M E M O R A N D U M. Meeting Date: November 16, Item No. E-3. To: Dan O Leary, City Manager. From: Carolyn J. Nivens, Human Resources Director

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1 M E M O R A N D U M Meeting Date: November 16, 2010 Item No. E-3 To: From: Subject: Dan O Leary, City Manager Carolyn J. Nivens, Human Resources Director Consider a resolution authorizing the City Manager to execute the Contract with CIG HealthCare, for the City of Keller Employee Medical Health Insurance, from October 1, 2010 through September 30, Action Requested: Background: Council approval of the resolution authorizing the City Manager to execute the Contract with CIG HealthCare, for the City of Keller Employee Medical Health Insurance, from October 1, 2010 through September 30, Each year the City seeks Request for Proposals on our medical health insurance to assure a competitive process and the lowest possible cost to the City and the employees. This year we received two (2) proposals. After negotiations and best and final bids, the lowest bidder is CIG HealthCare, whose bid represents a 16.5% increase from Fiscal Year The original renewal bid from CIG was a 30.8% increase. Upon best and final bid of inforce plan, CIG bid a 21% increase. We also asked the two (2) bidders, CIG and AET, to bid on another Plan Option which included minimal changes to our plan, such as increases to co-pays and annual limits on some benefits. This resulted in a 16.5% increase bid from CIG and a 25% increase from AET, resulting in the City going with CIG s bid. Financial Considerations: The proposed contract for employee medical insurance is an amount not to exceed $3,186, and is currently funded within the approved Fiscal Year Budget. Page 1 of 2

2 Financial Impact: Citizen Input/ Board Review: Legal Review: Alternatives: Supporting Documents: The total financial impact to the City for medical health insurance is an increase estimated at $340, This number may fluctuate slightly with vacancies, dependent additions, or other plan changes made by employees. Not applicable. City Attorney has reviewed. Not applicable. Supporting documents include: Proposed Resolution Exhibit A CIG HealthCare Contract Attachment A Benefit Summary OAP Copay Plan Attachment B Benefit Summary HMO Copay Plan Attachment C Vision Schedule Vision Benefits Recommendation: Staff recommends approval as submitted. Page 2 of 2

3 RESOLUTION NO. A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF KELLER, TEXAS, APPROVING THE CONTRACT WITH CIG HEALTHCARE, FOR THE CITY OF KELLER EMPLOYEE MEDICAL HEALTH INSURANCE, FROM OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011, IN THE TOTAL AMOUNT OF (OR AN AMOUNT NOT TO EXCEED) $3,186,298.20; AND AUTHORIZING THE CITY MAGER TO EXECUTE SAID CONTRACT DOCUMENTS RELATING THERETO ON BEHALF OF THE CITY OF KELLER, TEXAS. WHEREAS, WHEREAS, WHEREAS, WHEREAS, it has been determined by the City Council of the City of Keller, Texas that the City of Keller will continue to provide medical health insurance coverage for City of Keller employees; and a Request for Proposal for the contracts for the City of Keller Employee Medical Health Insurance was duly advertised in accordance with State law, and said bids were received, opened, and read aloud at 2:00 p.m., on June 25, 2010, at Keller Town Hall; and two (2) sealed bids were received and have been reviewed by the Director of Human Resources, and it has been determined that the bid submitted by CIG Healthcare is the lowest and most responsible bid; and the City Staff hereby recommends approval of said contract with CIG Healthcare, for the City of Keller Employee Medical Health Insurance. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF KELLER, TEXAS: Section 1: THAT, the above findings are hereby found to be true and correct and are incorporated herein in their entirety. 1

4 Section 2: THAT, the City Council of the City of Keller, Texas hereby approves the Contract for Medical Health Insurance with CIG HealthCare, for the City of Keller Employee Medical Health Insurance, from October 1, 2010 through September 30, 2011, in accordance with the terms and conditions in said Contract, attached hereto as Exhibit A ; and further authorizes the City Manager to execute all contract documents relating thereto on behalf of the City of Keller, Texas. Section 3: THAT, the cost associated with the implementation of said Contract with CIG shall not exceed $3,186, and shall be paid from Various Operating Budgets, budgeted therefor, as approved in the Fiscal Year Budget. AND IT IS SO RESOLVED. Passed by a vote of to on this the 16th day of November, CITY OF KELLER, TEXAS BY: P.H. McGrail, Mayor ATTEST: Sheila Stephens, City Secretary Approved as to Form and Legality: L. Stanton Lowry, City Attorney 2

