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Home My WebLink AboutRES 900409 - Accept Bid Health Benefit PlanRESOLUTIONW OE 11 A RESOLUTION TO ACCEPT THE BID ON PRUDEN 11ALRRUCARE OF AUSTtN TO BE THE SECONDARY HEAUTH BENEFIT PLAN FOR CITY FNLOYEES, AND AUTHORIZING TNI+ MAYOR 'TD S�[GN AND THE CITY 91ICRETARY'TO ATTEST, W I�HkAS, t "OlUMal 1 c y rw Yr TWK,e le rez i'ir1.uah.ltlCr.1i.,,prvR;tmLY.. _l`.i,7;9, taro. 6YN EAa,`r c...,' ATC INUT' ow Iu tn, E ljl-pl1'i_ttP 'r .. r .e` , fflKa, T� "r')y/ I.1l .,,M t"�. a i:',ta NON; TMEFORE, BTI' IT RESOLIJED BY TEF CITY COUNCIL OF THE CITY OF GEORGETOWN; TEMI:: SFACTION I . .�. ..t, te. w,t �' :gat. t nr 1 :ut. I r,::dY1 SECTION H ZLE Wl�,iay r 1gii ut ld (.Pill ir,hE . Jt OH i pini'?G1, 6-11 h .r.b,..�.r r L,.a,1Wlpi i._Iz II 41e'.v,., .il SECTION 1111 h� :;Irl 11 tt11, iajr } ai; ?`F v t r,j :'81m ti,rr i.n �,4d; �� Ip t 'it P.11 PKIV L., �.Ii-cti4 f IPEL ANI) APPROISE) IVIS 28th SAY OF wobT, mx {t d9 �UUA Iruaw( h L�1',r�? , IL I if Jif q E r fi t�S'1t}'r I FI�.i eta..1' Mlr,lazme i,a a �.hS, ( 7 L ''r�A:T'.BL i The Prudential Comprehensive Medical - cont'd) Plan III Deductible $250 Dptiod 1. Employee 2. Employee/Family 0 tiara 2 1. Employee 2, Employee/Spouse 3; Employee/Family 4, Employee/Children HMO Plan 0 tion 1 1. Employee 2. Employee/Family 0 tion 2 1, Employee 2. Employee/Spouse 3. Employee/Family 4. Employee/Children 582 CT ^6416968 Co-insurance 80% of $10,000 �. % mr�4f Monthly Premium $ 120,36 252,)1 313.13 241.94 BENEFIT SUMMARY PRUCARE Of AUSTIN ALI SERVICES AND SUPPLIES MUST BE PROVIDED OR AUTHORIZED BV vOUR PRIMARY CARE PHYSICIAN PLAN PAYS PHVSICIA.N Provider office visits (including periodic ION after $10 copayment physical examinations, pap smears, immunizations; per visit injections, well baby care, diagnostic x-ray and lab, hearing and vision screening) AllergyWork-upsand Sera 5014 Hospitai visits (including surgical 100% procedures, assistant surgeon, anesthesia and newborn care) Maternity (including prenatal, delivery, 100% after $10 copayment and pest-ratal care) per visit Inpatient psychiatric care 100% 20 day maximum per calendar yearl Outpatient psychiatric care 1001A after $OE copayment 20 visit maximum per calendar year per visit HOSPITAL SERVICES (Inpatient) Room and board (semi -private room, 10046 intensive are, preadmission testing, all other eligible hospital charges Newborn Care ION Psychiatric Care 108% 20 day maximum per calendar yearl HOSPITAL SERVICES (Outpatient) Surgery (services and supplies) 100% Emergency Room (for Emergency Care)2 100% after $25 Copayment per visit (Copayment waived if hospitalized Glass Ed 10 U. w7191am ZZ OTHER SERVICES Alcohol and drug detoxification and rehabilitation 100% 60 day maximum per condition for rehabilitative (10010 after $10 copayment services per visit for rehabilitative services) Infertility Services 15% Convalescent Nursing Home Care 100% 100 day maximum per period of care Home Health Care 100% Hospice Care 100% $1,400 maximum benefit per period of care Private Duty Nursing 100% Ambulance 100% after $25 copayment per Chemo/Radiation Therapy 100% Diagnostic X-ray and tab 100% Short-term Rehabilitative Services 100% after $10 copayment (includes physical and occupational therapy) per visit 60 day maximum per condition Speech Therapy 103 after $10 copayment 30 day maximum per condition per visit Durable Medical Equipment 15% Health-related classes at health centers 50% Prescription Drug Benefit $5 cod ayment per prescription refill at network pharmacy 1 Earn full day of treatment at an alternative mental health center will equal one half day treatment at an inpatient facility, An alternative mental health tenter includes a Psychiatric Day Treatment facility, Residential Treatment Center for Children and Adolescents and a Crisis Stabilization Unit, 2 Whether inside or outside the service area, prior authorization by Primary Care Physician isn't necessary for Emergency Care (described in your Certificate of Coverage), But, PruCare MUST be notified at 4654661 within 48 hours so that any continued tare can be authorized, If the medical condition doesn't require immediate Emergency Care, the Primary Care; Physician should be contacted first. G4603 Ed. la,Ba Car #7191619 Definitions COORDINATION OEBENEFTTS The total benefit available under this plan for a covered person when combined with other group health plan benefits will not exceed 100; of allowable expenses: COPAYMENT The amount which a patient is required to pay to a plan provider at the time of service, Services Nat Covered The services and supplies briefly described below are not covered under the plan, The services and supplies are those which are: m Not provided or authorized by your Primary Care Physician (except for Emergency Cars); i For any work -connected sickness covered by Workers' Compensation or similar law or for any work -connected injury; i Furnished by governmental plans; s Not medically necessary or experimental or educational in nature; i For Emergency Care, above the provider's usual charge; i For Emergency Care, above the prevailing charge for the service in the area; I Furnished by a close relative; i For blood that has been replaced; i Fordental-services including those for Temporomandibular Joint Disorders (TMJO) or malocclusion, This does not apply to treatment of malignancies or accident -related injuries; i For treatment of foot conditions except metabolic or peripheral vascular disease or open cutting operations: i For the-raatine purchase of eye glasses, or for radial keratotomy; i For cosmetic surgery, except when medically necessary (such as for injuries, birth abnormalities or defects, or reconstructive surgery); i For certain fertilization procedures, and Certain sex-related surgery; i For military service connected disabilities for which facilities are reasonably available; i For custodiai care; i For prescription drugs not prescribed by a network physician and/or not obtained at a network pdarmacy. This Benefit Summary provides a brief outline of the services covered by your PruCare NMOplan, Refer to your PruCare Handbook for information regarding the administration of the plan. After you enroll, you will receive a Certificate describing your coverage in greater detail. The complete terms of the coverage will be governed by a group contract issued by Prudential Health Care Plan, Inc, Although a;specific service may be listed as a covered benefit, it will not be provided unless, in the judgement of the plan physician, it medically necessary for the prevention, diagnosis or treatment of your sickness or . injury, PruCare is E service mark of The Prudential insurance Company of America, registered in the M, Patent and Trademark Office. Glass Ed 10 tc Cat a7191618