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R2003-0104 07-28-03 RESOLUTION NO. R2003-104 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PEARLAND, TEXAS, APPROVING HEALTH INSURANCE RENEWAL RATES FOR CIGNA HEALTHCARE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CiTY OF pEARLAND, TEXAS: Section 1. That the City received three renewal rates, attached hereto as Exhibits "A", "B" and "C", for health insurance benefits from Cigna HealthCare and such rates have been evaluated. Section 2. That the City Council hereby adopts the renewal rate for health insurance benefits in the amount described ir~ exhibit"C", attached hereto and incorporated for all purposes. PASSED, APPROVED and ADOPTED this the 281:h day of July , A.D., 2003. ATTEST: C~)t~ SE0~ETARY t~ APPROVED AS TO FORM: DARRIN M. COKER CITY ATTORNEY TOM REID MAYOR CIGNA HeMthCare EXHIBIT "A" Proposed Medical Rates 10H Grou Description: HOUSTON OA Inforce Current Renewal Monthly Change% Tier SubscribersMembers Rate Rate Premium Employee 188 188 $290.41 $338.04 $63,551.00 Emp + Spouse 21 42 $609.84 $709.85 $14,906.93 Emp + 58 166 $522.72 $608.45 $35,289.87 Child(ren) Emp + Family 33 131 $813.12 $946.47 $31,233.57 Total 300 527 $144,981.37 16.4% Grou Description: DALLAS OA- NO ENROLLMENT ;~ll:e IlL/ i IAOUI '-''~¥ ...... r ........... Inforce Current Renewal Monthly Change% Tier SubscribersMembers Rate Rate Premium Employee 0 0 $264.46 $307.83 $0.00 Emp + Spouse 0 0 $555.38 $646.46 $0.00 Emp + 0 0 $476.04 $554.11 $0.00 Child(mn) Emp + Family 0 0 $740.50 $861.94 $0.00 Total 0 0 $0.00 16.4% 1-1179OH11-SIF-1 Revisionl City of Pearland 5 of 12 06/25/03 CIGNA HealthCare Proposed Benefits 'Product: CIGNA HealthCare POS Open Access Sims State: TX Effective Date: Benefits Summary 10/01/2003 Category Description Medical Benefits Coinsurance PCP Office Visit Copay Specialist Office Visit Copay Hospital IP- Per Admit Copay Hospital IP Deductible -.Per Admit Hospital IP Copay Per Day Hospital IP Deductible - Per Day Hospital IP - Number of Copays Per Admission Hospital IP -Number of Deductibles Per Admission Hospital 1P Coinsurance Plan Deduct~le - Individual Plan Deductible - Family Out of Pocket Maximum - Individual Out of Pocket Maximum - Family Lifetime Maximum Annual Maximum Outpatient Facility Copay Outpatient Facility Deductible Outpatieat Coinsurance Emergency Room Copay Urgent Care Copay Skilled Nursing Facility Copay Skilled Nursing Facility Maximum Days Home Health Care Copay Home Health Care Maximum Visits DME Durable Medical Equipment Maximum EPA External Prosthetic Appliances Deductible External Prosthetic Appliances Maximum Chiro Short Term Rehab Copay Chiro Copay Short Term Rehab and Chiro Combined Maximum Visits Short Term Rehab Maximum Visits Self-Referred Chiro Maximum Visits MRI, CT PET Scans Copay PCL In Network $15 $25 NA NA NA 80% $0 $0 $2,500 $5,000 Unlimited NA 80% $75 $35 $0 60 $0 60 Included $3,500 Included $200 $1,000 Included $25 $25 60 NA NA $0' Excluded Out of Networ 70% NA NA NA $400 $800 $3,000 $6,000 - $1,000,000 NA $0 60 40 NA NA 60 NA Excluded 1-1179OH11-SIF-1 Revisionl City of Pearland 2 o fl2 06/25/03 CIGNA HealthCare Proposed Benefits Product: CIGNA HealthCare POS Open Access Situs State: TX Effective Date: Benefits Summary (Cont.) 10/01/2003 Category Description Medical Benefits (Cont.) Infertility Medicare COB: Retirees >=65 Admin Option Robust Reporting Package 24 Hour Health Info Line Well Aware Program (Diabetes, Asthma, Low Back) Well Aware Program (Cardiac) Well Aware Program (COPD) Well Being Newsletter Healthy Babies Healthy Rewards Life Source Organ Transplant Network Guest Privileges Language Line Dmgstore. Com Transition of Care In Network Option 1 NA Excluded Included Included Included Excluded Included Included Included Included Included Included Included Included Out of Netw0r 1-1179OH11-SIF-1 Revisionl City of Pearland 3 o fl2 06/25/03 CIGNA HeMthCare Proposed Benefits · ProdUct: CIGNA HealthCare POS Open Access Sims State: TX Effective Date: Benefits Summary (Cont.) 10/01/2003 Category· Description Pharmacy