5 EXHIBIT A CIG HealthCare Group Benefits Renewal City of Keller 1100 Bear Creek Pkwy Keller, TX SIC Code: 8999 Account Number: Total Eligible Employees: Employer Contributions: 319 Participating Subscribers: 313 Employee Contributions: Dependent Contributions: Waiting Period: First of the month following date of hire 100% 5 0% Eligibility Definition: Active Employees working 20 hrs Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are subject to change in the event of changes in benefits selected or changes in the risk factors upon which the Quoted Rates are based. In addition, state law may require regulatory approval of rates.if required regulatory approval has not been obtained on the proposed effective date, the healthplan shall use rates that are consistent with its then currently approved rating methodology and the quoted rates shall be effective immediately on the date for which they are approved for use. The Quoted Rates are guaranteed while the Group Service Agreement remains in effect until the next anniversary date, unless enrollment changes by 10% in which case the CIG Companies may change the Quoted Rate. Proposal # Page 1 of 15 7/6/10

6 EXHIBIT A Proposed Benefits Product: CIG HealthCare HMO Situs State: TX Effective Date: 10/01/2010 Category Description In Network Medical Benefits HMO Copay Modular Medical Management Program PHS+ PCP Office Visit Copay $25 Specialist Office Visit Copay $40 Hospital IP Copay - Per Admit $1,000 Hospital IP Copay Per Day Hospital IP - Number of Copays Per Admission Plan Deductible - Individual $0 Plan Deductible - Family $0 Out of Pocket Maximum - Individual $2,500 Out of Pocket Maximum - Family $5,000 OOP Max Copays Includes Copays Lifetime Maximum Unlimited Outpatient Facility Copay $400 Emergency Room Copay $150 Urgent Care Copay $75 Skilled Nursing Facility Copay $0 Skilled Nursing Facility Maximum Days 60 Home Health Care Copay $0 Home Health Care Maximum Days 60 DME Durable Medical Equipment Maximum Unlimited EPA External Prosthetic Appliances Deductible $0 External Prosthetic Appliances Maximum Unlimited Chiro Short Term Rehab Copay $40 Chiro Copay $40 Short Term Rehab and Chiro Combined Maximum Days 20 Short Term Rehab Maximum Days Self-Referred Chiro Maximum Amount Self-Referred Chiro Maximum Days MRI, CT PET Scans Copay $75 PCL Admin Option Excluded Infertility Excluded Bariatric Services Excluded Proposal # Page 2 of 15 7/6/10

7 EXHIBIT A Proposed Benefits Product: CIG HealthCare HMO Situs State: TX Effective Date: 10/01/2010 Category Description In Network Medical Benefits HMO Copay Bariatric Surgery - Lifetime Maximum Amount Health Advisor Excluded Surgical and Non-Surgical TMJ Medicare COB: Retirees >=65 Admin Option Robust Reporting Package Employer Features Excluded 24 Hour Health Info Line Well Aware Program (Diabetes, Asthma, Low Back) Well Aware Program (Cardiac) Well Aware Program (COPD) Well Aware Program (Weight Complications) Well Aware Program (Targeted Conditions) Well Aware Program (Depression Management) Incentive Points Program Excluded Well Being Newsletter Healthy Rewards Life Source Organ Transplant Network Guest Privileges Language Line Drugstore.Com Transition of Care Pharmacy Benefits Proposal # CIG PharmacyPlus 3-Tier Copay (FI) Retail - Generic Copay $10 Retail - Brand Copay $25 Retail - Non Preferred Copay $40 Mail Order - Generic Copay $20 Mail Order - Brand Copay $50 Mail Order Copay - Non-preferred $80 Retail - Individual Deductible Retail - Family Deductible OOP - Individual Maximum OOP - Family Maximum Standard Preventive Drugs Excluded from Deductible NO Ded & OOP Max Apply to MOD Do Not Apply to MOD MOD Program No Mandatory Page 3 of 15 7/6/10

