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Home My WebLink AboutCORRESPONDENCE - RFP - P985 BENEFITSCONFIRMATION OF COVERAGE: 2011 Renewal CARRIER/POLICY #: Client / Legal name: ERISA Plan name: Eligible employees: Client / Insured Address Great West / CIGNA City of Fort Collins City of Fort Collins 1,400 215 North Mason Street, 2"" Floor Fort Collins, CO 80522 This document will confirm renewal acceptance of the following coverage(s): Medical - Administration (Core and Advantage plans) �! Medical - Specific Stop Loss coverage with $215,000 deductible (Lifetime maximum increased to Unlimited, stop loss now covers ALL retirees and also covers transplants) Plan will be effective on: 1/1/2011 For a period of: 12 months Rates / fees (including any subsequent period caps or guarantees) for the above -referenced coverage(s) are: Medical and Rx administration fee: Per employee $32.71 (City NOT receiving Rx rebates) Cover Colorado Charged as a separate statement when fees are due Vision administration fee (Advantage Plan Only): Due to the move to the CIGNA platform, vision is no longer offered on the Advantage Plan Specific StoD Loss rate 1$215.000 deductible): Per employee $71.47 Covers Medical Only Covers transplants Covers ALL retirees Lifetime maximum increased to unlimited Includes coverage for dependents to age 26 MERCER MARSH MERCER kPOU AIAt GN c_K.T[R OUVER_ A description of benefits. - Core Plan In Network Deductible - $700 Individual[$1,400 Family Coinsurance - 80% Office Visit - $35 PCP/$45 Specialist Urgent Care - $50 Copay Preventive Care — 100% Out of Pocket - $5,000/$10,000 Inpatient Hospital - 80% after Ded Outpatient Surgery - 80% after Ded Emergency Room - $200 copay Rx — Remove Rx deductible Retail Generic: $10 copay or 10% (greater of), Preferred Brand: S20 copay or 20% (greater of), Non -preferred Brand: $40 copay or 40% (greater of) Mail Generic: $25 copay, Preferred Brand: $50 copay, Non -preferred Brand: $100 copay 90 day retail drug Generic: $30 copay or 10% (greater of), Preferred Brand: $60 copay or 20% (greater of), Non -preferred Brand: $120 copay or 40% (greater of) Out -of -Network Deductible - $1,400 Individual/$2,800 Family Coinsurance - 60% Office Visit - 60% after deductible Urgent Care - $50 copay Out of Pocket - $10;000/$20,000 Inpatient Hospital - 60% after Ded Outpatient Surgery - 60% after Ded Emergency Room - $200 copay Rx — 50% of cost 1) Remove $3,000/$5,000 OOP max on Rx 2) Remove $50 deductible on Rx 3) Includes coverage for dependents to age 26 4) Includes coverage for domestic partners: same sex only 5) Outpatient MH/CD covered at specialist copay: office visit subject to specialist copay, outpatient facility subject to coinsurance after plan deductible 6) Remove $2,500 calendar year maximum on DME 7) Remove $2,500 calendar year maximum on physical therapy 8) Remove lifetime maximum of S2,500,000 Advantage Plan In Network Deductible - $350 Individual/S700 Family Coinsurance - 90% Office Visit - $25 PCP/S35 Specialist Urgent Care - $50 Copay Preventive Care —100% Out of Pocket - $2,500/$5,000 Inpatient Hospital - 90% after Ded Outpatient Surgery - 90% after Ded Emergency Room - $200 copay Rx — No separate Rx deductible Retail Generic: $10 copay or 10% (greater of), Preferred Brand: $20 copay or 20% (greater of), Non -preferred Brand: $40 copay or 40% (greater of) Mail Generic: $25 copay, Preferred Brand: S50 copay, Non -preferred Brand: $100 copay Out -of -Network Deductible - $700 Individual/$1,400 Family Coinsurance - 70% Office Visit - 70% after deductible Urgent Care - $50 copay Out of Pocket - $5,000410,000 Inpatient Hospital - 70% after Ded Outpatient Surgery - 70% after Ded Emergency Room - S200 copay Rx - 50% of cost MERCER MARSH MERCER KROEE G YCARPENTER OI RWYWN 90 day retail drug Generic: $30 copay or 10% (greater of), Preferred Brand: $60 copay or 20% (greater of), Non -preferred Brand: $120 copay or 40% (greater of) 1) Remove S3,000/$5,000 OOP max on Rx 2) Includes