Benefits $I0/$20/$40 Copay - Generic Copay - Brand Non-Preferred Copay Mail Order Copay - Generic Mail Order Copay - Br.and Mail Order Copay - Non-preferred Retail - Individual Deductible Retail - Family Deductible OOP - Individual Maximum OOP - Family Maximum Oral Contraceptives Contraceptive Devices Lifestyle Drugs Insulin Needles & Syringes Glucose Test Strips/Lancets Prenatal Vitamins Oral Fertility Drugs Insulin Generic Push Formulary Prescriber Panel Description MIt/SA Benefits Option 2 - Low (POS) Inpatient Per Day Copay Inpatient Max Number of Days MH/SA Combined MH Outpatient Copay 1 to 20 Visits MH Outpatient Max Number of Visits Outpatient SA visits 1-2 Copay Outpatient SA visits 3-20 Copay SA Outpatient Max Number of Visits Group Therapy Outpatient Copay Group Therapy MH/SA Combined Maximum Visits MH/SA OON Buy-up Option Vision Benefits None In NeBvork $10 $20 $40 $20 $40 $80 $0 $0 NA NA Covered Covered Not Covered Covered Covered Covered Not Covered Covered Included Incentive Open In Network $100 8 $40 20 $15 $40 20 $20 40 Out of Network Excluded 1-1179OH11-SIF-1 Revisionl City of Pearland 4 of 12 06/25/03 CIGNA HealthCare EXHIBIT "B" prOPosed Medical Rates ;30H Grou Description: HOUSTON 0A 3lie LIJ ; IAOO~/I,I. v. v--l- ...... r Inforce Current Renewal Monthly Change% Tier SubscribersMembers Rate Rate Premium Employee 188 188 $290.41 $328.16 $61,694.70 Emp + Spouse 21 42 . $609.84 $689.12 $14,471.50 Emp + 58 166 $522.72 $590.67 $34,259.07 Child(mn) Emp + Family 33 131 $813.12 $918.83 $30,321.24 Total 300 527 $140,746.52 13.0% Group Description: DAI,I,AS OA - NO ENROLLMENT Inforce Current Renewal Monthly Change% Tier Subscribers'Members Rate Rate Premium Employee 0 0 $264.46 $298.84 $0.00 Emp + Spouse 0 O. $555.38 $627.58 $0.00 Emp + 0 0 $476.04 $537.93 $0.00 Child(mn) Emp + Family 0 0 $740.50 $836.77 $0.00 Total 0 0 $0.00 13.0% 1-1179OH21-SIF-1 Revisionl City of Pearland 5 of 11 07/10/03 CIGNA HealthCare Proposed Benefits Product: CIGNA HealthC~e POS Open Access Sims State: TX Effective Date: Benefits Summary 10/01/2003 Category Description Medical Benefits In Network Coinsurance PCP Office Visit Copay $20 Specialist Office Visit Copay $40 Hospital IP - Per Admit Copay NA Hospital IP Deductible - .Per Admit Hospital IP Copay Per Day NA Hospital IP Deductible - Per Day Hospital IP - Number of Copays Per Admission NA Hospital IP - Number of Deductibles Per Admission Hospital IP Coinsurance 80% Plan Deductible - Individual $0 Plan Deductible - Family $0 Out of Pocket Maximum - Individual $2,500 Out of Pocket Maximum - Family $5,000 Lifetime Maximum · Unlimited Annual Maximum Outpatient Facility Copay NA Outpatient Facility Deductible outpatient Coinsurance 80% Emergency Room Copay $100 Urgent Care Copay $50 Skilled Nursing Facility Copay $0 Skilled Nursing Facility Maximum Days 60 Home Health Care Copay $0 Home Health Care Maximum Visits 60 DME Included Durable Medical Equipment Maximum $3,500 EPA Included External Prosthetic Appliances Deductible $200 External Prosthetic Appliances Maximum $1,000 Chiro Included Short Term Rehab Copay $40 Chiro Copay $40 Short Term Rehab and Chiro Combined Maximum 60 Visits Short Term Rehab Maximum Visits NA Self-Referred Chiro Maximum Visits NA MRI, CT PET Scans Copay $50 Excluded PCL Out of Network 70% NA NA NA $400 $800 $3,000 $6,000 $1,000,000 NA $0 60 40 NA NA 60 NA Excluded 1-1179OH21-SIF-1 Revisionl City of Pearland 2 ofll 07/10/03 CIGNA HealthCare Proposed.Benefits , Product: CIGNA HealthCare POS Open. AcceSs Situs State: TX Effective Date: Benefits Summar~ (Cont.