8 EXHIBIT A Proposed Benefits Product: CIG HealthCare HMO Situs State: TX Effective Date: 10/01/2010 Category Description In Network Pharmacy Benefits CIG PharmacyPlus 3-Tier Copay (FI) Maintenance Drug List Oral Contraceptives/Devices Lifestyle Drugs Oral Fertility Drugs Self-Administered Injectables Optional Injectables Buy-Up Insulin & Insulin Needles & Syringes Glucose Test Strips Lancets Non Prenatal & Prenatal Vitamins Smoking Cessation Step Therapy Program Clinical Management Program Enh. - Benefit Exclusion Enh. - Intensive Appropriateness of Use Enh. - Utilization and Unit Cost Management Generic Push Formulary Prescriber Panel Covered Not Covered Not Covered Covered Not Covered Covered Covered Covered Covered Covered Excluded Enhanced Not Selected Not Selected Not Selected Incentive Open MH/SA Benefits Option 6 - Buy Up 2 Inpatient Per Admit Copay $1,000 MH Inpatient Max Number of Days 365 Inpatient - SA Maximum Days 365 Outpatient - MH visits 1 to 30 Copay $25 MH Outpatient Max Number of Visits 365 Outpatient SA visits 1 to 60 Copay $25 SA Outpatient Max Number of Visits 365 Group Therapy Outpatient Copay $25 Group Therapy MH/SA Combined Maximum Visits 365 Vision Benefits None Proposal # Page 4 of 15 7/6/10

9 EXHIBIT A Benefit Exceptions: Proposal # Page 5 of 15 7/6/10

10 EXHIBIT A Group Description: TX801 (ALL ACTIVE EMPLOYEES) Tier Subscribers Inforce Members Current Rate Renewal Rate Monthly Premium Change EMP 50 $ $ $30, % EMP + SPOUSE 12 $ $1, $12, % EMP+CHILD(REN) 19 $ $ $17, % EMP + FAMILY 49 $1, $1, $57, % Total $117, Proposal # Page 6 of 15 7/6/10

11 EXHIBIT A Proposed Benefits Product: Open Access Plus Situs State: TX Effective Date: 10/01/2010 Category Description In Network Out of Network Medical Benefits Proposal # Open Access Plus Copay Modular Medical Management Program PHS+ Office Visit Copay Primary Care Copay $25 Specialty Care Copay $40 Coinsurance 80% 60% Hospital IP Copay - Per Admit Hospital IP Deductible - Per Admit $200 Hospital IP Copay Per Day Hospital IP Deductible - Per Day Maximum Reimbursable Charge Option 2-110% Incl NSP & Bill Negotiation Collective Deductible/OOP Admin Option NO NO Combined Medical/Pharmacy Deductible/OOP Admin NO NO Option Annual Individual Plan Deductible $500 $500 Annual Family Plan Deductible $1,000 $1,000 Deduct Accumulator No Cross Accumulation No Cross Accumulation OOP - Individual Maximum Amount $2,500 $5,000 OOP - Family Maximum Amount $5,000 $10,000 OOP Max - Accumulator No Cross Accumulation No Cross Accumulation OOP Max Ded Excl Ded Excl Ded OOP Max Copays Excl Copays Excl Copays Lifetime Maximum Amount Unlimited Lifetime Maximum - Annual Reinstatement Amount Outpatient Facility Copay Outpatient Facility Deductible Emergency Room Copay $100 Emergency Room Deductible $100 Urgent Care Copay $40 Urgent Care Deductible $40 Other Health Care Facility IP Maximum Days 60 Lab/Radiology Standard Coverage Plan Ded/Coins Plan Ded/Coins MRI, CT PET Scans Copay 80% 60% Lab/Radiology Mid-Point Coins Option Coinsurance Page 7 of 15 7/6/10

