Vehicles
REQUEST FOR PROPOSALBID SHEET(S)
RFP 0601-2013: GROUP HEALTH INSURANCE
EAST TEXAS COUNCIL OF GOVERNMENTS SPECIFICATIONS
EAST TEXAS COUNCIL OF GOVERNMENTS
HUMAN RESOURCES DEPARTMENT
OPENING DATE: TUESDAY, MARCH 19, 2013
10:00 AM CST
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TEXAS 75662
REQUEST FOR PROPOSAL
Return Bid To: East Texas Council of Governments Human Resources Department Kilgore, TX, 75662
The enclosed REQUEST FOR PROPOSAL and accompanying Specifications with Bid
Sheets are for your convenience in bidding the enclosed referenced products and/or services
for East Texas Council of Governments. Sealed bids shall be received no later than: 10:00 AM
CST, MARCH 19, 2013, TUESDAY.
Please reference "RFP 0601-2013: GROUP HEALTH INSURANCE" in all correspondence
pertaining to this bid and affix this number to outside front of bid envelope for identification. All
bids shall be to the attention of the Human Resources Department.
East Texas Council of Governments appreciates your time and effort in preparing a bid. Please
note that all bids must be received at the designated location by the deadline shown. Bids
received after the deadline will be returned unopened and shall be considered void and
unacceptable. Bid opening is scheduled to be held in the Human Resources Department, 3800
Stone Road, Kilgore, Texas.
If Bidder desires not to bid at this time, but wishes to remain on the commodity bid list, please
submit a "NO BID" response (same time/location). East Texas Council of Governments is
always very conscious and extremely appreciative of the time and effort expended to submit a
bid. However, on "NO BID" responses please communicate any bid requirement(s) which may
have influenced your decision to "NO BID."
If response is not received in the form of a "BID" or "NO BID" for three (3) consecutive
REQUEST FOR PROPOSAL, Bidder shall be removed from said bid list. However, if you
choose to "NO BID" at this time but desire to remain on the bid list for other commodities,
please state the specific product/service for which your firm wishes to be classified.
Awards should be made approximately three weeks following the bid opening date. To obtain
results, or if you have any questions, please contact the Human Resources Department
at 903-984-8641.
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TEXAS 75662
RFP 0601-2013
GROUP HEALTH INSURANCE
REQUEST FOR PROPOSAL
INSTRUCTIONS/TERMS OF CONTRACT/GENERAL REQUIREMENTS
RFP 0601-2013: GROUP HEALTH INSURANCE
By order of East Texas Council of Governments, sealed bids will be received for: GROUP HEALTH INSURANCE
TO PROVIDE for an annual Contract commencing after the date of the award and continuing for
twelve month period. East Texas Council of Governments reserves the right to extend this
contract for four (4) additional one-year periods as it deems to be in the best interest of the city.
IT IS UNDERSTOOD that East Texas Council of Governments, reserves the right to reject any
and/or all bids for any/or all products and/or services covered in this bid request and to waive
informalities or defects in bids or to accept such bids as it shall deem to be in the best interests
of East Texas Council of Governments.
BIDS MUST BE submitted on the enclosed response. Each bid shall be placed in a separate
sealed envelope, with each form manually signed by a person having the authority to bind
the firm in a Contract, and marked clearly on the outside as shown below. FACSIMILE
TRANSMITTALS SHALL NOT BE ACCEPTED!
SUBMISSION OF BIDS:
Sealed bids shall be submitted no later than 10:00 AM, MARCH
19, 2013, TUESDAY to the address as follows:
East Texas Council of Governments Human Resources Department Kilgore, TX, 75662 MARK ENVELOPE: "RFP 0601-2013 GROUP HEALTH INSURANCE"
ALL BIDS MUST BE RECEIVED IN THE HUMAN RESOURCES DEPARTMENT
BEFORE OPENING DATE AND TIME.
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662
RFP 0601-2013
GROUP HEALTH INSURANCE
BIDDERS PLEASE NOTE: TWO COPIES OF THE FOLLOWING BID
SHEETS HAVE BEEN ENCLOSED FOR YOUR CONVENIENCE
Bid Affidavit Form (required) Response Form (required) Conflict of Interest Form (required) Actual rates, terms & conditions of proposal (required)
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662
RFP 0601-2013
GROUP HEALTH INSURANCE
PUBLIC NOTICE STATEMENT FOR ADA COMPLIANCE
East Texas Council of Governments acknowledges its responsibility to comply with the
Americans with Disabilities Act of 1990. Thus, in order to assist individuals with disabilities who
require special services (i.e. sign interpretative services, alternative audio/visual devices, and
amanuenses) for participation in or access to East Texas Council of Governments sponsored
public programs, services and/or meetings, East Texas Council of Governments requests that
individuals make request for these services forty-eight (48) hours ahead of the scheduled
program, service and/or meeting. To make arrangements, contact Brandy Brannon, HR
Director or other designated official at (903) 984-8641.
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662
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FUNDING: Funds for payment have been provided through East Texas Council of Governments
budget approved by their Executive Committee for this fiscal year only. State of Texas statutes prohibit the obligation and expenditure of public funds beyond the fiscal year for which a budget has been approved. Therefore, anticipated orders or other obligations that may arise past the end of the current fiscal year shall be subject to budget approval. LATE BIDS: Bids received in East Texas Council of Governments Human Resources
Department after submission deadline will be considered void and unacceptable. East Texas Council of Governments is not responsible for lateness or non-delivery of mail, carrier, etc., and the date/time stamp in the Human Resources Department shall be the official time of receipt. ALTERING BIDS: Bids can be negotiated, amended, and/or revised after the bid opening prior
to contract placement provided any changes are in writing as indicated in the enclosed executed waiver by East Texas Council of Governments to House Bill 1466, Article 21.49.16 of the Texas Insurance Code. Any interlineation, alteration, or erasure made before opening time must be initialed by the signer of the bid, guaranteeing authenticity. East Texas Council of Governments reserves the right to accept, negotiate, amend or reject any/all of the bid as it deems to be in the best interest of East Texas Council of Governments. WITHDRAWAL OF BID: A bid may not be withdrawn or canceled by the Bidder without the
permission of East Texas Council of Governments for a period of ninety (90) days following the date designated for the receipt of bids, and Bidder so agrees upon submittal of their bid. SALES TAX: East Texas Council of Governments is exempt by law from payment of Texas
State Sales Tax and Federal Excise Tax. Bidder shall include any sales taxes from concession sales of taxable items on East Texas Council of Governments property in the total price of the sale, and shall be responsible to report and pay such taxes in a timely manner. BID AWARD: East Texas Council of Governments reserves the right to award any combination
of the three sections as is deemed in the best interest of East Texas Council of Governments. East Texas Council of Governments also reserves the right to not award one or none of the CONTRACT: This bid, when properly accepted by East Texas Council of Governments, shall
constitute a Contract equally binding between the successful Bidder and East Texas Council of Governments. No different or additional terms will become a part of this Contract with the exception of Change Orders. CHANGE ORDERS: No oral statement of any individual shall modify or otherwise change, or
affect the terms, conditions or Specifications stated in the resulting Contract. All Change Orders
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662
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to the Contract will be made in writing by the East Texas Council of Governments Human Resources Director. IF DURING THE life of the Contract, the successful Bidder's net prices to other customers for
items awarded herein are reduced below the Contracted price, it is understood and agreed that the benefits of such reduction shall be extended to East Texas Council of Governments. A PRICE redetermination may be considered by East Texas Council of Governments only at the
anniversary date of the Contract and shal be substantiated in writing (i.e., Manufacturer's direct
cost, postage rates, Railroad Commission rates, Wage/Labor rates, etc.). The Bidder's past
history of honoring Contracts at the bid price will be an important consideration in the evaluation of the lowest and best bid. East Texas Council of Governments reserves the right to accept or reject any/all of the price redetermination as it deems to be in the best interest of the East Texas Council of Governments.