coverage for dependents to age 26 3) Includes coverage for domestic partners: same sex only 4) Outpatient MH/CD covered at specialist copay: office visit subject to specialist copay, outpatient facility subject to coinsurance after plan deductible 5) Remove $2,500 calendar year maximum on DME 6) Remove $2,500 calendar year maximum on physical therapy 7) Remove lifetime maximum of S2,500,000 8) Remove vision benefit Stop Loss Deductible - $215, 000 Contract Basis - "Paid" Specific Coverages — Medical Only Lifetime Maximum — Unlimited 1) Includes coverage for dependents to age 26 2) Includes coverage for domestic partners: same sex only 3) Covering ALL retirees 4) Covering.transplants 'Any fonts in red correspond to plan changes made for the 2011 plan year Conditions of coverage(s): As an authorized representative, I accept this confirmation of coverage. By signing below, I acknowledge agreement with the rates and benefits described above and that subsequent contract(s) shall conform to this document unless otherwise agreed to in writing. MERCER I-� M�RSN M[RUR KROLL E ML4 GVY CARVfNTfR OLIVE. WY Authorized Representative: Leaal Name of Administrator Signature: Date: This form must o ""Y) cy Insurer/ 12--27- be signed and returned to Mercer NAB prior to the effective -date of coverage. MERCER 7-, MARSH MLRCEP KP011 0111-fl- CONFIRMATION OF COVERAGE: 2011 Renewal CARRIER/POLICY #: Client / Legal name: ERISA Plan name: Eligible employees: Client / Insured Address: Great West /CIGNA City of Fort Collins City of Fort Collins 1,400 215 North Mason Street, 2"d Floor Fort Collins, CO 80522 This document will confirm renewal acceptance of the following coverage(s): Medical - Administration (Core and Advantage plans) N1 Medical - Speck Stop Loss coverage with $215,000 deductible (Lifetime maximum increased to Unlimited, stop loss now covers ALL'retirees and also covers transplants) Plan will be effective on: 1/1/2011 For a period of: 12 months Rates / fees (including any subsequent period caps or guarantees) for the above -referenced coverage(s) are: Medical and Rx administration fee: Per employee $32.71 (City NOT receiving Rx rebates) Cover Colorado Charged as a separate statement when fees are due Vision administration fee (Advantage Plan Only): Due to the move to the CIGNA platform, vision is no longer offered on the Advantage Plan Specific Stop Loss rate ($215 000 deductiblel: Per employee $71.47 Covers Medical Only Covers transplants Covers ALL retirees Lifetime maximum increased to unlimited Includes coverage for dependents to age 26 '22GNA p g g,�= emu► s MERCER LAMAMI MARSH M[RCLR KROU O CMKCNTCR OtWU[ MUM CONFIRMATION OF COVERAGE: 2011 Renewal CARRIER/POLICY #: Client / Legal name: ERISA Plan name: Eligible employees: Client / Insured Address Great West / CIGNA City of Fort Collins City of Fort Collins 1,400 215 North Mason Street, 2"d Floor Fort Collins, CO 80522 This document will confirm renewal acceptance of the following coverage(s): N1 Medical - Administration (Core and Advantage plans) �! Medical - Speck Stop Loss coverage with $215,000 deductible (Lifetime maximum increased to Unlimited, stop loss now covers ALL retirees and also covers transplants) Plan will be effective on: 1/1/2011 For a period of: 12 months Rates / fees (including any subsequent period caps or guarantees) for the above -referenced coverage(s) are: Medical and Rx administration fee: Per employee $32.71 (City NOT receiving Rx rebates) Cover Colorado Charged as a separate statement when fees are due Vision administration fee (Advantage Plan Only): Due to the move to the CIGNA platform, vision is -no longer offered on the Advantage Plan Specific Stop Loss rate ($215.000_deductible): Per employee $71.47 Covers Medical Only Covers transplants Covers ALL retirees Lifetime maximum increased to unlimited Includes coverage for dependents to age 26 poi 1 �v 7 llo��f.� C ND OT61 w,S (A t_v eP) a �Fp MERCER C~'E MARSH MIRCER KROU GVYCMVCMTER (RMR�yy,.,/,H