The URL can be used to link to this page

Home My WebLink AboutO-2004-2779 . e ORDINANCE NO. 2004-~11q AN ORDINANCE AUTHORIZING AND APPROVING AN AGREEMBNT WITH HUMAHA INSURANCE COMPANY, FOR ADMINISTRATIVE SERVICBS OF THE CITY'S MEDICAL PLAN, BPFECTlVE JAHl1ARY 1, 2005, ADOPTING nHEALTH SERVICE PLAN DBSIGNn OPTIONS, APPROPRIATING THE SUM OF $130,000.00, TO Fl1HD SAID ADMINISTRATIVE SBRVICES AGREEMENTS, MAKING VARIOUS FINDINGS AND PROVISIONS RELATING TO THB SUBJECT, FINDING COMPLIANCE WITH THE OPEN MEBTINGS LAW, AND PROVIDING AN BFFBCTlVE DATE HEREOF. BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF LA PORTE: Section 1. The City Council hereby approves and authorizes an agreement with Humana Insurance Company, for administrative services of the City's Employee Medical Fund Plan, a copy of which agreement is on file in the office of the City Secretary. The City Manager is hereby authorized to execute such document and all related documents on behalf of the City of La Porte. The City Secretary is hereby authorized to attest to all such signatures and to affix the seal of the City to all such documents. city Council appropriates the sum of $130,000.00 from City of La Porte Employee Health Services Fund Account No. 014-6144-515-6011, to fund said administrative services agreement for the 2005 calendar year, subject to network cost guarantee. Section 2. The City Council approves and adopts the four plan design options recommended by Humana Insurance Company, for the City of La Porte Employee Medical Fund (Coverage First 1500, Coverage First 1000, PPO 500 AND PPO 300), in form attached hereto and incorporated herein by this reference. City Council reserves for future decision, an Employee contribution Schedule by Plan Design, to be effective January 1, 2005, with the percentage of plan cost shared with employees to be determined by City Council. e e Section 3. The City Council officially finds, determines, recites, and declares that a sufficient written notice of the date, hour, place and subject of this meeting of the City Council was posted at a place convenient to the public at the City Hall of the City for the time required by law preceding this meeting, as required by the Open Meetings Law, Chapter 551, Texas Government Code; and that this meeting has been open to the public as required by law at all times during which this ordinance and the subject matter thereof has been discussed, considered and formally acted upon. The City Council further ratifies, approves and confirms such written notice and the contents and posting thereof. Section 5. This Ordinance shall be effective from and after its passage and approval, and it is so ordered. PASSED AND APPROVED, this 27th of September, 2004. By: CI'9) OF LA PORTE ~1kk:- Alton Porter, Mayor ATTEST: ~d.- d14M Mar a A. Gillett, City Secretary APPROt4 ~ ~ Knox W. Askins, city Attorney 2 e e REQUEST FOR CITY COUNCIL AGENDA ITEM Agenda Date Requested: 09-27-04 Appropriation Requested By: Sherri Samp~nn Source of Funds: Medical Fund Department: BURlaR Resourc:es Account Number: 014-6144-515-6061 Report: Resolution: Ordinance: x Amount Budgeted: $3,403,235 Exhibits: Ordinance Amount Requested: $3,403,23; Exhibits: Summary of Benefits Budgeted Item: YES NO Exhibits: SUMMARY & RECOMMENDATION The City of La Porte is self-funded for medical benefits for employees, retirees and their dependents To ensure the City was receiving the best rates and service for its employees, a consultant was used in March of this year to formulate a request for proposal and test the market. Additionally, our employees have had numerous customer service related problems with TML. The RFP requested services for health plan claims administration, utilization review and large case management, preferred provider network, disease management, pharmacy benefit management, COBRA and HIP AA administration. 18 Responses were received for some or all components of the RFP. After an initial evaluation by the Benefit Consultant, two companies were chosen for presentations to the Chapter 172 Board members, Aetna and Humana. Each company was asked to provide information regarding health plan claim administration, utilization review and large case management, preferred provider network, disease management, pharmacy benefit management, HIP AA and COBRA administration. Both companies had current clients and past clients that were willing to supply favorable references. Aetna and Humana both offered substantial savings on the network discounts, compared to TML and their average 30% discount. Aetna claimed to have discounts averaging over 50% and Humana claimed to have discounts averaging at 49%. Human offered new plan designs that are experiencing less than average annual increases to their health benefit costs. The Humana Plan designs also offered similar PPOs to the City's current plan design. The Chapter 172 Board of Trustees is recommending that Council authorize the City Manager to negotiate a 3 year contract with Humana, beginning January 01,2005, for Administrative Services of the City's medical plan. This proposal includes adopting the 4 plan design options Humana recommends for the City of La Porte (Coverage First 1500, Coverage First 1000, PPO 500 and PPO 300). Action Required bv Council: Authorize City Manager to award bid to Humana, to administer the City's Medical Plan and adopt 4 plan designs proposed by Humana. ~{uJ4nff&- ebra FeazeUe, Manager q-~:l-oif Date e e .: .:"':'-"--"'--.: . :.: .". .