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HomeMy WebLinkAboutPR 21042: CONTRACTS, BLUE CROSS AND BLUE SHIELD OF TEXAS, INC. r "J City of "' lei urt rthrrr Texas INTEROFFICE MEMORANDUM Human Resources Department Date: September 9, 2019 To: Ron Burton, Interim City Manager From: Elizabeth Diaz, Director of Human Resourc lJ Re: BC/BS Renewal Effective 11/1/2019 P.R. No. 21042 - A Resolution Authorizing the City Manager to Execute Contracts Between Its Third Party Administrator(Administrative Services Only) For The City of Port Arthur Group Medical, Dental Insurance; For Basic Life, For Basic Accidental Death and Dismemberment, And Excess Loss Indemnity with Blue Cross and Blue Shield of Texas, Inc. Nature of the request: The City of Port Arthur is self-insured and contracts with a third party administrator to administer its Health Insurance Plan for major medical health and dental insurance, basic life insurance, and basic accidental death and dismemberment insurance are also provided for employees and City Council appointees. Additionally,the City provides access to its major medical health insurance coverage, including prescription drug coverage, for its retirees under age 65. Medicare retirees as well as their Medicare dependent(s) transitioned to the Blue Cross Medicare Advantage PPO and Prescription Drug Plan 11/1/2016. The upcoming renewal initially offered a 13.4% funding adjustment over last year's funding level, however,with some modifications to the current level of benefits are delineated as follows: • Add MDLive /TELEDOC services • Increase ISL - $125 • Decrease ASL- 125% • Increase ER Copay from $150 to $200 • Increase RX Brand Copay from $35 to $40 • Add RX PA w/Fast Path • Exclude from pharmacy the following: o PPI o NSA o All OTC Given these adjustments along with a slight increase in dental costs, this year's renewal has been reduced to a 4.9% increase in recommended premium funding. Therefore, effective 11/01/19 all impacted plan participants will incur a 2.5% premium increase; whereby, the City will absorb the remaining premium cost. It should be noted that plan participants have not experienced a rate increase in the past few years. Staff Analysis, Considerations: The City of Port Arthur has a Preferred Provider Organization (PPO) insurance format which provides participants great latitude in selection of health care providers. This format has been deemed most beneficial for plan participants and most compatible with our organizational culture. The City also offers a lower cost Health Savings Account (HSA) option. The City is self-insured for major medical health insurance coverage. As we reviewed the upcoming renewal with Blue Cross and Blue Shield of Texas, staff feels the move to a Medicare Advantage plan for its Medicare retirees and/or Medicare dependents in November, 2016 has attributed to substantial savings to the City's health insurance fund over the past few years. Each renewal year comes with additional elements of the Affordable Care Act impacting the City's health insurance that must be taken into account. Also, this year's renewal reflects a 4.9% increase in recommended premium funding is included as Attachment "A" which is an analysis of this year's renewal proposal as presented by the City's insurance consultant, Mr. Mickey Moshier. Basic Life insurance and AD&D rates remained constant with no increase through 11/1/21. Additional efforts with regard to wellness and education regarding plan usage and alternatives will be a significant initiative in the upcoming renewal year. The 2019-2020 Open Enrollment period will be from October 1 to October 31,2019. Recommendation: It is recommended that the City Council adopt P. R. No. 21042 which authorizes the City Manager to execute contracts between its third party administrator (administrative services only) for the City of Port Arthur group medical, dental insurance; for basic life, for basic accidental death and dismemberment, and excess loss indemnity with Blue Cross and Blue Shield of Texas, Inc., and Dearborn National