DELIVERY: all delivery and freight charges (F.O.B. East Texas Council of Governments) are to
be included in the bid price.
DELIVERY TIME: Bids shall show number of days required to place goods ordered at the East
Texas Council of Governments designated location. Failure to state delivery time may cause bid to be rejected. Successful Bidder shall notify the Human Resources Department immediately if delivery schedule cannot be met. If delay is foreseen, successful Bidder shall give written notice to the Human Resources Director. East Texas Council of Governments has the right to extend delivery time if reason appears valid. Successful Bidder must keep the Human Resources Department advised at all times of the status of the order.
CONFLICT OF INTEREST: No public official shall have interest in this Contract, in accordance
with Vernon's Texas Codes Annotated, Local Government Code Title 5. Subtitle C, Chapter DISCLOSURE OF CERTAIN RELATIONSHIPS Effective January 1, 2008, Chapter 176 of the
Texas Local Government Code requires that any vendor or person considering doing business with a local government entity disclose in the Questionnaire Form CIQ, the vendor or person's affiliation or business relationship that might cause a conflict of interest with a local government entity. By law, this questionnaire must be filed with the records administrator of East Texas Council of Governments not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662
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ETHICS: The Bidder shall not offer or accept gifts of anything of value nor enter into any
business arrangement with any employee, official or agent of East Texas Council of
EXCEPTIONS/SUBSTITUTIONS: All bids meeting the intent of this REQUEST FOR
PROPOSAL will be considered for award. Bidders taking exception to the Specifications, or offering substitutions, shall state these exceptions in the section provided or by attachment as part of the bid. In the absence of such, a list shall indicate that the Bidder has not taken exceptions and shall hold the Bidder responsible to perform in strict accordance with the Specifications of the Invitation. East Texas Council of Governments reserves the right to accept any and all, or none, of the exception(s)/ substitution(s) deemed to be in the best interest of East Texas Council of Governments.
ADDENDA: Any interpretations, corrections or changes to this REQUEST FOR PROPOSAL
and Specifications will be made by addenda. Sole issuing authority of addenda shall be
vested in East Texas Council of Governments Human Resources Director. Addenda will be mailed to all who are known to have received a copy of this REQUEST FOR PROPOSAL. Bidders shall acknowledge receipt of all addenda.
DESCRIPTIONS: Any reference to model and/or make/manufacturer used in bid Specifications
will be made by addenda. Sole issuing authority of addenda shall be vested in the East Texas Council of Governments' Human Resources Director. Addenda will be mailed to all who are known to have received a copy of this REQUEST FOR PROPOSAL. Bidders shall acknowledge receipt of all addenda. BID MUST COMPLY with all federal, state, county, and local laws concerning these types of
DESIGN, STRENGTH, QUALITY of materials must conform to the highest standards of
manufacturing and engineering practice. All items supplied against credit must be new and unused, unless otherwise specified, in first- class condition and of current manufacturer.
MINIMUM STANDARDS FOR RESPONSIBLE PROSPECTIVE BIDDERS: A prospective
Bidder must affirmatively demonstrate Bidder's responsibility. A prospective Bidder must meet the following requirements: 1. Have adequate financial resources, or the ability to obtain such resources as be able to comply with the required or proposed delivery schedule; have a satisfactory record of performance; have a satisfactory record of integrity and ethics;
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662
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be otherwise qualified and eligible to receive an award. East Texas Council of Governments may request representation and other information sufficient to determine Bidder's ability to meet these minimum standards listed above.
REFERENCES: Upon the selection of finalist, East Texas Council of Governments may request
Bidder to supply, with this REQUEST FOR PROPOSAL, a list of at least three (3) references where like products and/or services have been supplied by their firm. Include name of firm, address, telephone number and name of representative. The references should be provided
BIDDER SHALL PROVIDE with this bid response, all documentation required by this
REQUEST FOR PROPOSAL. Failure to provide this information may result in rejection of bid.
SUCCESSFUL BIDDER SHALL defend, indemnify and save harmless East Texas Council of
Governments and all its officers, agents and employees from all suits, actions, or other claims of any character, name and description brought for or on account of any injuries or damages received or sustained by any person, persons, or property on account of any negligent act or fault of the successful Bidder, or of any agent, employee, subcontractor or supplier in the execution of, or performance under, any Contract which may result from bid award. Successful Bidder indemnifies and will indemnify and save harmless East Texas Council of Governments from liability, claim or demand on their part, agents, servants, customers, and/or employees whether such liability, claim or demand arise from event or casualty happening or within the occupied premises themselves or happening upon or in any of the halls, elevators, entrances, stairways or approaches of or to the facilities within which the occupied premises are located. Successful Bidder shall pay any judgment with costs which may be obtained against East Texas Council of Governments growing out of such injury or damages. In addition, Contractor shall obtain and file with East Texas Council of Governments, a Standard Certificate of Insurance and applicable policy endorsement evidencing the required coverage and naming East Texas Council of Governments as an additional insured on the required coverage.