} 10/01/2003 Category Description Medical Benefits (Cont.) Infertility Medicare COB: Retirees >=65 Admin Option Robust Reporting Package 24 Hour Health Info Line Well Aware Program (Diabetes, Asthma, Low Back) Well Aware Program (Cardiac) Well Aware Program (COPD) Well Being Newsletter Healthy Babies Healthy Rewards Life Source Organ Transplant Network Guest Privileges Language Line Drugstore. Com Transition of Care In Network Option 1 NA Excluded Included Included Included Excluded Included Included' Included Included Included Included Included Included Out of Network 1-1179OH21-SIF-1 Revisionl City of Pearland 3 ofll 07/10/03 CIGNA HealthCare .Proposed Benefits Product: CIGNA HealthCare 'POS OPen Access Situs State: TX Effective Date: Benefits Summary_ (Cont.) 10/01/2003 Category Description Pharmacy Benefits $10/$20/$40 Copay - Generic Copay - Brand Non-Preferred Copay Mail Order Copay - Generic Mail Order Copay - Brand Mail Order Copay - Non-preferred Retail - Individual Deductible Retail - Family Deductible OOP - Individual Maximum OOP - Family Maximum Oral Contraceptives Contraceptive Devices Lifestyle Drugs Insulin Needles & Syringes Glucose Test Strips/Lancets Prenatal Vitamins Oral Fertility Drugs Insulin Generic Push Formulary Prescriber Panel Description MH/SA Benefits Option 2 - Low (POS) Inpatient Per Day Copay Inpatient Max Number of Days MH/SA Combined MH Outpatient Copay 1 to 20 Visits MH Outpatient Max Number of Visits Outpatient SA visits 1-2 Copay Outpatient SA visits 3-20 Copay SA Outpatient Max Number of Visits Group Therapy Outpatient Copay Group Therapy MH/SA Combined Maximum Visits MH/SA OON Buy-up Option Vision Benefits None In Network $I0 $20 $40 $20 $40 $80 $0 $0 NA NA Covered Covered Not Covered Covered Covered Covered Not Covered Covered Included Incentive Open In Network $100 8 $40 20 $15 $40 20 $20 40 Out of Network Excluded 1-1179OH21-SIF-1 Revisionl City of Pearland 4 ofll 07/10/03 CIGNA HealthCare EXHIBIT "C" Proposed Medical Rates Site ID: TX830I-I Group Description HOUSTON OA Inforce Current Renewal Monthly Change% Tier SubscribersMembers Rate Rate Premium Employee 188 188 $290.41 $324.39 $60,984.94 Emp + Spouse 21 42 $609.84 $681.19 $14,305.02 Emp + 58 166 $522.72 $583.88 $33,864.94 Child(ren) Emp + Family 33 131 $813.12 $908.26 $29,972.42 Total 300 527 $139,127.31 11.7% TX801 Group Description: DALLAS OA - NO ENROLLMENT Inforce Current Renewal Monthly Change% Tier SubscribersMembers Rate Rate Premium EmploYee 0 0 $264.46 $295.40 $0.00 Emp + Spouse 0 0 $555.38 $620.36 $0.00 Emp + 0 0 $476.04 $531.74 $0.00 Child(ren) Emp + Family 0 0 $740.50 $827.14 $0.00 Total 0 0 $0.00 11.7% 1-1179OH21-SIF-1 Revisionl City of Pearland 5 of 11 07/10/03 CIGNA HealthCare Proposed Benefits Product: CIGNA HealthCare POS Open Access Situs State: TX Effective Date: Benefits Summary 10/01/2003 Category Description Medical Benefits Coinsurance PCP Office Visit copay specialist Office Visit Copay Hospital IP - Per Admit Copay Hospital IP Deductible -.Per Admit Hospital IP Copay Per Day Hospital IP Deductible - Per Day Hospital IP - Number of Copays Per Admission Hospital IP - Number of Deductibles Per Admission Hospital IP Coinsurance Plan Deductible - Individual Plan Deductible - Family Out of Pocket Maximum ~ Individual Out of Pocket Maximum - Family Lifetime Maximum Annual Maximum Outpatient Facility Copay Outpatient Facility Deductible Outpatient Coinsurance Emergency Room Copay Urgent Care Copay Skilled Nursing Facility Copay Skilled Nursing Facility Maximum Days Home Health Care Copay Home Health Care Maximum Visits DME Durable Medical Equipment Maximum EPA External Prosthetic Appliances Deductible External Prosthetic Appliances Maximum Chiro · Short Term Rehab Copay Chiro Copay Short Term Rehab and Chiro Combined Maximum Visits Short Term Rehab Maximum Visits Self-Referred Chiro Maximum Visits MRI, CT PET Scans Copay PCL In Network $20 $40 NA NA NA 80% $0 $0 $3,000 $6,000 Unlimited NA 80% $100 $50 $0 60 $0 60 Included $3,500 Included $200 $1,000 Included $4O $4O 60 Out of Network 7O% NA¸ NA NA $400 $800 $4,000 $8,000 $1,000,000 NA $0 60 40 NA NA NA 60 NA NA $50 Excluded Excluded 1.1179oH21-SIF-1 Revisionl City of Pearland 2 ofll 07/10/03 CIGNA HealthCare Proposed Benefits product: CIGNA HealthCare POS OPen Access Sims State: TX Effective Date: '10/01/2003 Benefits Summary (Cont.) Category' Medical Benefits (Cont.) Description Infertility Medicare COB: Retirees >=65 Admin Option Robust Reporting Package 24 Hour Health Info Line Well Aware Program (Diabetes, Asthma, Low Back) Well Aware Program (C. ardiac) Well