12 EXHIBIT A Proposed Benefits Product: Open Access Plus Situs State: TX Effective Date: 10/01/2010 Category Description In Network Out of Network Medical Benefits Open Access Plus Copay Home Health Care Maximum Days 60 Durable Medical Equipment Cvrd-Ded/Coins Durable Medical Equipment Maximum Amount Unlimited External Prosthetic Appliances Cvrd-Ded/Coins External Prosthetic Appliances Deductible $0 External Prosthetic Appliances Maximum Amount Unlimited Short Term Rehab and Chiro Combined Maximum Days 20 Short Term Rehab Maximum Days Chiropractic Care Maximum Amount Chiropractic Care Maximum Days Infertility Treatment Standard Coverage Not Covered Not Covered Infertility Opt 1 - Diagnoses/Corrective procedures Excluded Infertility Opt 1 - Diagnoses/Corrective procedure Not Covered Infertility Opt 2 - Opt 1 plus Invitro, GIFT, ZIFT, etc. Excluded Infertility Opt 2 - Opt 1 plus Invitro, GIFT, ZIFT Not Covered Infertility Opt 2 - Lifetime Maximum Amount Bariatric Services Excluded Bariatric Surgery - Lifetime Maximum Amount Preventive Care - Children thru Age 2 Not Covered Preventive Care Opt 2 - Annual Physicals Age 3+ Not Covered Preventive Care Opt 2 - Immunizations Preventive Care Opt 2 - Calendar Year Benefit Maximum Unlimited Amount Organ Transplant Not Covered Health Advisor Excluded Routine Foot Care Buy-up Excluded Not Covered Routine Foot Care Separate Buy-up Coinsurance Routine Foot Care - Cal Yr Buy-up Benefit Maximum Amount Surgical and Non-Surgical TMJ PCL PAC/CSR - Standard IP Admit/Case Management UR Program PAC/CSR IP Non Compliance Penalty Amount $750 PAC/CSR IP Non Compliance Penalty Percent 50% Medicare COB: Retirees >=65 Admin Option Proposal # Page 8 of 15 7/6/10

13 EXHIBIT A Proposed Benefits Product: Open Access Plus Situs State: TX Effective Date: 10/01/2010 Category Description In Network Out of Network Medical Benefits Open Access Plus Copay Medicare COB Type Percent of Medicare Eligible Well Aware Program (Diabetes) Well Aware Program (Cardiac) Well Aware Program (Asthma) Well Aware Program (Low Back Pain) Well Aware Program (COPD) Well Aware Program (Weight Complications) Well Aware Program (Targeted Conditions) Well Aware Program (Depression Management) Incentive Points Program 24HIL Healthy Rewards LifeSource Organ Transplant Network Transplant Program Language Line Transition of Care Case Management Provider Channeling Away From Home Care Drugstore.Com None Excluded Pharmacy Benefits Proposal # CIG Pharmacy 3-Tier Copay Plan Coinsurance 40% Retail - Generic Copay $10 Retail - Brand Copay $25 Retail - Non Preferred Copay $40 Mail Order - Generic Copay $20 Mail Order - Brand Copay $50 Mail Order Copay - Non-preferred $80 Retail - Individual Deductible Retail - Family Deductible Annual - Individual Maximum Annual - Family Maximum OOP - Individual Maximum OOP - Family Maximum Page 9 of 15 7/6/10

14 EXHIBIT A Proposed Benefits Product: Open Access Plus Situs State: TX Effective Date: 10/01/2010 Category Description In Network Out of Network Pharmacy Benefits CIG Pharmacy 3-Tier Copay Standard Preventive Drugs Excluded from Deductible Ded, Annual Max, OOP Max Apply to MOD MOD Program Maintenance Drug List Oral Contraceptives/Devices Lifestyle Drugs Oral Fertility Drugs Smoking Cessation Smoking Cessation Excluded from Deductible Non-Prenatal Vitamins Non-Prenatal Vitamins Excluded from Deductible Anti-Obesity & Anorexiants Anti-Obesity & Anorexiants Excl. from Deductible Self-Administered Injectables Optional Injectables Buy-Up Insulin Insulin Needles & Syringes Glucose Test Strips Lancets Prenatal Vitamins Step Therapy Program Clinical Management Program Enh. - Benefit Exclusion Enh. - Intensive Appropriateness of Use Enh. - Utilization and Unit Cost Management Generic Push Formulary Prescriber Panel NO Do Not Apply to MOD No Mandatory Covered Not Covered Not Covered Covered NO Covered NO Not Covered NO Covered Not Covered Covered Covered Covered Covered Covered Excluded Enhanced Not Selected Not Selected Not Selected Incentive Open MH/SA Benefits Proposal # OA Plus MHSA Combined CIG Behavioral Health In & Outpatient Mgmt. CAP MH/SA Hospital IP Coinsurance 80% 60% MH/SA Hospital IP - Per Admit Copay $200 MH/SA Hospital IP - Per Day Copay Page 10 of 15 7/6/10