WAGES: Successful Bidder shall pay or cause to be paid, without cost or expense to East
Texas Council of Governments, all Social Security, Unemployment and Federal Income Withholding Taxes of all such employees and all such employees shall be paid wages and benefits as required by Federal and/or State Law.
TERMINATION OF CONTRACT: This Contract shall remain in effect until Contract expires,
delivery and acceptance of products and/or performance of services ordered or terminated by either party with a thirty (30) day written notice prior to any cancellation. The successful Bidder must state therein the reasons for such cancellation. East Texas Council of Governments reserves the right to award canceled Contract to best Bidder as it deems to be in the best interest of East Texas Council of Governments.
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662
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TERMINATION FOR DEFAULT: East Texas Council of Governments reserves the right to
enforce the performance of this Contract in any manner prescribed by law or deemed to be in the best interest of East Texas Council of Governments in the event of breach or default of this Contract. East Texas Council of Governments reserves the right to terminate the Contract immediately in the event the successful Bidder fails to: 1. Meet schedules; 2. defaults in the payment of any fees; or 3. otherwise perform in accordance with these Specifications. Breach of Contract or default authorizes East Texas Council of Governments to exercise any or all of the following rights: 1. East Texas Council of Governments may take possession of the assigned premises and any fees accrued or becoming due to date; 2. East Texas Council of Governments may take possession of all goods, fixtures and materials of successful Bidder therein and may foreclose its lien against such personal property, applying the proceeds toward fees due or thereafter becoming due. In the event the successful Bidder shall fail to perform, keep or observe any of the terms and conditions to be performed, kept or observed, East Texas Council of Governments shall give the successful Bidder written notice of such default; and in the event said default is not remedied to the satisfaction and approval of East Texas Council of Governments within two (2) working days of receipt of such notice by the successful Bidder, default will be declared and all the successful Bidder's rights shall terminate. Bidder, in submitting this bid, agrees that East Texas Council of Governments shall not be liable to prosecution for damages in the event that East Texas Council of Governments declares the Bidder in default. NOTICE: Any notice provided by this bid (or required by law) to be given to the successful
Bidder by East Texas Council of Governments shall conclusively deemed to have been given and received on the next day after such written notice has been deposited in the mail to East Texas Council of Governments, by Registered or Certified Mail with sufficient postage affixed thereto, addressed to the successful Bidder at the address so provided; provided this shall not prevent the giving of actual notice in any other manner.
PATENTS/COPYRIGHTS: The successful Bidder agrees to protect East Texas Council of
Governments from claims involving infringement of patents and/or copyrights.
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CONTRACT ADMINISTRATOR: Under this Contract, East Texas Council of Governments may
appoint a Contract Administrator with designated responsibility to ensure compliance with Contract requirements, such as but not limited to, acceptance, inspection and delivery. The Contract Administrator will serve as liaison between East Texas Council of Governments Human Resources Department (which has the overall Contract Administration responsibilities) and the successful Bidder.
PURCHASE ORDER: A Purchase Order(s) shall be generated by East Texas Council of
Governments to the successful Bidder. The Purchase Order number must appear on all itemized invoices and packing slips. East Texas Council of Governments will not be held responsible for any orders placed/delivered without a valid current Purchase Order number.
PACKING SLIPS or other suitable shipping documents shall accompany each special order
shipment and shall show: (a) name and address of successful Bidder, (b) name and address of receiving department and/or delivery location, (c) Purchase Order number, and (d) descriptive information as to the item(s) delivered, including product code, item number, quantity, number of containers, etc.
INVOICES shall show all information as stated above, shall be mailed directly to East Texas
Council of Governments, 3800 Stone Road, Kilgore, TX, 75662.
PAYMENT will be made upon receipt and acceptance by East Texas Council of Governments
for any item(s) ordered and receipt of a valid invoice, in accordance with the State of Texas Prompt Payment Act, Article 601f V.T.C.S. Successful Bidder(s) required to pay subcontractors within ten (10) days.
ITEMS supplied under this Contract shall be subject to East Texas Council of Governments
approval. Items found defective or not meeting Specifications shall be picked up and replaced by the successful Bidder at the next service date at no expense to East Texas Council of Governments. If item is not picked up within one (1) week after notification, the item will become a donation to East Texas Council of Governments for disposition.
SAMPLES: When requested, samples shall be furnished free of expense to East Texas
Council of Governments.
WARRANTY: Successful Bidder shall warrant that all items/services shall conform to the
proposed Specifications and/or all warranties as stated in the Uniform Commercial Code and be free from all defects in material, workmanship and title. A copy of the warranty for each item being bid must be enclosed. Failure to comply with the above requirements for literature and warranty information could cause bid to be rejected.
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REMEDIES: The successful Bidder and East Texas Council of Governments agree that both
parties have all rights, duties and remedies available as stated in the Uniform Commercial
VENUE: This Agreement will be governed and construed according to the laws of the State of
Texas. This Agreement is performable in Kilgore, Texas.
ASSIGNMENT: The successful Bidder shall not sell, assign, transfer or convey this Contract, in
whole or in part, without prior written consent of East Texas Council of Governments.
SPECIFICATIONS and model numbers are for description only. Bidder may bid on description
only. Bidder may bid on alternate model but must clearly indicate alternate model being bid. Bidder must enclose full descriptive literature on alternate item(s).
SILENCE OF SPECIFICATION: The apparent silence of these Specifications as to any detail
or to the apparent omission of a detailed description concerning any point, shall be regarded as meaning that only the best commercial practices are to prevail. All interpretations of these Specifications shall be made on the basis of this statement. Each insurance policy to be furnished by successful Bidder shall include, by endorsement to the policy, a statement that a notice shall be given to East Texas Council of Governments by Certified Mail thirty (30) days prior to cancellation or upon any material change in coverage.
ANY QUESTIONS concerning this REQUEST FOR PROPOSAL and Specifications should be
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GENERAL REQUIREMENTS 1) The information contained in these specifications is confidential and is to be used only in connection with preparing a bid for all or part of the following employee benefit plans: Group Medical Insurance 2) Currently all products are offered on a June 1 effective date. 3) All bid responses should be provided on the enclosed response forms with the signature of your authorized representative. If attachments are necessary, please provide. DO NOT
MODIFY RESPONSE FORMS. Proposals must include two hard copies of the completed
Bid Affidavit, Response Form, Conflict of Interest Form including actual rates, terms and
conditions. Any additional information should be provided at the end of the response form.
Contact Brinson Benefits, Inc. for a copy of the response forms to be sent via email for your
convenience.
