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Resolution No. 97561 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RESOLUTION NO.•9756 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF VERNON DECLARING ITS INTENTION TO RENEW 2008 AETNA MEDICARE PRIVATE FEE -FOR -SERVICE (PFFS) PLAN GROUP AGREEMENT NO. 381741 BY AND BETWEEN CITY OF VERNON AND AETNA LIFE INSURANCE COMPANY AND HMO GROUP AGREEMENT NO. 381034 BY AND BETWEEN THE CITY OF VERNON AND AETNA HEALTH OF CALIFORNIA INC. AND AUTHORIZING THE CITY TO DO ALL ACTIONS DEEMED NECESSARY OR ADVISABLE CONCERNING HEALTH BENEFITS FOR ACTIVE AND RETIRED EMPLOYEES WHEREAS, on December 17, 2007, the City Council of the City of Vernon adopted Resolution No. 9497 ratifying and approving health care benefits with Aetna Health of California Inc. ("Aetna"); and WHEREAS, Aetna Life Insurance Company provided a 2008 Aetna Medicare Private Fee -For -Service (PFFS) Plan, Contract No. 381741 for GRP COINS 90 Open Benefits Package for an initial term of January 1, 2008 through December 31, 2008 and subsequent terms thereafter from January 15t through December 31st with rates subject to adjustment, which plan previously included all retired employees regardless of age with the active employees; however retired employees have now been (separated into two plans, retired employees under 65 with the active lemployees under one plan, and retired employees over 65 under a (separate plan; and WHEREAS, Aetna Health of California Inc. provided a Group Agreement No. 381034 for CITIZEN PLAN Benefits Package (HMO) for an initial term of January 1, 2008 through December 31, 2008 and subsequent terms thereafter from January lst through December 31st with rates subject to adjustment; and WHEREAS, Aetna Health of California Inc. and Aetna Life I lInsurance Company shall hereinafter be collectively known as Aetna; 0I= 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 WHEREAS, Aetna has advised the City of an increase of 15.8% for medical benefits for HMO (an additional $222,779.00) and an increase of 9.4% for medical benefits for POS Open Access for active and retired employees under 65 (PPO) (an additional $154,461.00) with rates for City Council benefits remaining the same; and WHEREAS, the Risk Manager has recommended that the City renew 2009 medical benefits for active employees based on an approximate annual premium for HMO of $1,630,155.00 and an approximate annual premium for PPO of $1,791,153.00 for a total of $3,421,308.00; and WHEREAS, Aetna has requested that the City declare its intention to renew the health benefit plans prior to memorializing the agreement or amendment in writing, if necessary; and WHEREAS, the City Council intends to renew the health benefit plans for 2009 based upon the recommendations of the Risk Manager. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE ICITY OF VERNON AS FOLLOWS: SECTION 1: The City Council of the City of Vernon hereby finds and determines that the recitals contained hereinabove are true and correct. SECTION 2: The City Council of the City of Vernon hereby gives notice of its intention to renew the health plans for active employees and retirees under 65 under the Plan Design & Benefits provided by Aetna health plans, a copy of which are attached hereto as - 2 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Exhibit A and incorporated by reference. SECTION 3: The City Council of the City of Vernon hereby gives notice of its intention to approve any agreements or amendments necessary to implement the renewal of the health plans for active employees and retirees under 65.` SECTION 4: The City Clerk of the City of Vernon shall certify to the passage of this resolution, and thereupon and thereafter the same shall be in full force and effect. APPROVED AND ADOPTED this 3rd day of November, 2008. ATTEST: Xt0161�- ANnELA GIRO , Cit y Clerk Name: Hilario Gonzales Title:/ Mayor Pro-Tem - 3 - 1 STATE OF CALIFORNIA ) 2 ) ss COUNTY OF LOS ANGELES ) 3 4 I, MANUELA GIRON, City Clerk of the City of Vernon, do hereby 5 certify that the foregoing Resolution, being Resolution No. 9756, was 6 duly adopted by the City Council of the City of Vernon at regular 7 meeting of the City Council duly held on Monday, November 3, 2008, and 8 thereafter was duly signed by the Mayor or Mayor Pro-Tem of the City of 9 Vernon. 10 e 11 AANU�ELA GIR N, City Clerk 12 13 (SEAL) 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 4 - I awl lei .Aetn City of Vernon Effective Date: 01/01/2008 Open Access® Managed Choice® POS PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Payment Limit (per calendar year) $2,000 Individual $5,000 Individual $4,000 Family $10,000 Family All covered expenses, excluding prescription drugs, accumulate separately toward the preferred or non -preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage (except any deductibles, and penalty amounts) may be used to satisfy the Payment Limit. Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. Lifetime Maximum $3,000,000 Primary.Care Physician Selection Optional Not applicable Certification Requirements Certification for certain types of Non -Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per occurrence. Pre -certification for certain procedures/treatments - excluded amount is $200 per occurrence. Referral Requirement None None Routine Adult Physical Exams/ $10 office visit copay; deductible 40% Immunizations waived 1 exam every 12 months for members age 18 and older. Routine Well Child Exams/Immunizations $10 office visit copay; deductible 40% waived 7 exams in the first 12 months of life, 2 exams in the 13th-24th months of life; 1 exam per 12 months thereafter to age 18. Routine Gynecological Care Exams Covered 100%; deductible waived 40% One exam per calendar year. Includes routine tests and related lab fees. Members may choose obstetrician/gynecologist as PCPs. Routine Mammograms Covered 100%; deductible waived 40% One baseline mammogram for covered females age 35-39, one mammogram per calendar year for covered females age 40 and over. Routine Digital Rectal Exam Member cost sharing is based on Member cost sharing is based on For covered males age 40 and over. the type of service performed and the type of service