Life Insurance Company for its 11/1/2019- 10/31/2020 plan year. Budget Considerations: Approval of P. R. No. 21042 which authorizes the City Manager to execute contracts with the following budgetary impact for which funds are available: Fund No. 614-1701-583.53.00 (Health Insurance Fund) Expected claims $7,120,001 Administration/Stop Loss $1,156,645 Dental $ 337,206 Basic Life/AD8cD $ 30,000_ Total $8,6438,52 P. R. No. 21042 9.9.19--ed RESOLUTION NO. A RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE CONTRACTS BETWEEN ITS THIRD PARTY ADMINISTRATOR (ADMINISTRATIVE SERVICES ONLY) FOR THE CITY OF PORT ARTHUR GROUP MEDICAL, DENTAL INSURANCE, BASIC LIFE, BASIC ACCIDENTAL DEATH AND DISMEMBERMENT, AND EXCESS LOSS INDEMNITY WITH BLUE CROSS AND BLUE SHIELD OF TEXAS,INC. FUND NO. (S): 614-1701-583.53-00 (HEALTH INSURANCE FUND) WHEREAS, the City Council of the City of Port Arthur deems it necessary and appropriate to provide major medical health care benefits for its City's employees, City Council appointees, and its retirees under the age of 65 effective on 11/01/2019; and, WHEREAS, the City Council deems it in the best interest of the citizens of Port Arthur to be self-funded and to accept the renewal from Blue Cross and Blue Shield of Texas, Inc. as a third party administrator at an estimated cost of $14,007 per year (administrative charge based on the present number of employees) as well as at a cost of$1,156,645 per year for stop loss premium (excess indemnity) per recommendation of the City's insurance consultant, Mickey Moshier, listed hereto as Attachment "A"; and, WHEREAS, the City's group health plan coverage encompasses the enactment of the Patient Protection and Affordable Care Act (PPACA) effectuated on March 23, 2010, with continuing provisions enacted annually, and do hereby affirm to continue to make changes to its existing health plan policies or products as required to comply with the law; and, current language ties the City of Port Arthur to specific disaster declaration by the President in which the City wishes P. R. No. 21042 9.9.19--ed to modify to a more standard term; and, WHEREAS, such contracting with Blue Cross and Blue Shield of Texas, Inc. complies with Sections 252.021(b), Competitive Requirements for Certain Purchases. 252.024, Section of Insurance Broker,and 252.048,Change Orders,respectively,of the Local Government Code;and, WHEREAS, the nature of the premiums to be charged by the City and the summary of benefits are as delineated in Exhibit"A",which reflects the costs for administration by Blue Cross and Blue Shield of Texas, Inc., the stop loss premium and the expected reserve; and, WHEREAS, the Basic Life Insurance will also be continued per Dearborn National Life which includes provisions to provide basic life insurance coverage to Fire Civil Service personnel at a rate of one times his/her base annual salary in accordance with the 10/01/2017 Collective Bargaining Agreement between the City $.22/per thousand dollar unit, and all other eligible employees' coverage will remain a$6,000 death policy,which will cost the City$.19/per thousand dollar unit/per employee/per month and attached as Exhibit"B"; and, WHEREAS, as part of the Dearborn National Life proposal, the City is also obtaining Accidental Death and Dismemberment Insurance on behalf of its employees which will remain at a cost of $.04/per thousand-dollar unit/per Employee (for a $5,000 accidental death and dismemberment policy for all eligible Employees)per month as attached Exhibit"B"; and, WHEREAS,the current year's renewal provides a 4.9% increase in premium to the City, to employees, City Council appointees, and to retirees under the age 65. It is being recommended that effective 11/01/2019 all impacted plan participants will incur a 2.5% premium increase, whereby the City will absorb the remaining premium increase cost. P. R. No. 21042 9.9.19--ed NOW,THEREFORE,IT BE RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR,TEXAS: Section 1. That, the City Council of the City of Port Arthur hereby accept the