4) East Texas Council of Governments has appointed Brinson Benefits as their Agent of Record/Employee Benefit Consultant and is not selecting a new broker/consultant
therefore; Medical Insurance should be submitted on a NET commission basis. If you are
required to include commissions in your products, please note this clearly on your response
form.
5) Retirees are not covered. Covered participants include: Full Time employees and COBRA participants. The census does identify these participants. 6) No telephone, telephonic or fax bids will be accepted. Bids must be sealed and delivered to the Human Resources Department at East Texas Council of Governments prior to the official bid opening time. East Texas Council of Governments will not be responsible for missing, lost or late proposals. Any bids received after the time set for opening will be returned to the sender. 7) The information contained herein is believed to be accurate and up-to-date, but is not intended to be an express or implied warranty. 8) Bids are to be submitted on the basis of the specifications contained herein. Alternate bids are encouraged and will be considered provided the alternatives enhance the current plan and are clearly explained. All deviations from the specifications must be clearly identified and explained. 9) East Texas Council of Governments reserves the right to negotiate, amend, accept or reject all or any part of the bids, waive minor technicalities, and award the bid that best serves the interest of East Texas Council of Governments. East Texas Council of Governments also reserves the right to waive or dispense with any of the formalities contained herein. 10) Proposals must be submitted for coverage on all eligible full-time regular employees and their dependents. Full-time is defined as 40 or more hours per week. Dependent is defined as the employee's spouse and/or unmarried children from birth to age 26 and claimed as a dependent. 11) Waiting period: Newly hired employees and their dependents must complete 0 days of active employment before becoming eligible for coverage.
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12) Eligibility: All full-time employees and their dependents are eligible on the first day of hire. Terminated employees and all others currently covered under COBRA may continue coverage under COBRA. 13) Contribution: Medical is employer paid for employee only coverage and contributes 30% to dependent coverage. 14) Social Security: East Texas Council of Governments has opted out of social security at this time but has a voluntary life retirement plan. 15) Workers' Compensation – East Texas Council of Governments has State Workers Comp. East Texas Council of Governments is aware of the time and effort you expend in preparing and submitting proposals to East Texas Council of Governments. Please let us know of any requirements in the RFP that are causing you difficulty in responding. We want to make this process as easy as possible so that all responsible vendors can compete for East Texas Council of Governments' business.
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East Texas Council of Governments GROUP MEDICAL INSURANCE a) East Texas Council of Governments offers a fully insured PPO plan. See attached plan design. The bid is based on duplication of current benefits. Alternate plan designs are welcome. b) East Texas Council of Governments pays 100% employee costs and 30% dependent costs. Dependent contribution strategy may change. COVERAGE
Employee & Spouse Employee & Child(ren) Employee & Family (included above EE) d) Effective date is June 1, 2013. e) All participants enrolled in the plan as of May 31, 2013 are to be covered on a "No loss/No gain" basis. "No loss/No gain" for participants is to include credit for accumulated deductible and coinsurance as applicable. The participant will provide documentation for this credit. e) The selected insurance provider will provide enrollment and educational materials, as well as participant in East Texas Council of Governments annual open enrollment presentations. f) East Texas Council of Governments must receive renewal rates by February 21st, preceding the June 1st renewal date. Refer to the Bid Affidavit. g) A true open enrollment is required annually. h) COBRA/HIPAA will be administered by COBRA Charmers, Inc. This is not anticipated to change. i) See attached (Exhibit 1) for current summary of benefits.
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2. Rates and History
Current Renewal Period Large Claim / Ongoing Medical Conditions Detail:
See attached claims data from TML: East Texas Council of Governments has
knowledge of the following relating to the large claims indicated by TML:
1) $20,249 – no further information known
2) $14,091 - no further information known
3) $32,331 - no further information known
4) $24,009 – employee actively back at work
PPO MEDICAL PLAN YEAR
Employee
NET OF COMMISSION
Child(ren)
RENEWAL
June 1, 2013 – May 31, 2014
June 1, 2012 – May 31, 2013
June 1, 2011 – May 31, 2012 June 1, 2010 – May 31, 2011 June 1, 2009 – May 31, 2010 June 1, 2008 – May 31, 2009
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Carrier History: June 1, 2012 – May 31, 2013 TML Intergovernmental Employee Benefits Pool June 1, 2011 – May 31, 2012 TML Intergovernmental Employee Benefits Pool June 1, 2010 – May 31, 2011 TML Intergovernmental Employee Benefits Pool June 1, 2009 – May 31, 2010 TML Intergovernmental Employee Benefits Pool June 1, 2008 – May 31, 2009 TML Intergovernmental Employee Benefits Pool East Texas Council of Governments EMPLOYEE INSURANCE EXHIBITS EXHIBIT I
Three Required Forms (provided below & available in MS Word format) -Bid Affidavit Form -Conflict of Interest Form EXHIBIT II
Summary of Benefits – Medical EXHIBIT III
EXHIBIT IV
Medical Claim Experience Reports
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EXHIBIT I
BIDDERS PLEASE NOTE: TWO COPIES OF THE FOLLOWING BID
SHEETS HAVE BEEN ENCLOSED FOR YOUR CONVENIENCE
Bid Affidavit Form (required) Response Form (required) Conflict of Interest Form (required) Actual fees, terms & conditions of proposal (required)
TWO COPIES MUST BE RETURNED TO THE HUMAN RESOURCES
DEPARTMENT NO LATER THAN 10:00 AM CST, MARCH 19, 2013, TUESDAY.
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EAST TEXAS COUNCIL OF GOVERNMENTS BID AFFIDAVIT (REQUIRED) The undersigned certifies that they are a duly authorized officer/agent and authorized to
execute the foregoing on behalf of the bidder. The bid prices contained in this bid has
been carefully reviewed and is submitted as correct. Bidder further certifies and agrees
to furnish any and all services effective June 1, 2013 upon the acceptance of the final
proposal as firm and final on or before April 1, 2012 (including any amendments and/or
negotiations) and upon the conditions contained in the Specifications of this REQUEST
FOR PROPOSAL. Subsequent renewals, specifically the initial renewal, must be
delivered to the Council no later than March 1, 2014 and firm and final no later than
April 1, 2014 for a June 1, 2014 effective date. The period of acceptance of this bid will
be _90 calendar days from the date of the bid opening. (Period of acceptance
will be ninety (90) calendar days unless otherwise indicated by Bidder.)