performed and Prostate -specific Antigen Test For covered males age 40 and over the place of service where it is rendered; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; deductible waived the place of service where it is rendered. Member cost sharing is based on the type of service performed and the place of service where it is rendered. Page 1 X_Netna City of Vernon Effective Date: 01/01/2008 Open Access° Managed Choice® POS PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Colorectal Cancer Screening Member cost sharing is based on Member cost sharing is based on For all members age 50 and over. the type of service performed and the type of service performed and the place of service where it is the place of service where it is rendered rendered Routine Eye Exams Not Covered Not Covered Routine Hearing Exams Not Covered Not Covered Office Visits to PCP $10 office visit copay; deductible 40% waived Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits $10 office visit copay; deductible 40% waived Allergy Testing Member cost sharing is based on Member cost sharing is based on the type of service performed and the type of service performed and the place of service where it is the place of service where it is rendered; deductible waived rendered Allergy Injections Member cost sharing is based on Member cost sharing is based on the type of service performed and the type of service performed and the place of service where it is the place of service where it is rendered rendered D�AGNOSTI�PRCpURES,t..� ...'REFE,RRED_Cbh,E� NQN*PREFERRED,CARE ..;°. Diagnostic Laboratory and X-ray 10% 40% (other than Complex Imaging Services) If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing Diagnostic X-ray for Complex Imaging 10% 40% Services II/tERGNCY� I]1CA.)'GARE_BARE .= NDN PREFERRED CARE..:.: Urgent Care Provider 10% after $25 copay 10% after $25 Copay (benefit availability may vary by location) Non -Urgent Use of Urgent Care Provider Not Covered Not Covered Emergency Room 10% after $25 copay; deductible Same as preferred care. waived Non -Emergency Care in an Emergency Not Covered Not Covered Room Ambulance 10% 40% HOPIT,LKC#RE _ z.�`� P�2EFER,., '. NON,PRERRED DARE Inpatient Coverage 10% 40% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Inpatient Maternity Coverage 10% 40% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Hospital Expenses (including 10% 40% surgery) The member cost sharing applies to all covered benefits incurred durinq a member's outpatient visit. Inpatient 10% 40% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient $10 copay; deductible waived 40% The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Inpatient 10% Limited to 30 days per calendar year. Page 2 City of Vernon Effective Date: 01/01/2008 Open Access® Managed Choice® POS PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY The member cost_sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient $10 copay; deductible waived 40% Limited to 20 visits per calendar year. The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Convalescent Facility 10% 40% Limited to 120 days per calendar year The member cost sharing applies to all covered benefits incurring during a member's inpatient stay. Home Health Care 10% 40% Limited to 120 visits per calendar year Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit Hospice Care - Inpatient 10% 40% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Hospice Care - Outpatient 10% 40% Up to a maximum benefit of $5,000 The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Private Duty Nursing -Outpatient (Limited to 10% 40% 70 eight hour shifts per calendar year) Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift Outpatient Short -Term Rehabilitation $10 copay; deductible waived 40% Includes Speech, Physical, Occupational and Spinal Manipulation Therapy, limited to 60 visits per calendar year Durable Medical Equipment 10% 40% Maximum annual benefit of $10,000 per member per calendar year Diabetic Supplies -- (if not covered under Covered same as any other Covered same as any other Pharmacy benefit) medical expense. medical expense Contraceptive drugs and devices not Covered same as any other Covered same as any other obtainable at a pharmacy (includes medical expense'. medical expense. coverage for contraceptive visits) Vision Eyewear Not Covered Same as preferred care Transplants 10% 40% Preferred coverage is provided at Non -Preferred coverage is an IOE contracted facility only provided at a Non-IOE facility. Bariatric Surgery Not Covered Not Covered The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Out of Area Dependents Coverage provided at the non -preferred benefit level of the plan. Infertility Treatment Member cost sharing is based on Member cost sharing is based on the type of service performed and the type of service performed and the place of service where it is the place of service where it is rendered rendered Diagnosis and treatment of the underlvinq medical condition. Comprehensive Infertility Services Not Covered Not Covered Advanced Reproductive Technology (ART) Not Covered Not Covered ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Page 3 XAetncq City of Vernon Effective Date: 01/01/2008 Open Access® Managed Choice° POS PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Voluntary Sterilization Member cost sharing is based on Member cost sharing is based on Including tubal ligation and vasectomy. the type of service performed and the type of service performed and the place of service where it is the place of service where it is rendered rendered PHARjUICI p �F2FERRED2 NONhP,EFERRED CARE .. Retail $5 copay for generic drugs and $15 copay for brand -name drugs up to a 30 day supply at participating pharmacies. Mail Order $10 copay for generic drugs and Not applicable $30 copay for brand -name drugs up to a 31-90 day supply from Aetna Rx Home Delivery& No Mandatory Generic (NO MG) - Member is responsible to pay the applicable copay only. Plan Includes: Diabetic supplies, Contraceptive drugs and devices obtainable from a pharmacy and Performance Enhancing Medication. Precert for growth hormones included. Expanded Precert included _Dependents Eligibility Spouse, children from birth