following contracts to Blue Cross and Blue Shield of Texas, Inc., attached hereto and made a part hereof; as is fully delineated herein: INSURANCE COVERAGE ADMINISTRATIVE SERVICES EFFECTIVE DATE Administrative Services Blue Cross and Blue Shield November 1, 2019 City of Port Arthur's Group Medical and Stop Loss Dental Blue Cross and Blue Shield November 1, 2019 Basic Life &AD&D Dearborn National Life November 1, 2021 Section 2. That, the City Manager is hereby further authorized to execute the necessary contracts and other documents on behalf of the City of Port Arthur subject to the approval of the City Attorney, and to make payment of necessary premium and administrative charges to bind coverage subject to the terms and conditions of the contract for Third Party Administrator (Administrative Services Only) and the Contracts for Insurance attached hereto as required effectuate said services; and, Section 3. That,the City Manager is hereby directed to take all actions necessary to ensure proper funding of the City of Port Arthur's Employee Health Insurance Fund; and, Section 4. That, a copy of the caption of this Resolution be spread upon the minutes of the City Council. READ,ADOPTED AND APPROVED this day of A.D. 2019 at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the following votes: P. R. No. 21042 9.9.19--ed AYES: Mayor Councilmembers Noes Thurman Bill Barite, Mayor ATTEST: Sherri Bellard, TRMC, City Secretary APPROVED AS TO FORM: Val Tizeno, City Attorney APPROVED FOR ADMINISTRATION: Elizabeth Diaz, Dir. of Human of Resources Ron Burton, Interim City Manger P. R. No. 21042 9.9.19--ed APPROVED AS TO THE AVAIABILITY OF FUNDS: Kandy Dani nterim Director of Finance P. R. No. 21042 9.9.19--ed ATTACHMENT "A" J.S. Edwards Sherlock INSURANCE AGENCY City of Port Arthur Benefit Renewals, Active Employees And Under Age 65 Retirees 11/1/19 Life Insurance: The renewal offer from the incumbent carrier, Dearborn National, indicated NO CHANGE to rates and benefits and also extended the current rates for 2 contract years, thru 11/1/21. Dental Insurance: Dental insurance is a fully insured contract that has been in place from Blue Cross Blue Shield of Texas for many years. Only active employees are eligible for this benefit. Records going back to the 2014 contract year indicate there has been no adjustment to rates to at least that contract year. Claims experience for the most recent accounting period reflected an 8% increase over the prior period. The renewal for 11/1/19 reflects a 5.5% rate adjustment which, based on current employee and dependent enrollment, will generate $18,551 in additional premium annually. This adjustment reflects both the City contribution and any additional amount the City chooses to apply to those employees covering their dependents. Current Rates Renewal Rates Employee $24.70 $26.06 4155 Phelan Boulevard • Beaumont,TX 77707 • P.U.Box 22237, 77720-2237 Beaumont(409)832.7736 • Fax(409)833-1721 • Houston(713)224-8723 J.S. Edwards Sherlock INSURANCE AGENCY Emp+1 $58.92 $62.16 Family $72.25 $76.22 With the premium adjustment, renewal rates are still very much in line, if not below, rates for comparable coverage for comparable employee/dependent bases. Health Plans: The City offers 2 health plans to active and under age 65 retirees. Both are Administrative Services Only (ASO, partially self- funded) plans. While the City directly funds claims initially, stop loss coverage is included in the plans to limit liability per individual and for overall contract claims costs. There has been no change in funding levels nor changes in benefits for the past few years. Overall claims experience for the most recent accounting period increased approximately 20%. The original renewal offer from the incumbent carrier reflected a 13.4% funding adjustment. Discussion and negotiations have yielded a reduction in the aggregate stop loss level from 130% to 125%, effectively reducing the City's overall clams liability by 5%. An increase in the specific stop loss (coverage liability for each covered member) from $100K to $125K yielded a savings of approximately $330K in "fixed costs". Benefits will remain as current with a few minor adjustments including a bump in the RX preferred brand name copay from $35 to $40 and elimination of over the counter available medications. We propose adding coverage for 4155 Phelan Boulevard ' Beaumont,TX 77707 • P.O.Box 22237,77720-2237 Beaumont(409)832-7736 • Fax(409)833-1721 • Houston(713)224-8723 J.S. Edwards Sherlock INSURANCE AGENCY MDLIVE/TELEDOC services affording all with the option of visiting by phone with physicians for minor medical situations. These changes have allowed us to develop a funding level adjustment of 4.9%. 1 have attached a copy of the revised BCBS exhibit reflecting current and the ultimate 4.9% health rate funding figures. Please let me know if you have questions on this or any other matter. I am at your service. UG ' Mickey Mos er MHP 4155 Phelan Boulevard • Beaumont,TX 77707 • P.O. 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Uc E u ua m o1111111 ° Xaova ya vm8 ci > m - m 1-dNwO Q@G > Um 42 m d ' mn im a` o oc = .c Um mo mwmu m mU WC cy Ed > dVm y 2N E E 4 CO onm aa c re Oa O ' a LCm` c g m m V — y E ,na m mm 3m 5Ec o LI` • '.° < o ¢ UEy U 3 = mac vm m U v W E Lm � w ma Eo 3 . Umchu > da ° m o Em -.TE w O 05 mLLy > A,-4.,..7, 2 3 a'= m m > = t c a E c o EymC '7OOm. ° cm Nm TE felt .6. ,'.2E3 .1t1 a ? ° .E mcEE c .o E o agovt E ¢ Rt gO Lcmm v v .5 .> N 3 a o • o . wEmo o Ili cc o0 mm 62. 075E mm mm ° •EE ° cm I LmU ` U d ofc'c v5 nc ¢ wm =U = Nm • 3 m d ° oF ¢ - mv ° °",' 0 m m E ?m y m C L1 ZosZzv . FCmmw > im >, Ze Lm -E. 2 2 c Co am ri3u 5wE 0 aa KLL1-- H _ 1- 1- ¢ D8 I I 1 P. R.No. 21042 9.9.19--ed EXHIBIT "A" PPO ASO Standard with Network BlueCross BlueShield Deductible and Split Copay 92 of Texas s BENEFIT HIGHLIGHTS Prepared For City of Port Arthur BlueChoice Network Effective Date : 11 /01 /2019 Benefit Agreement #: 002 This is a general summary of your benefits. Please refer to your Summary of Benefits and Coverage(SBC),or you may request a copy of the policy or plan document for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses. Please carefully review the plan's limitations and exclusions. Overall Payment Provisions In-Network Out-of-Network Benefits Benefits Deductibles Per-admission Deductible None $200 Calendar Year Deductible $1.500 Individual/ $2000 Individual/ Applies to all Eligible Expenses except inpatient Hospital Expenses(unless $3.500 Family $6,000 Family otherwise indicated) Three-month Deductible carryover applies*** Yes Yes Out-of-Pocket Maximum *Please note that the RX OOP will be separate from this medical OOP and $5,000 Individual/ $6,500 Individual/ that both combined meet ACA compliance. $10,200 Family $15,000 Family Deductible applies to Out-of-Pocket • Yes-no option Yes" Copayment applies to Out-of-Pocket Yes-no option Yes" Network Deductible&Out-of- Out-of-Network Deductible&Out-of Copayment amounts and per admission deductibles are applied but will continue to Pocket will only apply toward Network Out-of-Pocket will only be required after the benefit percentage increases to 100%. Network Deductible&Out-of- apply toward Out-of-Network Pocket Maximum Deductible&Out-of-Network Out-of- Pocket ut-0fPocket Maximum Credit for Out-of-Pocket Maximum from prior carrier(applied on initial group enrollment only) Yes Yes Copayment Amounts Required Physician office visit/consultation: Primary Care Copayment Amount for office visit/consultation when i $35 Primary Care Copayment services rendered by a Family Practitioner,OB/GYN,Pediatrician,Behavioral Health Practitioner,or Internist and Physician Assistant or Advanced Practice Nurse who works under the supervision of one of these listed physicians Specialty Care Copayment Amount for office visit/consultation when $50 Specialty Care Copayment services rendered by a Specialty Care Provider Refer to Medical/Surgical Expenses section for more information Urgent Care center visit $75 Copayment Amount Refer to Urgent Care Services section for more information Outpatient