Aware Program (COPD) Well Being Newsletter Healthy Babies Healthy Rewards Life Source Organ Transplant Network Guest Privileges Language Line Drugstore. Corn Transition of Care In Net~vork Option 1 NA Excluded Included Included Included Excluded Included Included Included Included Included Included Included Included Out of Netsvork 1-1179OH21-SIF-1 Revisionl City of Pearland 3 of 11 07/10/03 CIGNA HealthCare Proposed Benefits · prOduct: CIGNA HealthCare POS Open Access Situs State: TX Effective Date: Benefits Summary_ (Cont.) 10/01/2003 Category Description Pharmacy Benefits $10/S20/$40 Copay - Generic Copay - Bran~ Non-Preferred Copay Mail Order Copay - Generic Mail Order Copay - Brand. Mail Order Copay - Non-preferred Retail - Individual Deductible Retail - Family Deductible OOP - Individual Maximum OOP - Family Maximum Oral Contraceptives Contraceptive Devices Lifestyle Drugs Insulin Needles & Syringes Glucose Test Strips/Lancets Prenatal Vitamins Oral Fertility Drugs Insulin Generic Push Formulary Prescriber Panel Description MH/SA Benefits In Network $10 $20 $40 $20 $40 $80 $0 $0 NA NA Covered Covered Not Covered Covered Covered Covered Not Covered Covered Included Incentive Open In Network Option 2 - Low (POS) Inpatient Per Day Copay $100 Inpatient Max Number of Days MH/SA Combined 8 MH Outpatient Copay 1 to 20 Visits $40 MH Outpatient Max Number of Visits 20 Outpatient SA visits 1-2 Copay $15 Outpatient SA visits 3-20 Copay $40 SA Outpatient Max Number of Visits 20 Group Therapy Outpatient Copay $20 Group Therapy MH/SA Combined Maximum Visits 40 MH/SA OON Buy-up Option Vision Benefits None Out of Network Excluded 1-1179OH21-SIF-1 Revisionl 4 of 11 City of Pearland 07/10/03 CIGNA Healthcare Proposed Benefits Product: CIGNA PPO Situs State: TX Benefits Summary (Cont.) Category Description MH/SA Benefits {Mental Health - Alcohol & Drug Abuse} MH/SA Cost Sharing Vision Benefits Miscellaneous Benefits Effective Date: 10/01/2003 Inpatient Coinsurance Outpatient Coinsurance Outpatient Copay Inpatient Deductible - Per Admit Inpatient Deductible - Per Day Inpatient Cal Year Max Days Inpatient Lifetime Max Days Outpatient Cal Year Max Days Outpatient Lifetime Max Days None 24 HIL Extended Preventive Care TMJ PCL DME In Network 90% N/A $25.00 30 60 Included Included Included Included Included Out Network 70% 50% N/A 30 60 1-1 I790H21-SIF-1 Revision 1 City of Pearland 7of11 08/ 11 /03 CIGNA HealthCare Proposed Medical Rates Group Description : PPO OUTLIER (EES OUT OF THE OA POS NETWORK Subscribers Current Monthly Renewal Tier Premium Rate Premium Rate Premium Employee 0 $450.46 $450.46 $0.00 Emp + Spouse 0 $945.98 $945.98 $0.00 Emp + Child(ren) 0 $810.84 $810.84 $0.00 Emp + Family 0 $1,261.31 $1,261.31 $0.00 Total 0 Rate $0.00 Pass Group Description : SUPER 65 PPO Subscribers Current Monthly Renewal Tier Premium Rate Premium Rate Premium Employee 1 $182.04 $439.02 $439.02 Emp + Spouse 0 $382.28 $921.95 $0.00 Emp + Child(ren) 0 $327.67 $790.24 $0.00 Emp + Family 0 $509.71 $1,229.27 $0.00 Total 1 $439.02 1-1 I790H21-SIF-1 Revision 1 City of Pearland 8 of l l 08/11/03 CIGNA Healthcare Underwriting Contingencies For City of Pearland *The rates are guaranteed for a period of 12 months while the contract remains in force. *The employer contributes at least 50% toward the total cost of the plan. *No seasonal employees are covered under this plan. *The current waiting period is 30 days. *This quote assumes all employees are located in the network area, and that all employees are only eligible for the product offerings specified. *The CIGNA HealthCare Companies retain the right to modify the rates and benefits set forth in this quotation, or to decline to offer coverage if any of the information upon which these rates or benefits was based changes or is not accurate. *If any information set forth in this form changes at any time while coverage is provided to you by CIGNA HealthCare Companies, you must notify us within 30 days of these changes. *There is a minimum participation of 50% required. This will be based on the total eligible