to age 19 or age 24 if in school Pre-existing Conditions Exclusion On effective date: Waived After effective date: Waived This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; Orthotics; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Page 4 XAetna City of Vernon Effective Date: 01/01/2008 Open Access® Managed Choice® POS PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member's preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non -preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step -therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are provided by Aetna Life Insurance Company. Page 5 ; s CD k G .0 CD/ CD E CO .a=— / DC i 0 I'D 90 [§GE ± 0QW/ 2 §RCD ( \/§) 2§(0 §#CD /§§� CL $ -0 CD -3 E;/e 0®E43 \AZ( -4 3M&a 0= \/\ =rCD ,n2§ 222\ ./ (ƒ /\/§ a2/7 k2n CD 0 cc CD 0 m 0CL W CD cn C, �Co /{ 2£Q. (D � DCD CD C 3m (A � ! >mCD CD * k o � /§ M §§� ƒQ $ D 7k /©2 § 0 \ (D m a � 0 CD m � ■ � ■ X-Aetila City of Vernon Effective Date: 01/01/2008 HMO - California PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK PL%>,., FVW RES. ': r PAhTIC11111111 IP ING_PROVI.DERS / REFERREd Deductible (per calendar year) None Individual _ None Family Out -of -Pocket Maximum $1,500 Individual (per calendar year) $3,000 Family Member cost sharing for certain services may not apply toward the Out -of -Pocket Maximum. Only those participating providers/referred out of pocket expenses resulting from the application of coinsurance percentage and copays (except any penalty amounts and pharmacy cost sharing) may be used to satisfy the Out -of Pocket Maximum. Once Family Out -of -Pocket Maximum is met, all family members will be considered as having met their Out -of -Pocket Maximum for the remainder of the calendar year. Lifetime Maximum Unlimited unless otherwise indicated. Primary Care Physician Selection Required Referral Requirements Required for all non -emergency, non -urgent and non - Primary Care Physician services, except direct access services =PREVENTII%E CARE3�,g 4 PAR�TI��IPATING.PROVIDERS /�12EFERRED x Routine Adult Physical Exams / Immunizations $20 copay (Age and frequency schedules apply) Well Child Exams / Immunizations $20 copay (Age and frequency schedules apply) Routine Gynecological Care Exams $20 copay Includes Pap smear, HPV screening, and related lab fees. Direct access to participating providers without a referral. Members may choose ob/gyns as PCPs. One exam per calendar year. Routine Mammograms $20 copay One baseline mammogram for females age 35-39; and one annual mammogram for females age 40 and over Routine Digital Rectal Exams / Prostate Specific Antigen Member cost sharing is based on the type of service Test performed and the place of service where it is For males age 40 and over rendered. Colorectal Cancer Screening Member cost sharing is based on the type of service For all members 50 and over. performed and the place of service where it is Frequency schedule applies rendered. Routine Eye Exam Not Covered Age/Frequency Schedule may apply. Routine Hearinq Screeninq Subiect to Routine Physical Exam cost sharing Primary Care Physician Visits Office Hours: $20 copay After Office Hours/Home: $25 copay Office Visits Maternity OB Visits $20 copay for initial visit only, thereafter covered 100% Allergy Treatment Same as applicable participating provider office visit member cost sharing Allergy Testing Same as applicable participating provider office visit member cost sharina Diagnostic Laboratory $20 copay If performed as a part of a physician's office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit cost sharing. Page 1 XAetna City of Vernon Effective Date: 01 /01 /2008 HMO - California PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK Diagnostic X-ray $20 copay Outpatient hospital or other Outpatient facility (except for Complex Imaging Services) Diagnostic X-rav for Complex Imaging Services $20 copay Urgent Care $100 copay Non -Urgent use of Urgent Care Provider Not Covered Emergency Room $100 copay Non -Emergency Care in an Emergency Room Not Covered Ambulance Covered 100% Inpatient Coverage Covered 100% per admission The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Inpatient Maternity Coverage Covered 100% per admission The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Surgery Covered 100% per visit The member cost sharina applies to all covered benefits incurred durina a member's outpatient visit. Inpatient Serious Mental Illness and Serious Emotional Covered 100% per admission Disturbances of a Child The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Inpatient Non -Serious Mental Illness Covered 100% per admission Limited to 30 days per calendar year The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Serious Mental Illness and Serious Emotional $20 copay per visit Disturbances of a Child The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Outpatient Non -Serious Mental Illness $25 copay per visit Limited to 20 visits per calendar year The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. 0ALCOHOIJMQ ABUSE SEt UICEE . f : 'PA"ICIP,ATING PROVIDERS /„REFERRED „ Inpatient Detoxification Covered 100% per admission The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Detoxification $20 copay The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Inpatient Rehabilitation Not Covered The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Rehabilitation Not Covered The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. OTHER SERVICES ,��, PARTIGIPATI,N�zj?RO,UIDERS/REFERRED Skilled Nursing Facility Covered 100% per admission The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Home Health Care Covered 100% Hospice Care - Inpatient Covered 100% per admission The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Hospice Care - Outpatient Covered 100% The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Private Duty Nursing Not Covered unless pre -authorized Outpatient Rehabilitation Therapy (Includes speech, $20 copay physical and occupational therapy) Treatment over a 60-day consecutive period per incident of illness or injury beginning with the first day of treatment. Page 2 XAetna City Vernon Effective Date: 01/01/2008 HMO - California PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK Subluxation $15 copay Direct access to participating providers without a referral. Limited to 20 visits per calendar year Durable Medical Equipment 20% Limited to $10,000 per calendar year Diabetic Supplies Pharmacy cost sharing applies if Pharmacy coverage is included; otherwise PCP office visit cost sharing applies. Dental Not Covered Vision Eyewear Not Covered Transplants Covered 100% per admission Coverage is provided at an IOE contracted facility only Bariatric Surgery Covered 100% per admission The member cost sharina applies to all covered benefits, i ncu rred durina a member's inpatient stay. Infertility Treatment Member cost sharing is based on the type of service Diagnosis and treatment of the underlying medical condition. performed and the place of service where it is rendered. Comprehensive Infertility Services Not Covered Coverage includes Artificial Insemination and Ovulation Induction Advanced Reproductive Technology (ART) Not Covered ART coverage includes In -Vitro Fertilization (IVF), Zygote Intra-Fallopian Transfer (ZIFT), Gamete Intra-Fallopian Transfer (GIFT), cryopreserved embryo transfers, Intra-Cytoplasmic Sperm Injection (ICSI) or ovum microsurgery. Voluntary Sterilization Subject to applicable service type member cost sharing Including tubal ligation and vasectom . PHARMACY= PRESCRIPTIQN bRt�,GBENEFjTS ,w„ ,r, ARTICIPATING PROVIDERS /REFERRED„ Retail $15 copay for formulary generic drugs, $35 copay for formulary brand -name drugs, and $50 copay for non - formulary brand -name and generic drugs up to a 30 day supply at participating pharmacies. Mail Order $30 copay for formulary generic drugs, $70 copay for formulary brand -name drugs, and $100 copay for non - formulary brand -name and generic drugs up to a 31-90 day supply from Aetna Rx Home Delivery& Pharmacy Managed Self Injectables (PMSI) First prescription fill at any retail or mail order drug facility. Subsequent fills must be through Aetna Specialty Pharmacy® No Mandatory Generic (NO MG) - Member is responsible to pav the applicable copav only. Plan Includes : Contraceptive drugs and devices obtainable from a pharmacy and Performance Enhancing Medication. Precert included Step Therapy included with 90 day Transition of Care Exclusions and Limitations "For this plan, "participating providers" refers to the Aetna Value Network participating providers. For any questions or concerns about accessing and obtaining services from Aetna Value Network specialty physicians, please call Member Services at 1-888-98-AETNA (1-888-982-3862). This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased. Page 3 XAetna City of Vernon Effective Date: 01/01/2008 HMO - California PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK • All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates. • Cosmetic surgery. • Custodial care. • Dental care and dental x-rays. •Donor egg retrieval. • Durable medical equipment. • Experimental and investigational procedures, (except for coverage for medically necessary routine patient care costs for Members participating in a cancer clinical trial). • Hearing aids. • Home births • Immunizations for travel or work • Implantable drugs and certain injectable drugs including injectable infertility drugs. • Infertility services including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents. • Nonmedically necessary services or supplies. • Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over- the-counter medications (except as provided in a hospital) and supplies • Radial keratotomy or related procedures. • Reversal of sterilization. • Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling. • Special duty nursing. • Therapy or rehabilitation other than those listed as covered in the plan documents. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and therefore, cannot guarantee any results or outcomes. Consult the plan document (i.e. Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. The availability of a plan or program may vary by geographic service area. Some benefits are subject to limitations or visit maximums. With the exception of Aetna Rx Home Delivery, all participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. If your plan covers outpatient prescription drugs, your plan may include a drug formulary (preferred drug list). A formulary is a list of prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to applicable limitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary. The medications listed on the formulary are subject to change in accordance with applicable state law. For information regarding how medications are reviewed and selected for the formulary, formulary information, and information about other pharmacy programs such as precertification and step -therapy, please refer to Aetna's website at www.aetna.com, or the Aetna Medication Formulary Guide. Many drugs, including many of those listed on the formulary, are subject to rebate arrangements between Aetna and the manufacturer of the drugs. Rebates received by Aetna from drug manufacturers are not reflected in the cost paid by a member for a prescription drug. Page 4 XAetna City 1 / Vernon Effective Date: 01/01/2008 HMO - California PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage basis or a deductible, use of formulary drugs may not necessarily result in lower costs for the member. Members should consult with their treating physicians regarding questions about specific medications. Refer to your plan documents or contact Member Services for information regarding the terms and limitations of coverage. Aetna Rx Home Delivery® refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna Inc., that is a licensed pharmacy providing mail-order pharmacy services. Aetna's negotiated charge with Aetna Rx Home Delivery may be higher than Aetna Rx Home Delivery's cost of purchasing drugs and providing mail-order pharmacy services. Certain primary, care providers are affiliated with integrated delivery systems or other provider groups (such as independent practice associations and physician -hospital organizations), and members who select these providers will generally be referred to specialists and hospitals within those systems or groups. However, if a system or group does not include a provider qualified to meet member's medical needs, member may request to have services provided by a non -system or non -group providers. Member's request will be reviewed and will require prior authorization from the system or group and/or Aetna to be a covered benefit. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification), inpatient and outpatient rehabilitation). When the Member obtains covered services from participating providers, the provider will obtain precertification. If the Member obtains covered services from a nonparticipating provider, the Member must obtain the precertification. Precertification requirements may vary. Members may refer to their plan documents for a complete list of medical services that require precertification. Certain benefits like comprehensive infertility and advanced reproductive technology (ART) services, if covered under your plan, are subject to a select network of participating providers, from which you will be required to seek care to receive covered benefits. Members or providers may be required to precertify, or obtain prior approval of coverage for certain services such as non -emergency inpatient hospital care. Certain benefits like comprehensive infertility and advanced reproduction technology (ART) services, if covered under your plan, are subjecfito a select network of participating providers, from which you will be required to seek care to receive covered benefits. Page 5 CITY CLERK'S OFFICE INTEROFFICE MEMORANDUM DATE: November 5, 2008 TO: Willard Yamaguchi, Chief Deputy City Attorney/Risk Manager FROn Nelly Giron, City Clerk RE: Resolution No. 9756 - A Resolution of the City Council of the City of Vernon Declaring Its Intention to Renew 2008 Aetna Medicare Private Fee -For -Service (PFFS) Plan Group Agreement No. 381741 By and Between City of Vernon and Aetna Life Insurance Company and HMO Group Agreement No. 381034 By and Between the City of Vernon and Aetna Health of California Inc. and Authorizing the City to Do All Actions Deemed Necessary or Advisable Concerning Health Benefits for Active and Retired Employees Transmitted herewith is a copy of Resolution No. 9756 referenced above, which was approved by City Council on November 3, 2008. Thank you. NG:dr c: Karina Rueda Resolution No. 9756 RESOLUTION NO. 10,097 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF VERNON APPROVING THE RENEWAL OF HEALTH CARE BENEFITS FOR RETIRED EMPLOYEES FOR THE CALENDAR YEAR 2010 WITH AETNA HEALTH INC. AND AETNA LIFE INSURANCE COMPANY INC. WHEREAS, on November 3, 2008, the City Council of the City of Vernon adopted Resolution No. 9756 approving the renewal of health care benefits with Aetna Life Insurance Company for Medicare Private fee -for -service (PFFS) Plan Group and HMO Group with Aetna Health Inc. (collectively, "Aetna") for the period of January 1, 2008 through December 31., 2008 and a subsequent term thereafter from January 1, 2009 to December 31, 2009; and WHEREAS, Aetna has advised the City of an increase of 9.2% for medical benefits for the Health Maintenance Organization plan (HMO) (an additional $1,817.00 per year) and an increase of 17.1% for medical benefits for Open Access Managed Choice POS (PPO) (an additional $3,032.00 per year) for retired employees under 65 years old, for an approximate total annual premium of $21,529.00 for HMO and $20,760.00 for PPO; and WHEREAS, Aetna has advised the City of an increase of 1.6% for medical benefits for the HMO (an additional $491.00 per year) and an increase of 16.4% for medical benefits for the PPO (an additional $29,104.00 per year) for retired employees over 65 years old, for an approximate total annual premium of $30,511.00 for HMO and $206,836.00 for PPO; and WHEREAS, Aetna has offered the City an HMO and PPO plan for the period of January 1, 2010 through December 31, 2010, for a one (1) year term; and WHEREAS, the City Council intends to renew the health benefit plans for 2010 based upon the recommendations of the Risk Manager. NOW, THEREFORE, BE IT RESOLVED BY THE.CITY COUNCIL OF THE CITY OF VERNON AS FOLLOWS: SECTION 1: The City Council of the City of Vernon hereby finds and determines that the recitals contained hereinabove are true and correct. SECTION 2: The City Council of the City of Vernon hereby approves the renewal for medical benefits with Aetna Health Inc. and Aetna Life Insurance Company Inc. for retired employees that are summarized in the Plan Design & Benefits provided by Aetna, a copy of which is attached hereto as Exhibit A and incorporated by reference. SECTION 3: The City Council of the City of Vernon hereby authorizes the City Administrator, or his designee, to take whatever action is deemed necessary or desirable for the purpose of implementing and carrying out the purpose of this Resolution and the transactions herein approved or authorized. 2 SECTION 4: The City Clerk of the City of Vernon shall certify to the passage, approval and adoption of this resolution, and the City Clerk of the City of Vernon shall cause this resolution and the City Clerk's certification to be entered in the File of Resolutions of the Council of this City. APPROVED AND ADOPTED this 9th day of November, 2009. ATTE MAMELA GIRON, City'Clerk Name: Hilaric Gonzales Title: Mayor _3_ STATE OF CALIFORNIA ) ) ss COUNTY OF LOS ANGELES ) I, MANUELA GIRON, City Clerk of the City of Vernon, do hereby certify that the foregoing Resolution, being Resolution No. 10,097, was duly passed, approved and adopted by the City Council of the City of Vernon at a regular meeting of the City Council duly held on Monday, November 9, 2009, and thereafter was duly signed by the Mayor or or Pro-Tem of the City of Vernon. Executed this �67�day of November, 2009, at Vernon, California. (SEAL) 1 � MANUELA GIRON City Clerk - 4 - EXHIBIT a )(Aetna Medicare City of Vernon - HMO MAPD Group Plan Aetna Medicare sM Plan (HMO) Medicare 5 Special Plan Rx Group 012 Arizona, California, Connecticut, Colorado, Delaware, District of Columbia, Florida, Georgia, Illinois, Maryland, Maine, New Jersey, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia PLAN DESIGN AND BENEFITS Lifetime Maximum Unlimited Primary Care Physician Selection Required