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HomeMy WebLinkAboutSpecial City Council Packet 06.19.2019NEXT RES. NO. R18-28 NEXT ORD. NO.O 18-01 CITY OF LAUREL SPECIAL CITY COUNCIL AGENDA TUESDAY — JUNE 19, 2019 — 6:15 P.M. WELCOME . . . By your presence in the City Council Chambers, you are participating in the process of representative government. Tonight is a special meeting of the City Council duly called by the Mayor for the purpose of discussing one item of city business. No further business or discussion shall be conducted at this Special Meeting. 1. Pledge of Allegiance. 2. Roll Call of the Council. 3. Resolution R18-28: A resolution of the City Council authorizing the Mayor to sign an agreement with Pacific Source Health, Delta Dental and VSP for the provision of the employee health insurance benefit program. 4. Adjournment. The City makes reasonable accommodations for any known disability that may interfere with a person's ability to participate in this meeting. Persons needing accommodation must notify the City Clerk's Office to make needed arrangements. To make your request known, please call 406-628-7431, Ext. 2, or write to Bethany Langve, PO Box 10, Laurel, MT 59044, or present your request at City hall, 115 West First Street, Laurel, Montana. WHEREAS, the City Council previously authorized the City's Health Insurance Committee to seek bids to provide health insurance for the City's employees and dependents; and WHEREAS, the City of Laurel complied with its procurement policy and Montana Law by utilizing a competitive bid process to ensure the selected bidder will provide satisfactory health care coverage and in the City's best interest; and WHEREAS, City staff reviewed the proposals and determined the proposal submitted by PacificSource was the most responsive to the City's request, and hereby recommends selection of the same. NOW THEREFORE BE IT RESOLVED by the City Council of the City of Laurel, Montana, that the Mayor is authorized to sign an agreement with PacificSource Health for the employee health insurance program, a copy of which is attached hereto; and BE IT FURTHER RESOLVED, the Mayor is authorized to sign agreements with Delta Dental and VSP for the employee dental and health insurance. Introduced at a regular meeting of the City Council on June 19, 2018 by Council Member PASSED and ADOPTED by the City Council of the City of Laurel, Montana, this 19`h day of June, 2018. APPROVED by the Mayor this 19`h day of June, 2018. CITY OF LAUREL Thomas C. Nelson, Mayor Bethany Langve, Clerk -Treasurer Approved as to form: Sam Painter Civil City Attorney R18-28 Accept Agreement. PacificSource Health Plan, VSP and Delta Dental 0 Z rj -n . m 1 0 0) m Nj i -o I 1;:;� (D (D X =3 0 (D C: X; X !4 Ln CD C (D 0 z X. + m (D I.. 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Box 10 Laurel, MT 59044-0010 Dear Kelly: Blue Cross and Blue Shield of Montana (BCBSMT) is proud to present a fully insured renewal that underscores the value of our health plans. We appreciate the opportunity to continue serving you, your employees and their families. At BCBSMT, our goal is to build a stronger health care system for tomorrow while giving employers immediate solutions to the issues they are facing today — like rising health care costs and the need to engage employees in making smart decisions about their health. To drive long-term change, BCBSMT launched the most robust Value -Based Care initiatives in Montana. These programs are transforming our health care system — shifting the emphasis of health care from volume to quality, transparency and accountability — while reducing costs. BCBSMT launched the most robust transparent pricing initiative in Montana, giving City of Laurel employees the power to easily shop for health care based on quality and cost. The Cost Estimator is powered by BCBS Axis(], the largest database of health care quality and cost information in the health care industry — and the only data resource that includes health care information from every ZIP code in the United States. We also continue to provide the greatest savings on medical care in the industry. A January 2016 Milliman National Benchmark Comparison found that health care providers offer Blue Cross and Blue Shield (Blue) plan members almost 14 percent better savings than our competitors. In addition, it found that in -network utilization was approximately six percent higher for Blue plan members than for our competitors. As the industry leader and your health benefits partner for the past year, BCBSMT is well equipped to support your goals and objectives with cost-effective programs, exceptional account management, and new tools and resources to improve the quality and reduce the cost of your employees' health care. Your Agent, Dave Allen will contact you soon to set up a personal visit to discuss your renewal and available options. Our goal is to ensure that your annual plan renewal is understandable, that desired benefit options are promptly delivered for your consideration, and that the required documentation to complete the renewal is processed efficiently. We appreciate the continued opportunity to serve you, your employees, and their dependents. If you have questions about your renewal or if I can help in anyway, please contact me at (406) 437-6363. Sincerely, Shellie Wherley Account Executive Enclosures/cc: Dave Allen A DIVISION Of HEALM CARE SERVICE CORPORATION. A MUTUAL LEGAL RESERVE COMPANY. AN INDEPENDENT LICENSEE OF THE BLUE CROSS AND BLUE SHIELD .ASSOCIAIION Kelly Strecker City of Laurel Page 2 201R Renewal Tnformation: Effective 7/1/2018 Triple Option: Blue Dimensions 80/20 PPO Plan Type BIue Dimensions PPO: 80/20 co -ins In -network; Single 65/35 Co -Ins Out -of -Network Office Visit Copay $25 Par Professional Provider services done in office setting. Deductible $1,000 Individual/$2,000 Family Out -of -Pocket Maximum $2,500 Individual/$5,000 Family Efficient RX $100 Deductible — waived on Generics PerformanceFormulary Retail/Value Pharmacy: $10/$40/60% up to max $200 per fill; 90 -day supply at Value Pharmacy Retail only at 3 Copays. Retail/Prime Network: $15/$50/60% up to max of $250 per fill; Mail Order: $20/$80/60% up to max of $400 per fill 90 -day supply Specialty RX: $100/$200 copays after deductible. OON Specialty: 50% co-insurance; *Performance Formulary applies at renewal Accident Process off Standard Medical Benefits Preventive Benefit In -Network: 100% coverage up to allowable fee for routine/preventive services including Well Child and routine Mammograms. Out -of -Network: Ages 19+ - Deductible applies; Well Child under 19 — deductible waived; Routine Mammo rams —first $70 is aid; deductible applies EAPx If group wishes to purchase EAP services — we can provide pricing thru Magellan Behavioral Health. HCSC Renewal Rates below do not include the $75 COBRA [COBRA administered Administration Fee and Activity Fees. blue' Dimensions `80/20 PPO Renewal ; Single $803.52 Two P $1,782.60 Employee/Child/Children $1,278.42 Family $2,048.18 Single Medicare $450.15 2P/Iv4ed $899.17 Kelly Strecker City of Laurel Page 3 ?.MR Renewnl Tnfnrmntinn- Effective 7/1/2015 Triple Ontion: Blue Dimensions 70/30 PPO Plan Type Blue Dimensions PPO: 70/30 co -ins In -network; Single 55/45 Co -Ins Out -of -Network Office Visit C6pay $35 Par Professional Provider services done in office setting. Deductible $1,500 Individual/$3,000 Family Out -of -Pocket Maximum $3,500 Individual/$7,000 Family Efficient RX $100 Deductible — waived on Generics Performance Formulary RetailNalue Pharmacy: $10/$40/60% up to max $200 per fill; 90 -day supply at Value Pharmacy Retail only at 3 Copays. Retail/Prime Network: $15/$50/60% up to max of $250 per fill; Mail Order: $20/$80/60% up to max of $400 per 61190 -day supply Specialty RX: $100/$200 copays after deductible. OON Specialty: 50% co-insurance; *Performance Formulary applies at renewal `Accident Process off Standard Medical Benefits Preventive Benefit In -Network: 100% coverage up to allowable fee for routine/preventive services including Well Child and routine Mammograms. Out -of -Network: Ages 19+ - Deductible applies; Well Child under 19 — deductible waived; Routine Mammograms — first $70 is aid; deductible applies EAP*` If group wishes to purchase EAP services — we can provide pricing thru Magellan Behavioral Health. COBRA HCSC Renewal Rates below do not include the $75 COBRA :administered Administration Fee and Activity Fees. Blue Dimensions 70/30 PPO Renewal Single $755.13 Two P $1,675.68 Employee/Child/Children $1,199.65 Family $1,924.39 Single Medicare $423.14 2P/Med 1 $846.28 Kelly Strecker City of Laurel Page 4 Rine Choice HSA PPO $3.500 Deductible Plan— effective 7/1/18 Plan Type Blue Choice PPO/HSA Compatible Plan $627.84 100/0 co-insurance feature after deductible is met Deductible $3,500 Individual/$7,000 Family In -network $998.26 $7,000 Individual/$14,000 Family Out -of -network Out -of -Pocket Maximum $3,500 Individual/$7,000 Family In -network $7,000 Individual/$14,000 Family Out -of -network Performance Formulary Non -Preventive Covered Brand/Generic Drugs apply to Medical Deductible/OOP Out -of -Network Specialty Drugs: 50% co-insurance after deductible. *Performance Formulary applies: Non -Covered drugs; Step Therapy, Prior Authorization and dispensing limits apply. 90 -Day at retail only available thru Extended Supply Value Preferred Pharmacies Accident Process off Standard Medical Benefits Preventive Benefit 100% coverage In -Network up to allowable fee for routine/preventive services including Well Child and Mammograms. Out -of -network routine/preventive Mammograms — First $70 paid; deductible and Co-insurance applies Out -of -Network Routine/Preventive — 19+ (Adult) — Deductible and co- insurance applies Out -of -Network Well Child Services — Under 19 — co-insurance a lies deductible waived COBRA — Vendor Our records indicate COBRA is not administered thru Administered HCSC/BCBSMT. Blue Choice HSA $3,500 Renewal Single $627.84 Two P $1,393.17 Em l/Child ren $998.26 Family $1,600.36 Kelly Strecker City of Laurel Page 5 Important Notices and Enclosures: ✓ RenewaI Paperwork: I will forward the Merit Group Application once you finalize the review of the renewal and determine if you are electing to make any benefit modifications. ✓ Open Enrollment Notice: Please share a copy of the enclosed open enrollment notice with your employees. ✓ HIPAA/Special Enrollment Rights Notice: Please share a copy of the enclosed Special Enrollment notice with your employees. ✓ Summary of Benefits and Coverage (SBC): BCBSMT is required to provide a Summary of Benefits and Coverage (SBC) with your renewal packet. You, as the employer, must distribute a copy of the enclosed SBC to all individuals eligible for your group health insurance policy. The requirements and timelines are detailed in the enclosed attachment. 2018 SBCs for your Blue Dimensions PPO and Blue Edge Plus PPO plans offered at renewal are enclosed for your reference. ✓ 2018 Pharmacy Changes: 2018 Notice of Pharmacy changes is enclosed that highlights the changes incorporated to applicable BCBSMT group plans effective 1/1/18 or at renewal. ✓ Participation Requirement Notice: Please review the requirement with your agent/consultant to ensure your group is meeting participation requirements. ✓ Value Added Services/Resources/Tools: The enclosed brochures provide you an overview of the additional services, resources and tools that are provided to your employees and their families. We encourage you to share this information with them. If you would like to order any of these materials, please contact me. Blue Cross and Blue Shield of Montana 2018 Fully Insured Large Group Business Pharmacy Changes BCBSMT has identified the following opportunities that will help manage costs while still offering our members a high quality and effective prescription drug program. The following is a summary of the changes for our customers. This is effective January 1, 2018 or upon a group's renewal unless specifically noted: ✓ Six -Tier Benefit Design: o Blue Choice/Blue Options - Standard Plans will move to a Six -Tier benefit design upon their 2018 renewal/effective date. Preferred and Non -Preferred Tiers for Generics, Brand Name Drugs and Specialty Drugs. Current Blue Choice/Blue Options Plan Designs will be discontinued and replaced with the following Plan Designs: o $0/$10/$50/$100/$150/$250 — at Value Preferred Pharmacies. Blue Choice Efficient RX and 5 Tier Drug Plan replaced by plan design above. Blue Options 4 Tier Drug Plan replaced by plan design above. Separate RX Out of Pocket on Blue Options Plans removed. o $0/$10/$35/$75/$150/$250 - at Value Preferred Pharmacies Blue Choice 4 Tier Drug Plan $81$35/$75/$150 replaced by plan design above. o 10%/10%/20%/30%/40%/50% -at Value Preferred Pharmacies Blue Choice HSA Plans with co -ins after deductible replaced by plan design above. ✓ HDHP/HSA Eligible Plans - $0 Copay Preventive Drug List: o Revised Drug List effective 1/1118 and upon renewal. ✓ Terminology Change: o Formulary & Non -Formulary Drug Changing to Preferred and Non -Preferred Drug. ✓ Drug List and Pharmacy Networks: o MT Standard Insured and Custom Insured Plans will remain on their Current 2017 Drug List and Pharmacy Network for 2018. ■ Performance Drug List ■ Value Network (Pharmacy Network) CVS/Target Pharmacies — Out -of -Network as of 1/1/17. ✓ Want more information? Find a Pharmacy or search the Performance drug list on www.mvprime.com. See www.bcbsmt.com for Drug List, Value Pharmacy and additional Pharmacy Resources. Please work with your Account Executive with any questions. Please note: This is a general overview of changes and not a guarantee of payment. Please reference the specific benefit materials and information on your plan. i to ':i, .ta; Account Name CITY OF LAUREL Account Number 138674 Rate Effective Date 07/01/2018 Experience Period: Incurred: 11/01/2015-10/31/2017 Active Contracts as of 02/28/2018 66 Projected Claims PCPM based on Experience with Pooling: $788.14 Credibility 64.59% Adjusted Manual Claims PCPM: $756.34 Credibility 35.41% Total Projected Claims PCPM: $776.88 Desired Loss Ratio* 81.79% Calculated Premium PCPM** $949.85 Premium at Current Rates PCPM $949.85 Calculated Premium Rate Action 0.0% Final Premium Rate Action 0.0% • Change in Demographics -0.2% • Annual Trend 7.5% *Includes provisions for Administrative Costs, State Taxes 8v Assessments, and Commissions **Reflects the effects of Health Insurer and Reinsurance Fees, plus any federal and state taxes applicable to these fees. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. 04/05/2018 Registered Marks Blue Cross and Blue Shield Association 6 pTarn)fly7 h alkI g advantage, of preventive iiheafth ccasarn'7cas Preventive check-ups and screenings can help find illnesses and medical problems early and improve the health of you and everyone in your family. Your health plan covers screenings and services with no out-of-pocket costs like copays or coinsurance as long as you visit a doctor in your plan's provider network. This is true even if.you haven't met your deductible. Some examples of preventive care services covered by your plan include general wellness exams each year, recommended vaccines, and screenings for things like diabetes, cancer or depression. Preventive services are provided for women, men and children of all ages. For more details on what preventive services are covered at no cost to you, refer to the back of this flier for a listing of services, or see your benefits materials. Learn more on immunization recommendations and schedules by visiting the Centers for Disease Control and Prevention website at www.cdc.gov/vaccines. These preventive services are covered by your plan at no cost to you' SCREENINGS FOR ❑ Abdominal aortic aneurysm ❑ Alcohol abuse and tobacco use ❑ Cardiovascular disease (CVD) including cholesterol screening and statin use for the prevention of CVD ❑ Colorectal and lung cancer ❑ Depression ❑ Falls prevention and vitamin D use for stronger bones ❑ High blood pressure, obesity, diabetes and depression ❑ Sexually transmitted infections, HIV, HPV and hepatitis ❑ Tuberculosis COUNSELING FOR ❑ Alcohol misuse ❑ Domestic violence Healthy diet and physical activity counseling for adults who are overweight or obese and have additional cardiovascular disease risk factors ❑ Obesity ❑ Sexually transmitted infections ❑ Skin cancer prevention ❑ Tobacco use, including certain medicine to stop ❑ Use of aspirin to prevent heart attacks ❑ Aspirin for preeclampsia prevention ❑ Breast cancer screening, genetic testing and counseling ❑ Breastfeeding support, supplies and counseling ❑ Certain contraceptives and medical devices, morning after pili, and sterilization to prevent pregnancy ❑ Cervical cancer screening ❑ Chlamydia, gonorrhea, syphilis, HIV and hepatitis B screenings ❑ Counseling for alcohol and tobacco use during pregnancy ❑ Folic acid supplementation during pregnancy ❑ Human papillomavirus (HPV) DIVA test ❑ Osteoporosis screening ❑ Screenings during pregnancy, including screenings for anemia, gestational diabetes, bacteriuria, Rh(D) compatibility, pre- eclampsia SCREENINGS FOR ❑ Autism ❑ Cervical dysplasia ❑ Critical congenital heart defect screening for newborns ❑ Depression ❑ Developmental delays ❑ Dyslipidemia (for children at higher risk) ❑ Hearing loss, hypothyroidism, sickle cell disease and phenylketonuria (PKU) in newborns ❑ Hematocrit or hemoglobin ❑ Lead poisoning ❑ Obesity ❑ Sexually transmitted infections and HIV ❑ Tuberculosis ❑ Vision screening ASSESSMENTS ANIS COUNSELING ❑ Alcohol and drug use assessment for adolescents ❑ Obesity counseling ❑ Oral health risk assessment, dental caries prevention fluoride varnish and oral fluoride supplements ❑ Skin cancer prevention counseling ❑ Diphtheria, Pertussis, Tetanus ❑ Haemophilus Influenzae Type B (Hib) ❑ Hepatitis A and B ❑ Human Papillomavirus (HPV) ❑ Inactivated Poliovirus (Polio) ❑ Influenza (Flu) ❑ Measles, Mumps, Rubella (MMR) ❑ Meningitis ❑ Pneumococcal ❑ Rotavirus ❑ Varicella (Chicken Pox) ❑ Zoster (Herpes, Shingles) r J BlueCross BlueShield of Montana Well Tri° Make Your Fitness Program Membership VVorkfo r fou ! Fitness can be easy, Tun and affordable. Well onTarget makes it possible with the Fitness Program. Since you are a Blue Cross and Blue Shield of Montana member, the Fitness Program is available exclusively to you and your covered dependents (age 18 and older). The program gives you unlimited access to a nationwide network of more than 10,000 fitness locations. If you want, you can choose one gym close to home and one near work. You can visit gyms while you're on vacation or traveling for work. Other program perks include: •- i -• • • r. • • C yH_ ig k'i"-..c"�u, b E'rr''t <''iYYtx$ b'•i..5 .'',.% .-�,,y { G„ Ki ! ?3v"#.i t 3's �". i cE„nkie"a5 ���'2�56 YF �ko-£ >r _ � ,��'_' 4 �4 �z�'✓x �� 'i 4'a1 r� { ,s✓'�^X^$-' 4'.xg .zy '�tv � -i 'c5� h r ..4 ��.f, S,.S. d i`�4't-d�m'+'r`-• ._ Y S � 5 tib. �"' 1"kV� °` �„ � �y. T'"y M '�C ,y „� ,{ v� , ,. • .� .� .i ...YS� ARE YOU READY FOR FITNESS? It's easy to sign up: 1. Go to bcbsmt.com and log in to Blue Access for MemberssM 2. Under "Quick Links," choose "Fitness Program." On this page, you can enroll, search for nearby fitness locations and learn more about the program. 3.Click "Enroll Now." Then search and select the fitness location that is best for you. Remember, you can visit any participating fitness location after you sign up. 4.Verify your personal information and method of payment. Print or download your Fitness Program membership ID card. You may also request to receive the ID card in the mail. 5.Visit a fitness location today! Prefer to sign up by phone or have questions about the Fitness Program? Just call the toll-free number 888 -762 -BLUE (2583) Monday through Friday, between 7 a.m. and 7 p.m. CT (6 a.m. and 6 p.m. MT). The one-time enrollment fee and monthly membership fee for the Fitness Program are both subject to applicable taxes. " Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal for more information. The Fitness Program is provided by Tivity Health'", an independent contractor that administers the Prime Network of fitness locations. The Prime Network is made up of independently owned and operated fitness locations. Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 350150.0218 BlueCross BlueShield of Montana I/Vi riiT r e In 01 1 A lNew Way to Experience, N.N, Well onTarget offers personalized tools and resources to help you — no matter where you may be on the path to health and wellness. Well onTarget can give you the support you need to make healthy choices — while rewarding you for your hard work. MEMBER WELLNESS PORTAL The heart of Well onTarget is the member portal, available at wellontarget.com. It uses the latest technology to offer you an enhanced online experience. This engaging portal links you to a suite of innovative programs and tools. Q Self-directed courses: These courses let you work at your own pace to reach your health goals. Learn more about nutrition, fitness, losing weight, quitting smoking and managing stress. Track your progress and reach your milestones as you make your way through each lesson. Reach your milestones and earn Blue PointssM ' o Health and wellness content: The health library teaches and empowers through evidence -based, reader -friendly articles. e ToaIs and trackers: These resources can help keep you on course while making wellness fun. Use a food and exercise diary, symptom checker and health trackers. ` Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal at wellontarget.com for further information. 60 e ©MOM % LD a `�� C)I Z HEALTH ASSESSMENT (HA) The HA uses adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. This confidential report offers you tips for living your healthiest life. Your answers will help tailor the Well onTarget portal with the programs that may help you reach your goals. BLUE POINTS PROGRAM Blue Points can help motivate you to maintain a healthy lifestyle. Earn points for participating in wellness activities. You can redeem points in the online shopping mall. The program gives you points instantly, so you can use them right away. If you want a larger reward, you can purchase additional points when you check out. FITNESS PROGRAM`} Fitness can be easy, fun and affordable. The Fitness Program is a flexible membership program that gives you unlimited access to a nationwide network of more than 9,000 fitness centers. If you want, you can choose one gym close to home and one near work. And you can visit gyms while you're on vacation or traveling for work. Other program perks include: o No long-term contract: Membership is month to month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25 per member. • Blue Points: Get 2,500 points for joining the Fitness Program. Earn additional points for weekly visits. • Convenient payment: Monthly fees are paid via automatic credit card or bank account withdrawals. © Web resources: You can go online to locate gyms and track your visits. • Health and wellness discounts: Save money through a nationwide complementary and alternative medicine network of 40,000 health and well-being providers, such as massage therapists, personal trainers and nutrition counselors. It's easy to join the Fitness Program! Just call the toll-free number 888 -762 -BLUE (2583) Monday through Friday, from 8 a.m. to 9 p.m. in any continental U.S. time zone. FITNESS TRACKING Track your fitness activity using popular fitness devices and mobile apps. WELLNESS PROGRAM QUESTIONS? Call Customer Service at 877-806-9380. The Fitness Program is provided by Healthways, Inc., an independent contractor that administers the Prime Network of fitness centers. The Prime Network is made up of independently owned and operated fitness centers. Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 350148.0616 09 BlueCross BlueShield of Montana Care When and Where You Need it Just Got Easier Getting sick is never convenient, and finding time to get to the doctor can be hard. Blue Cross and Blue Shield of Montana (BCBSMT) provides you and your covered dependents access to care for non- emergency medical issues and behavioral health needs through MDLIVE. Whether you're at home or traveling, access to a board-certified doctor is available 24 hours a day, seven days a week. You can speak to a doctor immediately or schedule an appointment based on your availability. Virtual visits can also be a better alternative than going to the emergency room or urgent care center.' MDLIVE doctors or therapists can help treat the following conditions and more: General Health Allergies Asthma Nausea Sinus infections Pediatric Care Cold Flu Ear problems Pinkeye Behavioral; Health Anxiety/depression Child behavior/learning issues Marriage problems ( Blue Cross and Blue Shield of Montana, a Division of fleapit Care Service Corporation, a Mutual Legal Reserve Company. an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross". Blue ShieW and the Coss and Shield Symbols are registared service marks of the Blue Cross and Blue Shield Association, an association of independent BU Cross and Blue Shield Plans. MDLIVE, an independent company, provides virtual visit services for Blue Cross and Blue Shield ofMontana. MDLIVE operates and administers the virtual visit program and is solely responsible for its operations and that of its contracted providers. MDLIVE and the MOLWE logo are registered trademarks of MOLIVE.Inc. and may not he used without vaittan permission. 