15 EXHIBIT A Proposed Benefits Product: Open Access Plus Situs State: TX Effective Date: 10/01/2010 Category Description In Network Out of Network MH/SA Benefits OA Plus MHSA Combined MH/SA Hospital IP Combined Maximum Days 365 MH/SA Outpatient Copay $25 MH/SA Outpatient Coinsurance 60% MH/SA Intensive Outpatient Copay $25 60% MH/SA Intensive Outpatient Coinsurance 80% 60% MH/SA OP & MH Group Therapy Combined Maximum Visits MH Grp Therapy Copay $25 MH Grp Therapy Coinsurance 60% MH/SA OP Tiered Copay Option Excluded MH/SA OP Tier 1 Copay MH/SA OP Tier 1 Visits (1 to _) Maximum MH/SA OP Tier 2 Copay MH/SA OP Tier 2 Visits (Tier 1 Max to _ ) Maximum MH/SA OP Tier 3 Copay MH/SA OP Tier 3 Visits (Tier 2 Max to _ ) Maximum Standard IP Review/Case Mgmt UR Program OP Review/Case Mgmt Buy Up 1 UR Program Excluded OP Review/Case Mgmt Buy Up 2 UR Program Excluded Transition of Care (90 day period) Vision Benefits None Benefit Exceptions: Proposal # Page 11 of 15 7/6/10

16 EXHIBIT A Group Description: TX302D (ALL ACTIVE EMPLOYEES) TX302F (ALL ACTIVE EMPLOYEES, ALL COBRA PARTICIPANTS) TX302L (ALL PRE-65 RETIREES) TX302P (ALL PRE-65 RETIREES) TX302W (ALL ACTIVE EMPLOYEES) TX302X (ALL ACTIVE EMPLOYEES, ALL PRE-65 RETIREES) Tier Subscribers Inforce Members Current Rate Renewal Rate Monthly Premium Change EMP 84 $ $ $50, % EMP + SPOUSE 14 $ $1, $14, % EMP+CHILD(REN) 30 $ $ $26, % EMP + FAMILY 55 $ $1, $63, % Total $155, Proposal # Page 12 of 15 7/6/10

17 EXHIBIT A A. General Terms of this Proposal Underwriting Contingencies For City of Keller The CIG HealthCare Company identified herein ("CIG") is pleased to present this Proposal for a Guaranteed Cost group medical and pharmacy benefit plan (the "Plan") sponsored by City of Keller.This proposal is valid for 60 days from its original date of release, 07/06/2010. Any revisions or updates to this proposal will not renew this valid timeframe unless expressly communicated by CIG. Proposal Caveats CIG may revise or withdraw this Proposal if: 1 there is a change to the effective date of the quote. 2 the policy period length is different than 12 months. 3 the policy will not be sitused in TX. 4 the Plan benefits are different than shown in the RFP or benefit modifications are requested. 5 there is a change in any law, regulation, or required assessment or tax that changes CIG's costs in offering the plan. 6 enrollment increases or decreases by 10% or more, by product or for the total account, from the enrollment assumptions used in establishing the rates and/or fees set forth herein. 7 participation is below 70%. This will be based on the total eligible employees, identified as it is not the exclusive provider of Medical (/ Pharmacy / Vision) or like products for all of City of Keller's employees in all worksites 9 the demographics (i.e., age and number enrolled) of the group either as a result of the event or as the result of post-enrollment changes is determined by CIG to be substantially different than the demographics assumed in determining the rates quoted or the demographics of the group, at renewal we will adjust the original rate for the demographic difference and apply the quoted cap to the original rate. 10 the employer contributes less than 50% toward the total cost of the plan. 11 the employer changes its contribution to the plan rates (either the percentage or amount). 12 either one or more of the quoted sites withdraws prior to the effective date or terminates during the contract term, or at any time following enrollment. 13 the current waiting period is different than. 14 the final enrollment deviates from the quoted enrollment such that it results in a needed change in premium rates. Rates are based on final enrollment factors, including total number of enrollees, their age, sex, demographics, location and the distribution of enrollees by product or membership tier. 15 any of the information upon which these rates or benefits were based (including Medical History Information) changes or is inaccurate. 16 there is any reimbursement arrangement ("gap" cards, etc.) that subsidizes or reduces the out-of-pocket obligation of insured persons under the policy. 17 include pre 65 retirees in the HMO and Open Access Plus plan. Proposal # Page 13 of 15 7/6/10