Referral Requirements Required for all non -emergency, non -urgent and non - Primary Care physicians services, except direct access services. Routine Physical Exams/Immunizations Covered 100% (One annual exam/Pneumonia, Flu, Hepatitis B) Routine Gynecological Care Exams Covered 100% Includes related lab fees for covered females age 18 and older. Direct Access to participating providers One routine GYN visit and pap smear every 365 days Routine Mammograms Covered 100% One baseline mammogram for members 35-39; and one annual mammogram for members age 40 and over Routine Digital Rectal Exams / Prostate Specific Antigen Covered 100% Test For males age 40 and over. Colorectal Cancer Screening Covered 100% For all members 50 and over. Bone Density Testing Covered 100% Routine Eye Exam Covered 100% Direct access to participating providers. One annual exam. Routine Hearing Screening Covered 100% One (1) annual exam Hearing Aid Reimbursement Discounts where available Primary Care Physician Visits (Office hours) $5 copay (After Office Hours) $10 copay (does not apply to CA) Specialist Office Visits $15 copay Podiatry $15 copay Limited to Medicare covered benefits only Allergy Testing/Treatment $15 copay M0001_7A 70650 Pagel City of Vernon - HMO MAPD Group Plan )(Aetna: Medicare Aetna Medicare sM Plan (HMO) Medicare 5 Special Plan Rx Group 012 Arizona, California, Connecticut, Colorado, Delaware, District of Columbia, Florida, Georgia, Illinois, Maryland, Maine, New Jersey, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC For initial testing by a specialist; PCP copay for routine injections at PCP office with or without physician encounter �i:�� /mil .,r-� mf�� y�--,�/y�-� .�yx��-;� -.. � f i --vim vs�, ::��"l �" �ay",��t�• .� r �. � , -: � �,� w � .. J a %. -i � a�� - 6.; a, ; .lj �� �, � r.. >u; e �s � <- 1n�V s ' x> :�a"✓�,� �,..si !ti�� � / �3e f �� � ¢`�' y ..� i r � � � w .. �� " 's v,�` �� � c� �`� 1'�..vp� , �t1 vE� � •. . � s� �.,/h. �.i a � f �� „h. � �, ..,.i ?i �. / � .'� r ✓`.i t t� Y Us �� F, Ht - �.,a�:� � izrc RdF zi- ��s s e a,� J�; ,. ,,.���„"�,� 5 ,,;.w.<.d;<:;,.��u�urervo,.,nrJ ,,,.:✓r/1�, :%,_s,,.,,, �. .fit .su �?�,..cnsr<a>o,2.'r.>�;,�sca,,,�,,,,__,�1.,� � �. ,x,.,: <r..,� N'�,sx,.:,xi,. ,a.:_;s✓<.,�o..F� � ..s>i..r �S �� �r �,.,,�/,sr;�i ,.a��,�2i„r� Diagnostic Laboratory and X-Ray $15 copay '- ? ram. i�a �- z ii --r :� .� ,� r:! f t.r�, U� /efj; ii" �,�?N S. l 3 s 5�.,. -3 .� �t -�:F .k sF%s e i,`:;,'j/ ! r .� P. �;�.ry .:i.f! .;.� a ey�C$ as ?.:s. �d r'C eyi. .�.%�. e ✓,..,rf �. ,. v...,.,ta ,v. ,.., „ru,� i :.A�.e ax „`. �..,.., �INE` f_.a,/,.; sic..,, n�, �'.,r137a; �+f,,.,,;., Lr.,, ✓.sz.,,,e.x ,o_rv„r-s ,: .,.fti ,a Urgent Care Provider $35 copay 11 ' 1 Room-, Worldwide (waived if admitted) $50copay Ambulance Covered 00%i)eril• • Inpatient Coverage Covered 100% The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Outpatient Surgery Covered 100% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. Inpatient Mental Illness Covered 100% The member cost sharing applies to covered benefits incurred during a member's inpatient. stay. Outpatient Mental Illness $15 copay The member cost sharing applies to covered benefits incurred during a member's outpatient visit. Inpatient Substance Abuse (Detox and Rehab) Covered 100% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Substance Abuse (Detox and Rehab) $15 copay The member cost sharing applies to covered benefits incurred during a member's outpatient visit. Skilled -Nursing Facility Covered 100% o (100 days per Medicare benefit period; prior authorization from HMO required) The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Home Health Care Covered 100% Hospice Care Covered by Medicare at Medicare certified Hospice Outpatient Short -Term Therapy (speech, physical, cardiac $15 copay and occupational Chiropractic Care $15 copay For manual manipulation of the spine to the extent covered by Medicare Durable Medical Equipment/Prosthetic Devices Covered 100% Diabetic Supplies No copay for strips, lancets and glucometer M0001_7A 70650 Page 2 XAetTla Medicare City of Vernon - HMO MAPD Group Plan Aetna Medicare SM Plan (HMO) Medicare 5 Special Plan Rx Group 012 Arizona, California, Connecticut, Colorado, Delaware, District of Columbia, Florida, Georgia, Illinois_, Maryland, Maine, New Jersey, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC Outpatient Complex Radiology $15 copay Outpatient Dialysis $15 copay Dental * Discounts where available Vision Eyewear Allowance $70 reimbursement every 24 months Coaching Included One phone call per week Prescription drug calendar year deductible None Prescription drug calendar year deductible must be satisfied before any Medicare Prescription Drug benefits are paid. Covered Medicare Prescription Drug expenses will accumulate toward the pharmacy deductible. Retail - Cost -Sharing $10 Copay for Generic $20 Copay for Preferred Brand $35 Copay Non -Preferred Brand Up to one month (31 day) supply at indicated copay or coinsurance (Three month (90 day) supply available at retail. Dollar copayments or applicable coinsurance will apply for each month supply.) Mail Order through Aetna Rx Home Delivery - Cost- $20 Copay for Generic Sharing $40 Copay for Preferred Brand $70 Copay for Non -Preferred Brand Up to a three month (90 day) supply available via our preferred vendor, Aetna Rx Home Delivery. M00012A 70650 Page 3 )(Aetna: Medicare City of Vernon - HMO MAPD Group Plan Aetna Medicare SM Plan (HMO) Medicare 5 Special Plan Rx Group 012 Arizona, California, Connecticut, Colorado, Delaware, District of Columbia, Florida, Georgia, Illinois, Maryland, Maine, New Jersey, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia Catastrophic Coverage PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC Greater of $2.50 or 5% for covered generic (including brand drugs treated as generic) drugs. Greater of $6.30 or 5% for all other covered drugs. Catastrophic Coverage benefits start once $4,550 in true out-of-pocket costs is incurred. Requirements: Precertification Yes Step -Therapy Yes Formulary Standard * Dental Riders are not available in the following service areas : DE01, ME01, NY03, VA01, and TX05 Please refer to the plan documents (Evidence of