~'.-" . . . .' . Humana 'c'ov.e.rag~~'i.r.~t@ "~'P.O.. s.um:~~:rY"<?f.B.~~e~'its l~" ~~J~ .' ij'C'l' . ~M> ,-, ~. '. .' ,i!'i~ TEXAS CoverageFirst 1000 Plan 35, Option 84 Plan pays for services from PARTICIPATING providers Plan pays for services from NONPARTICIPATING providers Up-Front Benefit · Annual member benefit (Applies Allowance to medical seNices received from participating providers only. Does not apply to member copayments, mental health services or Rx benefits.) $500 per calendar year per member Not applicable Annual Deductible · Individual $1,000 $2,000 (per calendar year) (copayments do · Family $3,000 $6,000 not apply) Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammography · Annual routine Pap smears · Routine adult lab and X-rays · Annual routine adult physical 100% after $20 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician * includes lab and X-ray) Physician Services · Office visits (excludes diagnostic 100% after $20 copayment per 70% after deductible lab and X-ray, outpatient surgery) visit to a Level One participating · Prenatal benefit (office visit physician or $35 copayment per copayment applies to first visit visit to a Level Two participating only) physician * · Allergy testing (covered as part of office visit) · Diagnostic tests, lab and X-rays 80% after deductible 60% after deductible · Allergy serum · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit Coverage First PPO combines the cost-saving incentives of a modern health plan with freedom of choice and an annual benefit allowance. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-10434-HH 1/04 . e CoverageFirst 1000 Plan pays for services from Plan pays for services from Plan 35, Option 84 PARTICIPATING providers NONPARTICIPATING providers Hospital Services · Inpatient care (semiprivate room 100% after $1 00 copayment 70% after deductible and board, nursing care, leU) (2) per day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $1 00 copayment 70% after deductible per visit after deductible (copayment is waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical · Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) . Home health care (up to 100 visits per calendar year) (2) · Durable medical equipment (2) . Physical. speech and hearing therapy (2), (5) · Ambulance (1) . Private duty nursing (inpatient hospital only) · Hospice (2) · Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health . Inpatient (up to 30 days per 100% after $1 00 copayment 70% after deductible Services (4) calendar year)'(2) per day for first five days per admission . Inpatient professional services 80% 60% . Outpatient (up to 30 visits per calendar year) -Individual sessions 100% after a $20 copayment 70% per visit - Group sessions 100% after a $10 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness . Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. e CoverageFirst 1000 Plan 35, Option 84 Plan pays for services from PARTICIPATING providers e Plan pays for services from NONPARTICIPATING providers Maximum · Individual Out-ot-Pocket Expense Limit · Family (per calendar year) (excludes deductibles and copayments) $2,000 $6.000 $4.000 $12.000 Litetime Maximum Benefit $1.000.000 Payments - Plan benefits are paid based on reasonable charges. as defined in your Certificate. Participating providers agree to accept reasonable charges. as listed in negotiated payment schedules, as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers, the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and .,ecialist physicians and other :oviders in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency care services received while out of the service area are covered at the participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TIle amount of benifits pll11'ided depeluls /lpOlI the plall selccted. Premiums will 1'1I1')' according III the sl'iectioll made. For .Itencf(/IIJuestiolls abom the plan. coniacr. YOllr belu;fits adminislrator. limitations and This is a partial and summarized list of nitations and exclusions. Your group .,1ay have specific lirnications and exclusions not included on this list. Please check your Certificate for this complete listing. The Certificate is the docl1.1nent upon which benefit payment will be determined. Unless stated mhen'vise. no coverage will be provided for the following situations. 1. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness or injury tor which the insured person is in any ..vay paid or entitled to payment or care and treannent by or tl1rollgh a government program, other than Medicaid or as otherwise provided by Texas law. 3. Education or training; medical services provided by the insured person's parent, spouse, brother. sister or child. 4. Investigational or experimental drugs or substances not approved by Humana or by the Food and Drug Administration. 