HomeMy WebLinkAboutSpecial City Council Packet 06.19.2019 - RevisedNEXT RES. NO. R18-28
NEXT ORD. NO. 018-01
CITY OF LAUREL
SPECIAL CITY COUNCIL AGENDA
TUESDAY — JUNE 19, 2019 — 6:30 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. Rall 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.
i k1111 T , C&U,
11AS1,11,11 I 1300411FUR - -
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.
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 deten-nined 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 19th day of June, 2018.
CITY OF LAUREL
Thomas C. Nelson, Mayor
ATTEST:
Bethany Langve, Clerk -Treasurer
Approved as to form:
Sam Painter Civil City Attorney
R18-28 Accept Agreement. PacificSource Health Plan, VSP and Delta Dental
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April 26, 2018
Kelly Strecker
City of Laurel
P.O. Box 10
Laurel, MT 59044-0010
PO Box 8OB26
Billings, Montana 59108
Customer Information Line: 800.447.7828
www.bcbsmt.com
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 O, 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 HEALTH CARE SERVICE CORPORATION, A MUTUAL LEGAL RESERVE COMPANY. AN INDEPENDENT LICENSEE OF THE BLUE CROSS AND BLUE SHIELD ASSOCIATION
Kelly Strecker
City of Laurel
Page 2
71118 Renewal Infnrmntinn- Fffeetive 7/1/201R Trinle Ontion: Blue Dimensions 80/20 PPO
Plan Type
Blue 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
Performance Formulary
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 Mammograms — first $70 is aid; deductible applies
EAPX
If group wishes to purchase EAP services — we can provide pricing
thru Magellan Behavioral Health.
COBRA HCSIC
Renewal Rates below do not include the $75 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/Iv1ed
$899.17
Kelly Strecker
City of Laurel
Page 3
201 R Renewal Tnformation: Effective 7/1/2018 Triple Option: Blue Dimensions 70/30 PPO
Plan Type
Blue Dimensions PFO: 70/30 co -ins In -network;
Single
55/45 Co -Ins Out -of -Network
Office Visit Copay
$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
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 Mammograms — first $70 is aid; deductible applies
EAP*
If group wishes to purchase EAP services — we can provide pricing
thru Ma ellan 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
$846.28
Kelly Strecker
City of Laurel
Page 4
Rhee Chnice HSA PPC} 53.500 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
applies 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:
✓ Renewal 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 $8/$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 1/1/18 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.
Shield
ofMontana
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 & 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
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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.
. l 354351.1217
These preventive services are covered by your plan at no cost to you'
1 NA
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
r
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W,
❑ Aspirin for preeclampsia prevention
❑ Breast cancer screening, genetic testing and
counseling
❑ Breastfeeding support, supplies and counseling
❑ Certain contraceptives and medical devices, morning after
pill, 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) DNA test
❑ Osteoporosis screening
❑ Screenings during pregnancy, including screenings for anemia,
gestational diabetes, bacteriuria, Rh(D) compatibility, pre-
eclampsia
tri
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 AND COUNSELING
❑ Alcohol and drug use assessmentfor 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)
®J BlueCross B1ueShield of Montana Well onTargeto
Make Your Fitness Program Membership
\/\/o r k for You!
Fitness can be easy, fun 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:
No long-term contract: Membership is month to
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Complementary and Alternative Medicine (CAM)
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Blue Pointss'": Get 2,500 points for joining the Fitness
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can redeem points for apparel, books, electronics, health
and personal care items, music and sporting goods."
Web resources: You can go online to locate gyms and
track your visits.
® Convenient payment: Monthly fees are paid via automatic
credit card or bank account withdrawals.
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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
09 BlueCross BlueShield of Montana
A New Way to Experience Wellness
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.
* 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.
Tools 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
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a�
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.
SLUE 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:
• 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.