352512.0217 Website: Visit the website MDLiVE.com/bcbsmt Choose a doctor Video chat with the doctor You can also access through Blue Access for Members" Mobile App: Download the MDLIVE app from the Apple App Store'', Google Play" Store or Windows° Store Open the app and choose an MDLIVE doctor Chat with the doctor from your mobile device G 9 -1! co:ginWc;--,-B hod a�} To re istra', you'll neeed to up-avide you first ?skid Iasi plasne, date of babtb and BUSNIm-pipber ID nmtder. In the event of an emergency, this service should not take the place of an ennrgeney mom or urgent care center, MULIVE dochus do not take lite place of your primary care duclot. Proper diagnosis should coma horn yoordoctut, and medical advice is always between you and your doctor. Internet/Wi-ri connection is needed for ccmputer access. Data charges may applywhen using your tablet or smartphone. Check your phone cartie(s plan for derails. Video on -demand consultations for behavioral health are available by appointment. Service is limited to interactive -audio consultations (phone only), along with the ability to prescribe, alien clinically appropriate. in texas. Service is limited to interactive-audio/video (video only), along with the ability to prescribe, vdten clinically appropriate, in Idaho, Montana. New Mexico and Uklahoma. Virtual visits are currently not available in Arkansas. Service availability depends on nxmber s location. Virtual visits may not be available on all plans. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulations and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA -controlled substances, non -therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care far polential misuse of services. App Store is a service mark of Apple Inc. Google Play Store is a trademark of Google Inc. ('Google'). Windows is a registered mark of Microsof r" BlueCr®ss BlueShi.eld. of Montana y .. a ofcon Provider Funder°, from Blue Cross and Blue Shield of Montana (BCBSMT), is an innovative tool using the nation's largest claims database that helps your employees find in -network doctors and hospitals, compare the costs and quality for more than 1500 procedures, and estimate out-of-pocket costs before making treatment decisions. Members can log in to Blue Access for Memberss•! on mobile or the web to use Provider Finder to: o Find a network primary care physician, specialist or hospital. • Filter search results by doctor, location, specialty, ZIP code, language and gender — even get directions from Google MapsTlm • Estimate the cost of a provider's procedures, treatments and tests — and estimate their out-of-pocket expenses. • Determine if a Blue Distinction®.Center is an option for treatment. © View patient feedback and add a provider review. Check the clinical quality data from Blue Cross and Blue Shield as well as independent third parties. Search in Spanish. o Review providers' certifications, recognitions, awards and publications. Accurate This tool helps members estimate the overall cost of procedures, treatments, and tests, while calculating their out-of-pocket expenses, all based on the search parameters, they choose. Members are able to compare estimated costs between different providers, based on typical episodes of care. With information on over 20,000 healthcare facilities and more than 400,000 professional providers, as well as cost information for more than 1,500 treatment categories, Provider Finder is a robust database. Personal This tool provides information and costs that apply to a specific member's health benefit plan to estimate the cost of care. This means members can instantly see how much they will need to pay in deductible, coinsurance or copayments, in addition to seeing how much their plans may pay. Data are presented in a:format that's easy to navigate and helps your employees better understand how their benefits work. Active, Engaged Employees Lower Health Care Costs You want your employees to live healthier, happier lives while lowering your costs for their health care. Provider Finder does just that — giving accurate, transparent and personal information based on the employee's specific benefit plan. This tool is available on mobile as well, helping members where they are and when they need access to this information. Blue Cross and Blue Shield of Montana. a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent licensee of the Blue Cross and Blue Shield Association 350608.0315 in, to You Medication Covered at $0 CosL �, r.• Your health plan may include certain prescription and over-the-counter (OTC) preventive medicines, as a benefit of membership, at no cost to you when you use a pharmacy or doctor in your health plan's network. There is no co-pay, deductible or coinsurance, even if your deductible or out-of-pocket maximum has not been met. Coverage for these medicines can vary according to the type of plan you are enrolled in. Call the Customer Service number listed on your member ID card to find out what drugs are covered at no cost share under your plan. Below are the preventive care drugs that may be covered under your plan for both adults and children. Please see the Women's Contraceptive Coverage List for a list of contraceptive methods that may be covered at no cost to you. Age limits, restrictions and other requirements may apply.* Generic Drugs = bold Brand Drugs = CAPITAL LETTERS 354674.1017 ACTHIB ADACEL AFLURIA/ PF/QUADRIVALENT BEXSERO BOOSTRIX CERVARIX COMM DAPTACEL DIPHTHERIAITETANUS TOXOID EPIGERIX-B FLUAD FLUARIX QUADRIVALENT FLUBLOK FLULAVAL QUADRIVALENT FLUVIRIN FLUZONE/HIGH-DOSE/INTRADERMAL/QUADRIVALENT/SPLIT GARDASIL GARDASIL 9 HAVRIX HIBERIX INFANRIX IPOL INACTIVATED IPV KINRIX M-M-R 11 MENACTRA MENHIBRIX MENOMUNE-A/C/Y/W 135 MENVEO PEDIARIX PEDVAX HIB PENTACEL Generic Drugs = bold Brand Drugs = CAPITAL LETTERS PNEUMOVAX 23 PREVNAR 13 PROQUAO QUADRACEL RECOMBIVAX HB ROTARiX ROTATEQ TENIVAC TETANUS/DIPHTHERIA TOXOIDS TRUMENBA TWINRIX VAQTA VARIVAX cholecalciferol cap 400 unit, 1000 unit cholecalciferol chew tab 400 unit, 1000 unit cholecalciferol drops 400 unit/0.03 mL (per, drop), 5000 unit/mL (1000 unit/0.2 ml) cholecalciferol oral liquid 400 unit/mL cholecalciferol tab 400 unit, 1000 unit Some of these products maybe covered under your medical benefit it provided by a doctor in your health plan's netwrork. Pieseripton coveraga for these drugs may vary according to the terns and conditions of the plan. A prescription may be requited to covet without cost-sharing under die pharmacf benulit for non-grimifathered plans. The plan may also require a generic drug lobe hied fast belote tho btand%cision. nhis infunnation is lot inlamiational purposes only, does not constitute legal or otreradvice and should not be relied upon to determine coverage. bealinent decisions are ben%v-ir the member and his to her health care pimidet. Coverage is all. -Is subject to die hmitations and exclusions of the benefit plan. for details about your plan. dmck your benefit materials or call the Pharmacy Program number on your mc,ty 10 card. Third -parry brand names are die property oftheirrespectiveowners. Enrollment: Enrolled Employees: 67 If enrollment differs by 10% or more, the rate guarantee is void and subject to a new rating evaluation. If plan(s) quoted below are not purchased with 75 days of effective date stated above, the rate guarantee is void and subject to a new rating evaluation. Contract Period: 12 month rate only * Medical Deductible Credit: Included at no charge Medical OOP Credit: NOT Included, unavailable option Rx, Dental, Vision and other deductible and OOP credits are not available. Commissions: 1.32% COBRA Administration: COBRA administration through PacificSource Administrators is included in premium. Eligibility: Employees must work a normal workweek minimum of 20 or more hours PacificSource requires a minimum of 75% of all eligible employees to participate in the plan. Note: Waiving to Individual coverage is counted against participation • PacificSource requires that the employer contribute a minimum of 75% to the employee rate or 50% of the total rate. Based on the information submitted, this is at 100% EE and fixed varying amount for dep and must be maintained by employer. Yes No ✓ Are there retirees under 65 (Early Retirees)? ✓ Are there retirees over 65 (Medicare Eligible)? ✓ Are there COBRA participants? Other: Refer to Value Added Services Quote Information: Standard PacificSource benefit structure, limitations and exclusions apply. Yes No ✓ Matching, as best as possible, Groups Ded/Coins/OOP/Copay structure ONLY? ✓ Benefits are Standard "chassis" PacificSource structure, limitations and exclusion? ✓ Matching Groups current benefit limitations and exclusions? ✓ If applicable, is the copay bundling option defined (PS Standard, Option B, Option A)? MDL Rx Formulary? Which copay bundling option? Any other Notes: ER copay match does not apply ificsOUYCQ lfEAtTtf BAN_ Date Printed: May 31, 2018 Group Name: City Of Laurel Effective Date: July 1, 2018 Agent: Eric Allen Enrollment: Enrolled Employees: 67 If enrollment differs by 10% or more, the rate guarantee is void and subject to a new rating evaluation. If plan(s) quoted below are not purchased with 75 days of effective date stated above, the rate guarantee is void and subject to a new rating evaluation. Contract Period: 12 month rate only * Medical Deductible Credit: Included at no charge Medical OOP Credit: NOT Included, unavailable option Rx, Dental, Vision and other deductible and OOP credits are not available. Commissions: 1.32% COBRA Administration: COBRA administration through PacificSource Administrators is included in premium. Eligibility: Employees must work a normal workweek minimum of 20 or more hours PacificSource requires a minimum of 75% of all eligible employees to participate in the plan. Note: Waiving to Individual coverage is counted against participation • PacificSource requires that the employer contribute a minimum of 75% to the employee rate or 50% of the total rate. Based on the information submitted, this is at 100% EE and fixed varying amount for dep and must be maintained by employer. Yes No ✓ Are there retirees under 65 (Early Retirees)? ✓ Are there retirees over 65 (Medicare Eligible)? ✓ Are there COBRA participants? Other: Refer to Value Added Services Quote Information: Standard PacificSource benefit structure, limitations and exclusions apply. Yes No ✓ Matching, as best as possible, Groups Ded/Coins/OOP/Copay structure ONLY? ✓ Benefits are Standard "chassis" PacificSource structure, limitations and exclusion? ✓ Matching Groups current benefit limitations and exclusions? ✓ If applicable, is the copay bundling option defined (PS Standard, Option B, Option A)? MDL Rx Formulary? Which copay bundling option? Any other Notes: ER copay match does not apply PlciticS,ource HEALTH PLANS City of Laurel Rates: Medical Plans: PSN 500 25_20 2500 $779.77 $1,729.93 $1,240.65 $1,987.66 $584.83 $1,169.66 2x Family Ded/OOP Rx 100, 10140/60% to $200 2x Mail Order PSN 1500 35_30 PSN 1000 2520 3500 2500 $701.93 EE 1 $746.91 $1,557.63 $1,295.02 ES $1,657.02 $1,788.82 $1,487.62 EC $1,188.36 $1,052.90 EF $1,903.89 Rx 100, 10/40160% to $200 2x OON Ded/OOP Smed $560.18 Prev Rx 2P Med $1,120.36 2x Family Ded/OOP Rx 100, 10140/60% to $200 2x Mail Order PSN 500 25_20 2500 $779.77 $1,729.93 $1,240.65 $1,987.66 $584.83 $1,169.66 2x Family Ded/OOP Rx 100, 10140/60% to $200 2x Mail Order PSN 1500 35_30 3500 PSN 3500+Rx $701.93 $583.61 $1,557.63 $1,295.02 $1.115.14 $927.94 $1,788.82 $1,487.62 $526.45 $1,052.90 2x Family Ded/OOP 2x Family Ded/OOP Rx 100, 10/40160% to $200 2x OON Ded/OOP 2x Mail Order Embedded Ded Prev Rx Signature: Date: Note: EAP is not included Benefit Period: Calendar Year Conditions: Offer assumes the contract situs and issuance of contract is in Montana This quote assumes PacificSource will be the only carrier providing coverage to the employer group's employees Open Enrollment will be one month prior to the renewal date Regulations require PacificSource to determine, based on the information provided in the quoting process, whether an employer is subject to Chapter 26 of the Montana Code Annotated. This proposal is made on the condition you are not a Small Employer Employer will promptly notify PacificSource of any change in participation and Employer contribution ACA established a number of taxes and fees that are incorporated into your premiums. Two of those fees are: (1) the Annual Fee on Health Insurers or "HIT(Health Insurer Tax)": and (2) the Transitional Reinsurance Fee. Both fees began in 2014. (1) Section 9010(a) of ACA requires that ("health insurers) pay an annual fee to the federal government, commonly referred to as the Health Insurer Fee. The amount of this fee will be determined by the federal government. This fee helps fund premium tax credits and cost-sharing subsidies offered to certain individuals who purchase coverage on health insurance exchanges. As of late 2015, this fee currently has been suspended for 2017 only. The fee still applies in 2016 and, pending any further legislation, could recontinue in 2018. (2) Section 1341 of ACA provides for the establishment of a temporary reinsurance program (for a three year period (2014-2016) which is funded by Reinsurance Fees collected from health insurance issuers and self-funded group health plans. Federal and state governments provide information as to how these fees are calculated. Federal regulations establish a flat, per member, per month fee. The temporary reinsurance programs, funded by these Reinsurance Fees, help to stabilize premiums in the individual market. �'NC[r# S{niiCO cartl' r � ftciticS.ource HEALTH PLANS Outline of Coverage PSN 500+2520 S2 City of Laurel Option B Bundling. This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. PLEASE READ YOUR MEMBER HANDBOOK CAREFULLY. Provider Network: PSN MEMOWMTI-1 All Providers Please note: Your actual costs for services provided by a non -participating provider may exceed this policy's out-of-pocket limit for non -participating provider services. In addition, non -participating providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and this amount is not counted toward the non -participating out- of-pocket lirnit. Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service Well bab /Weil child care No char e* � �" 5°o,,Co,� 131,'atlra�ce � �.� Well woman visits Preventive mammograms s No W-01 , Immunizations rt Preventive colonoscopyNo char e* De : tib efhe : 3` /Qco=ace Prostate cancer screenin No char e MEN,, AI WM4 Office home visits U1, and Naturopath office visits Specialist office and home visits Telemedicine visits $25 co Pis i Mull Y, ffl'ef efff . . N PSGOOC.MT.LG.0118 Service Office procedures and supplies Surgery .. . - . . - .. .. . • , . - �} 3 Deductible then 20°lo co insurance ®e c i = e E e t Outpatient rehabilitation Deductible then 20% co insurance' i ergo ca= r1s a - services �- f3Y' i .y,�\., ,j�Sy 42 : {` �G X� Si �� -. b 6 � ^C}'b .-....�.i• �d:{".f ice^ .Y � 'inW`,�'. S'�rv,"iyA? '7'�hS board Deductible then 20% Go insura.p.664, Inpatient room and Inpatient rehabilitation peductibJe then 20% co insurance �®� u�'I=� 4 e � - " e=- ° r. , � x services � x Skilled nursing facility care Deductible then 20% co insurance'e u`te 'erg °o coir s =a e Y)dc %r,..v°��w��"'.t�# '"k"r ^ i.'' "y ``•f.� `yam j Y.s f .tF ;2" ..� O�utpatientSe ices�.E, Outpatient surgery/services Deductible then20% co insurance �i.`�` fib°co ase Advanced diagnosticDe°ductiblethen ,. 20%coinsurance e�,tia�b' imaging Diagnostic and therapeutic Detluctible then 20°lo co insurance be he =Y °lo c `i uta` oe radiology/lab ,cti Y Ur�entand Emergency Services a_ 7 s :_ ti x t a cel Urgent care center visits $25 co pay/uisit`euchep�U Emergency room visits — Deductible then,$100 co paylvisit edctt e e = 'I,0 �co aa1u s" ' 0°locoins } c� medical emergencylus 20% co insurance^ s =a Emergency room visits — Deductible theh $100 co paylvisit edIE y he . t °o paves ° e non-emergencyfus.20%:co insurance"� ° i sir cel Ambulance, ground Deductible then 20°lo co insurance RAW Ambulance, air Deductible then'20°Jo co insurance '^ S. :: ,i.^'+ u.. ..i._; f `•' xx x r -{ Se''v.S _ x. p rs-.a y ' 0�a., 1 �'r, fa".'ra'.� '' el.� ..„+.t, ka"F . r ¢ ;x kyra.' C,Sf.'..»`°,..✓ Physician/Provider services Deductible then 20°l0 ca msrance ®ed,�ti •`1 tie k- 50 eco Os lobal char e � t � Hospital/Facility services Deductible then`2�°Io co` insurance.e " ct s f e 5°0 =au a =e x `� x x Mental�Healfh/Chemical'13ependency SerAv�ices-- ..- � ,::Ca"'-�_.:;c.. ,.,z.,�:�c,.�*,�ar.;_.,-.. ,.r.^�+...:�. yes. s-.�..,,..t:J. a �.•. �. �..c:-., _ -- . _ Deductible,then,20°loco insurance ®.P'�G'i `. � e : '` �'/ ,o ��� Inpatient care Residential programs z r ° { o insurance Ded ` = e o } Deductiblerthen 2010 c � " n �+��'W+ �,.7*o-=k1 �i':`�iR.3. � ,h ,yn•..C��"z"i W€i'gK �*.� h2 ?N53c'xl *+. P`. �+r,;<U "�4{�.^`4+� z`�. '�'h"'k��^.�.' :u`::. Other�Couered�S e'r Y�1reS. ,L'4u:Y�5s.�4 1be� S5v^_� ,......::.TrT. _r>.v ..».. .• � /visit* i e he'10U °e Allergy injections $5 co pay ®u�c 20rb664,jnsurance fle- ozi be -e ,35 0 o'Osa a cep Durable medical e ui ment Detluctible'then Home health care Deductible thenf20°loco insurance . `a b a b e e: ct� . Chiropractic manipulations and acupuncture `Deductible .then charge ®pci. t ;c 1 . ; . e ; "a Transplants a ,No y This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. " Co -pay waived if admitted into hospital. PSGOOC.MT.LG.0118 * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT.LG.0118 i i6 p s Prescription Drug Benefit Summary HEALTH PIANS MT 10-40-60P 100D S2 MDL City of Laurel This PacificSource health plan includes coverage for prescription drugs and certain other pharmaceuticals, subject to the information below. This plan complies with federal health care reform. PRESCRIPTION DRUG DEDUCTIBLE $100 per person The deductible is an amount of covered pharmacy expenses the member pays for brand medications each calendar year before the following benefits begin. Co -payments, differential between brand and generic drugs, drugs obtained without using the PacificSource member ID card, and non -participating pharmacy charges do not accumulate toward the deductible. The deductible does not apply to Tier one drugs. The amount you pay for covered prescriptions at participating and non -participating pharmacies applies toward your plan's participating medical out-of-pocket limit, which is shown on the Medical Benefit Summary. The co -payment and/or co-insurance for prescription drugs obtained from a participating or non -participating pharmacy are waived during the remainder of the calendar year in which you have satisfied the medical out-of-pocket limit. Each time a covered pharmaceutical is dispensed, you are responsible for the amounts below: ^ Remember to show your PacificSource member ID card each time you fill a prescription at a retail pharmacy. If your ID card is not used, your benefits cannot be applied and may result in higher out-of-pocket cost. * Not subject to annual prescription drug and/or medical deductible. "Compounded medications are subject to a preauthorization process. Compounds are generally t� covered only when all commercially available formulary products have been exhausted and all the ingredients in the compounded medication are on the applicable formulary. MAC B - Unless the prescribing provider requires the use of a brand name drug, the prescription PSG BS. MT. LG. RX. 0118 Up to a 30 day supply: $10 co pay* Deductible then Deductible therif the` lesser of 3200 co pay $40 co ay.,or 60% co insurance' Partic�patmg 11llail girder rmacy .. ......,.. w.. __,.e.... ._. .._.. Wim_,. _.._.._0 Up to a 30 day supply: $10 Deductible then Deductible ther��the lesser co pay* $40 co pay of $200 co pay or.6.Q°/°, eo insurance: 31 — 90 day supply: $20 co pay* Deductible then $80 co pay Deductible then:ahe lesser of $400 co pay or 60°lo ;4,h J ce � r J Non 16, 06Pharmacy � ;r 30 day max fill, no more than three fills allowed er ear: Deductible: then 90% co insurance = . Ti"K-4-S"pecialty Drugs Part�c�pat�ng SpecialtyPharmacy ti Up to a 30 day supply: Deductible then the lesser of $200 co=pay or 20°1° co insurance y ` T�er 4FSpec�alty Drugs Not,f��ledthrough_Parfic�patinglSpectaltyPharm_acy � �� ry � ��, 30 day max fill, no more than ° Deductible then 90 /° three fills allowed er ear: co insurance .._". _ _:' Up to a 30 day supply: ,Deductible then the lesser of $2100 co -pay ar 60°l0 co insurance .x ^ Remember to show your PacificSource member ID card each time you fill a prescription at a retail pharmacy. If your ID card is not used, your benefits cannot be applied and may result in higher out-of-pocket cost. * Not subject to annual prescription drug and/or medical deductible. "Compounded medications are subject to a preauthorization process. Compounds are generally t� covered only when all commercially available formulary products have been exhausted and all the ingredients in the compounded medication are on the applicable formulary. MAC B - Unless the prescribing provider requires the use of a brand name drug, the prescription PSG BS. MT. LG. RX. 0118 will automatically be tilled with a generic drug when available and permissible by state law. If you receive a brand name drug when a generic is available, you will be responsible for the brand name drug's co -payment andlor co-insurance plus the difference in cost between the brand name drug and its generic equivalent after the deductible is met. if your prescribing provider requires the use of a brand name drug, the prescription will be filled with the brand name drug and you will be responsible for the brand name drug's co -payment andlor co-insurance after the deductible is met. The cost difference between the brand name and generic drug does not apply toward the medical plan's deductible or out-of-pocket limit. See your member handbook for important information about your prescription drug benefit, including which drugs are covered, limitations, and more. PSGBS.MT.LG.RX.0118 0--,) PadticSource HEALTH PLANS Outline of Coverage PSN 1000+2520 S2 -- City of Laurel Option B Bundling This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. PLEASE READ YOUR MEMBER HANDBOOK CAREFULLY. Provider Network: PSN 1 ice a - •- "• s •_ - c q - "'- - a $2,000 All Providers $1,000 -ag a ..® � •- a ®. •. All Providers $2,500 $5,000 Please note: Your actual costs for services provided by a non -participating provider may exceed this policy's out-of-pocket limit for non -participating provider services. In addition, non -participating providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and this amount is not counted toward the non -participating out- of-pocket limit. Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service _ • - . - . . - Prevenf�ve Care Well bab~/Well child careNo char e* �����35°I'o�co nsuran�E �- Preventive h sicals No char e'` ..,� �`3�5%�'co��r�su a.�ce �� We(I woman visitsgg gft No char e No�ch'�e Preventive mammograms Wk..charge�lo cLie= r Immunizations N ar eo ch'f�No�c� -.,_.... g :� ....:940 Ml • * -, -_ s. y'�,yt'�NC'�'+ k .�y�y�.r �`�-r,�k�„�•,-�+ Preventive colonoscopy No charge Deduct ble t e, 35 o ca4gi.5 nc Prostate cancer screeningNo char e*.�°locoinsuie Professional Serv►ces� z Fz..zr Office and home visits $25 co a luisit �b1et}�eri35°eco tnsGa ee Naturopath office v_�MAce Specialist office an ............ $25 co pay/visitvisits Dedaeble the35consuncew Telemedicine visits $25 co paylvisit*Dedmc itetlie3SQ/� const an PSGOOC.MT.LG.0118 Service Office procedures and No char e g pe, o fb°k°s i hie«. supplies , Deductible then 20% co insurance Dedcf e a cel Surgery ,,°moo, Outpatient rehabilitation Deductible then' 20%' co insurance- Dau services 1 lospitalvSeruices `_<v. ` a M* s z e /° nsura� DeductibCe then' 20% co insurance �° Inpatient room and board _educ[e Inpatient rehabilitation o �� e o coir s e* Deductible then 20 /° co insurance services gM�educt�bl'e Skilled nursing facility care e°oag urance.' M��'•{f ersL 77 3} v:. $jE 1 S M C}ut agent Services , then 20% co insurancep�edt�ble tet°100= Outpatient surgery/services Deductib{e �suanCe Advanced diagnostic co Uedct�blethe 5°° c Yinsa�e Deductible then 20°lo insurance . imaging Diagnostic and therapeutic o r „ Deductible then 20 /0 eo insurance Dent etible hen 35°° co �nsura�e radiology/lab f Urgenf`and Emergency Services .: $25 co Deductblethe5°loconsuance . Urgent care center visits pay/vis�t� Emergency room visits — ,max Deductible then $100 co pay/visitDeduct�ble�t'hen$�104 co payus�t . ° lus 20°lo co insurance^ lus20 oo �hsranc ; medical emer enc aX43' ra tt Emergency visits — xvv x xg t Deductible then V120 WcopayviSitDuct�bie_het room 'lus35°° �nstrace� �. non -emergency lus 20% co insurance^' Deductible then 20°!o c0 insuranceR ®z,, tib e E Ambulance, ground then 20J°.'co msur�ance De uc� b( t%e to, W, s e Ambulance, air Deductible t �3 Ma#ern�tyySCi�V �lre7a 1 { S V 7 } lL CrTi Physician/Provider services } o . D'edu"ct�ble�ther 3�5�go co��su�a�ce� Deductible then 2010 co insurance (global charge) onsue Hospital/Facility services , Deucible then 20% co insuran ce cbeuct%ens°0 dt Men#a1 Heal#hlChe"PA Dependency Services Ig $25 co ��y, ttblehe°o come Office visits �L pay/visit �Deutbletfast5%ot�suneF Inpatient care Deiductible then 20% co insurance then 20°lo co insurance Detic5tblete„°/ cone a� Residential programs Ded'u`ctible r7 fJtherCauered Services 2- �,'. la 5ti7artce Allergy injections ,$5 co pay/visit* �Deduetibleihen�U% asp °o c seance Durable equipment Deductible then 20% coinr medical Deductible then 20% co assurance®deibleica -r a0ce4 Home health care Chiropractic manipulations - $25 co a /'isit e uctibletlle a -,o s" anee and acupuncture 3p - Y 5co�sn�ce Deductible then No charge 1 ®ectbe theme 100 Transplants -_,..z.