I hereby certify that the foregoing bid has not been prepared in collusion with any other
Bidder or individual(s) engaged in the same line of business prior to the official opening
of this bid. Further, I certify that the Bidder is not now, nor has been for the past six (6)
months, directly or indirectly concerned in any pool, agreement or combination thereof,
to control the price of services/commodities bid on, or to influence any individual(s) to
bid or not to bid.
Bids provided (check all that apply):
Medical – Group Medical Insurance Company Name
Company Address (street, Town, state, zip)
Telephone Number
E-mail address
Fax Number
Contact Name
Authorized Signature
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EAST TEXAS COUNCIL OF GOVERNMENTS RESPONSE FORMS (REQUIRED)
PPO MEDICAL PLAN YEAR
Employee
NET OF COMMISSION
Child(ren)
June 1, 2013 – May 31, 2014
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CONFLICT OF INTEREST QUESTIONNAIRE
FORM CIQ (REQUIRED)
For vendor or other person doing business with local governmental entity
This questionnaire is being filed in accordance with chapter 176 of the Local OFFICE USE
Government Code by a person doing business with the governmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. 1 Name of person doing business with local governmental entity.
2 Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3 Name each employee or contractor of the local governmental entity who makes
recommendations to a local government officer of the governmental entity with respect
to expenditures of money AND describe the affiliation or business relationship.
4 Name each local government officer who appoints or employs local government
officers of the governmental entity for which this questionnaire is filed AND describe
the affiliation or business relationship.
Adopted 11/02/2005
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662 Page 21
RFP 0601-2013
GROUP HEALTH INSURANCE
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
5 Name of local government officer with whom filer has affiliation or business relationship. (Complete
this section only if the answer to A, B, or C is YES.
This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has
affiliation or other relationship. Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer
of the questionnaire? Yes No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? Yes No D. Describe each affiliation or business relationship. Signature of person doing business with the governmental entity Adopted 11/02/2005
EAST TEXAS COUNCIL OF GOVERNMENTS • HUMAN RESOURCES DEPARTMENT • 3800 STONE ROAD • KILGORE, TX, 75662 Page 22
SCHEDULE OF MEDICAL EXPENSE BENEFITS FY11-12
East Texas COG
Plan Benefits Effective: June 1, 2012
800-847-1213 Claims
This schedule represents a summary of benefits. For complete details of benefits and requirements please refer to the Medical Benefits
Booklet. Non network discounted items will be paid per usual and reasonable guidelines.
The Plan pays a higher benefit for eligible expenses incurred through a Network provider. To locate Network providers, consult your Provider Directory, the TML IEBP website () or call TML IEBP at (800) 282-5385. Maximum Lifetime Benefit
Maximum Lifetime Benefit for Chemical Dependency
1 Treatment Plan Maximum Lifetime Benefit for Hospice Care
6 month episode of care One Wig for Oncology Covered Individuals
One Prosthetic Bra for Oncology Covered Individuals
One Treatment Episode of the Medically Necessary Hearing Appliance
Custom Molded Foot Orthotics
(Unless medically documented physiological change) Calendar Year Maximum for Diabetic Related Therapeutic Footwear/Shoes
Inpatient Private Duty Nursing Medical Management/Concurrent Review
Calendar Year Maximum for Non-Serious Mental/Nervous
Inpatient and Residential Calendar Year Maximum for Chemical Dependency
Inpatient and Residential Calendar Year Maximum for Chiropractic Care
Speech Therapy
12 Outpatient Visits Physical Therapy (PT)/Occupational Therapy (OT)
18 Outpatient Visits (maximum for PT and/or OT) Nutritional Counseling
1 Treatment Episode 100% Benefit Pre-Existing Conditions
Maximum Benefit
Initial 12 Months of benefit eligibility, (inclusive of any plan waiting period) Same as any other illness thereafter Any Pre-Existing Condition Limitation period is reduced by the period of other "Creditable Coverage". The Pre-Existing condition limitations do not apply to Covered Individuals less than nineteen (19) years of age. Notification Requirements
Notification enables clinical support and educations, such as:
Perform pre-op education for the patient and ensure adherence to nationally recognized guidelines in order to maximize quality and cost efficiency; Facilitate post-op discharge planning to optimize clinical outcomes; and Refer patients to Centers of Excellence. Notification is required for the following admissions and/or procedures:
LATE NOTIFICATION PENALTY
INPATIENT ADMISSIONS
Scheduled Specialty Admissions
Facility: twenty-four (24) hours after Facility: If admission Notification is Orthopedic/Spine Surgeries (spinal surgeries, total actual admission or by 5 pm the next not received within seventy-two knee replacements, and total hip replacements) business day for weekend/holiday (72) hours of the admission, a 50% Transplants: At least ten (10) working days prior to reduction will be applied to the any pre-transplant evaluation, the covered contracted benefit eligible rate. Primary Physician/Healthcare individual or a family member must provide Professional: Prior to Admission Primary Physician/Healthcare Notification to Medical Care Management; failure Professional: If an advanced to do so will result in a Late Notification Penalty of admission Notification is not $400 or a reduction in benefits received, a 100% reduction will be Reconstructive/Potentially Cosmetic procedures applied to the contracted benefit Bariatric Surgeries: Morbid Obesity Services (after the approved six (6) month physician supervised weight management treatment plan) Congenital Heart Disease
Other Inpatient Admissions
Facility: twenty-four (24) hours after Facility: If admission Notification is Skilled Nursing Facility actual admission or by 5 pm the next not received within seventy-two Psychiatric/Chemical Dependency Inpatient business day for weekend/holiday (72) hours of the admission, a 50% reduction will be applied to the Psychiatric/Chemical Dependency Residential contracted benefit eligible rate. Acute Care Hospital/Facility Long Term Acute Care Facility Acute Rehabilitation Facility Scheduled Cesarean Section Delivery Inpatient Pregnancy/Maternity (Delivery Admission)
Facility: twenty-four (24) hours after Facility: If admission Notification is Vaginal Delivery admission in excess of forty-eight actual admission or by 5 pm the next not received within seventy-two business day for weekend/holiday (72) hours of the admission, a 50% Cesarean delivery admission in excess of ninety-six reduction will be applied to the contracted benefit eligible rate. All High Risk obstetrical or antepartum care or other undelivered admission Newborns who remain in the hospital after mother Prior to commencement for Sonogram/Ultrasound in excess of three (3) outpatient and Home Health Amniocentesis procedures, within forty-eight (48) hours of multiple birth diagnosis Home Health (uterine monitoring) Multiple birth diagnosis SCHEDULED OUTPATIENT/OFFICE SURGICAL
PROCEDURES
Blepharoplasty (eyelid surgery) Three (3) working days prior to Breast Surgery Carpal Tunnel Release (nerve decompression) Jaw Surgery (including mandibular joint) Joint Surgery (excluding fingers & toes) LATE NOTIFICATION PENALTY
Laparoscopy (except sterilization) Myringotomy or Myringoplasty (tympanic/ear drum Nasal Surgery Tonsillectomy and/or Adenoidectomy Uvulopalatoplasty (roof of mouth surgery) Reconstructive Surgery Cochlear Device and/or implantation Artificial Intervertebral Disc Surgery Stereotactic Radiosurgery Bariatric Surgery (obesity surgery) OUTPATIENT/OFFICE INFUSION THERAPY
For Pain Management Prior to commencement MISCELLANEOUS
Psychiatric/Chemical Dependency Day Treatment Prior to commencement Hospice Home Health Care Physician Home Visit Cardiac Rehabilitation Pulmonary Rehabilitation Positron Emission Tomography (PET) scans Computerized Axial Tomography (CAT) scans Computerized Tomographic Angiography (CTA) Magnetic Resonance Imaging (MRI) scans Magnetic Resonance Angiography (MRA) scans Single Photon Emission Computed Tomography Dental Injury (inpatient and outpatient) Dialysis for Kidney/Renal failure Hyperbaric Oxygen Therapy Radiation Therapy Medically Necessary Evidence Based Genetic Durable Medical Equipment For charges in excess of $1,000 prior to purchase, lease or rental Population Health Engagement supports members in all stages of health. This program provides information to the Covered
Individual regarding healthy lifestyle choices and management of chronic disease states. The program offers personalized
professional coaching to support the healthy lifestyle of change and plan of action. Online tools and educational material(s) are
available to the Covered Individual. The population health engagement team consists of an interdisciplinary team of licensed
professional nurses, counselors, behaviorists, registered dietitians and certified diabetes educators.