Q 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.
o 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 B1ueShield of Montana
Care When and
Where You Need 1t
Just Got Easier_
1 � P
1 J
a�t�Y
Q d
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 Pediatric Care Behavioral Health
Allergies Cold Anxiety/depression
Asthma = Flu Child behavior/learning issues
Nausea Ear problems - Marriage problems
Sinus infections = Pinkeye
Blue Cross and Blue Shield of Montana, a Division of Heaith Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
t
Blue Cross%Blue Shield' and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
MDLIVE, an independent company, provides virtual visit services for Blue Cross anti Blue Shield ofMontana. MDLIVE operates and administers the virtual visit program and is solely responsiblefor
its operations and that of its contracted providers.
MDLIVE and the MDLP/E logo are registered trademarks of MDLIVE. Inc. and may not be used without vxitten 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 PlayV` Store
or Windows° Store
Open the app and choose an MDLIVE doctor
Chat with the doctor from your mobile
device
c=ex z ri ?Jf,ecie t0daif
To r=coisI r, you'll neeed to ppravide our first and as! inaime.
date of bia-tb and BCBSNIT unember M nanribea.
In the even of an emergency, this service should not take the place of an emergency room or urgent cate center. MDLIVE doctors do not take tire place of your primmycae ducmr. Prefer diagmmsis should crone from your doctor, aril medical advice
is always betweenyou and your doctor.
InterneY i-Ficonnectionisneededforccmputeraccess.Datachargesmayapplywhenusingyourtabletorsmarlphone.Checkyourphonecarrier"s plan for details. Video on -demand consulta tions for behavioral health are available by
appointment. Service is limited to interactive -audio consullationsiphone only), along with [fie ability to prescribe. when clinically a ppropriale. in I exas. Service islimiled tointetaclivu-audio!video[video only), along with the ability to prescribe, j ,
when clinically appropriate, in Idaho, Montana. New Mexico and Oklahoma. Virtual visits are currently not available in Arkansas. Service availability depends on members location. Virtual visits may not be available on all plans.
MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDUV E operates subject to state regulations and may not be available in certain states. MDLIVE does not guarantee that a presctiption 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 lot abuse. MDLIVE physicians reserve the right to deny care for potential 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 or Microsof P°
x
ost Management.
u .-.F
Provider Finder°, 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
Memberszm , on mobile or the web to use Provider Finder to:
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 MapeTm.
4 Estimate the cost of a provider's procedures, treatments and tests — and
estimate their out-of-pocket expenses.
o 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.
a Search in Spanish.
o Review providers' certifications, recognitions, awards and publications.
It's easy, immediate, secure — and available at bcolsmi.com.
Searches on Provider Finder are: Active, Engaged Employees lower Health
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 health care 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.
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
"N�������s������� �%����� � ~ ^
='.–~�� =`=T
Medication Covered at $0 Cost to You
F/&�c(/peJa/. 7, 2878
Your health plan may include certain prescription and uvap<he«ountar<OTC preventive
nned/oin*a, as a benefit ofmembership, atnocost toyou when you use a pharmacy
or doctor in your health plan's network. There is n000'pa\\ deductible or coinsurance,
/ even ifyour deductible or out-of-pocket nnaxinounn has not been met. Coverage for these
' fr
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
onat share under your plan, 8o|ovv are the preventive ouro drugs that may be covered
under your plan for both adults and children. P|oaoo see the Women's Contraceptive
Coverage List for o list of contraceptive methods that may be covered at nocost toyou,
Age hnnita' restrictions and other requirements may apply.*
folic acid caps, 0.8 mg
folic acid tabs, 400 meg, 800 mco
FERROUS SULFATE LIQUID, 220 MG/5 IVIL
FERROUS SULFATE SYRUP
i---:.. 7n — nn—
deterrent) tab sr 12hr 150 rnq
xmrn*nm-rnAhmmQKAmVIT
–
Generic Drugs ~hold Brand Drugs ~ CAPITAL LETTERS 354674.1017
ACTHIB
ADACEL
AFLURIA/PF/QUAORIVALENT
BEXSERO
BOOSTRIX
CERVARIX
COMM
DAPTACEL
DIPHTHERIA(FETANUS TOXOID
ENGERIX-B
FLUAD
FLUARIX QUADRIVALENT
FLUBLOK
FLULAVAL QUADRIVALENT
FLWIRIN
FLUZONE/HIGH-DOSEANTRADERMAL/QUADRIVALENT/SPLIT
GARDASIL
GARDASIL 9
HAVRIX
HIBERIX
INFANRIX
IPOL INACTIVATED IPV
M-M-R 11
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-195
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS
PNEUMOVAX 23
PREVNAR 13
PROQUAD
QUADRACEL
RECOMBMAX HB
ROTARIX
ROTATED
TENNAC
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 may be covered under your medcal benefit if provided by a doctor in your health plan's natmik. Prescription coverage tot these drugs mayvary according to the terms and conditions of the plan. A prescription may be
required to cover without cost•shaiing under die pharmacy benefit tot non•gmndfatheted plans. The pian may also require a generic thug to be tried fust before the biand version.