___........ .. _.......t__...., ._w. This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. ^ Co -pay waived if admitted into hospital. PSGOOC.MT.LG.0118 * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT.LG.0118 Pacitic-Source. HEALTH PLAN'S Outline of Coverage PSN 1500+35_30 S2 City of Laurel Option B Bundling This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. PLEASE READ YOUR MEMBER HANDBOOK CAREFULLY. Provider Network: PSN Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. { PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1%, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service $1,500 All Providers $3,000 d �,''}: i h All Providers $3,500 $7,000 Please note: Your actual costs for services provided by a non -participating provider may exceed this policy's out-of-pocket limit for non -participating provider services. In addition, non -participating providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and this amount is not counted toward the non -participating out- of-pocket limit. Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. { PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1%, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service a rb jC' . y ;-.?if.x. ' Preventr�e,Care - a .. ...a �__. .� W r.. _.... Well bab /Wel child care _.. 45%�c�o No charge..._ ..... _ .._... .- Preventive physicals No charge*; �� X45°� co ns>,� ane ���`� No char e* Nocha9e Iffl, MX_ Well woman visits Preventive mammograms No charge * t Fla char a*� 4-M Ed -1 y Immunizations x `a No charge - '.. No c , 7_7g- OEM Preventive colonoscopy n; No charge * ` De acete4{5°l0 Q ih�san e l ? _... . _.._......-._. _ ,, y _ Prostate cancer screening rso�a $35 Office and home visits co pay/visaDeducttbethen.51oco%rar�ce< Naturopath office visits $3;5 coYpay/visit* De u�tlethenv° o s of p $35 co -�Dedu�c�ib e,then�4��0 o�ms��ranc�j visits - pay/visit _ *�� a� ductib(e then coin .anceR Telemedicine visits $35 co pay/visit _D PSGOOC.MT.LG.0118 Service- Oficerocedures and p 3 . No charged s ns ae supplies Surgery p Deductible then 30% eo insurance �De�ducib.I.efie F 'tecta Outpatient rehabilitation peductible then„30°lo co insurance®�e e ibi t e = ' ' ©=-fn services H y ^i{r 4” : —ri ...' �.: i-'• 'i y YA" , F M 2+�iJ "SC -d S '"a �''+..e"'.=C%l��i {' "':L'Y� �:X's. k' '.y ai�G+'�5��^y'- `4°�: i ` EV, 3Q%co msurance4Dredact�th°°nsuran ���� Inpatient room and board Deductible then? Inpatient rehabilitation then 3Q% co insurance �Dei:e °o co ssuranee services Deductible Skilled nursing facility care w'+-rW+'i Deductible then 30% co insurance peducfi b�iehgg Wco�;uare -" A 'z�"`*�F l .S Outpatient Sertces t Deductible then 30% co InsuranceDeducttble h Qom/ ns a Outpatient surgery/services Advanced diagnostic ��. Deductible then 30% co insurance: ®edtacttbJe tete % co Insp phoe = �� imaging Diagnostic and therapeutic g p 30% co ��Ded.uct ble then l5°o�co p s rran.. Deductible then insurance radiology/lab Ukrgent`andEmergency_Servtces ;� � ¢` 1N.s sr 35ca a /vis$ it*Deus# blehen, /oco��nsrance, Urgent care center visits p Y Emergency room visits — Deductible then $1 fl0 co pay/visit jDcth n�0opayvis R. (us30%:co Insurance^Eus30oo rns__ursance N medical emergency _eg x Emergency room visits — Deductible then $100 co pay/visa en00copas f tDeucblet us45�o rns non-emergency lus 30% co insurance^� Deductible then 3Q°10 co insuranceDe uctEblt =S eflQo' "co msuuace Ambulance, ground .. _....z' .,.:. !'^...A Deductible then 3Q% co insurance Decucib�ihe`0 o Its cel Ambulance, air ..A�tr[� 5+ }t—' .3/ `e t .�'r .y } t �xY �a .:•` 1m3 Y' S:. i Y L 15 . L;. Y S^jL :`�ry` 1 �"iv^ F �%J'i Y f }t Physician/Provider services Deductible then 30% co insurance uctibetthe 5%or�surart`ce Deductible then 30% co insurance}etie e 45I?!o o nsurce Hospital/Facility services - xFS xt „r• 1, bi ,,,, E:. Services MentalHealthlChem�calDepende,icy ',t cep Office visits $35 co pay/visit* y _..�e5°.coria Deductible�then 30°l co ms'urance pectic e;e 50 'sre cel Inpatient care 30% Ded ° ctlbt e °a con ra Residential programs Deductible then co insurance $ - p,Sw . - T .y... j . 5` S ��.. � ',.+ 2 E''• x.d� �'F'YY � h � Y. TY `3: Kt ,'}' � b. �. ,'. ..,Z. 'a J * ii w HidY j Y w Tx x% Other Covered Services_ , s. 77777777 � t = �ranc�e Allergy injections $6 co P, ay s��� Dductiie�'e ;4oe ay/ v:� (171 '01 then 30%co msuranea Deductieer=4a"°� moo- s a Durable medical equipment {Deductible _ ,, then 30%co insuranceettbe he f ' co isu�ra Home health care Deductible .o Chiropractic manipulations D the 5°T a=rn`sur ee $35 co pay/visits uctib`e and acupuncture Oild�ct le th 45 c E . Transplants . Deductible'then No charge 4 rY This is a brief summary of benefits. Refer to your -handbook for additional information or a further explanation of benefits, limitations, and exclusions. ^ Co -pay waived if admitted into hospital. PSGOOC.MT.LG.0118 * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT.LG.0118 r o s P a `Source HEALTH PLANS Outline of Coverage PSN HSA 3500+Rx S2 City of Laurel This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. PLEASE READ YOUR MEMBER HANDBOOK CAREFULLY. Provider Network: PSN Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service.- Participating Providers $3,500 $7,000 Non -participating Providers $7,000 $14,000 No charge' = r� � �No char�ge� �` $700 Participating Providers $3,500 Non -participating Providers $7,000 $14,000 Please note: Participating provider deductible and out-of-pocket limit accumulates separately from the non -participating provider deductible and out-of-pocket limit. Even though you may have the same benefit for participating and non -participating providers, your actual costs for services provided by a non -participating provider may exceed this policy's out-of-pocket limit for non -participating provider services. In addition, non -participating providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and this amount is not counted toward the non -participating out-of-pocket limit. Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service.- .:> y t : Lr�,,. '''z^ r rx+...w•--_.= z-; ..� �;.,s t � � s x s+ -^y r � � .r^� c�S^ s .Wel( baby/Well child care No charge' = r� � �No char�ge� �` v Well woman visits No charge's Preventive mammograms -- No charge N - r- Immunizations No charge " .�* „� "c.g> �� _E' �°IN Preventive colonoscopy No charge ®ed ctibfi.c! rg-e „ Prostate cancer screenin 9 No char e*:NEW jo °sa_010ber' ~ .s a g . -Professional Services 4Y -,Civ�.„!°h1 k, L .' +E! } �� �rr.Y` Yk y'z Office home Deductible then No,charge° �d-uct�,blethen �h�g �����Y and visits rt ,;�De� Naturopath office visits ,Deductible then No.charge _ � e��it ctible�e�ac� �.,, PSGOOC.MT.LG.0118 Specialist office and home Deductible then No PIW99 Visits Telemedicine visits .,--'�,,,� nnab tiblcharge --Z Office procedures and supplies Surgery Deductible then No I Outpatient rehabilitation01 -tibji�Mh D 6 d U d, services "41'r, NO board Deductible then No charge � •D'e�a�c.�t�t (npatient room and Inpatient rehabilitation _ L Deductible then No charge � Deducrib�l'� J se �' ° cha ige services 37- --'7,- ------------------.......... then N b h��� am I Skilled nursing facility care W, INNIMU charge b 1 1:2 1 4 M - - -------- T7 M N t M hJa surgery/services Outpatient surgery/s Deductible .N.0 Me Advanced diagnostic t N A M imHmIMoMvMT "Deductible then N6charge rgq, imaging L; u therape tic Diagnostic and Deductible then N' "h radiology/lab - Rep 'R, MM N C Urgent care center visits Emergency room visits — 'dtibld-1hab:� charge bed cfiib(e :i:� medical emergency Emergency room visits 71 h We n -emergency on Deductible AM i, Ma UE Ambulance, ground Hibl&-"th n-'-, No charge * 7777777777-v%char, ---.Deductible -j No INNII WE" adtf Ambulance, air charge TI- Maternity '5A 2 MM �i; Physician/Provider services Deductib4le then No -ha' ... e'0'V Gil U, ART a (global charge) tbg o char Hospital/Facility services 016 a Ng W OR, M , �� � �W I AMI Deductible then No charge' -� p}ed�e�th�„ e:N;o�eha �qe� Office visits • MONA charge i rg ED then No ro (npatient care Deductible R. bible enhgt "th. Residential programs J)" A Deductible tiblNo charge M mog, 2:k R Other -Covered aG Allergy injections Deductible -tib "charge V - i -b PLO'No:- Durable medical equipment ae Home health care Lim Chiropractic manipulations .7R and acupuncture T 7 NO M a.- 01 '0 :V4 r. p, q PSGOOC.MT.LG.0118 This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT.LG.0118 PaciticSource HEALTH PLANS Citv of Laurel Prescription Drug Benefit Summary MT 3500D S2 MDL This PacificSource health plan includes coverage for prescription drugs and certain other pharmaceuticals, subject to the information below. This plan complies with federal health care reform. MEDICAL PLAN DEDUCTIBLE You must meet the medical plan deductibles, which are shown on the Medical Benefit Summary, before your prescription drug benefits begin for Tier one, Tier two, Tier three, compound, and/or Tier four prescription drugs. The amount you pay for covered prescriptions at participating and non -participating pharmacies applies toward your plan's participating medical out-of-pocket limit, which is shown on the Medical Benefit Summary. The co -payment and/or co-insurance for prescription drugs obtained from a participating or non -participating pharmacy are waived during the remainder of the calendar year in which you have satisfied the medical out-of-pocket limit. PACIFICSOURCE PREVENTIVE RX Your prescription benefit includes certain outpatient drugs as a preventive benefit at no charge. This includes specific drugs that are taken regularly to prevent a disease or to keep a specific disease or condition from progressing. Preventive drugs are taken to help avoid many illnesses and conditions. These preventive drugs are not subject to the deductible. You can get a list of covered preventive drugs by contacting our Customer Service team or visit PacificSource.com/drug-list/. Each time a covered pharmaceutical is dispensed, you are responsible for the amounts below: ^ Remember to show your PacificSource member ID card each time you fill a prescription at a retail pharmacy. If your ID card is not used, your benefits cannot be applied and may result in higher out-of-pocket cost. * Not subject to annual medical deductible. **Compounded medications are subject to a preauthorization process. Compounds are generally covered only when all commercially available formulary products have been exhausted and all the ingredients in the compounded medication are on the applicable formulary. MAC B - Unless the prescribing provider requires the use of a brand name drug, the prescription PSGBS.MT.LG.RX.0118 will automatically be filled with a generic drug when available and permissible by state law. If you receive a brand name drug when a generic is available, you will be responsible for the brand name drug's co -payment and/or co-insurance plus the difference in cost between the brand name drug and its generic equivalent after the deductible is met. If your prescribing provider requires the use of a brand name drug, the prescription will be filled with the brand name drug and you will be responsible for the brand name drug's co -payment and/or co-insurance after the deductible is met. The cost difference between the brand name and generic drug does not apply toward the medical plan's deductible or out-of-pocket limit. If your physician prescribes a non -formulary drug due to medical necessity it may be subject to preauthorization. See your member handbook for important information about your prescription drug benefit, including which drugs are covered, limitations, and more. PSGBS.MT.LG.RX.0118 That is the annual deductible? Your plan's deductible is the amount of money that you pay first, before your plan starts to pay. You'll see that many services, especially preventive care, are covered by the plan without you needing to meet the deductible. The individual deductible applies if you enroll without dependents. If you and one or more dependents enroll, the individual deductible applies for each member only until the family deductible has been met. Deductible expense is applied to the out-of-pocket limit. Note that there is a separate category for participating and non -participating providers when it comes to meeting your deductible. Only participating provider expense applies to the participating provider deductible and only non -participating provider expense applies to the non -participating provider deductible. What is the'out-oE-pocket limit? The out-of-pocket limit is the most you'll pay for covered medical expenses during the plan year. Once the out-of-pocket limit has been met, the plan will pay 100 percent of covered charges for the rest of that year. The individual out-of-pocket limit applies only if you enroll without dependents. If you and one or more dependents enroll, the individual out-of-pocket limit applies for each member only until the family out-of-pocket limit has been met. Be sure to check your Member Handbook, as there are some charges, such as non-essential health benefits, penalties and balance billed amounts that do not count toward the out-of-pocket limit. Note that there is a separate category for participating and non -participating providers when it comes to meeting your out-of-pocket limit. Only participating provider expense applies to the participating provider out-of-pocket limit. Only non -participating provider expense applies to the non -participating provider out-of-pocket limit. Payments to providers Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Participating providers accept the fee allowance as payment in full. Non -participating providers are allowed to balance bill any remaining balance that your plan did not cover. Services of non -participating providers could result in out-of-pocket expense in addition to the percentage indicated.. Allowable fee for non -participating providers Outside the PacificSource service area and in areas where our members do not have reasonable access to a participating provider through one of our third party provider networks, the allowable fee, depending upon the services and supply, will be based on the use of the UCR or the participating provider contracted rate, whichever is greater. For more detailed information, please refer to the Non- participating Providers section of your policy. 