employees, identified as 300 employees. *If a decision is not reached within 60 days from the date the rates and/or fees set forth herein are received, then Connecticut General Life Insurance Company and its affiliated companies and entities (collectively, "CIGNA") reserves the right to revise said rates and/or fees. *If enrollment increases or decreases by 15% or more from the enrollment assumptions used in establishing the rates and/or fees set forth herein, CIGNA reserves the right to revise said rates and/or fees. *Connecticut General may cancel the policy as of any Premium Due Date if the number of insured Employees fails to meet the minimum required per group participation rules; or for failure to comply with any other material plan provision relating to Employer contributions or group participation rules. *No Medicare eligible retirees are covered under this plan. *Medical History Information is accurate to the best of your knowledge *State law may require regulatory approval of rates. If, as of their proposed effective date, regulatory approval is not obtained, the healthplan shall use rates consistent with its then currently approved rates and the foregoing rates shall be effective automatically upon approval. 1-1 I79OH21-SIF-1 Revision 1 City of Pearland 9 of 11 08/ 11 /03 CIGNA Healthcare Underwriting Contingencies For City of Pearland (cont.) *Out of Network benefit maximums are reduced by In -Network utilization. *Urgent Care is subject to plan deductible and coinsurance if member is out of area. *Emergencies are always covered In -Network provided that the situation meets CIGNA HealthCare's standard definition of an Emergency. *All covered Out -of -Network services are subject to plan deductible and coinsurance. *CIGNA HealthCare is the exclusive provider of healthcare coverage to your employees. *The mandatory amendments to your Group Service Agreement require regulatory approval. We expect to receive approval prior to the proposed effective date of these contract amendments. However, if the amendments have not been approved as of the proposed effective date, the amendments will be postponed until the required regulatory approval is received. 1-1 I790H21-SIF-1 Revision 1 City of Pearland 10 of 11 08/ 11 /03 CIGNA Healthcare Underwriting Contingencies For City of Pearland (cont.) The CIGNA HealthCare Companies reserve the right to change the Quoted Rates and/or Quoted Benefits or to decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed Effective Date indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of this summary information form. If any of the information identified above changes either prior to the proposed Effective Date or while coverage is in effect, you agree to notify us promptly of such change. The "Underwriting Contingencies" set forth above shall survive execution of any insurance policy, application, etc., issued by Connecticut General Life Insurance Company or any other CIGNA HealthCare company, and shall further survive the effective date of any such policies. The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the rates. Please review the Benefit Summary and its attachments for information about the benefits available in your sites. "CIGNA Healthcare" refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel -Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. Client Signature Bill Eisen Client Name Date City Manager Title 1-1 I790H21-SIF-1 Revision 1 City of Pearland 11 of 11 08/11/03 CIGNA Hea,1thCare CIGNA HealthCare Group Benefits Proposal City of Pearland 3519 Liberty Drive Pearland, TX 77581 SIC Code : 9131 Group Contact : Mary Hickling Account Number : 3196548 Total Eligible Employees: 300 Participating Subscribers : 300 Employer Contributions : Employee Contribution : 100% Dependent Contribution: 0% Waiting Period : 30 days Eligibility Definition : Active Employees working 30 hrs 10/01/2003 END STATE RENEWAL BENEFIT B UYDOWN #2 Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are subject to change in the event of' changes in benefits selected or changes in