This nformation is lot informational purposes only. does not constitute legal of otheradvice and should not be relied upon to determine coverage. treatment decisions are hemzsmn the member and his of her health care provider. Coverage is
a:.ivs suhiect to the limitations and exclusions of the benefit plan. for details about your plan. check your benefit materials or call the Pharmacy Program number on your me ter ID card.
Third -party brand names are the properzy of their respective owners.
:i'f iGSource
HFALTA PLANS
QU"'W l�$St1171�i�lOtiS
NEU
Data 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 rale 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?
�3Which copay bundling option?
Any other Notes:
ER copay match does not apply
0epa-aficSource
0
HEALTH PLANS
Cifiv of Laurel
Rates:
Medical Plans:
PSN 500 2520
2500
$779.77
$1,729.93
$1,240.65
$1.987.66
$584.83
$1,169.66
2x Family Ded/OOP
Rx 100, 10/40/60% to $200
2x Mail Order
Note: EAP is not included
Benefit Period: Calendar Year
PSN 1500 35_30
PSN 1000 25_20
3500
2500
EE $746.91
ES
$1,657.02
EC
$1,188.36
EF
$1,903.89
Smed
$560.18
2P Med
$1,120.36
2x Family De
2x Family Ded/OOP
2x Family Ded/OOP
2x CON Ded/OOP
Rx 100, 10(40/60% to $200
Embedded Ded
2x Mail Order
PSN 500 2520
2500
$779.77
$1,729.93
$1,240.65
$1.987.66
$584.83
$1,169.66
2x Family Ded/OOP
Rx 100, 10/40/60% to $200
2x Mail Order
Note: EAP is not included
Benefit Period: Calendar Year
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 De
2x Family Ded/OOP
Rx 100, 10/40/60% to $200
2x CON Ded/OOP
2x Mail Order
Embedded Ded
Prev Rx
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.
Pnkifi.Sau+ce.cdm
, o
+ i i` YAC
HEALTH PLANS
Outline of Coverage
PSN 500+25_20 S2
r
City of Laurel Option B Bundling
i
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
= . • - i i - • . , . • - i •
Pre"venfiverCare -�il6�
, _r�. ,� ��� �>'�'yf -� z �+ � dY*ca 4SYC"C T"+r.+ "5^.�,t'✓.'
.a.h..... ..✓.:+..k. ti.:. .� ._.wJ'.xH1 ,..,, x..::.1' � ..�..a, ..�"....i... k"++` -+3r � r:' a .wx.:i..-..a..l.rci..{v1� 3:.v'ta'.'�.0 ..Cr.ur;:.�iv�s.Jde:d?>`H
Well baby/V1/ell child care
�` No charge* t. x '���35%�#o�sr�rafnc;'"e���-
Preventive
' No charge `- �Axo�;Lrs f ranee
physicals
�
Well woman visits
No charge* h�
Preventive mammogramso�c
of e T .
Immunizations°
No charge* k :e.