Hospital Emergency Room/Treatment Room visit $200 Copayment Amount $200 Copayment Amount Refer to Emergency Room/Treatment Room section for more information Maximum Lifetime Benefits Per Partici•ant Unlimited Inpatient Hospital Expenses In-Network Out-of-Network Benefits Benefits inpatient Hospital Expenses All services must be preauthorized All usual Hospital services and supplies,including semiprivate room,intensive 80%of Allowable Amount after 60%of Allowable Amount after per- care,and coronary care units per-admission Deductible admission Deductible(if applicable) (if applicable) Penalty for failure to preauthorize services None $250 For Inpatient Facility Services,Blue Cross Blue Shield of TX or the Host Blue's Participating Provider is required to obtain preauthorization.If preauthorization is not obtained,the Participating Provider will be sanctioned based on Blue Cross Blue Shield of TX or the Host Blue's contractual agreement with the Provider,therefore the member will be held harmless for the Provider sanction A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Ded,Split Copay Rev.3/2019 for eff.dates 07/01/19&after(4.2019 Release) Page 1 of 5 PPO ASO Standard with Network BlueCrossBlueShield Deductible and Split Copay co of Texas BENEFIT HIGHLIGHTS Prepared For City of Port Arthur BlueChoice Network Effective Date : 11 /01 /2019 Benefit A . reement #: 002 Medical/Surgical Expenses In-Network Out-of-Network Benefits Benefits Medical/Surgical Expenses Services performed during the office visit/consultation when rendered by a Primary 100%of Allowable Amount after 70%of Allowable Amount after Care Provider,including lab and x-ray(does not include Certain Diagnostic Procedures $35 Primary Care Copayment" Deductible and surgical services) Services performed during the office visit/consultation when services rendered by a 100%of Allowable Amount after 70%of Allowable Amount after Specialty Care Provider,including lab&x-ray(does not include Certain Diagnostic $50 Specialty Care Copayment Deductible Procedures and surgical services) Lab&x-ray in other outpatient facilities(excluding Certain Diagnostic Procedures) 100%of Allowable Amount 70%of Allowable Amount after Deductible -Physician surgical services performed in any setting 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Physician inpatient hospital visits 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test,CT-Scan 80%of Allowable Amount after 60%of Allowable Amount after (with or without contrast),MRI,Myelogram,PET Scan. Deductible Deductible -Home Infusion Therapy(Services must be preauthorized) 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible -All other outpatient services and supplies 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Virtual Visit MDLIVE(Standard) -Virtual Visit Medical Yes 100%of Allowable Amount after $20 Copayment NA -Virtual Visit Behavioral Health No NA NA -Telemedicine Vendor(Specific procedures and providers) NA Does not apply In Vitro Fertilization Services Not Covered Extended Care Expenses Extended Care Expenses -All services must be preauthorized 100%of Allowable Amount 70%of Allowable Amount after Deductible Skilled Nursing Facility Limited to 25 day maximum each Year* Home Health Care Limited to 60 visit maximum each Year* Hos•ice Care Unlimited Special Provisions Expenses Mental Health(Serious Mental Illness (SMI)included)and Chemical Dependency(Substance Use Disorder) Inpatient Services 80%of Allowable Amount after per- 60%of Allowable Amount after Inpatient Chemical Dependency treatment must be provided in a Chemical admission Deductible per-admission Deductible(if Dependency/Residential Treatment Center(RTC) (if applicable) applicable) -Hospital services(facility) Penalty for failure to preauthorize services None $250 Preauthorization required for inpatient,residential treatment centers(RTC),partial hospital program admissions,and certain outpatient professional services -Physician services 80%of Allowable Amount after 60%of Allowable Amount after Calendar Year Deductible Deductible Outpatient Services 100%of Allowable Amount after 60%of Allowable Amount after -Services performed during office visit/consultation when rendered by a Primary $35 Primary Care Copayment Deductible Care Provider(does not include psychological testing) Amount -All outpatient services and psychological testing 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Ded,Split Copay Rev.3/2019 for e(f.dates 07/01/19&after -2G' e!ease; Page 2 of 5 PPO ASO Standard with Network f BlueCross BlueShield a� Deductible and Split Copay , of Texas *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated "Prima Care/S.