brand name pftsm toti medicatim M=mly pmeribcd by °physicians. The Pteferred Drug LM is updated Suott&= the year. The most gatrent version is avaifa6ie At q JUL -21 -2003 10 :35 P. 12/12 United f ealthCare IRsnrance Company Exclusions lrsxclus = from coverage listed in the Gerdflem apply also to . ;chin 1�.ii� In addition, the foil - - owing exclusions a Any = djs for the parppse of appetite: �spprloa , tpaticttt Presottption Dntg Products obtained from a non- Netwostri aratacy. nth waig �s product, Comjwtmded drags that do not contain at least one t r�a a %r Pcescri perm Py � a l't�saipdioa Order of Refgl. or dispensed (days supply ar Qttaatitiyii�t) wl±ach aeceeds the supply JbIdt Drugs available Oyer- ft that do'not mquim a Prescsrptio�n Order or Rn611 by federal or state law before helm, dispensed. Any drag that is 'therapeztticalty equivalent to an Drugs which are prescribed, dispensed or intended for use while overt b conater drng. ; A n h patfem in a Rospital, SUlied Nur tg Facility, or A speaistty medieadon Prescription Drug praduat (such as ]Fszperimenta4 iavesti ational or iJnpravcm Services end irmwitwom and allergy seinm) which, dac to it, ohazsctzrisiics as datormiued by as, most typicalfy be medications; medications used for a Twfi tntal indimdons andtor doss, jje regimens detetminod by as to -bc 64Kdowntel, sdtnimstacd or st>perviscx[ by a gnaiificd Provider or ticcnsed/cestified health profesdond in except ntedically gmxvriaft rnodiCations presonbed for the trcalxnerlt of cancer, for a particular indication, if that drug is as outpatient settinp . Durable Medical Equipment. Prescribed and non - prescribed reccphwd for the treatment of that indication in a standard otatiett taappiies, ocher than the diabcdc supplies and inhaler r��c cMRVnditttn or recommended in the medical iiteratuire, spacers $cal ` lY stated as covered Rtplscameat pseeax"op Dntg rrodaels rewlSng from a prescription fUraished by the local, state or lost stolen, bro)= or dcslroycdonsT IZcfill federaCgoverument. Any prescription Drug Prodnct to the General and injectable vitamins, except Cite following which extent payment or bew is are provided fim tho local, state or a Peon Order or Refin: prenatal vitamins, federal goventmutt (for example, MediCar t), except as, vitamins with 9nodde, and single wtity vitamins. , otherwise provided by law. PreaCripROM Drag Prpdacts for fWaidug Cessation. PT=VhCm Dmg Ymdnc'ts'for any condidon, injury, S timers Unit Bose patkagit g ofd Drug Pm&,=. or mental illness arising out of, or in the course 04 employment Medications Used for casmeft prrgoses, for which benefits are paid tntder any workers' compenmabion law or voter similar laws, Praoription Drag Fro teU when teacnbed 10 treat iafertili if t}'• New Prescription Drug Pmducts or new dosage form that arc downah cd to not be a Covered Health Service. Thie sammMy of i3satcfas is khadad Daly to hig6Ggla;ye,e 8w�e5ts for arvcrage YaraplsaarayaeicoverallyoDroutPshprtp�escrptioadengekgaeD�es Pl � °O n`t'6 ��# anti sfioald act be; =Red upon to dctmaine Cvv=0 Gstiag of viocq Tnnirstioaa, eroelusians and a � of m Dreg Rider and yaw Certificate of dm6ptioa the�� orall the terms and conditions orcovessgC. dtia desaW m cm UM im Capisafizesl4aaie &Benefit Su 1 -Rider o ym¢ P �yE Rider rnd CcrtiScate of Coverage ptevarl mrmasy Ors defmad m the c+n Dms hider- arorcerme m cf Coverage. 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O .1,0 ""' V1 i-+ M C- \.p � : 69 69 69 d' m 00 M 64 b9 69 d' r- •--� E9 fig 69 r 3 Cd o - a i p + + p4 O O PH o W W a U ., .. .. 1 RESOLUTION NO. 2 3 A RESOLUTION OF THE MAYOR AND CITY 4 COMMISSION OF THE CITY OF SOUTH MIAMI, 5 FLORIDA, RELATING TO LEGAL SERVICES; DIRECTING 6 ADMINISTRATION TO INITIATE A REQUEST FOR 7 PROPOSALS FOR LEGAL SERVICES FOR THE CITY OF 8 SOUTH MIAMI; PROVIDING AN EFFECTIVE DATE. 9 10 WHEREAS, not withstanding the excellent representation the City receives from 11 its current legal counsel, it is the desire of the Mayor and City Commission to consider 12 comparing the legal services and costs provided by the City's current provider to those 13 being offered by other eligible firms and or attorneys. 14 15 NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY 16 COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA; 17 18 Section 1. That the administration is hereby authorized and instructed to 19 initiate a request for proposals for legal services in substantially the same form attached. 20 21 Section 2. That the administration is further instructed to advertise for sealed 22 bids for legal services and to submit the bids received to the City Commission for 23 acceptance or rejection. 24 25 Section 3. This resolution shall take effect immediately upon approval. 26 27 PASSED AND ADOPTED this day of , 2003. 28 29 ATTEST: APPROVED: 30 31 32 CITY CLERK MAYOR 33 34 Commission Vote: 35 READ AND APPROVED AS TO FORM: Mayor Feliu: 36 Vice Mayor Russell; 37 Commissioner Wiscombe: 38 CITY ATTORNEY Commissioner Bethel: 39 Commissioner McCrea: 40 Additions shown by underlining and deletions shown by everstfi g. REQUEST FOR PROPOSALS - CITY ATTORNEY The City of South Miami, an established Florida municipality of approximately 10,700 residents located in Miami Dade County, seeks proposals from qualified attorneys and law firms to act as City Attorney.` Proposals should be submitted in accordance with the requirements and guidelines set forth below. The deadline for proposals is [30 days after day on which ad runs]. PROPOSAL REQUIREMENTS 1. Five (5) copies of the proposal, to be received by [30 days after day on which ad runs] at the following address: City of South Miami, c/o City Clerk's Office, 6130 Sunset Drive, South Miami, Florida 33143, (305) 663 - 63`40. 