{-h
Preventive colonoscopy
No charge ®edot�et�focohsur�ace
Prostate cancer screening
No charge*',� nl�cin.si�ce*
t..w._
� .:.:�K. s.`.3}'�..R�"n,+•� -v i. G:� �ry t `?_ ,T `�"'xL.,`$. °� '�� } 4~ ' ^TN`+'� 'x�"` •k d L.X. 5 '+. �7.y +.+a.>t `x;". g!'z ."�,
Professional{Services
.n::+k'z'w'SiW..a-,>s�+x '�.��.i....t'.ck'r._..ci _Ltr...:r ✓ �. v:. ri+J�i. .w s:�'".t4r. 3,n.+-.:...: �.4 ... `2� uaL.., 3.�5�.:..i"_,a �«�..�✓.•��.'�..v_.k` L_...1.ti�Nb�G .�+��.1:';5��_�...^�_-?.
Office home visits
$25=co pay/visit edc lel` °lam=�tsaa
and
Naturopath office vi
I ITUfa, aeti v oa' Vie'
Specialist office and home
$25 co edret�b et�`n�3'5= o yo- E.Ear,
paylvis�t
visits
y
Telemedicine visits
$25 co pay D0e'`3'Slo"o"�s.
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.
A 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
PaciticSource Prescription Drug Benefit Summary
HEALTH PLANS 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:
Partrcrpatmg Retarl`Pharmacy^
v
Detluctrble then the
Up to a 30 day supply:
$10 pay*
Deductrble then
lesser
co
of $200 co pay
$40 co pay
rnsurance:
Partrcrpatmg_ Mar! Order Pharmacy � '�
_
Deductrble then the
Deductrble then
Up to a 30 day supply:
$1 d co pray*
lesser of $200 co pay
$4Q co pay
°
QO% 01o, rnsurance;
Deductrble then` the
Deductrble fhen
31 — 90 day supply:
$20 co pay*
lesser of $400 co pay
_
$80 co pay
°
or;fi0,/o co msur._ance
Non_partrcrpating Pharmacy„ 1
30 day max fill, no more than
Deductrble then co rnsurance
"b"
three fills allowed per year:
F90%
Trer 4 Spectalfy Drugs Partrcrpatmg Specialty Pharmacyrr
Up to a 30 day supply:
;Deductrble then the lesser of $200 co, pay or 20°l0 co rnsurance
Trer 4 Specialty Drugs Not filledtlirough
Partictpatrng Specialty Pharmacy
r . t
30 day max fill, no more than
o `.
Deductrble then 90 /° co rnsurance
three fills allowed per year:
r _
_2� _w.. -L2i
Up to a 30 day supply: ;Deductible then the lesser of $200 co' pay or 60% co msuranceT
,
^ 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
'.�_. 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 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
:�f A
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
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:
Set"VICE' as. ME
Prevenfrve Care x 4
care _....._. haWell baby/Well child r e* t$ X35°loconsurane011
Preventive physicals No charge35Oclgg g,
o rms e_
Well woman visits No chargepg
°char�ge�
Preventive mammograms No char e'"' igip��Noct7=Cge.
Immunizations No charge �.. �KN�a�Ie� A
Preventive colonoscopy No charge*educt�bleth3/0' trance
Prostate cancer screeningNo char e* 5°:o cA ns`a a e
Professional Services Manz
Office and home visits ;' $25 co paylvisit Dedu fblethen35°� co=ins=
Naturopath office visits Detlutib�eheo�
Specialist office and homer oWN
$25 co pay/visit De�du�ct�blehen`3�o.CO�.t�nsUr nce
visits
Telemedicine visits $25 co a /visit* educf�eth5c ntf
p.Y_
PSGOOC.MTIG.0228
$2,000
All Providers
$1,000
All Providers
$2,500
$5,000
Please note: Your actual costs for services provided by a non -participating provider may exceed this
policy's out-of-pocket limit for non -participating provider services. In addition, non -participating
providers can bill you for the difference between the amount charged by the provider and the amount
allowed by the insurance company, and this amount is not counted toward the non -participating out-
of-pocket limit.