-cial Care co.a ments are defined in the Overall Pa ment Provisions section in this document. Special Provisions Expenses, cont. In-Network Out-of- fi i s r k Benefits Benefits eefits Emergency Room/Treatment Room Accidental Injury&Emergency Care -Facility charges 80%of Allowable Amount after$200 Copayment Amount (Copayment Amount waived if admitted,Inpatient Hospital Expenses will apply) -Physician charges 80%of Allowable Amount after Deductible Non-Emergency Care -Facility charges 80%of Allowable Amount after$200 60%of Allowable Amount after$200 Copayment Amount(Copayment Copayment Amount&Deductible Amount waived if admitted, Inpatient (Copayment Amount waived if Hospital Expenses will apply) admitted,inpatient Hospital Expenses will apply) -Physician charges 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Urgent Care Services Urgent Care center visit,including lab&x-ray services(does not include 100%of Allowable Amount after$75 70%of Allowable Amount after Certain Diagnostic Procedures and surgical services) Copayment Amount Deductible Certain Diagnostic Procedures;such as Bone Scan,Cardiac Stress Test, CT-Scan(with or without contrast),MRI,Myelogram,PET Scan,surgical 80%of Allowable Amount after 60%of Allowable Amount after procedures and all other services and supplies. Deductible Deductible Ground and Air Ambulance Services 80%of Allowable Amount after Deductible Preventive Care Routine annual physical examinations,well-baby care exams, 100%of Allowable Amount 70%of Allowable Amount after immunizations 6 years of age&over,and any other preventive health Deductible services as determined by USPSTF Immunizations for Dependent children through the date of the child's 6th 100%of Allowable Amount 100%of Allowable Amount birthday Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing function Covered same as any other sickness Covered same as any other sickness Hearing Aid Maximum Hearing aids are subject to 1 per ear per 36 month period *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated Special Provisions Expenses, cont. In-Network Out-of-network Benefits Benefits Physical Medicine Services Chiropractic Care-Office Services 80%of Allowable Amount after 60%of Allowable Amount after Deductible Deductible Maximum Limited to 35 visits each Year* All other Physical Medicine Services rendered by any other eligible Provider will be allowed on the same basis as any other sickness. *Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Ded,Split Copay Rev.3/2019 for eft dates 07/01/19&after 4 21;1.9?eiease) Page 3 of 5 PPO ASO Standard with Network BlueCrossBlueShield Deductible and Split Copay cv (11ofTexas Pharmacy Benefits Participating Pharmacy* Non-Participating Pharmacy (member files claim) Drug List** Basic Compound Drugs Not Covered Non-sedating antihistamine(NSA)drugs and combination Not Covered medications containing a non-sedating antihistamine and decongestant Proton Pump Inhibitors None Cover prescribed over-the-counter(OTC)medications Excluded Cover prescription medications with OTC equivalents(same No ' strength,same active ingredients) If no,cover Omeprazole 20 mg No Prescription Drug Deductible*** None Prescription Drug Out-of-Pocket Maximum All benefits,including prescription drug benefits(retail and mail service)apply to the Out-of-Pocket Maximum shown on page 1. Separate Prescription Drug Out-of-Pocket Maximum applies to Retail&Mail Service Pharmacy:Individual: $1,000/Family: $3,000 Vaccinations