'reauthorization Coverage of certain medical services and surgical procedures requires a benefit determination by PacificSource before the services are performed. This process is called 'preauthorization'. Preauthorization is necessary to determine if certain services and supplies are covered under this plan, and if you meet the plan's eligibility requirements. You'll find the most current preauthorization list on our website, PacificSource.com/member/preauthorization.aspx. PSGOOC.MT.LG.0118 The Patient's right to know the costs` of medical procedures. The insured, or the insured's agent, may request an estimate of the member's portion of provider charges for any service or course of treatment that exceeds $500. PacificSource shall make a good faith effort to provide accurate information based on cost estimates and procedure codes obtained by the insured from the insured's health care provider. The estimate may be provided in writing or electronically. It is not a binding contract between PacificSource and the member, and is not a guarantee that the estimated amount will be the charged amount, or that it will include charges for unforeseen conditions. Contact Customer Service at (877) 590-1596 to request an estimate. Emergency medical conditions For emergency medical conditions, non -participating providers are paid at the participating provider level. Emergency medical condition means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of a person, or an unborn child in the case of a pregnant woman, in serious jeopardy, result in serious impairment to bodily functions; or result in serious dysfunction of any bodily organ or part. With respect to a pregnant woman who is having contractions, for which there is inadequate time to affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to the health or safety of the woman or the unborn child. PSGOOC.MTIG.0118 4n: ") PacificSource HEALTH PLANS 3 -W PacIfIcSource Health Plans Member Guide We're Here to Help At PacificSource, everything we do revolves around taking care of people. That's why we offer quality customer service that you can access by phone or email. Our average hold time for calls is less than 20 seconds. If you call, you'll talk with a live person—not an automated response system. Or email us, if you prefer. Our friendly, professional Customer Service Representatives will be happy to help you. Your PacificSource ID Card Your ID cards will be mailed directly to your home within a few weeks of enrollment. Once you receive them, you can discard any old cards. Please begin using your new card for your healthcare services. When you visit your doctor or pharmacy, be sure to present your card. This ensures they have the correct insurance information. If you need your ID card before it arrives, you can print a temporary ID card on our secure member site at InTouch.PacificSource.com/members/lDcard/ temporary. You may also access your ID card using our free myPacificSource mobile app. See the "Online and MobileTools" section for more information. If you have any questions or haven't received your ID cards, please contact our Customer Service Department. Provider Network Your plan uses a participating provider network to ensure maximum access to providers for all members. Visit PacificSource.com/find-a-provider or call Customer Service for assistance finding participating providers in your plan's network. Tip: Be sure to select the appropriate network for your area and plan. Your network information is listed on your ID card. You can search by specialty, last name, location, or other details to access a list of providers. Or you can create your own personalized provider directory to download and print. Note that some health plans require you to select a primary care provider (PCP). Outside Our Service Areas If you live or are traveling outside of Idaho, Montana, Oregon, or select Washington counties (Clark, Cowlitz, Klickitat, Pacific, Skamania, and Wahkiakum counties), use one of these networks: • Alaska and Washington (except for the counties noted above): First Choice Health" Network • All other states (except Alaska, Washington, and those noted above): First Health® Network To find providers in the First Choice Health Network or the First Health Network, visit PacificSource.com/find-a- provider. Dental Network Plans For Dental Advantage Network plans (Idaho and Oregon only), you can save money by using Dental Advantage Network providers. You'll pay your plan's co -pay and/or co-insurance at the participating provider (in -network) level. In most cases, when you visit an Advantage dentist, we'll waive your deductible. For Dental Advantage Essentials plans, you're only covered when you see a provider who participates in the Dental Advantage Essentials Network. Pharmacy PacificSource Drug Lists The PacificSource drug lists are guides to help your doctor identify medications that can provide the best clinical results at the lowest cost. To find out which list applies to your prescription drug plan, check your Summary of Benefits or PacificSource member ID card. If no "drug list" f is noted on your card, use the "PDL" list. Access our drug lists at PacificSource.com/drug-list. Using the CVS Caremark° Pharmacy Network We contract with CVS Caremark for pharmacy management services. If your health plan includes a prescription drug benefit, you can enjoy automatic savings from CVS Caremark. Just show your PacificSource ID card when you buy your prescriptions. CVS Caremark's network includes nearly 98% of all walk-in pharmacies in the United States. Ask your local pharmacy's staff if they participate with CVS Caremark, or look up the pharmacy at Caremark.com/wps/portal. Mail Order Services If your plan includes prescription drug coverage, mail order service may be a convenient, cost-saving option for you. We partner with both CVS Caremark and Wellpartner Pharmacy to provide you this service. Visit PacificSource. com/member/mail-order-rx for more information. PacificSource Pharmacy Services (541) 225-3784 I (800) 624-6052, ext. 3784 CJS Caremark Caremark.com i (866) 329-3051 Wellpartner.com 1 (877) 568-6460 A Online and Mobile Tools At PacificSource.com, and the myPacificSource mobile app, you can access tools, information, and resources to help you make the most of your PacificSource benefits. InTouch You can access coverage and benefit information through InTouch, our secure web portal at PacificSource.com. It allows you to easily and conveniently manage your insurance coverage and health, 24/7. Sign into InTouch to: • Look up coverage information in your member handbook/policy, or read benefit summaries. • Look up claims. • View explanations of benefits. • Review your family's enrollment history. • Check deductible and your out-of-pocket status. • Track preauthorizations. • Look up your share of your family's healthcare expenses. • Change your address. • Order replacement ID cards. • Estimate healthcare costs using ourTreatment Cost Navigator. • Access the CafeWell health and wellness resource. myPacificSource Mobile App Our free mobile app gives you secure, on -the -go access to all your coverage information, no matter where you are. The myPacificSource app is available for both iPhone° and Android". Visit PacificSource.com/mobile for more information. _4 Health Management Programs and Services Condition Support Our Condition Support Program offers education and support to members with asthma, diabetes, heart failure, chronic obstructive pulmonary disease, coronary artery disease, or juvenile diabetes. This program is available to eligible PacificSource members with medical coverage. AccordantCare With AccordantCare, we offer rare disease management and specialty pharmacy programs that provide individual support and coordination for our members with certain rare diseases, or those requiring injectable medications or biotech drugs. For more about health management programs and other health and wellness extras, visit PacificSource.com/ extras. Submitting a Claim Usually, your provider will submit claims for you. If you need to fill a covered prescription or see a provider for a covered service before you receive your new ID card, or if you see a nonparticipating provider, you can pay and then submit a copy of the provider's itemized receipt or statement for reimbursement. On our website, you'll find details about how to submit a claim. Visit PacificSource.com/YourPlan/#Claim for more information. PacificSource Health Plans Ment bev Guide Value-added Extras Your PacificSource coverage also includes the following no -cost wellness programs and services. For details about these programs and more, visit PacificSource.com/extras. 24 -Hour NurseLine Have a health-related question? Our 24 -Hour NurseLine is staffed around the clock, 7 days a week—so you'll never be without a registered nurse to talk to. Call them toll-free at (855) 834-6150. CafeWell This secure online health engagement portal helps you keep track of, and make the most of, your health. To access CafeWell, sign into InTouch, go to Benefits, and select Wellness – CafeWell. Weight Management Programs As part of your PacificSource medical coverage, you can enjoy special offers for one of the following programs: • Weight Watchers°: Be reimbursed for some program costs when you participate in person or in the online program. • Jenny Craig°: Join the Jenny All Access program for 50% off the enrollment fee, plus 5% off all Jenny Craig food. Tobacco Cessation Program With your PacificSource medical coverage, you can participate in the Quit For Life® tobacco cessation program. Kick tobacco for good with nicotine replacement therapy and one-on-one phone support. The Quit For Life° Program is brought to you by the American Cancer Society® and Optum. Virtual Healthcare Visits with Teladoc° We've partnered with Teladoc as of January 1, 2018, to offer you virtual Customer Service healthcare visits. Teladoc is a national network of U.S. board-certified physicians and pediatricians that you can see on -demand, 24/7, via phone or online video consultations, from wherever you happen to be; some limitations apply. For a jd alm virtual visit with Teladoc, you pay the same as you would a regular office visit. Depending on your plan, this could be a co -pay amount or you may first need to Direct: (208) 333-1596 meet your deductible. Toll-free: (800) 688-5008 Assist America° Global Emergency Services I�do0t_.,,,, If you have a medical emergency 100 or more miles from home or abroad, Direct: (406) 442-6589 Assist America is on call to coordinate your care and help ensure you get the treatment you need. Toll-free: (877) 590-1596 Hospital-based Education Classes , Get reimbursed up to $150 per plan year for health and wellness classes offered Direct: (541) 684-5582 by hospitals, including first aid, CPR, financial planning, and more. Toll-free: (888) 977-9299 Prenatal Program If you're expecting, our