Trend Data
PacificSource bases large group premiums on data accumulated from the entire Montana large group
population. Certain factors such as demographics are incorporated into the rating process.
PacificSource bases trend projections on a combination of PacificSource Montana large group data
and the PacificSource Oregon group book of business. The large group premium increases for the last
five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%.
The member is responsible for the above deductible and the following amounts:
Set"VICE' as. ME
Prevenfrve Care x 4
care _....._. haWell baby/Well child r e* t$ X35°loconsurane011
Preventive physicals No charge35Oclgg g,
o rms e_
Well woman visits No chargepg
°char�ge�
Preventive mammograms No char e'"' igip��Noct7=Cge.
Immunizations No charge �.. �KN�a�Ie� A
Preventive colonoscopy No charge*educt�bleth3/0' trance
Prostate cancer screeningNo char e* 5°:o cA ns`a a e
Professional Services Manz
Office and home visits ;' $25 co paylvisit Dedu fblethen35°� co=ins=
Naturopath office visits Detlutib�eheo�
Specialist office and homer oWN
$25 co pay/visit De�du�ct�blehen`3�o.CO�.t�nsUr nce
visits
Telemedicine visits $25 co a /visit* educf�eth5c ntf
p.Y_
PSGOOC.MTIG.0228
Service
.. . - ® • - • . , . . - • • -
Office procedures and
supplies
m
then 20% insuranc°t�sa�e
Surgery
Deductible ,co
Outpatient rehabilitation
Deductible then 2010 co insurance. De�u�t[b e t e `°o -ao� s fiance
services
v R. k .*e. ''z «Yt., ..j, r'T i't t`? '� Y^- ., 4w. h'fh^�C'2.ti §v; £ Y+2 5 moi#' `•
then 20% co insurance�dcbiet
Inpatient room and board
DeductibCe
Inpatient rehabilitation
20% co insuranceDeduct[b1e o p ISIS raacei
Deductible then
services
MR e
ducible#h35°10sera
Skilled nursing facility care
Deductible then 20% co insurance cn
Outpatient surgery/services Deductible #hen 20°lo co insurance�Ueduct blefh�5°.0 co m�re
>
Advanced diagnostic
_
WN
20% co = 5°o co [ sera cep
Deductible then msiarance: �p�e�d�uct�bl;e��ie MEMO
ima in
Diagnostic and therapeutic
�y
o DerlItibleuhen'510 .
20 /o
Deductible then co insurance: co'[nsr�rnce
radiolo Ilab
v
tlrgerit and Emergency Servicesy.7V
25 co a /visit* Delucti le they'S°1ocoinsu once
$
Urgent care center visits
p Y .
Emergency room visits –
Deductible then $100 co pay/visit; euctible#hen$Ii00coylv[sa
lus 20% co insurance^ ��,�'�'lirs �O��co i su.�ari,�,A����
medical emer enc
Emergency visits –
Deductible then $� 00 co paylvisl iAW
—, uctibl he BOO o pa v+s[t�:
�
9 Y room
o ^ lus 35 �nsiur� { cen
non-emergency
lus 20% co insurance �o
then 20% co insurance Dedue#ib a#po°i
Ambulance, ground
Deductible
20% Du4ct�blethe20lQco�sa�c+
Ambulance, air
Deductible #hen co insurance
Physician/Provider services
°Ded6`,-t, - °��
D>edu�tble th�3r,.% co�ins�u�'ancye.
uctible then 20 o insturance
�7
then 20% co Abe ucf b est en s 0 > n u. a`�cIP
Hospital/Facility services
;Deductible 4insurance
Menta`IsHealfiilCiiemical Dependtency Services �. ,
?ntYae
Office visits
$25 co pay/visit*eiiatikle�e5°00
le then Q5 co insurance Dejuctile#°°a'
Inpatient care
Dectib o-
du
then 20%'co insurance *�D,e,ucf[blte°1 nsurar✓e
Residential programs
Deductible
2
Other C{Ducted Services_
FW.-vI,
$5 co Deduef[ le #hen 5 ° !Iasuranae
Aller injections
pay/visit
Deductible then % co'insurancerNEuW& est e` 5 ° 'o' su once
Durable medical e ui ment
q P��
� M�"
Deductible then 20% co insurance® dtae#bleu easttra,ce
Home health care
Chiropractic manipulations
$25 co pay/visit
����ctibl�.e
and acupuncture
:
r i e .