obtained through Pharmacies**** Yes 80%of Allowable Amount minus All ACA vaccines,including flu Copayment Amount and deductible (standard) Covered at pharmacies participating in Prime's Vaccination Network only: Zero Copayment Deductible does not apply Retail Pharmacy (Copayment amounts are based on a 30-day supply. With appropriate prescription order,up to a 90-day supply is available. Copayment • amounts apply to Out-of-Pocket Maximum.) Preferred/Non-Preferred Generic Drug $15 Copay 80%of Allowable Amount minus copay or deductible Preferred Brand Name Drug $40 Copay 80%of Allowable Amount minus copay or deductible Non-Preferred Brand Name Drug/Preferred Specialty Drug(preferred 80%of Allowable Amount minus copay specialty pharmacy network) $60 Copay or deductible Specialty Drug 80%of Allowable Amount minus copay $150 Copay or deductible Specialty Drugs are not covered unless obtained through the specialty pharmacy network. Specialty Drugst Specialty Lock-Out through specialty pharmacy network provider applies: No coverage available for specialty drugs when purchased through any other provider. Mail Order Program Yes (Copayment amounts are based on a 30-day supply. With appropriate prescription order,up to a 90-day supply is available. Copayment amounts apply to the Out-of-Pocket Maximum.) 3 Tier Generic Drug $15 Copay Preferred Brand Name Drug $40 Copay Non-Preferred Brand Name Drug $60 Copay MAC 3-Generic Incentive(Standard)-Members electing to purchase brand name drugs when a generic equivalent is available, will be required to pay the difference between the cost of the generic and brand name drug,plus the applicable copay. *To locate a preferred/participating pharmacy in your area,go to myprime.com or contact customer service at the phone number on the back of your identification card. **The drug lists are available at:bcbstx.com/member/rx_drugs.html ***Three-month Deductible carryover does not apply to prescription drug deductible. A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Ded,Split Copay Rev.3/2019 for eff.dates 07/01/19&after.4/2019 Release, Page 4 of 5 PPO ASO Standard with Network f BlueCross BlueShield Deductible and Split Copay ora of Texas • ""Select Participating Pharmacies have been contracted to provide vaccination services. Each pharmacy may have age,scheduling,or other requirements that will apply. Members are encouraged to contact the store in advance. Benefit does not include childhood immunizations,subject to state regulations. tFor more information on the specialty drug program,call(877)627-6337. Diabetes Supplies are available under the Prescription Drug benefits of your plan. Diabetic Supplies include insulin and insulin analog preparations,insulin syringes necessary for self-administration,prescriptive and non-prescriptive oral agents,all required test strips and tablets which test for glucose.ketones,and protein,lancets and lancet devices,biohazard disposable containers,glucagon emergency kits,and other injection aids.All provisions of this portion of the plan will apply including Copayment Amounts and any pricing differences that may apply to the items dispensed. Standard UM Programs(prior authorization and step therapy)and exclusions apply,including auto updates and FastPath. Note:To confirm standard benefits,refer to the Pharmacy page on Product Central on FYiBlue. Effective 11/1/19 adding Fast Path/PA to Rx. Removed all PPIs,NSAs and OTC. Group Executive Name and Title Signature Date (Please type or print) Agent of Record Name Signature Date (Please print or type) BCBSTX Representative Name Signature Date (Please print or type) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association NGF 151+Business PPO ASO Standard with Network Ded,Split Copay Rev.3/2019 for eff.dates 07/01/19&after(4.2019 Release) Page 5 of 5 Blue Cross and Blue Shield of Texas Dental Summary of Benefits Prepared for CITY OF PORT ARTHUR—Account#31118 Group#031120 Effective 11/01/2018 TYPE OF SERVICE BENEFIT GENERAL PROVISIONS FOR PREVENTIVE,BASIC AND MAJOR CARE BENEFITS Calendar Year