2. The full name of the attorney or firm (Florida Bar membership required), with addresses and telephone and telecopier numbers. 3. A resume of the attorney /firm; and in the case of law firms, resumes of the individual attorney(s) who will work on City matters and a statement identifying the individual attorney who will attend meetings and have primary responsibility for City matters and whether that.attorney(s) represents other municipalities. 4. A list of any other attorneys or law firms with whom the attorney /firm has a contractual relationship or other business affiliation; and; in the case of law firms, a list of all attorneys in the firm. 5. To be eligible to respond to this RFP,; the proposing attorney or firm must demonstrate s /he can perform the scope of services described in the guidelines. In this regard, the respondent shall send a cover letter outlining the scope of services available from the attorney /firm (see Guidelines below); the relevant experience and expertise of 1 the attorney /firm; and the form and amount of the compensation requested, including fee structure, method of billing, costs and the charge for costs which will be separately billed, all charges which are not included in the basic fee, including paralegal, faxes, photocopies or other charges, billing period and whether billing will be itemized.' Please include a description of the attorney /firm's professional liability insurance coverage. 6. A disclosure of the following: (a) any relationships between the attorney or attorneys of the firm and any Commission member, his /her spouse, or family: (b) any relationship between attorney or attorneys of the firm and any business or entity owned by a Commission member of their family or in which a Commission member or their family has or had an interest (c) any other information concerning any relationships between the attorney or attorneys of the firm and any Commission member which the Applicant deems might be relevant to the Commission's consideration; (d) such other pp g governmental or quasi - governmental entities which are represented by the attorney or the V th fr and the nature of the re resentation in such matters* and (e) a a tt orneys o e m, p , "conflict list" if same is maintained by the attorney or the firm. GUIDELINES I. Under the City Charter, the Commission may appoint a City 'Attorney, who shall be an officer of the City who shall serve at the pleasure of the Commission. The City Attorney and such Assistant City Attorneys as may be necessary who shall act as the legal advisor for the municipality and all of its officers in matters relating to their official powers and duties. The City Attorney shall be a lawyer of at least five years practice in the courts ` of the State of Florida immediately preceding the tine of his or her appointment. He or she shall prepare or review all ordinances, resolutions, contracts, bonds and other written instruments in which the municipality is concerned and shall endorse on each his or her approval of the form, language and execution thereof. When required by the Commission, he or she shall prosecute and defend, for and in behalf the City, all complaints, suits, and controversies in which the City is a party, before any court or other legally constituted tribunal; he or she shall render such opinions on legal, matters affecting the City as the Commission may direct; must agree to attend all required meetings and enter into such agreements as required by Commission as a condition of employment; and he or she shall perform such other professional duties as may be required by ordinance of resolution of the Commission. i 2. The City Attorney is expected to provide the following minimum legal services: (a) Attendance at all meetings of the City Commission, including special and emergency meetings, and all required committee or agency meetings; (b) Preparation of resolutions and ordinances; (c) Preparation of legal opinions; (d) Preparation of contracts, employment agreements and other documentation (e) Expert advice on local government law and procedures (including, without limitation, Chapter 166 Fla. Stat. Public Records Act, appropriations and procurement laws, competitive bidding law, Ethics Code for Public Officials, conflicts of interest and parliamentary procedure) (f) Advice on general questions of zoning, land use, labor, utilities; municipal finance litigation and other matters, and (g) Liaison with outside counsel, with required. Applicants` who offer a scope of services greater than the minimum requirements should so indicate, in response to paragraph 6 above. 3. The City Attorney, whether an individual or a law firm, will be subject to strict conflict of interest standards to be developed by the Commission, in addition to existing law or ethnical guidelines. Among other things, the City Attorney will not be permitted to represent any client before the Commission or any Committee, department or agency of the City, and will agree not to undertake any other private representation which might create a conflict of interest with the City. The City Attorney may not represent any Commission member, individually, or, any member of their family or any business in which the Commission member of their family has an interest. 4. All proposals received will be considered public' records. 5. The City will consider all proposals using such criteria as the Commission may adopt in its sole discretion. 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