then No n.- uziii ehe = 5o4$i sync,
Transplants
Deductible
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
OW, Pacitic-Sourc e Outline of Coverage
HEALTH PLAN'S 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
All Providers $11500 $3,000
..
3,000w 01:
All Providers $3,500 1 $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 follow.mg amounts:
Service
M
Well baby/Well child care
Preventive physicals Nocharge*_
Well woman visits
k.SW0
'20 1 N1 I
W
ar e
Preventive mammograms KIM,
LIN ME
Immunizations No char e* Notthar e�
Preventive colonoscopy No charge* >eu tib et e5°off oaG
'
Prostate cancer screening �� " -, " No char _;
...........
Office and home visits
�,
Naturopath office visits t
Specialist office and home
$35 'c t!
,
visits
Ma.
$35 co S. q t h J ni NOR -
Telemedicine visits
PSGOOC.MT.LG.0118
Service
Office procedures and
s `
No charged Die bl 4oasura ee
u a r
supplies
then 30°fo co} etl ct be a : a�nnis l f
Surgery
Deductible insurance
Outpatient rehabilitation
oF8 Y
suranceDtueti iet ,x surnae
Deductible Cheri 3010 co mE
services
Deduct eh4b°in�su
Deductible thenJ30% co_msuranceMA
Inpatient room and board
°x
Inpatient rehabilitation
30°lo co msurance®educt�ble i3 _,.a o cottPr_ afie
Deductible then
services
"'"'
Skilled nursing facility care
e Dedact�l�le tide /o coansu�ce
Deductible then 30% co mstarancRM
1w'w.v'4
-a.
cSiea.S^µ.s1"
.:
OWN
.
then 30°lo co msurance 0e8 uctiblh5 loeomsua
Outpatient surgery/services
Deductible
Advanced diagnostic
o " a ' MNA i }
3010 Dedut[Ie twamgete 4 co�nsuravgmwn
imam
Deductible then, co insurance Ifo
o
RE 10,00
Diagnostic and therapeutic
o//o ;��
Deductible then 30% co msurance Dxed cf{{blethe45oco iC�s�irance
/lab
radiology/lab
llrgentand EmergencyServ�ces ,art = xs
,.
s^Yyp
$35 co a IVIS -1 Deduetible hen 45 to o i s ance
Urgent care center visits
pY
Emergency room visits —
$100 co a /visit-D"end �ctibl'ethen$100=0 a luisi�
Deductikile then f p Y
medical emer enc
Cus 30 /o co msurance�~�
Emergency room visits —
OO coaf
Deductible thei:v-t$ co pay/visit pedLict�bleyt a �p
co ���� Cus 4 1,% sura ce
non -emergency
!us 30% .. msurance^ U
} z. ;� Raw . I",A
Deductible,then 30%.co msurance bectib'eiLQ�/n
Ambulance, ground
� 0°1o0tnSt.J a�e
Deductible then 30% co insurance Deductr�b� ANO
Ambulance, air
Maferrity Services }
3oi Y Yy.i
3
, x
Physician/Provider services /op�4suaCe
Deductible then 30%co insurancejci�b�e3tfee`nf
HospitallFacility services
Deductible then 30%'co insurance De `ict�bfi
= s° 10
Deductible then 30% co insurance �eu� �b� h�e"�5�o catns�r tic
Inpatient care
then 3,0°lo co ins at e'' °o cp ns fa
Residential programs
,Deductible
>
$5 co pay/visits �Deducfi`ale e 4 } ocosurane
AIIer m ections
Deductible Cheri 30% co msyurancee4a0o cis�e
Durable medical equipment
is
Deductible then 30% co msuranceeductb e= he
Home health care
Chiropractic manipulations
I
a
r } wot�b"le,the '5°I.Q.' o 'suranee
$35 co pay/visa*D,e : u m
and acupuncture
y v then No charge Dedictleth510 o turance
Transplants
Deductible
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
PaciticSource
HEALTH PLANS
City of Laurel
Outline of Coverage
PSN HSA 3500+Rx S?