5. Treatment, services. supplies or surgery that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or ad\oice on their care, unless provided by rider. TX-10434-HH 1/04 e Exclusions 7. Weekend non emergency hospital admissions. S. In-vitro fertilization. unless our In- Viero Fertilization Rider is included in the Group Policy; any. medical or surgical treannenc of in fertility; infertility evaluations; sex change services or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect. birth abnormality of a newborn or for breast reconstruction or as otherwise srated ill the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery, unless the expenses a. are medically necessary diagnostic and/ or surgical treatment of the temporomandibular Gaw or craniornandibular) joint; b. are for the surgical removal of a nllllor or lesions in the mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw. except injuries resulting from biting or che'wing, sustained while the person is covered by the Group Policy. For an injury, the care and treatment must be pro\oided within the 12 mon~h period beginning on the date of the injury. Also. the insured person must remain covered R!Y..~~:mm Insured by Humana Insurance Company @2004 Humana Inc. e under the Group Policy dUring the 12 momh penod while the care and treatment is bemg received. We will not cover any treatment related to the preparation or the fitting of dentures. including demal implants. 11. Any service, supply or treatmem connected with custodial care. 12. Sickness or injury caused by the insured person's; a. engaging in an illegal occupation; or b. commission of or an attempt to commit a criminal act. 13. Any treatment to reduce obesity, including, but not limited to. surgical procedures. "14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mother: or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complicat.ions due to the abordon. 15. Vision analysis. testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and trearmem of complications of noncovered procedures. uruess required by sta te law. e e . ~.. - ._~ . ...---,_..... - -.--.. -. .. - .;" . '" "."... , ....... .... -- ,.. --" .~..---- . . ". . ... . . .. <.. 0" -: "': Humana Co.v~'rag:e~.j:rs~~ _'PPO.:s'u'~~~r~ ~f B~"nefits- w~~ - > - ~4li1i TEXAS CoverageFirst 1500 Plan pays for services from Plan pays for services from Plan 35. Option 100 PARTICIPATING providers NONPARTICIPATING providers Up-Front Benefit . Annual member benefit (Applies $500 per calendar year Not applicable Allowance to medical services received from per member participating providers only. Does not apply to member copayments, mental health services or Rx benefits.) Annual Deductible · Individual $1.500 $3,000 (per calendar year) (copayments do · Family $4,500 $9,000 not apply) Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 10% after deductible age 18) . Annual routine mammography . Annual routine Pap smears · Routine adult lab and X-rays · Annual routine adult physical 100% after $20 copayment per 10% after deductible examinations (16 years and visit to a Level One participating above: excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16: physician * includes lab and X-ray) Physician Services . Office visits (excludes diagnostic 100% after $20 copayment per 10% after deductible lab and X-ray, outpatient surgery) visit to a Level One participating · Prenatal benefit (office visit physician or $35 copayment per copayment applies to first visit visit to a Level Two participating only) physician * · Allergy testing (covered as part of office visit) · Diagnostic tests, lab and X-rays 80% after deductible 60% after deductible · Allergy serum · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 10% after deductible visit CoverageFirst PPO combines the cost-saving incentives of a modern health plan with freedom of choice and an annual benefit allowance. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-23441-HH 1/04 e e CoverageFirst 1500 Plan pays for services from Plan pays for services from Plan 35, Option 100 PARTICIPATING providers NONPARTICIPATING providers Hospital Services · Inpatient care (semiprivate room 100% after $100 copayment 70% after deductible and board, nursing care, leU) (2) per day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $1 00 copayment 70% after deductible per visit after deductible (copayment is waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical . Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) · Home health care (up to 100 visits per calendar year) (2) . Durable medical equipment (2) . Physical, speech and hearing therapy (2), (5) · Ambulance (1) · Private duty nursing (Inpatient hospital only) · Hospice (2) · Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health · Inpatient (up to 30 days per 100% after $1 00 copayment 70% after deductible Services (4) calendar year) (2) per day for first five days per admission · Inpatient professional services 80% 60% · Outpatient (up to 30 visits per calendar year) -Individual sessions 100% after a $20 copayment 70% per visit - Group sessions 100% after a $10 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness . Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) \ " Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. e .CoverageFirst 1500 Plan 35, Option 100 Plan pays for services from PARTICIPATING providers e Plan pays for services from NONPARTICIPATING providers Maximum -Individual Out-Of-Pocket Expense Limit - Family (per calendar year) (excludes deductibles and copayments) $3.000 $9,000 $6,000 $18,000 Lifetime Maximum Benefit u.ooo,ooo Payments - Plan benefits are paid based on reasonable charges. as defined in your Certificate. Participating providers agree to accept reasonable charges, as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians, the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers, the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and -oecialist physicians and other roviders in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent ( contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency care services received while out of the service area are covered at the participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TIle amount of benifits pro,Aded depends upon the plall selected. Premiums u,ill vary according to the selectioll made. For general questio/ls abom the plall, conract YOI~r beu~ts administrator. limitations and This is a partial and summarized list of nitations and exclusions. Your group _.lay have specific limitations and exclusions not included on this list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit payment will be determined. Unless st:lted otherwise. no coverage will be provided for tht: following situations. I. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness or injury for which the 1l1sured person is in any way paid or entitled to paynllmt or care and treatment by or through a government program, other than Medicaid or as otherwise provided by Texas law. 3. Education or mining; medical services provided by the insured person's parent, spouse, brother, sister or child. 4. Investigational or experimental drugs or substances not approved by Humana or by the Food and Dnlg AdminiStl"ation. 5. Treatment, services. supplies or surgery that is not medically necessary. 6. Purchase or fitting of hearing aids, . implantable hearing devices or advice on their care, unless provided by rider. ( TX-23441-HH 1/04 e Exclusions 7. Weekend non emergency hospital admissions. 8. In-vin-o fertilization. unless our In- Vin-o Fercilization Rider is included in the Group Policy; any medical or surgical treatment of infertility; infertility evaluations; sex change services or reversal of elective steriliz,,1tion. 9. Plastic. cosmetic or reconstructive surgery. unless a nmcoonal impairment is present or if required to correct a congenital defect. birth abnormality of a newborn or for breasr reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or ora] surgt:ry. unless the expenses a. are medically necessary diagnostic and/or surgical treamlent of the temporomandibular Gaw or craniomandibu]ar) joint; b. are for the surgical removal of a tumor or lesions in the mouth; or c. are incurred in connection \vith an injury to sound natural teeth or jaw, except injuries resulting tram biting or chewing, sustained while the person is covered by the Group Policy. For an injury, the care and treatment must be pl"Ovided within the 12 month period beginning on the date of the injury. Also. the insu.red person must remain covered }~!2..~~;mm Insured by Humana Insurance Company @2004 Humana Inc. . under the Group Policy during the 12 month period while the care and treatment is being received. We wiII not cover any treatment rebted to the preparation or the fitting of dentures. including dental implants. 11. AllY service. supply or treannent connected witl1 custodia] care. 12. Sickness or injury caused by the insured person's: a. engaging in an illegal occupation: or b. commission of or an attempt to commit a criminal act. 13. Any tream1enc to reduce obesity, including, but not limited to. surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mother: or b. the pregnancy is a result of rape or incest; or c. the services are received to trear medical complications due to the abortion. 15. Vision analysis, testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and treatment of complications of lloncovered procedures. unless required by state law. e e ;-i -":" :....--.:~." "._:; :.~ ,- .":.~ - :'~"~~.~~.: : ...; :<.~ .; :~~~ .~ ': ~:;.~..:;~." ;u~:~ --;-"~ .-~-~--'- - . - -.. >.. . . .... .. -.' '. ~ .. ." - .... .... Hum a naP PO sU}T1~~r.'y~~~.:~e.ri:~f..i.is' -. '") ~.. ~!:;l:--~3",=-;;="m:'J0~;r.'~~--~~' ~'~~ ~--~~"" '--~':n-;oo ->'m'- "~""""= ~~:<~~ r~~ ~~~~~it'~~,~~'~t~;;,~~ ~1&yrj(11-t~1~1l.~~'~~~:~~:::~@~;'~ ~~~~~I~~t~:S~f~~'~;"!~~i~~~!'J~:.'t*~ ,~~ _~E.~~~~,,- ......~~.........'""'-'~o:'lJ~,,~ig'.-.LlI._#l.,...~W4__.iiO':l.:;;~:J.