Medical Intensive Care Management services help you use your benefits wisely during periods of treatment due to serious
sickness or injury. This is done through early identification of the need for Medical Intensive Care Management. The Medical
Intensive Care Manager will try to conserve your benefits by making sure that your care is handled as efficiently as possible. The
Medical Intensive Care Management staff consists of licensed, professional nurses. They are aware of the importance of the
doctor/patient relationship. Medical Intensive Care Management also monitors the care of the Covered Individual, offers
emotional support to the family and coordinates communications among healthcare providers, patients and others. These
objectives will be met through Plan benefits (and non-Plan benefits as arranged by Medical Intensive Care Management) to
Covered Individuals who are eligible.
Medical Intensive Care Management is an option. However, should Medical Intensive Care Management be refused by the Covered Individual or physician, benefits will pay at the Non Network benefit percentage and will not, at any time, pay at 100% for any medical services under the out of pocket provision of this Plan. If Medical Intensive Care Management is refused, all future payments for any medical services will be paid at the reduced benefit. The individual Deductible and Out of Pocket amount must be met each calendar year. The Medical Intensive Care Management Team will coordinate care and document Notification communication. What Happens on Inpatient Treatment?
The Covered Individual must notify Medical Care Management per the Notification Requirements. If the Notification is made
after the above-referenced time frames, a Late Notification Penalty will apply. Concurrent stay review requirements apply to all
inpatient confinements. No benefits will be paid for any charges related to non-notified days or services.
Unproven Medical Procedures/Treatment – Experimental/Investigational/Unproven Services: medical, surgical,
diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug
therapies, medications or devices that, at the time we make a determination regarding coverage in a particular case, are
determined to be any of the following:
Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use; Determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature; Subject to review and approval by any institutional review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered Experimental or Investigational.); The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial, or the experimental arm of a Phase 4 Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; The subject of cohort studies in the prevailing published peer-reviewed medical literature; Well-conducted randomized controlled trials. Two (2) or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received; or Well-conducted cohort studies. Patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group. Medically Justified – A service that, while unproven, has been studied by a Randomized Control Trial (RCT), well conducted
cohort study, or presentation of a case series, whose results have been accepted in abstract form by a major national specialty
society for presentation at a society meeting, or has been published or accepted for publication in a peer-reviewed medical
journal. Case series must be either from multi-institutional sites, or confirmed by another investigator at a separate site. In
order to be considered to have "significant potential as an effective treatment," it must be established that the proposed
treatment is likely to produce functional improvement rather than solely an improvement in, for example, x-rays or lab test that
are not associated with a superior health outcome; "Equivalent to those standards defined by the National Institutes of Health".
Evidence Based Medicine (EBM) – Aims to apply the best available evidence gained from the scientific method to medical
decision making. It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).
EBM recognizes that many aspects of medical care depend on individual factors such as quality and value of life judgments,
which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in
principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical
treatment, even as debate continues about which outcomes are desirable.
Humanitarian Use Device (HUD) – The coverage determination on an HUD will be made according to the hierarchy of
evidence applied towards the evaluation of any technology, in the same way the evaluation would be applied to a service or
technology that is FDA approved without a Humanitarian Device Exemption. If the device is determined to be proven for the
use it should be covered; if the device is determined to be unproven for use then it should not be covered.
Multiple Surgery – the primary medical surgical procedure is considered at 100% of the allowable charges, the second
surgical procedure is considered at 50% of allowable charges and the third or following procedure is considered at 50% of
allowable charges. The ineligible amount may be the Covered Individual's out of pocket expense.
Qualified Medical Child Support Order (QMCSO) Managing Conservator of a Minor Child
TML IEBP will extend benefits to children of covered employees who are divorced, separated or born out of wedlock pursuant
to a Qualified Child Support Order as prescribed by Sections 154.186 & 154.187 of the Texas Family Code. TML IEBP will impose
the late entrant limitation if time of enrollment is subject to the late entrant provision. If the child is covered under a Qualified
Medical Support, the child will obtain Continuation of Coverage rights if coverage is lost due to a qualifying event.
TML IEBP will require the Covered Individual to complete the application form to have benefits paid by the managing conservator of a minor child. Once the form is complete, TML IEBP will review the request and make a decision if the request meets the definition of a Qualified Medical Child Support Order for TML IEBP. Within thirty (30) days of receipt, TML IEBP will provide a written notice of the decision regarding manager conservator of an eligible minor child healthcare benefits. TML IEBP will send notices to each attorney or other representative who may be identified in the order for correspondence. Deductible Per Calendar Year
Non Network
Individual Deductible waived for the following benefits: Individual $2,000
Second Surgical Opinions, Network Preventive Care Benefits and Preferred Lab Network and Non Network Deductibles are separate and do not
accumulate toward one another.