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.
1:1111 1110, 1111
011 V WMWO� IM11
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
&IM
Participating Providers
$3,500
$7,000
Non -participating Providers
$7,000
$14,000
Participating Providers
$3,500
$71000
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
�g
We(I baby/Well child care
� No char e'� ��� h�f-�a�g
,Na
Well woman visitsNo
Preventive mammograms
No charge*. p
Immunizations
Preventive colonoscopytheme
Prostate
No charge
cancer screening
lu
P,
. . . . . . . . . . . .
Office and home visits
.Deductible then No charge D dycb� tnarge-
Naturopath office visits
5 o', charge R,
, ghlffl
PSGOOC.MT.LG.0118
Specialist office and Home
then Deductible Ap N'
visits
.-.,,
ED e.al No charge gA
Telemedicine visits
-
Office procedures and
Otlble'AhenN
supplies
Surgery
Outpatient rehabilitation
Deductible then No chargee
services
ILI RR
M, NZ M
"
ON
then No Ycharge �n N arae
inpatient room and board
;Deductible .�� � eductib�.l�e��t �c
Inpatient rehabilitation
then No charge Ded r GtilJ e J �eNo c J41
Deductible
'M 0
Skilled nursing facility ca
Deductible
�s
=U-MOL
Outpatient surgery/serviceDedu
Advanced diagnostic
-'N --h En ........... b
D6d6dtil5l6jN b p,
imaging
Diagnostic and therapeutic
radiology/lab
Ur ent�and Emjerge`ncy Services
Deductible then N'b"ch-le'arge.,
Urgent care center visits
Emergency visits -
ctiblelemo
room
charge
Deductible then on'rdfta' r.g' e),":end =
medical emer enc
-7
Emergency room visits
Deductible
non-emeLgencs y
ib etirocla ,e ,�
then No
Ambulance, ground
::Deductible chargeDduc
g"
h_ hj'��'N.6,tft�t Vj
Ambulance, air
i�.
-'a TM %41
Physician/Provider servicesDeductible
0.
g�
then o chargeF 1'o h'a' r,
(global..char ge)
--N
Deductible then No charge Ic' M
Hospital/Facility services
M -.9M VR
Mental HeaithlChemical Dependency MM
Mw
LW
W.
- w rIt'AI al.
Dediactiblethen No charge Ded M® e
Office visits
-'
No harge ®edct�le eo c, ages
care
Deductible then
chargeInpatient
�"
Mdi
Residential programsAc
-S
. t -e ybr�6
-vub.
L
Deductible then No chargeDeduc#bl=e'µNoc
Allergy injections
A", k�-V�
j qi�'charge 11-d ij Ine, �—
-;Q'iM6,'tibT t em__;Wo SEEM
nt�
Durable medical equipment
- " .0$'
--,7all
0-
a
VII
Home health care
-I
Chiropractic manipulations
and acupuncture
Trnnonlonfe
fem,
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
tD-!) 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/dru_q-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
Deductible then
Deductible, hen :_
Deductible hien
Up to a 30 day supply:
No,char e
No char e., ..:; ....
. No, char: e
Pariic�pat►ngMail_Order --`
,
rPharmacyN _
Deductible then
Deductible when
Deductible then
Up to a 90 day supply:
har "e
No
pc
Nonppartrcrpating Pharmacy G,;_ -
_....m .. _. ..... _r v
L `
30 da max fill no more than'D
y Deductible then; 90°I° co insurance
three fills allowed per yeal: -
Specralty i?arircipatingxSpeeialty,Pharrnacyp
Ttert4 Drugs _
Up to a 30 day supply:
lDeducttble hen No charge
t
Tier 4`Spec�alt� Drugs through Partrc�paiing Specialty Pharmacy„ ;
_LNatYfillect 'y W'r .....