~~~ ~i!'1 TEXAS PPO 300 Plan pays for services at Plan pays for services at Plan 44. Option 5 PARTICIPATING providers NONPARTICIPATING providers Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammogram · Annual routine Pap smear · Routine adult lab and X-ray · Annual routine adult physical 100% after $20 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above: excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician * includes lab and X-ray) Physician · Office visits (includes diagnostic 100% after $20 copayment per 70% after deductible Services lab/X-ray, allergy testing) (excludes visit to a Level One participating outpatient surgery) physician or $35 copayment per · Prenatal care (office visit visit to a Level Two participating copayment applies to first visit physician* only) · Allergy serum 90% after deductible 60% after deductible · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $ 5 copayment 70% after deductible per visit Hospital · Inpatient care (semiprivate room 100% after $1 50 copayment per 70% after deductible Services and board, nursing care, leU) (2) day for first five days per admission. and after deductible · Outpatient surgery - facility (2) 100% after $50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 90% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $1 00 copayment per 70% after deductible visit after deductible (copayment waived if admitted) Prescription Drugs · Rx4 See attached rider. if applicable Other Medical · Skilled nursing facility (up to 60 90% after deductible 60% after deductible Services days per calendar year) { HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-23443-HH 1/04 e e PPO 300 Plan 44, Option 5 Plan pays for services at PARTICIPATING providers Plan pays for services at NONPARTICIPATING providers Other Medical - Home health care (up to 700 90% after deductible 60% after deductible Services (cont.) visits per calendar year) (2) - Durable medical equipment (2) - Physical, speech and hearing therapy (2), (5) - Ambulance (1) - Private duty nursing (inpatient hospital only) - Hospice (2) - Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health -Inpatient (up to 30 days per 100% after $1 50 copayment per 70% after deductible Services (4) calendar year) (2) day for first five days per admission -Inpatient professional services 90% 60% - Outpatient (up to 30 visits per calendar year) - Individual sessions 100% after a $35 copayment 70% per visit - Group sessions 100% after a $20 copayment 70% per visit Serious Mental -Inpatient (up to 45 days per Covered the same as any Covered the same as any Illness calendar year) (2) other illness other illness - Outpatient (up to 60 visits per calendar year) Chemical -Inpatient (2) Covered the same as any Covered the same as any Dependency - Outpatient other illness other illness Services (lifetime maximum of three separate series of treatments for each insured person) Annual Deductible - Individual $300 $600 (per calendar year) (copayments do not - Family $900 $1,800 apply) Maximum - Individual $2,500 $5,000 Out-Of-Pocket Expense Limit - Family $7,500 $15,000 (per calendar year) (excludes deductibles and copayments) Lifetime Maximum $~,OOO.OOO Benefit * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. Payments - Plan benefits are paid based on reasonable charges, as defined in your '"":ertificate. Participating providers agree to .:cept reasonable charges, as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians, the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent - contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the service area are covered at participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TIll! amount of berrefirs provided depe/lds Ilpon the plern selected. Premiums will lIar)' aa:ordi/lg to the selection made. Fllf gelreml questions erbout the pler/l, COllterct )'OUI" bL~lifit.~ admi/listrator. limitations and This is a partial and summarized list of lim.itations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for ( ',is complete listing. The Certificate is \ .Ie document upon which benefit payment will be determined. Unless stated otherwise, no coverage will be provided for the following situations. 1. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness 0\' injury tor which the insured person is in any way paid or emided to paymem or care and treatm.ent by or through a government program. other than Medicaid or as otherwise provided by Texas law; 3. Education or training; medical services provided by the insured person S parent, spouse, brother, sister or child. -l-. Investigational or experimental drugs or substances not approved by Hwnana or by the Food and DrugAdministration. 5. Treaunent, services. supplies or surgery that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on their care, unless provided by rider. 7. Weekend nonemergency hospital admissions. '..~ . TX-23443-HH 1/04 Exclusions 8. In-vitro fertilization, unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical treatment of infertility; infertility evaluations; se.'C change services or reversal of elective the certificate. 9. Plastic. cosmetic or reconstructive surgery, unless a nmctional impairmenc is present or if required to correCt a congenital defect, birth abnormality of a newborn or for breast reconstruction or as othel"\vise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery, unless the expenses a. are medically necessary diagnostic and/or sUl"gical treatment of the temporomandibular Gaw or craniomandibular) joint: b. are for the surgical removal of a nJmor or lesions in the mouth; or c. are incurred in connection \vith an injury to sound nantral teeth or jaw. except injuries resulting from biting or chewing, sust.:uned while the person is covered by the Group Policy. For an injury, the care and treatment must be provided within the 12 mondl period ~ Ff2-~_ Insured by Humana Insurance Company @2004 Humana Inc. beginning on the date of the injury. Also, the insured person must remain covered under the Group Policy during the 'J 2 month period while the care and trearment is being received. We will not cover any trearment related to the preparation or the fitting of dennu:es, including dental implants. 