the risk factors upon which the Quoted Rates are based. In addition, the Quoted Rates are subject to regulatory approval. If required regulatory approval has not been obtained on the proposed effective date, the healthplan shall use rates that are consistent with its then currently approved rating methodology and the quoted rates shall be effective immediately on the date for which they are approved for use The Quoted Rates are guaranteed while the Group Service Agreement remains in effect until the next anniversary date, unless enrollment changes by 15% in which case the CIGNA Companies may change the Quoted Rate. 1-1I790H21-SIF-1 Revisionl City of Pearland 1 oft 08/30/03 CIGNA. Healthcare Proposed Benefits Product: CIGNA HealthCare POS Open Access Situs State: TX Effective Date: 10/01/2003 Benefits Summary Category Description Medical Benefits Coinsurance PCP Office Visit Copay Specialist Office Visit Copay Hospital IP - Per Admit Copay Hospital IP Deductible - Per Admit Hospital IP Copay Per Day Hospital IP Deductible - Per Day Hospital IP - Number of Copays Per Admission Hospital IP - Number of Deductibles Per Admission Hospital IP Coinsurance Plan Deductible - Individual Plan Deductible - Family Out of Pocket Maximum - Individual Out of Pocket Maximum - Family Lifetime Maximum Annual Maximum Outpatient Facility Copay Outpatient Facility Deductible Outpatient Coinsurance Emergency Room Copay Urgent Care Copay Skilled Nursing Facility Copay Skilled Nursing Facility Maximum Days Home Health Care Copay Home Health Care Maximum Visits DME Durable Medical Equipment Maximum EPA External Prosthetic Appliances Deductible External Prosthetic Appliances Maximum Chiro Short Term Rehab Copay Chiro Copay Short Term Rehab and Chiro Combined Maximum Visits Short Term Rehab Maximum Visits Self -Referred Chiro Maximum Visits MRI CT PET Scans Copay PCL In Network $20 $40 NA NA NA 80% $0 $0 $3,000 $6,000 Unlimited NA 80% $100 $50 $0 60 $0 60 Included $3,500 Included $200 $1,000 Included $40 $40 60 NA NA $50 Excluded Out of Networl 70% NA NA NA $400 $800 $4,000 $8,000 $1,000,000 NA $0 60 40 NA NA 60 NA Excluded 1-1I790H21-SIF-1 Revisionl City of Pearland 2ofll 08/28/03 CIGNA Healthcare Proposed Benefits Product: CIGNA. HealthCare POS Open Access Situs State: TX Effective Date: Benefits Summary (Cont.) Category Description Medical Benefits (Cont.) 10/01/2003 Infertility Medicare COB: Retirees >=65 Admin Option Robust Reporting Package 24 Hour Health Info Line Well Aware Program (Diabetes, Asthma, Low Back) Well Aware Program (Cardiac) Well Aware Program (COPD) Well Being Newsletter Healthy Babies Healthy Rewards Life Source Organ Transplant Network Guest Privileges Language Line Drugstore.Com Transition of Care In Network Option 1 NA Excluded Included Included Included Excluded Included Included Included Included Included Included Included Included Out of Networl 1-1I790H21-SIF-1 Revisionl City of Pearland 3ofll 08/28/03 CIGNA Healthcare Proposed Benefits Product: CIGNA HealthCare POS Open Access Situs State: TX Effective Date: 10/01/2003 Benefits Summary (Cont.) Category Description Pharmacy Benefits MH/SA Benefits $10/$20/$40 Copay - Generic Copay - Brand Non -Preferred Copay Mail Order Copay - Generic Mail Order Copay - Brand Mail Order Copay - Non -preferred Retail - Individual Deductible Retail - Family Deductible OOP - Individual Maximum OOP - Family Maximum Oral Contraceptives Contraceptive Devices Lifestyle Drugs Insulin Needles & Syringes Glucose Test Strips/Lancets Prenatal Vitamins Oral Fertility Drugs Insulin Generic Push Formulary Prescriber Panel Description Option 2 - Low (POS) Inpatient Per Day Copay Inpatient Max Number of Days MH/SA Combined MH Outpatient Copay 1 to 20 Visits MH Outpatient Max Number of Visits Outpatient SA visits 1-2 Copay Outpatient SA visits 3-20 Copay SA Outpatient Max Number of Visits Group Therapy Outpatient Copay Group Therapy MH/SA Combined Maximum Visits MH/SA OON Buy -up Option Vision Benefits None In Network $10 $20 $40 $20 $40 $80 $0 SO NA NA Covered Covered Not Covered Covered Covered Covered