?,.._..i -
30 day max fill, no more than
Deductible then 90% co insurance
three fills allowed per ear:
Carnpaund Drugs** �, n
Up to a 30 day supply:
f�
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 tilled 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
'hat 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-of-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.
Preauthorization
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.MT.LG.0118
I
n
4_t �
Paci f icSource
HEALTH PLANS
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"(
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.
pacifirsource Phermgcy Services
(541) 225-3784 ', (800) 624-6052, ext. 3784
Caremark.com j (866) 329-3051
!'
t3i'(?'
Wellpartner.com 1 (877) 568-6460
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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.
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 !'l`;.=;,�,'i'' Id
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
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
M1.141tana
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
Eta
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
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
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
v
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.
A• vCx Sr i'�
MEMBERS _ PROVIDERS AGENTS j CAREERS
InTouch for Employers
Access your PacificSource account Inlo ntatlon
24/7
!fIr00�l ( i
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
-IEALTI-i PLANS
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.
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 InTouch login button in the right
column.
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.
Paci f icsource
Helena: 406.422.1008. 855.422.1008
PacificSource.com
PacificSource PacificSource Preventive Drug 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.
Preventive Drug List 0916 Updated September 12, 2016
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
Online Tools 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 Android"
Visit PacificSource.com/mobile.
WebMD Daily Victory8m 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 Life® 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 Watchers" 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
OD-)
Paci f icS®urce
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.
Caremark' 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.
LifeTracs-Transplant 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.
.................................................................................................................................
C-)
PacificSource
HEALTH PLANS
Helena: 406.422.1008 9 855.422.1008
PacificSource.com
0
TELADOC
6
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
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 isjust a click or call away!
Teladoc.comAvailable on the ilihone
App Store'
1-855-201-7488
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Healthcare
via phone, video,
or mobile app
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
There are three convenient ways to get started. When asked to
enter the name of your employer or insurance carrier, please
enter PacificSource.
Online: Log in or register with InTouch for Members through
PacificSource.com. You'll find the Teladoc Remote link under Tools.
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.
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
E_ 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.
�►-- i� .�
3 .
Talk to a
doctor anytime!
Teladoc.com
(855) 201-7488
Teladoc.com/mobile
CI
Paci f icSource
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 -today 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 aTeladoc 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
PacificSource
HEALTH PLANS
The ActiveUlt DireCtTl
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.
d,
v
Idaho
Direct: (208) 333-1596
Toll-free: (800) 688-5008
Montana
Direct: (406) 442-6589
Toll-free: (877) 590-1596
Direct: (541) 684-5582
Toll-free: (888) 977-9299
T -FY
Toll-free: (800) 735-2900
Era Espar1ol
Direct: (541) 684-5456
Toll-free: (800) 624-6052
ext. 1009
Entail
cs@pacificsource.com
Par. iiia..'Snurce,corn
Paci f icSource
HEALTH PLANS
CL13419 011&
PEAK1
ADMINISTRATION
City of Laurel
Benefit Contact
PO Box 10
Laurel, MT 59044
April 2, 2018
RE: July 2018 VSP Renewal
Dear: Benefit Contact
VW
We appreciate your business and thank you for choosing VSP and Peakl 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.
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 Peakl 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 Peakl Administration.
Sincerely,
Amy Markham
Implementation Coordinator
Peakl Administration
608 Northwest Boulevard Ste. 200 Coeur d'Alene, Idaho 83814 // mypeakl.com
March 31, 2017
CITY OF LAUREL
ATTN: (VEVA HALL/KELLY S
115 W 1ST ST
LAUREL, MT 59044
RE: Contract renewal for CITY OF LAUREL
Group # 15937-51611 ER# 7474
Dear Valued Customer:
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deltadentalins.com
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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 Term
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
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