11. Any service, supply or treaonem connected with custodial care. 12. Sickness or injury caused by dle insured person's: a. engJging in an illegal occupation; or b. commission of or an attempt to commit a criminal act. 13. Any trearment to redl.lce obesity, including, but not limited to, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy wouJd endanger the life of the modler; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to dle abortion. 15. Vision analysis, testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and treatment of complications of non covered procedures, unless required by state law; e e '--'-"~O:=."."'-;""":.~':""": ~~.'-:":;"':::'..~~:':~-:" ".'-," '~'.=':-.."~_"".-." . .:'. -4. ... ...~I ." ,r ,... . .... '~..'.' _ .. ':: ' '. .', ":"~ Hum a naP p'O .:Su~'mary:of:'Ben'e:fi'ts.:. /.-,.; ..', ..-'.. . . ~ r"" 4 . . ';', . '.: '. -"-;. ;" : ";: '~"" ~ ~ '. : .: '" ". ".- .. I... .' . ;j)~" itI.. ;r~'10"'W~W7~~..i;;'-;"'~'1;;7""i.;r,c;r':::~'EiJr '."~: 'I:'",,"::;'-:~~~I~-.m",:].J.\t':-:::'T"'~T'''1(l.v';':I?~T.'~lc3;ftrl llin,' i~,:<-;;;1';.\~"",'J;f.r~!l';:;~~ ~t},{> _".";,.<\"T;, """~'~".:H~h; ""'"". "'" ',,, .,;,. ",' ! ~"'<t;r.'T',;,- '- '"i .,~ ,-WCr,M-~" .,1<(.?f't<""'SJ 'l"';t\; ~~ 1. ~~~...;;t~~t5;.lL":.~.~i?~"t:":~,~~';:"!,;;2~~~~l.}..~?2.:.'\i.~~~~';~::t):~ ~'1>.-!i~'"'"W~,~~ :..l~~ TEXAS PPO 500 Plan pays for services at Plan pays for services at Plan 44, Option 3 PARTICIPATING providers NONPARTICIPATING providers Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mammogram · Annual routine Pap smear · Routine adult lab and X-ray · Annual routine adult physical 100% after $25 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $40 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician * includes lab and X-ray) Physician Services · Office visits (includes diagnostic 100% after $25 copayment per 70% after deductible lab/X-ray, allergy testing) (excludes visit to a Level One participating outpatient surgery) physician or $40 copayment per · Prenatal care (office visit visit to a Level Two participating copayment applies to first visit physician * only) · Allergy serum 80% after deductible 50% after deductible · Inpatient services · o.utpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit Hospital Services · Inpatient care (semiprivate room 100% after $250 copayment per 70% after deductible and board, nursing care, leu) (2) day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $1 00 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 50% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $150 copayment per 70% after deductible visit after deductible (copayment waived if admitted) Prescription · Rx4 See attached rider, if applicable Drugs Other Medical · Skilled nursing facility (up to 60 80% after deductible 50% after deductible Services days per calendar year) HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. When you see participating providers. you receive the highest level of benefits available under your plan. At the same time. you retain the flexibility to see any physician. TX-1 041 O-HH 1/04 e e PPO 500 Plan 44, Option 3 Plan pays for services at PARTICIPATING providers Plan pays for services at NONPARTICIPATING providers Other Medical - Home health care (up to 100 80% after deductible 50% after deductible Services (cont.) visits per calendar year) (2) - Durable medical equipment (2) - Physical, speech and hearing therapy (2), (5) - Ambulance (1) - Private duty nursing (inpatient hospital only) - Hospice (2) - Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health -Inpatient (up to 30 days per 100% after $250 copayment per 70% after deductible Services (4) calendar year) (2) day for first five days per admission -Inpatient professional services 80% 50% - Outpatient (up to 30 visits per calendar year) - Individual sessions 100% after a $40 copayment per 70% visit - Group sessions 100% after a $25 co payment per 70% visit Serious Mental -Inpatient (up to 45 days per Covered the same as any Covered the same as any Illness calendar year) (2) other illness other illness - Outpatient (up to 60 visits per calendar year) Chemical -Inpatient (2) Covered the same as any Covered the same as any Dependency - Outpatient other illness other illness Services (lifetime maximum of three separate series of treatments for each insured person) Annual - Individual $500 $1,000 Deductible (per calendar year) - Family $1,500 $3,000 (copayments do not apply) Maximum - Individual $3,000 $6,000 Out-Of-Pocket Expense Limit (per - Family $9,000 $18,000 calendar year) (excludes deductibles and copayments) Lifetime Maximum U,OOO,OOO Benefit t. * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details. Payments - Plan benefits are paid based on reasonable charges, as