Not Covered Covered Included Incentive Open In Network $100 8 $40 20 $15 $40 20 $20 40 Out of Networl Excluded 1-1I790H21-SIF-1 Revisionl City of Pearland 4ofll 08/28/03 CIGNA Healthcare Proposed Medical Rates HOUSTON OA Site ID : TX830H Group Description : Inforce Current Renewal Monthly Change% Tier Subscribers Members Rate Rate Premium Employee 188 188 $290.41 $324.39 $60,984.94 42 $609.84 $681.19 $14,305.02 Emp + Spouse 21 Emp Children) + 58 166 $522.72 $583.88 $33,864.94 131 $813.12 $908.26 $29,972.42 Emp + Family 33 Total 300 527 $139,127.31 11.7% Site ID : TX801 Group Description : DALLAS OA — NO ENROLLMENT Inforce Current Renewal Monthly Change% Tier Subscribers Members Rate Rate Premium $264.46 $295.40 $0.00 0 Employee 0 Emp + Spouse 0 0 $555.38 $620.36 $0.00 Emp + 0 0 $476.04 $531.74 $0.00 Children) 0 $740.50 $827.14 $0.00 Emp + Family 0 Total 0 0 $0.00 11.7% 1-1I790H21-SIF-1 Revisionl City of Pearland 5 of 11 08/28/03 CIGNA Healthcare Proposed Benefits Product: CIGNA PPO Situs State: TX Benefits Summary Category Medical Benefits Medical Cost Sharing Pharmacy Benefits RxPRIME Three -Tier Copay Pharmacy Cost Sharing Description Effective Date: 10/01/2003 Inpatient Coinsurance Outpatient Coinsurance PCP Copay Hospital IP Deductible - Per Day Hospital IP Deductible - Per Admit ER Deductible Plan Deductible - Individual Plan Deductible - Family Out of Pocket Maximum - Individual Out of Pocket Maximum - Family Lifetime Maximum Pharmacy Coinsurance Copay - Generic Copay - Brand Copay - Non -Preferred Copay - Non -Preferred Mail Order Copay - Generic Mail Order Copay - Brand Mail Order Copay - Non -preferred Drug Deductible Network Match % Formulary Insulin Oral Fertility Drugs Prenatal Vitamins Glucose Test Strips/Lancets Insulin Needles & Syringes Contraceptive Devices Oral Contraceptives No Mandatory Generic In Network 90% 90% $10.00 N/A N/A $25.00 $150.00 $300.00 $1,000.00 $2,000.00 $1,000,000.00 N/A $10.00 $20.00 $40.00 N/A $20.00 $40.00 $80.00 N/A 95% Open Covered Covered Covered Covered Covered Covered Covered Covered Out Network 70% 70% N/A N/A N/A $25.00 $300.00 $600.00 $2,000.00 $4,000.00 N/A 40% N/A N/A N/A N/A N/A N/A N/A N/A Open 1-1I79OH21-SIF-1 Revisionl City of Pearland 6of11 08/28/03 CIGNA Healthcare Proposed Benefits Product: CIGNA PPO Situs State: TX Benefits Summary (Cont.) Category Description MH/SA Benefits {Mental Health - Alcohol & Drug Abuse} MH/SA Cost Sharing Vision Benefits Miscellaneous Benefits Effective Date: 10/01/2003 Inpatient Coinsurance Outpatient Coinsurance Outpatient Copay Inpatient Deductible - Per Admit Inpatient Deductible - Per Day Inpatient Cal Year Max Days Inpatient Lifetime Max Days Outpatient Cal Year Max Days Outpatient Lifetime Max Days None 24 HIL Extended Preventive Care TMJ PCL DME In Network 90% N/A S25.00 30 60 Included Included Included Included Included Out Network 70% 50% N/A 30 60 1-1I790H21-SIF-1 Revisionl City of Pearland 7of11 08/28/03 CIGNA HealthCare Proposed Medical Rates Group Description • PPO OUTLIER (EES OUT OF THE OA POS NETWORK Current Renewal Monthly Tier Subscribers Premium Rate Premium Premium Rate Employee 0 $450.46 $450.46 $0.00 Emp + Spouse 0 $945.98 $945.98 $0.00 Emp + Child(ren) 0 $810.84 $810.84 $0.00 Emp + Family 0 $1,261.31 $1,261.31 $0.00 $0.00 Total 0 Rate Pass • Tier Subscribers Current Renewal. Monthly Premium Rate Premium Premium Rate $182.04 $439.02 $439.02 Employee 1 Emp + Spouse 0 $382.28 $921.95 $0.00 Emp + Child(ren) 0 $327.67 $790.24 $0.00 0 $509.71 $1,229.27 $0.00 Emp + Family Total 1 $439.02 1-1I790H21-SIF-1 Revisions City of Pearland 8 of 11 08/28/03 CIGNA IHealthCare Underwriting Contingencies For City of Pearland *The rates are guaranteed for a period of 12 months while the contract remains in force. *The employer contributes at least 50% toward the total cost of the plan. *No seasonal employees are covered under this plan. *The current waiting period is 30 days. *This quote assumes all employees are located in the network area, and that all employees are only eligible for the product offerings specified. *The CIGNA