Coverage) for a complete listing of benefits, exclusions and limitations. The following is a partial listing of exclusions and limitations under the Aetna Medicare sM Plan (HMO): • All applicable services not referred by your network primary care doctor, except for services received as a result of an emergency or urgent situation; • Services that are not medically necessary or covered under the Original Medicare Program • Plastic or cosmetic surgery unless medically necessary • Custodial care • Experimental procedures or treatments beyond Original Medicare limits • Routine foot care that is not medically necessary • Drugs used for weight loss, weight gain or anorexia • Drugs used for cosmetic purposes or to promote hair growth • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations • Barbiturates • Outpatient drugs that the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale • Drugs used to promote fertility • Drugs used for symptomatic relief of cough and colds • Non-prescription drugs (OTC) • Benzodiazepines • Drugs when used for the treatment of sexual or erectile dysfunction M0001_7A_70650 Page 4 )(Ae1rla° Medicare City of Vernon - HMO MAPD Group Plan Aetna Medicare sM Plan (HMO) Medicare 5 Special Plan Rx Group 012 Arizona, California, Connecticut, Colorado, Delaware, District of Columbia, Florida, Georgia, Illinois, Maryland, Maine, New Jersey, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH INC This material is for informational purposes only. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Aetna does not provide care or guarantee access to health services. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Health information programs provide general health information and are not a substitute for diagnosis 'or treatment by a physician or other health care professional. Discount Programs provide access to discounted prices and are not insured benefits. While this material is believed to. be accurate as of the print date, it is subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Members must use network pharmacies to receive plan benefits except in limited, non -routine circumstances when a network pharmacy is not available, including illness while traveling within the United States but outside of the plan's service area where there is no network pharmacy. An additional cost may be incurred for drugs received at an out -of - network pharmacy. If an individual qualifies for extra help with the Medicare prescription drug plan, premium and costs at the pharmacy may be lower. Upon enrollment in the Aetna Medicare plan, Medicare will tell us how much extra help an individual is getting. An individual can obtain information on whether they qualify by calling 1-800-Medicare (1-800-633- 4227). TTY/TDD users should call 1-877-486-2048. Benefits coverage is provided by Aetna Health Inc., Aetna Health of California Inc. and/or Aetna Health of Illinois Inc., which are Medicare Advantage organizations with a Medicare contract and benefits, limitations, service areas and premiums subject to change on January 1 of each year You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A, if applicable. You must use network providers except for emergent care or out -of -area urgent care/renal dialysis. If your primary physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. ***This is the end of this plan benefit summary*** M0001_7A 70650 Page 5 City of Vernon - 2010 PFFS Group Plan X1 Aetna Medicare Aetna Medicare Open sM Plans Medicare 90 Open Plan Rx Group 012 National Service Area including Puerto Rico PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC Deductible (per calendar year) $0 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member Coinsurance 10% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $2,000 Includes deductible. Certain other member cost sharing elements may not apply towards the Payment Limit. Lifetime Maximum Unlimited except for where otherwise indicated Primary Care Physician Selection Not Applicable Referral Requirements None One baseline mammogram for members 35-39; and'one annual mammogram for members age 40 and over Routine Digital Rectal Exams / Prostate Specific Antigen Covered100% Test For males age 40 and over. Colo-re-ctal Cancer Screening Covered 100% For all members 50 and over. Bone Density Testing Covered 100% Routine Eye Exam Covered 100% One annual exam. Routine Hearing Screening Covered 100% One (1) annual exam Hearing Aid Reimbursement Discounts where available Primary Care Physician Visits (Office hours) 10% (After Office Hours) 10% Specialist Office Visits 10% H5736_7F_70614 Prepared: 10/16/200911:49 AM Pagel M XAetna Medicare City of Vernon - 2010 PFFS Group Plan Aetna Medicare Open SM Plans Medicare 90 Open Plan Rx Group 012 National Service Area including Puerto Rico PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC Allergy Testing/Treatment 10% For initial testing by a specialist; with or without physician encounter Laboratory and 10% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. Inpatient Substance Abuse (Detox and Rehab) 10% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Substance Abuse (Detox and Rehab) 10% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. Skilled Nursing Facility 0% per day - days 1-20; 10% per day - days 21-100 (100 days per Medicare benefit period) The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Home Health Care Covered 100% Hospice Care Covered by Medicare at a Medicare certified hospice Outpatient Short -Term Therapy (speech, physical, cardiac 10% and occupational) Chiropractic Care 10% For manual manipulation of the spine to the extent covered by Medicare Durable Medical Equipment/Prosthetic Devices 10% H5736_7F_70614 Prepared: 10/16/200911:49 AM Page 2 City of Vernon - 2010 PFFS Group Plan, XAetm M ed Ica re Aetna Medicare Open sM Plans Medicare 90 Open Plan Rx Group 012 National Service Area including Puerto Rico PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC Podiatry 10% Limited to Medicare covered benefits only Diabetic Supplies Covered 100% Includes test strips, lancets and glucometer Outpatient Complex Radiology 10% Outpatient Dialysis 10% Prescription drug calendar year deductible must be satisfied before any