Deductible(4th quarter carryover applies) S50 Individual/$150 Family Deductible Credit from Prior Carrier N/A Calendar Year Maximum per Participant $1,000 PREVENTIVE CARE BENEFITS(deductible waived) 100% • Oral Examinations,X-Rays,Cleanings BASIC CARE BENEFITS 80% o Fillings, Extractions,Endodontics.Oral Surgery,Root Canal Therapy MAJOR CARE BENEFITS 50% G Prosthetics(dentures,bridgework),Crowns,Inlays and Onlays ORTHODONTIC BENEFITS(no deductible) No o Orthodontic Diagnostic Procedures and Treatment Available Only to Participants Under 19 Years of Age N/A Lifetime Maximum per Participant N/A TEMPOROMANDIBULAR JOINT(TMJ)BENEFITS(no deductible) No Lifetime Maximum per Participant N/A • This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions. O The following eligibility provisions apply: Dependent children are covered until age 26. Disabled dependent children can be covered beyond age 26. Retirees are not eligible for coverage. Employees may enroll dependent children up to age 5 on the first of the month following application with no late enrollment penalty. o A pre-existing condition exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of the dental contract. This exclusion will not apply to: Any participant who becomes effective on the dental contract date who was covered under a previous group dental care contract by the Employer. Any participant who has been continuously covered for 24 months under a group dental care contract with BCBSTX which included prosthetic benefits. o When the course of treatment will be in excess of 5300, a predetermination request should be submitted to BCBSTX in advance of treatment. Please note that our dental is a 'freestanding"product and can be purchased separately from the Health Care Services Corporation product, i.e., an employee can have only himself covered for health, but have dental for the family and vice versa. 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(/) to �n _ L V QJ U ca •�44 W LL tr) co e•-1 O W Lip Cr N en up .zr N 4) LL U O O .--I LL C v) Ln CC LU > ' COMCr) LU I- u O� al-1 co n M ULU cLU U r1 ei N L_ LU O , W y rs-+ \ Q) ..c> >4' p e1 v CO W ICC .4-, W iin v� Ce ▪ v} o n N 0 0 N O LU W > n u +� a-+ fZ + CC C C w Q1 0) N C C j Q QJ C C CL CU v a o Q Q Y v a1 E p — v v 0 CC Ln o o u, LU u LU Lo : rl N aa) -1 N0 Cal a1 c2S c, Z CU CU °� °, Z Ln Ln CD CD > > LU to a) LL v V V LL im V V I C) aJ (1) C) i Q1 a) Q1 a) u LL N v a) v LL J i- L L J i i i i Q LU a) C) C1 C) LU W a1 a1 a1 2 V1 CC CC C = N CC CC CC CC * P. R. No. 21042 9.9.19--ed ' EXHIBIT "B" mow Dearborn National May 20,2019 CITY OF PORT ARTHUR ATTN: ELIZABETH VILLARREAL PO BOX 1089 PORT ARTHUR TX 776411089 Subject: Renewal Analysis Group Policy Number: G31118 Anniversary Date: November 1,2019 IDear Policyholder: Dearborn National would like to thank you for allowing us the opportunity to provide you and your employees with Group insurance products. We have reviewed the current demographics of your group insurance programs. We are pleased to inform you that there will be no change in the existing rates for the upcoming renewal period. Rates will be guaranteed until November 1,2021. Products Current Rates Renewal Rates Life $0.19 per $1,000 $0.19 per $1,000 AD&D $0.04 per$1,000 $0.04 per$1,000 If you have any questions pertaining to your renewal, or would like more information including the availability of other products as well as a quote for additional benefit programs, please contact your local 1 Dearborn National sales office or insurance broker. IWe value our relationship with you and look forward to providing quality service to you in the future. Sincerely, Underwriting Department-In Force Team 1 1 1 701 East 22nd Street, Lombard, IL 60148 A Fax: 312.540.4706 Products and services marketed under the Dearborn National'brand and the star logo are underwritten and/or provided by Dearborn National's Life Insurance Company (Downers Grove,IL)in all states(excluding New York),the District of Columbia.the United States Virgin Islands.the British Virgin Islands,Guam and Puerto Rico.