HealthCare Companies retain the right to modify the rates and benefits set forth in this quotation, or to decline to offer coverage if any of the information upon which these rates or benefits was based changes or is not accurate. *If any information set forth in this form changes at any time while coverage is provided to you by CIGNA HealthCare Companies, you must notify us within 30 days of these changes. *There is a minimum participation of 50% required. This will be based on the total eligible employees, identified as 300 employees. *If a decision is not reached within 60 days from the date the rates and/or fees set forth herein are received, then Connecticut General Life Insurance Company and its affiliated companies and entities (collectively, CIGNA") reserves the nght to revise said rates and/or fees. *If enrollment increases or decreases by 15% or more from the enrollment assumptions used in establishing the rates and/or fees set forth herein, CIGNA reserves the right to revise said rates and/or fees. *Connecticut General may cancel the policy as of any Premium Due Date if the number of insured Employees fails to meet the minimum required per group participation rules' or for failure to comply with any other material plan provision relating to Employer contributions or group participation rules. *No Medicare eligible retirees are covered under this plan. *Medical History Information is accurate to the best of your knowledge *State law may require regulatory approval of rates. If, as of their proposed effective date, regulatory approval is not obtained, the healthplan shall use rates consistent with its then currently approved rates and the foregoing rates shall be effective automatically upon approval. 1-1I79OH21-SIF-1 Revisionl City of Pearland 9 of l l 08/28/03 CIGNA HealthCare Underwriting Contingencies For City of Pearland (cont.) *Out of Network benefit maximums are reduced by In -Network utilization. *Urgent Care is subject to plan deductible and coinsurance if member is out of area. *Emergencies are always covered In Network provided that the situation meets CIGNA HealthCare's standard definition of an Emergency. *All covered Out -of -Network services are subject to plan deductible and coinsurance. *CIGNA HealthCare is the exclusive provider of healthcare coverage to your employees. *The mandatory amendments to your Group Service Agreement require regulatory approval. We expect to receive approval prior to the proposed effective date of these contract amendments. However, if the amendments have not been approved as of the proposed effective date, the amendments will be postponed until the required regulatory approval is received. 1-1I79OH21-SIF-1 Revisionl City of Pearland 10 of 11 08/28/03 CIGNA Healthcare Underwriting Contingencies For City of Pearland (cont.) The CIGNA HealthCare Companies reserve the right to change the Quoted Rates and/or Quoted Benefits or to decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed Effective Date indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of this summary information form. If any of the information identified above changes either prior to the proposed Effective Date or while coverage is in effect, you agree to notify us promptly of such change. The "Underwriting Contingencies' set forth above shall survive execution of any insurance policy, application, etc., issued by Connecticut General Life Insurance Company or any other CIGNA HealthCare company, and shall further survive the effective date of any such policies. The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the rates. Please review the Benefit Summary and its attachments for information about the benefits available in your sites. "CIGNA Healthcare" refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel -Drug, Inc. and its affiliates CIGNA Behavioral Health, Inc., Intracorp, and HMO or servi - c,' j . y subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. Client Signature William Eisen Client Name Date City Manager Title 1-1I79OH21-SIF-1 Revisionl City of Pearland 11 of 11 08/28/03