The Family Deductible is a cumulative dollar amount and applies collectively to all covered family individuals. Once the Family Deductible has been satisfied, no further deductible requirements will be applied for any covered family individual during the remainder of the calendar year. For a confinement that continues into a new calendar year, amounts applied toward the prior calendar year Deductible will also count toward the next calendar year Deductible for charges during that confinement. All other charges are subject to the new calendar year Deductible. Out of Pocket Amount Per Calendar Year
Non Network
Once the Network Deductible and Out of Pocket amount is Individual $2,000
satisfied per individual, the plan pays 100% of eligible Network Eligible Expenses incurred with a Non Network provider will
never pay at 100%.
The Family Out of Pocket is a cumulative dollar amount and applies collectively to all covered family individuals. Once the Family Out of Pocket is satisfied, no further Out of Pocket requirements will be applied for any covered family individual during the remainder of the calendar year. For a confinement that continues into a new calendar year, amounts applied toward the prior calendar year Out of Pocket will also count toward satisfying the next calendar year Out of Pocket for charges during that confinement. All other charges are subject to the new calendar year Out of Pocket amount. Access Fees and Other Penalties
Emergency Room access fees, Notification penalties and any other ineligible expenses do not apply to Deductible or Out of
Pocket expenses.
BENEFIT PERCENTAGE PAYABLE AFTER DEDUCTIBLE/COPAY
Non Network
Specialty Physicians for Emergent/Immediate Care
Anesthesiologist, Hospitalist, Pathologist, Radiologist, Emergency Room Physician Related to Emergent/Immediate Care services rendered at a Network/Non Network hospital and/or outpatient surgery/radiology diagnostic clinic. Specialty Physicians for Scheduled Services 80%
Anesthesiologist, Hospitalist, Pathologist, Radiologist, Emergency Room Physician Related to Scheduled Services rendered at a Non Network hospital and/or outpatient surgery/radiology diagnostic clinic. BENEFIT PERCENTAGE PAYABLE AFTER DEDUCTIBLE/COPAY
Non Network
Facility Charges
Inpatient Hospital Benefits 80%
Outpatient Hospital Surgery
Emergency Room for Emergent/Immediate Care
Facility charges after $100 access fee (waived if admitted) Physician
Office Visit Fees $30 100%
Other Physician Services 80%
Accident Benefit 80%
Second Surgical Opinion
Preferred Lab Program
Includes laboratory expenses from a Preferred Lab Provider and Preferred Lab drawing site. Physician professional fee is payable as Other Physician Services 80% if not done at a Preferred Lab drawing site. Other Outpatient Lab (Non Preferred Lab) and X-ray
Preventive Care Benefits (Calendar Year Wellness Benefits Effective 1-1-2012)
100% 100% up to UR&C Routine physicals and tests for Employees and Dependents are limited to $500 per individual per calendar year. If preventive care eligible expenses exceed $500, the expenses will not be paid. Network routine Mammograms, Pap screening, PSA tests and Colon Cancer screening do not apply to the $500 maximum. Routine Mammograms, Pap screening and PSA tests are limited to one (1) exam per calendar year. Network immunizations, inoculations and their administrative charges are paid at
100% and do not apply to the $500 maximum. (See Medical Benefits booklet for
immunizations paid at 100%).
All Non Network provider expenses are subject to usual and reasonable allowable amount.
Emergency Ambulance Services
Maximum payable for Ground Ambulance: $1,500 per occurrence. Maximum payable for Air Ambulance: $9,000 per occurrence. Home Health Care
Maximum payable per 2-hour visit is $100. Eligible supplies, equipment and therapy are not included in the $100 maximum and are eligible under other major medical expense benefit. Hospice Care (Inpatient and Outpatient); Maximum six month episode of care. 80% 50%
Inpatient and Residential limited to 7 days per calendar year. Day treatment limited to 14 days per calendar year. Outpatient limited to 26 individual or group visits per calendar year. Intensive Outpatient accumulates to the 26 outpatient visit limit per calendar year. Medication checks are not included in the 26 outpatient visit limit per calendar year. Chemical Dependency
Chemical Dependency benefit is limited to one treatment program per lifetime and will never pay at 100%. Inpatient and Residential limited to 7 days per calendar year. Day treatment limited to 14 days per calendar year. BENEFIT PERCENTAGE PAYABLE AFTER DEDUCTIBLE/COPAY
Non Network
Outpatient limited to 26 individual or group visits per calendar year. Intensive Outpatient accumulates to the 26 outpatient visit limit per calendar year. Medication checks are not included in the 26 outpatient visit limit per calendar year. Serious Mental/Nervous Illness 80%
Expenses incurred by a Covered Individual for treatment of "Serious Mental/Nervous Illness" are payable as any other illness subject to the lifetime maximum of the plan as stated in the Schedule of Benefits. The term "Serious Mental/Nervous Illness" means the following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic & Statistical Manual (DSM): 1. schizophrenia; 2. paranoia and other psychotic disorders; (hypomanic, manic depressive and mixed); major depressive disorders (single episode or recurrent); 5. schizo-affective (bipolar or depressive); obsessive compulsive disorder (OCD); and depression in childhood and adolescence. Chiropractic Care 10 visits per calendar year
Medical Supplies
Durable Medical Equipment and Related Supplies (never pays at 100%)
Prosthetics/Non Foot Orthotics (never pays at 100%) 80%
One Wig for Oncology Patients
One Prosthetic Bra for Oncology Patients
Custom Molded Foot Orthotics 1 pair
(Unless medically documented physiological change) One Treatment Episode of the Medically Necessary Hearing Appliance
Speech Therapy 12 Outpatient Visits
Physical/Occupational Therapy 18 Outpatient Visits (maximum for PT and OT)
Nutritional Counseling 1 Usual and Reasonable charged treatment episode 100%
Morbid Obesity Treatment Predetermination Approval and Designated Center
18 years of age or older; never pays at 100% Other Major Medical Expenses
Prescription Drugs (see Prescription Drug Benefit schedules)
Coverage for eligible prescriptions and eligible biotech prescriptions that are available through the Pharmacy Benefit Manager will be paid per the prescription schedule of benefits. Prior authorization is required on all biotech prescriptions. Call RxResults at (888) 871-4002. Eligible Biotech prescriptions may be purchased from network providers per the prescription schedule of benefits. For eligible prescriptions purchased outside of the Pharmacy Benefit Manager or the Network Providers, the plan will pay at the out of network benefit percentage and will not, at any time, pay at 100% for any prescription services under the Out of Pocket provision of the Plan. Eligible Benefits
The usual and reasonable fees charged for medical service and supplies covered by this Plan and that are generally furnished
for cases of comparable nature and severity in the particular geographical area where incurred. Any agreement as to fees or
charges made between the individual and the doctor shall not bind the Plan in determining its liability with respect to expenses
incurred. Expenses are incurred on the date which the service or supply is rendered or obtained. The Covered Individual also
must have an obligation to pay the expense.