18 EXHIBIT A

19 EXHIBIT A B. Scope and Application of this Proposal Unless otherwise indicated, this Proposal: Underwriting Contingencies For City of Keller 1 supersedes and renders null and void any prior CIG offer or proposal with respect to the Plan. 2 or policy may be canceled as of any Premium Due Date if the number of insured Employees fails to meet the minimum required per group participation rules; or for failure to comply with any other material plan provision relating to Employer contributions or group participation rules. 3 requires a separate benefit option due to state regulations, if you have purchased OAP/PPO with CIG Behavioral Advantage and you have members residing in NC or CA. 4 does not apply to part-time or seasonal employees for any plan. 5 includes the Network Savings Program (NSP) and other bill negotiation. 6 includes a maximum reimbursable charge for out-of-network coverage equal to 110% of a fee schedule developed by CIG based upon a methodology similar to that used by Medicare to determine the allowable fee for similar services in the geographic market. OR 80th percentile of charges made by providers of such service or supply in the geographic area where the service is received. 7 includes a maximum reimbursable charge for out-of-network coverage equal to 80th percentile of charges made by providers of such service or supply in the geographic area where the service is received. 8 assumes all employees are located in the network area, and that all employees are only eligible for the Connecticut General or other CIG company product offerings specified. 9 requires you notify us within 30 days if any information set forth in this form changes at any time while coverage is provided to you by CIG HealthCare Companies. 10 may require regulatory approval of rates. If, as of their proposed effective date, regulatory approval is not obtained, the healthplan shall use rates consistent with its then currently approved rates and the foregoing rates shall be effective automatically. If a product is new and has never had approved rates, the effective date of coverage will be postponed until regulatory approval is received. 11 allows caveats and conditions set forth in this document to survive execution of any final contract and/or issuance by CIG HealthCare of any policy and/or Group Service Agreement. 12 includes post 65 employees that are eligible for Open Access Plus plan. 13 excludes charges for converting a qualified member of a group plan to an individual plan. 14 is a high-level summary of the proposed coverage. It does not identify all the categories of health care expenses that are covered or excluded. 15 may include state required continuation rates which will match the rates for the underlying plan. For Nebraska and New York Over Age Dependents the rates will match the employee rate for the underlying plan. Proposal # Page 14 of 15 7/6/10

20 EXHIBIT A Underwriting Contingencies For City of Keller The CIG HealthCare Companies reserve the right to change the Quoted Rates and/or Quoted Benefits or to decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed Effective Date indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of this summary information form. If any of the information identified above changes either prior to the proposed Effective Date or while coverage is in effect, you agree to notify us promptly of such change. The Underwriting Contingencies set forth above shall survive execution of any insurance policy, application, etc., issued by Connecticut General Life Insurance Company or any other CIG HealthCare company, and shall further survive the effective date of any such policies. The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the rates. Please review the Benefit Summary and its attachments for information about the benefits available in your sites. CIG Healthcare refers to various operating subsidiaries of CIG Corporation. Products and services are provided by these subsidiaries and not by CIG Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc. and its affiliates, CIG Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIG Health Corporation and CIG Dental Health, Inc. I UNDERSTAND AND AGREE ON BEHALF OF CONTRACTHOLDER THAT CIG HEALTHCARE MAY, NOTWITHSTANDING THE TERMS OF THE INSURANCE POLICY OR SERVICE AGREEMENT REVISE ANY PREMIUM RATES OR PREPAYMENT FEES AT ANY TIME IF THE ENROLLMENT OR EMPLOYER CONTRIBUTION LEVEL IS DIFFERENT THAN ASSUMED BY CIG HEALTHCARE IN UNDERWRITING THE CONTRACT. Client Signature Date Client Name Proposal # Title Page 15 of 15 7/6/10

21 Attachment A - Benefit Summary OAP Copay Plan

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34 Attachment B - Benefit Summary HMO Copay Plan

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45 Attachment C - Vision Schedule Vision Benefits