free Prenatal Program offers you support, useful information, and resources during this very important time for you and your baby. Toll-free: (800) 735-2900 Prenatal vitamins: Women between the ages of 15 and 45 with prescription drug coverage are eligible to receive select physician -prescribed prenatal P Esp-fits 1 vitamins at no cost—all co -pays and deductibles are waived—when filled Direct: (541) 684-5456 through an in -network pharmacy. Visit our website for details. Toll-free: (866) 281-1464 Gym Membership Program With the Active&Fit® gym membership program, you can access any gym"aa'( within your plan's network for a one-time initiation fee of $25 plus a monthly fee cs@pacificsource.com of $25 per member. Visit PacificSource.com/extras for details about For more information, visit these and other no -cost programs and services. PacificSource.com/YourPlan Cl B1 1017 Access to Administration Online Services for Your Group Health Plan At PacificSource, we're committed to providing you with flexible, personalized service. One way we do that is through PacificSource InTouch for Employers—a secure, employers -only area of our website. Once you log in, you can enroll new members in your plan, access your plan's contract documents, pay your bill, and much more -24 hours a day. If you prefer doing business online, you'll appreciate the convenience of InTouch. Use InTouch to: Administer enrollment and generate reports • Enroll new members in your plan and update information for existing members, ensuring your employees can get important benefit information as soon as possible • View, change, or download enrollment and census information • View and download enrollment totals for your group by family composition category • Verify employee and dependent enrollment by name or member number • Print temporary ID cards for one or all employees with the click of a button View and pay your bill • View statements in our Payment Center • Pay your bill online with our eCheck option and review your eCheck payment history Access information and request ID cards • View the contact information for your Membership Representative • Access the most up-to-date benefit handbook • Access your plan's contract documents and benefit summaries • Request ID cards Manage InTouch account access • Set up access for members of your administration team with the Group Administrator feature • Administer all of your groups and their subgroups through a single login InTouchAdmin_salesMT0314 Getting Started Is Easy! To start using PacificSource InTouch for Employers, simply visit, PacificSource.com and click "Employers.' Then click the "Register Now" link, which you'll find under the InTouch login button in the right column. MEMBERS f•Yr: PROVIDERS AGENTS CAREERS InTouch for Employers Access your PacificSource account Inlormabon 24x7 Once your registration is processed, you will receive an email message indicating that your new user ID has been activated. If you need to add access for additional staff members, you can log in and add them yourself (in the Group Administrator role), or we can help with the setup. continued on reverse PacificSource HEALTH PLATS Questions and Answers Can I change my password? Yes, you may change your password at any time. From your InTouch home page, click "Account" in the top menu, and then click the "Change Password" link. What happens if I forget my password? If that happens, you can click the "Forgot My Password" link on the login page.You will be prompted to answer two hint questions and can then select a new password. Can I access multiple group accounts without having to log in and out? Yes.You can administer all of your groups and their subgroups through a single login. When you first log in, you'll be able to select from a list of your groups. Once you are logged in, you'll see the current group name on the green button near the top of the page. When you're ready to work with a different group, simply click on this green button to pull......................................................................................................... down a list of your available groups.There's no need to log in and out. Why can't I access all of our group accounts? If you are not able to access one of your groups, it may mean that your InTouch "Group Administrator" has not yet granted you that permission.Your InTouch Group Administrator is the primary user and has access to all of your group or subgroup accounts. In this role, they can grant other staff members, "Users;' full or limited access. What if I have questions or comments? If you have questions or comments about InTouch, you may contact the InTouch for Employers Team: Call (800) 624-6052, ext. 3742 • Email intouchforemployers@pacificsource.com In addition, you are welcome to contact your Membership Services Representative. Your Representative's contact information appears on your InTouch Contact Us page and on your monthly billing statement. Or you can reach us by phone toll-free at (866) 999-5583 to be connected to the appropriate person. To start using PacificSource In Touch for Employers, simply visit, PacificSource.com and click "Employers." Then click the "Register Now" link, which you'll find under the In Touch login button in the right column. :......................... ........................................... ................ ..................... ............................... Paci f icsource Helena: 406.422.1008 •855.422.1008 PacificSource.com PacificSource PacificSource Preventive ®rug List The Preventive Drug List is included in our individual and small group plans*, and is an optional benefit for large groups. With this new benefit, the drugs listed below are paid at 100 percent. A full list of covered drugs can be found on our website at PacificSource.com/drug-list. Show your PacificSource ID card each time you purchase prescriptions at a participating pharmacy to ensure you're receiving the bestbenefit. If you have questions, please email our Customer Service Department at cs@pacificsource.com, or call toll-free: (800) 688-5008 in Idaho, (877) 590-1596 in Montana, or (888) 977-9299 in Oregon. Heart/Blood Pressure acebutolol HCL isradipine amiloride-HCTZ labetalol HCL amlodipine besylate lisinopril amlodipine besylate benazepril lisinopril -HCTZ atenolol losartan potassium atenolol- chlorthalidone losartan -HCTZ benazepril HCL methyclothiazide benazepril HCTZ metolazone bisoprolol fumarate metoprolol tartrate bisoprolol -HCTZ metoprolol -HCTZ bumetanide moexipril-HCL captopril nadolol chlorothiazide nicardipine HCL chlorthalidone nifedipine ER clonidine HCL pindolol diltiazem ER propranolol HCL diltiazem HCL propranolol -HCTZ enalapril maleate quinapril HCL enalapril -HCTZ spironolactone felodiprine ER spironolactone -HCTZ fosinopril sodium torsemide fosinopril -HCTZ trandolapril furosemide triamterene -HCTZ guanfacine HCL valsartan-HCTZ hydrochlorothiazide verapamil ER indapamide verapamil ER PM irbesartan irbesartan-HCTZ verapamil HCL *Except for the Oregon Standard Bronze, Silver, or Gold plans. i Bone Health alendronate sodium ibandronate sodium Cholesterol atorvastatin calcium pravastatin sodium lovastatin simvastatin Diabetes glimepiride glipizide -metformin glipizide glyburide glipizide ER metformin HCL glipizide XL metformin HCL ER Mental Health bupropion HCL olanzapine carbamazepine olanzapine ODT citalopram HBR olanzapine -fluoxetine HCL fluoxetine HCL paroxetine HCL imipramine HCL quetiapine fumarate imipramine pamoate risperidone lithium carbonate sertraline HCL nortriptyline HCL venlafaxine HCL Preventive Drug List 0916 Updated September 12, 2016 OnlineTools and Resources at PacificSource.com InTouch for Members Members can access their benefit information by logging on to the secure InTouch area of our website.They can view their claims, the status of preauthorizations and referrals, the accumulated expenses towards their plan's deductible, and more. Health Manager Health Manager is an online health and wellness center available through InTouch. Powered byWebMD®, it includes personalized wellness information and a variety of helpful, easy-to-use online tools including a health risk assessment. myPacificSource Mobile App Members can stay "InTouch" with their PacificSource coverage, no matter where they are, with our free mobile app.The myPacificSource app is available for both iPhon& and AndroidT" Visit PacificSource.com/mobile. WebMD Daily Victorysm Mobile App The Daily Victory mobile app helps beginners form a sustainable exercise habit, starting with as little as five minutes a day. Log in authentication and progress tracking is accessible through the Health Manager. Provider Directory Members can find up-to-date participating provider information based on their location or the provider's name. Members can also make a personalized directory. Wellness and Care Management Programs 24 -Hour NurseLine Most medical situations don't happen during business hours. Our 24 - Hour NurseLine is staffed around the clock, 7 days a week, so members will never be without a registered nurse to talk to if they have health- related questions.The member toll-free number is (855) 834-6150. Prenatal Care Program Our Prenatal Care Program helps expectant mothers learn more about their pregnancy and the development of their child. Participants receive educational materials and toll-free telephone access to a nurse consultant. High-risk members receive additional proactive nurse support. ValueAdded salesMT0914 Prenatal Vitamins Pregnant members with pharmacy coverage are eligible to receive up to nine months of physician - prescribed prenatal vitamin supplements at no cost (all copays and deductibles are waived).This program covers two generic prenatal vitamins, which are only available through Wellpartner mail order pharmacy. Tobacco Cessation Our Quit For Lifer program, brought to you by Alere Wellbeing and the American Cancer Society, can help tobacco users kick the habit. Members receive phone and online support, as well as a Quit Kit with nicotine replacement therapy patches or gum to help keep them on track. (bupropion, bupropion SR, or Chantix are doctor prescribed.) Member toll-free number: (866) 784-8454. Hospital -Based Education Classes Members can receive a reimbursement of up to $50 per eligible health and wellness class or series offered by hospitals, and up to $150 per member per plan year. Weight Management Programs Members with medical coverage can: • Participate in a Weight Watchere program and receive an annual reimbursement of $100 ($40 if an online Weight Watchers participant) for their Weight Watchers membership. • Choose a Jenny Craig® program discount: free 30 -day trial with Jenny As You Go, or 30 percent off the enrollment fee with Jenny All Access. For full details and eligibility requirements, visit the Members > Extras and Wellness area of PacificSource.com. continued on reverse C-) Pacif icSource HEALTH PLANS Discounted Gym Membership PacificSource members have access to discounted gym memberships of up to $120 per year through GlobalFit. Brown Bag Wellness Seminars We offer Brown Bag Wellness Seminars tailored to the specific wellness interests of employers with 100 or more employees. These informational seminars for employees are held at the worksite or other convenient locations. Wellness for Kids Nine- and six -year-olds currently covered by a PacificSource medical plan may be invited by mail to join HealthKicks!, a children's program that promotes healthy behaviors. Parents will receive an invitation to enroll their child in HealthKicks! If enrolled, children will receive age-appropriate, fun activity books on health and wellness topics to encourage healthy habits. Contact us for more information. Condition Support Program Our Condition Support Program offers support and information to members with asthma and diabetes (including members age 18 and younger), heart failure (HF), chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD).The program includes personal support to help participants reach their health and wellness goals; ongoing support to help them maintain healthy lifestyle changes; and newsletters with current and helpful information about their health condition. Participants may also contact our nurses and registered dietitian via email or toll-free phone number to ask - -> health questions. AccordantCare® Rare Disease Management Program Our members with certain chronic, rare conditions receive ongoing one-on-one support and care coordination to ensure optimal care, decrease complications, and improve health outcomes. CaremarkO Specialty Pharmacy Caremark° Specialty Pharmacy Services is our provider for injectable medications and biotech drugs. A pharmacist -led CareTeam provides individual follow-up care and support to our members with certain conditions. Nurse Case Management Our Health Services Department provides individual case management for members who require specific help in managing their healthcare needs. Nurse Case Managers work collaboratively with providers and members to improve members' health, financial outcomes, and quality of life. LifeTracsmTransplant Network We partner with LifeTracTransplant Network to ensure that our members requiring transplant services have access to nationally recognized centers of excellence. Our Case Managers assist members by coordinating all phases of transplant services. Serving clients since 1988, LifeTrac is a national network of more than 50 carefully selected facilities that perform organ and bone marrow transplants - one of the most comprehensive networks in the United States. Travel Program Assist America® Global Emergency Services Members with medical coverage who experience a medical emergency when traveling 100 or more miles from home or abroad can call Assist America for help. Services include medical consultation and evaluation, medical referrals, foreign hospital admission guarantee, critical care monitoring, and when medically necessary, evacuation to a facility that can provide treatment.These services are provided at no cost to members when arranged and provided by Assist America. Member toll-free number within the United States: (800) 872- 1414; from outside the United States: 00-1-(609) 986-1234. Please note: These value-added programs are not available with all plans. Check with your PacificSource Sales Representative for details. .......................... ..................... ............................................... .................................... ................ : Questions? You're welcome to contact your PacificSource Sales Representative for more information about any of these value-added programs. ...............................................................................-.......... ......... ......................... ...................... -6) PacificSource HEALTH PLANS Helena: 406.422.1008 9 855.422.1008 PacificSource.com O TELADOC,. NZ Paci f icSource HEALTH PLANS You have access to a doctor 24 hours, 7 days a week with Teladoc@. You already have access to Teladoc and you can talk to a doctor now for or less. Set up your account by web. phone or mobile app. SET UP YOUR ACCOUNT IN 3 EASY STEPS 201= Contact Teladoc 24/7/365 Access to Teladoc's nationwide network of board-certified doctors is available to you by phone, video or mobile app. Talk with a physician A doctor will review your medical history and contact you in minutes. Resolve the issue A doctor will diagnose and prescribe medication, if medically necessary, to the pharmacy of your choice. Teladoc is just a click or call away! Teladoc.com _EZiieplay 1-855-201-7488 4)7007 701/ IeaUoc Inc n •q•rts •eserveJ Cu•nuele tlsca nm•.1 Ie atloc cu•n Aaoa u•ul l•,e M:, oI am J,jgj na•1s of n:,n:-I'll ,mt slertsl-: r,,, IIS. ¢1 olnr cu,; L,- non S1,11 I? naservce •mrt ul Annex•¢ VIS un unit Healthcare 3 viahone, video, - rm mobile ob e a pp As a PacificSource member, you have access to a U.S. board-certified doctor 24 hours a day, 7 days a week, year-round with Teladoc. Here's how to get started and what you need to know. 1. Set up your account Talk to a There are three convenient ways to get started. When asked to doctor agtime! enter the name of your employer or insurance carrier, please enter PacificSource. Teladoc.com Online: Log in or register with InTouch for Members through PacificSource.com. You'll find the Teladoc Remote link under Tools. (855) 201-7488 This will provide a direct link for you to set up your Teladoc account. Mobile app: Download the app and click "Activate account" Visit Teladoc.com/mobile to download the app. Teladoc.com/mobile By phone: Teladoc can help you register your account over the phone. Call toll-free (855) 201-7488. + 2. Provide medical history Your medical history provides Teladoc doctors with the information EE they need to make an accurate diagnosis. 3. Request a consult Once your account is set up, request a consult anytime you need care. And talk to a doctor by phone, web, or mobile app. See reverse for FAQ. PacificSource HEALTH PLANS Teladoc° Member Frequently Asked Questions What is Teladoc? you have anonymous call blocker on, you will be returned Teladoc is the first and largest provider of telehealth to the bottom of the waiting list. The consult request is cancelled if you miss three calls. medical consults in the United States, giving you 24/7/365 access to quality medical care through phone and video consults. Is there a time limit when talking with a doctor? Who are the Teladoc doctors? Teladoc doctors are U.S. board certified in internal medicine, family practice, or pediatrics. They average 20 years practice experience, are licensed in your state, and incorporate Teladoc into their day-to-day practice as a way to provide people with convenient access to quality medical care. Does Teladoc replace my doctor? No. Teladoc does not replace your primary care physician. Teladoc should be used when you need immediate care for nonemergent medical issues. It is an affordable, convenient alternative to urgent care and ER visits. What kind of medical care does Teladoc provide? Teladoc provides general medical care for adults and children, and behavioral healthcare for adults. Examples of common medical conditions Teladoc can address include: sinus problems, pink eye, bronchitis, allergies, flu, ear infection, urinary tract infections, and upper respiratory infections. What consult methods are available? You can talk with a Teladoc doctor via a phone consult, video consult within the secure member portal, or video consult within the Teladoc mobile app. How do I set up my Teladoc account? You can set up your account through InTouch at PacificSource.com, or through the Teladoc website or mobile app. You can also call Teladoc to get started. If setting up your account online, when asked to enter the name of your employer or insurance carrier, please make sure to enter PacificSource. How do I request a consult to talk to a doctor? Visit the Teladoc website, log into your account, and click "Request a Consult." You can also call Teladoc to request a consult by phone. How quickly can I talk to the doctor? Median call back time is just 10 minutes. If you miss the doctor's call, whether you are away from the phone or There is no time limit for consults. Can Teladoc doctors write a prescription? Yes. Teladoc doctors can prescribe short-term medication for a wide range of conditions when medically appropriate. Teladoc doctors do not prescribe substances controlled by the DEA, nontherapeutic, and/or certain other drugs, which may be harmful because of their potential abuse. How do I pay for a prescription called in by Teladoc? When you go to your pharmacy of choice to pick up the prescription, you may use your health/prescription insurance card to help pay for the medication. You will be responsible for the co -pay based on the type of medication and your plan benefits. Is the consult fee the same price, regardless of the time? The exact amount you will pay is based on your plan design. This dollar amount is shown on your summary of benefits. How do I pay for the consult? You can pay with your HSA (health savings account) card, credit card, prepaid debit card, or by PayPal. If the Teladoc doctor recommends that I see my primary care physician or a specialist, do I still have to pay the Teladoc consult fee? Yes. Just like any doctor appointment, you must pay for the consulting doctor's time. Can I provide consult information to my doctor? Yes. You have access to your electronic medical record at anytime. Download a copy online from your account or call Teladoc and ask to have your medical record mailed or faxed to you. C Paci f icSource HEALTH PLANS The ActiveUlt Dired' Fitness Center ' Program The Active&Fit Direct program provides you with access to a broad network of participating fitness centers and participating YMCAs. Freedom and flexibility Active&Fit Direct program gives you access to 9,000+ fitness centers nationwide. You can switch fitness centers to ensure you find the right fit. The program also includes access to the Active&Fit Direct website, which features a fitness center locator and online fitness tracking. Get started Visit PacificSource.com/ActiveAndFit for more information. A $25 enrollment fee, $25 for the current month (regardless of the enrollment date within that month), and $25 plus applicable taxes for the next month are due when you enroll ($75 plus applicable taxes). Each month's fee is $25 (plus applicable taxes). After a 3 -month commitment, participation is month-to- month. Once enrolled, you may view or print your fitness card and take it to any fitness center/YMCA in the Active&Fit Direct network. Once the fitness center verifies your enrollment in the Active&Fit Direct program, you will sign a standard membership agreement and receive a card or key tag from the fitness center to check in for future visits. Try out a fitness center Many fitness centers/YMCAs offer guest passes so you can try out their location. You may request a guest -pass letter through the Active&Fit Direct website to take to the fitness center, where available. Note: You will need to register and sign in to request the guest -pass letter. The Active&Fit Direct program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Active&Fit Direct is a trademark of ASH and used with permission here. W1.A Direct: (208) 333-1596 Toll-free: (800) 688-5008 Montana Direct: (406) 442-6589 Toll-free: (877) 590-1596 I -e mm Direct: (541) 684-5582 Toll-free: (888) 977-9299 1f y Toll-free: (800) 735-2900 En Fspai'i0l Direct: (541) 684-5456 Toll-free: (800) 624-6052 ext. 1009 Email cs@pacificsource.com PacifiCSour c:fe.c-ol:: Paci f icSource HEALTH PLANS CLB1119 0118 9^-A, PEAKI . 4, ADMINI,TRA`IIQN City of Laurel Benefit Contact PO Box 10 Laurel, MT 59044 April 2, 2018 RE: July 2018 VSP Renewal Dear: Benefit Contact V au - We appreciate your business and thank you for choosing VSP and Peak1 Administration. We are pleased to present you with our VSP contract renewal information. We are committed to providing you with quality plan designs combined with excellent customer service. As part of the law, carriers are required to apply additional taxes to their rates. Your new rates include all of the new Affordable Care Act (ACA) taxes required by Federal Law. EE Only Rates thru .0/20 $6.79 EE Only i: - EE+Spouse $13.59 EE+Spouse $13.61 EE+Child(ren) $14.55 EE+Child(ren) $14.59 EE+Famlly $23.25 EE+Family $23.28 Please sign below that you agree to the rates stated above and will renew as is: Signature: If you need to make any changes, please complete the attached employer agreement and we will update accordingly. Your business is very important to us. Thank you for allowing Peak1 Administration to serve your insurance and account based product needs. If you have any questions about your renewal, please give us a call at 877.404.9443 or email benefits@mypeak1.com. We appreciate your continued confidence in VSP and Peak1 Administration. Sincerely, �nkq � � �jo M_.r asn Amy Markham Implementation Coordinator Peak1 Administration 608 Northwest Boulevard Ste. 200 Coeur d'Alene, Idaho 83814 // mypeak1.com March 31, 2017 CITY OF LAUREL ATTN: NEVA HALL/KELLY S 115 W IST ST LAUREL, MT 59044 RE: Contract renewal for CITY OF LAUREL Group 9 15937-51611 ER# 7474 Dear Valued Customer: deltadentalins.com We appreciate your business and thank you for choosing Delta Dental Insurance Company (Delta Dental). Your employees are among the millions nationwide who trust their smiles to Delta Dental. We are pleased to present you with your dental plan contract renewal information. We are committed to providing you with quality plan designs combined with excellent customer service. When reviewing your Delta Dental PPO"' plan, we considered cost factors related to your group's dental service utilization and claims experience. Our analysis indicates that no change in your current rate is necessary. The following is the renewal information for your dental plan: Effective Date July 1, 2017 Contract 'Perm Two Years % increase 0.00% Current Rates Renewal Rates Employee $37.30 $37.30 Employee & Spouse $68.68 $68.68 Employee & Child(ren) $72.16 $72.16 Employee & Family $114.28 $114.28 Delta Dental Insurance Company Telephone: 800-521-2651 Delta Dental of California Telephone: 888-335-8227 Delta Dental Mid -Atlantic Region Delta Dental of Delaware, Inc. Delta Dental of the District of Columbia Delta Dental of New York, Inc. Delta Dental of Pennsylvania (Maryland) Delta Dental of West Virginia Telephone: 800-932-0783 9