Medicare Prescription Drug benefits are paid. Covered Medicare Prescription Drug expenses will accumulate toward the pharmacy deductible. Retail - Cost -Sharing $10 Copay for Generic $20 Copay for Preferred Brand $35 Copay Non -Preferred Brand Up to one month (31 day) supply at indicated copay or coinsurance (Three month (90 day) supply available at retail. Dollar copayments or applicable coinsurance will apply for each month supply.) H5736_7F_70614 Prepared: 10/16/200911:49 AM Page 3 M XAetna° Medicare City of Vernon - 2010 PFFS Group Plan Aetna Medicare Open SM Plans Medicare 90 Open Plan Rx Group 012 National Service Area including Puerto Rico PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC Mail Order through Aetna Rx Home Delivery - Cost- $20 Copay for Generic Sharing $40 Copay for Preferred Brand $70 Copay for Non -Preferred Brand Up to a three month (90 day) supply available via our preferred vendor, Aetna Rx Home Delivery. Catastrophic Coverage Greater of $2.50 or 5% for covered generic (including brand drugs treated as generic) drugs. Greater of $6.30 or 5% for all other covered drugs. Catastrophic Coverage benefits start once $4,550 in true out-of-pocket costs is incurred. Requirements: Precertification Yes Step -Therapy Yes Formulary Standard Please refer to the plan documents (Evidence of Coverage) for a complete listing of benefits, exclusions and limitations. The following is a partial listing of exclusions and limitations under the Aetna Medicare Open Plan: • "Services that are not medically necessary or covered under the Original Medicare Program unless otherwise noted • Plastic or cosmetic surgery unless medically necessary • Custodial care • Experimental procedures or treatments beyond Original Medicare limits • Routine foot care that is not medically necessary • Drugs used for weight loss, weight gain or anorexia • Drugs used for cosmetic purposes or to promote hair growth • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations • Barbiturates • Outpatient drugs that the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale • Drugs used to promote fertility • Drugs used for symptomatic relief of cough and colds • Non-prescription drugs (OTC) H5736_7F_70614 Prepared: 10/16/200911:49 AM Page 4 XiAetna° Medicare - Benzodiazepines City of Vernon - 2010 PFFS Group Plan Aetna Medicare Open sM Plans Medicare 90 Open Plan Rx Group 012 National Service Area including Puerto Rico PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC - Drugs when used for the treatment of sexual or erectile dysfunction This material is for informational purposes only. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Aetna does not provide care or guarantee access to health services. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Discount Programs provide access to discounted prices and are not insured benefits. VAhile this material is believed to be accurate as of the print date, it is subject to change. Members must use network pharmacies to receive plan benefits except in limited, non -routine circumstances when a network pharmacy is not available, including illness while traveling within the United States but outside of the plan's service area where there is no network pharmacy. An additional cost may be incurred for drugs received at an out -of - network pharmacy. If an individual qualifies for extra help with the Medicare prescription drug plan, premium and costs at the pharmacy may be lower. Upon enrollment in the Aetna Medicare plan, Medicare will tell us how much extra help an individual is getting. An individual can obtain information on whether they qualify by calling 1-800-Medicare (1-800-633- 4227). TTY/TDD users should call 1-877-486-2048. Benefits coverage is provided by Aetna Life Insurance Company, a Medicare Advantage organization, with a Medicare contract and benefits, limitations, service areas and premiums subject to change on January 1 of each year. You can receive covered services from any licensed doctor or hospital that is eligible to receive payment from Medicare, agrees to treat you and accepts the Aetna Medicare Open Plan private fee -for -service terms and conditions of payment. This product does not require a contracted network. You must be entitled to Medicare Part A and continuetopay your Part B premium and Part A, if applicable. A Medicare Advantage Private Fee -for -Service plan works differently than a Medicare supplement plan. Your doctor or hospital must agree to accept the plan's terms and conditions prior to providing healthcare services to you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies. Providers can find the plan's terms and conditions on our website at: www.aetna.com ***This is the end of this plan benefit summary*** H5736_7F_70614 Prepared: 10/16/200911:49 AM Page 5 City of Vernon - 2010 Medicare Advantage Renewal Increase Summary Based on Current Enrollment PFFS Group Plan Enrolled Rate Band MDCR members Current Rate Renewal Rate Rate Inc. II 1 $234.80 $293.40 25.0% III 8 $289.80 $342.90 18.3% VI 31 $383.10 $440.80 15.1 % VI I 1 $381.70 $534.90 40.1 % National Avg 16.4% HMO MAPD Group Plan Enrolled State/Serv. Area MDCR members Current Rate California/ CA02 13 $150.80 Nevada/ NV01 1 $239.68 Renewal Rate Rate Inc. $151.20 0.3% $274.62 14.6% National Avg 1.8% 71 c O U W a`o Q c_ NU _p !t U a N N N w N N CL C O y. N C N r7 O G 'O O � d U C 0 '- O N T 8cn N W N l0 EaN N Ol t W �0 � C wg V N C N C N M r+ O m a ayi c C N C T M E m d d 10 T D a > FL- v c Q N CL c�p N U OI C > Cn ID Ip L N (1 N (p (D C CL V > N O N O Ep°��' c vi dti t O N y C O E m m E N u E �s - N N N N O � X V C a) MD � T 7 �'NO C N 7 I CITY CLERK'S OFFICE INTEROFFICE MEMORANDUM DATE: November 10, 2009 TO: illard Yamaguchi, Chief Deputy City Attorney/Risk Manager FROM: Nelly Giron, City Clerk RE: Resolution No. 10,097 A Resolution of the City Council of the City of Vernon Approving the Renewal of Health Care Benefits for Retired Employees for the Calendar Year 2010 With Aetna Health Inc. and Aetna Life Insurance Company Inc. Transmitted herewith is a copy of Resolution No. 10,097 referenced above, which was approved by City Council on November 9, 2009 Thank you. NG : di c: Resolution Nos. 9756, 9757, 10,097 Agreement No. 09-018