defined in your r:ertificate. Participating providers agree to :cept reasonable charges, as listed in negotiated payment schedules, as payment in full. For services rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers, the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent e contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the service area are covered at participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TI,e amount of benefits provided depends upon the plan selecfed. Premiums will var}' according to the selecrion made. For .general qllesriorls about rlll! plan, c"//tact )'OIlT benljirs admillistrator. limitations and This is a partial and sununarized list of lim.itations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for ."'tis complete listing. The Certificate is .e document upon which benefit payment will be determined. Unless stated otherwise, no coverage will be provided tor the following siruations. I. A sickness 01" injury which is covered under any Workers' Compensation or similar law. 2. Sickness 01' mjury for which the insured person is in any way paid or entitled co payment or care and treatmenC by or through a government program, other than Medicaid or as othen.vise provided by Texas law. J. Education or training; medical services provided by the insured person's parent, spouse, brother, siscer or child. 4. Investigational or experimental drugs or subst:lI1ces not approved by Humana or by the Food and Drug Administration. 5. Treannem, services. supplies or surgery .that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on dleir care. unless provided by rider. 7. Weekend nonemergency hospital admissions. TX-10410-HH 1/04 Exclusions 8. In-vitro fertilization, unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical treatment of intertility; infertility evaluations; se.x change services or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect, birth abnormality of 3 newborn or for breast reconstruction or as othelwise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or orJI surgery. unless the expenses :t. are medically necessm:y diagnostic and/or surgical treatment of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a nmlor or lesions in the mouth: or c. are incun'cd in connection with an injury to sound natural teeth or jaw. except injUl.ies resulting from biting or chewing, sustained while the person is covered by the Group Policy. For an injury. the care and treatment must be provided within the 12 month period beginning on the date of the injury. !.~~- Insured by Humana Insurance Company @2004 Humana Ine. Also, the insured person must remain covered under the Group Policy during the 12 month period while the care and treatment is being received. We will not cover any tl-ea011ent related co the preparation or the fitting of dentures, including dental implants. 11. Any service, supply or treatment connected ,"vith custodial care. 12. Sickness or injury caused by the insUl-ed person's: a. engaging in an illegal occupation: or b. commission of or an attempt to conunit a criminal act. 13. Any treatment to reduce obesity, including, but not limited co, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mother; or b. the pregnancy is a result of rape or incest: or c. the services are received to treat medical complications due to the abortion. 15. Vision analysis. testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and tl-eaonenc of complications of noncovered procedures. unless required by state law. e e : I " . ~ ~. H U M'a naP. PO' R X'4:prescriPtion."oru.g' C()verage Level One - $10, Level Two - $25, Level Three - $50, level. Four -: 25% How the Rx4 structure works Covered prescripoon drugs are assigned to one of four difterent levels with corresponding copaymem amounts. The levels are organized as tollows: . Level One: lowest copayment for low COSt generic and brand-name drugs. . Level Two: higher copayment "tor higher cost generic and br:md-name drugs. . Level Three: higher copayment than Level Two for higher cost. mostly br:md-name drugs that may have generic or brand-name alternatives 011 Levels One orTwo. . Level Four: highest copayment tor high-technology drugs (certain brand-name drugs, bioteclmology drugs and self-administered injectable medications). . Medications may be moved from one level to a different level during the plan year. Please check our Web site or contact Customer Service for the most up-to-date information. Some drugs in all levels may be subject ro dispensing limit:ltions. based on age, gender. duration or q'u.1nrity. Additionally, some Level Four drugs may need prior authorization ill order to be covered. III these cases, your physician should contact Humana Clinical Pbarmacy Review at '1-800-555-CLlN (2546). Members can visit Hum,1na's Web site, www.humana.com. to obtain intormation abom thc::ir prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Humanas CustOmer Service with questions or to request a Humana Rx4 Drug List by mail. We will also work with physicians and pharmacists to e.."\.l'lain the Rx4 structure. For a complete listing of participating pharmacies, please refer to our Web site or your participating provider directory. Coverage at participating pharmacies When you present your membership card at a participating pharmacy, you are required to make a copayment for each prescription based on the current assigned level of the drug. Drugs assigned to: Copayment per prescription or refill Level One: 810 Levellrvvo: 825 Level Three: S50 Level Four: 25%* of the cotal required payment to the dispensing pharmacy per prescription or refill. * lrhe tota.lma;wl1um out-of-pocket copaymenc costs for drugs in Level Four is limited to $2,500 per calendar year, per member. . If the dispensing pharmacy's charge is less than the corresponding copayment, you will only be responsible tor the lower amount. . Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change ifHumana receives any retrospective volume discounts or prescription drug rebates. There are no claim torms to file if you use a participating pharmacy and present YOllr membership card with each prescription. Nonparticipating pharmacy coverage * You may also purchase prescribed medications from a nonparticipating pharmacy. You will be required to pay for YOllr prescriptions according to tbe following rule. . You pay '100 percent of the dispensing pharmacy's charges. You file a claim torm with Humana (address is on the back ofID card). - Claim is paid at 70 percent of the dispensing phannacy's charges. after they are first reduced by the applicable copayment. . Your copaymenrs for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription dntg rebates. *" In Georgia. the nonparticipating benefits are paid the same as the participating benefits. per state reguiation. Coverage specifics GN-12140-HH 5/03 Your coverage includes the tollovving: . A 30-day supply or the amount prescribed. vvhichever is less. for each prescription or refill. . Contraceptives. . Certain self-administered injectable drugs and related supplies approved by Humana. . Certain dn.lgs, medicines or medications that, under tederal or Sc,1te la"", may be dispensed only by prescription from a physician. Mail-order benefit e e For your convenience. you may receive a ma....amum 90-day supply per prescription or refill through the mail (maximum 3D-day sllpply tor self-administered injectable drugs). The same requirements apply when purchasing m.:dications through a participating mail-order pharmacy as apply when purchasing in person at a pharmacy. Members can call Customer Service or \risit our Web site for more information, including mail-order torms. Definition of terms . Drug List: a list of prescription dntgs, medicines. medications and supplies specified by Humana. This list identifies drugs as Level One, Level Two, Level Three or Level FOllr and indicates applicable dispensing limits and/or any prim' authOrization requirements. (This list is subject to change.) . Copaymel1t: the amount to be paid by the member tOlovard the COSt of each separate prescription or refill of a covered drug when dispensed by a phannacy. . Nonparticipating pharmacy: a pharmacy which has not been designated by Hwnana as a partic:iparing pharmacy. . Participating pharmacy: a pharmacy which Iu1s entered into an agreement widl Humana or which has been designated by Humana to provide services to all covered persons. Participating pharmacy desigl1<ltion by Humana may be limiteCl to specified services. Limitations and exclusions .. GN-12140-HH 5/03 Unless specifically stated otherwise, no coverage is provided for the fo.llO\\o;ng: . Any portion of a prescription or refill that exceeds a 30-day supply for a medication - 90-day supply for a prescription or refill pO-day supply for self-administered injectables) purchased through mail order. . Prescription refills in excess of the number specified by the physician'S original order or dispensed more than one year fium the date of the original order . The administration of a covered medication . Immunizing agents or biological serums or allergy extracts (may be covered under the medical plan) . Infertility drugs (except where required by law) . Drug delivery implants . Any drug, medicine or medication labeled "Caution -limited by federal law to investigational use" or any experime.ntal drug, medicint: or medication, even though a charge is, or may be, made to the member . Any cosrs related to the mailing, sending or delivery of prescription dmgs . Any drug used for weight control (except where required by law) . Any drug pl:escribed for a nOIlcovered sickness or injury . Abortifacienrs (drugs used to induce abortions) . Any dnlg prescribed for impotence and/or sexual dysfunction, e.g.Viagra . Injectable drugs. including but not limited to immunizing agents, biological sera, blood, blood plasma or sdf-administered injectable drugs not approved by Humana . Dietary supplements, except for amino acid modified preparations and Jow-protein modified food products necessary tor the treatment of inherited metabolic diseases. This is only a partial list of limitations and exclusions. Please refer to the Certificate of Coverage/Insurance for complete details regarding prescription drug coverage. ,,~~- Insured by Humana Health Insurance Company ofFlorid1, Inc., Hwnana Insurance Company, Humana Health Plan, Inc., or Humana Insurance of Puerto Rico, .Inc. @20D3 Humana Inc. HumanaPPO