Usual and Reasonable
A usual and reasonable charge is deemed to be 110% of the amount prescribed by the Centers for Medicare and Medicaid
Services (CMS), RBRVS, other specialty CMS fee schedules and the Ingenix Essential RBRVS Fee Schedule.
Filing Deadline
No benefits are payable for claims submitted by the employee or a provider more than twelve (12) months from the date the
expense was incurred, unless it was not reasonably possible to furnish the information within the filing deadline as determined
by the Group Benefits Administrator, or within ninety (90) days after a non-compensable claim decision is made by the
employer's workers' compensation carrier or by the Workers' Compensation Division of the Texas Department of Insurance,
whichever is later. All requested additional information relating to the claim must also be received within the same time frame.
Benefits will not be recalculated to allow a better benefit for charges incurred at a later date.
Extenuating Circumstances
If a Covered Person requires care from a specialist care provider, but there is not a Network specialist care provider within a
seventy-five (75) mile radius from the employee's place of business, the provider would be paid at 80% subject to the Network
Deductible, Network Out of Pocket and subject to usual and reasonable allowable amounts.
Integration of Benefits
Applies when a covered person may receive benefits for medical expenses from more than one source. The benefits payable
under this plan will not exceed 100% of the eligible benefit when combined with all other plans.
Continuation of Coverage (COC)
The right to COC was created by a Federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COC can
become available to you when you would otherwise lose your group health coverage. It can also become available to other
members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For
additional information about your rights and obligations under the Plan and under Federal law, you should review the Plan
book or contact TML IEBP, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754, (800) 282-5385.
Right of Recovery
A Right of Recovery Form will need to be completed on all claims where the diagnosis indicated it could be accident related.
The Covered Individual specifically delegates to the Group Benefits Administrator the right to make a claim or assert a cause of
action on the Covered Individual's behalf against any source of recovery, and assign to the Group Benefits Administrator the
right to any proceeds from the claim or cause of action.
Self-Audit Reimbursement
Any Covered Individual, who reviews their eligible medical expenses and discovers an overcharge made by the medical facility
or practitioner, may provide the Group Benefits Administrator with a copy of the original billing, corrected billing and an
explanation. The Covered Individual will be reimbursed 30% of the amount of savings generated. The reimbursement may not
exceed the Covered Individual's individual calendar year Deductible and Out of Pocket amount.
Claims Appeals
TML IEBP will conduct a full and fair review of your appeal. The appeal will be reviewed by appropriate individual(s) on the TML
IEBP staff for internal review; or a health care professional with appropriate expertise during the initial benefit determination
process.
The appellant may request an independent review from an independent state licensed external review organization that is credentialed under URAC. The external review will be conducted by a random URAC selected reviewer who was not consulted initially during the external clinical excellence review. Once the review is complete, if the denial is maintained, the appellant will receive a written explanation of the reasons and facts relating to the denial. Appeal of Emergent Care Request for Benefits (Adverse Notification Determination Prior to Claim Submission)
Appeal of Urgent/Emergent Request for Benefits
(Adverse Pre-Determination/Notification Request)
Type of Request for Benefits or Appeal
Business Hours/Days
If the appellant appeals the adverse notification determination or Internal
one hundred eighty (180) days after
declination of notification, the appellant must appeal within: receiving the denial based on a completed review process If the appellant's request for emergent benefits is incomplete TML IEBP Internal
twenty-four (24) hours of receipt of
will send the urgent/emergent incomplete pre-
appellant's information determination/notification information declination letter within:
The appellant must provide a completed information request within: Internal forty-eight
the TML IEBP declination due to incomplete information If the request for urgent/emergent benefits is complete and not Internal seventy-two
approved, TML IEBP will send an urgent/emergent pre-
determination/notification denial letter within:
If the appellant's request an Independent Review Organization, (IRO),
External
one hundred twenty (120) days of
the external review appeal request must be submitted for the review receipt of the original denial or response to your appeal The IRO will complete the review and TML IEBP will submit the
External
seventy-two (72) hours
response of an expedited urgent/emergent pre-
determination/notification of a benefit appeal within:
Appeal of Non Emergent Care Request for Benefits (Pre Determination/Notification Prior to Claim Submission)
Appeal of Non-Emergent Request for Benefits
(Adverse Pre-Determination/Notification Request)
Type of Request for Benefits or Appeal
Business Hours/Days
Appeal Process
The appellant must appeal the denial no later than: Internal
one hundred eighty (180) days after
receiving the denial
If the request for a pre- determination/notification is benefit
Internal
five (5) days
information incomplete, TML IEBP will notify the appellant within:
If the request for pre-determination/notification is clinical information
Internal fifteen
incomplete, TML IEBP will notify you within:
The appellant must then provide completed information within: Internal
forty-five (45) days after receiving an
extension notice*
TML IEBP will notify you of the first level appeal decision within:
Internal fifteen
after receiving the first level appeal The appellant must appeal the first level appeal (file a second level Internal sixty
after receiving the first level appeal decision TML IEBP will notify you of the second level appeal decision within: Internal fifteen
days after receiving the second level appeal* The appellant may request the appeal be submitted to an Independent External
one hundred twenty (120) days of
Review Organization, (IRO). The External Review Request must be receipt of the original denial or submitted within: response to your appeal The IRO must complete the review of a non emergent claim or benefit
External
forty-five (45) days
appeal within:
* A one-time extension of no more than fifteen (15) days only if more time is needed due to circumstances beyond their control Post Service Claims Appeal
Post-Service Claims
Type of Claim or Appeal
Business Hours/Days
The appellant must appeal the claim denial no later than: Internal
one hundred eighty (180) days after
receiving the denial
If the appellant's claim is incomplete, TML IEBP will notify the appellant Internal thirty
The appellant must then provide completed claim information within: Internal
forty-five (45) days after receiving an
extension notice
TML IEBP will notify the appellant of the first level appeal decision Internal thirty
days after receiving the
first level appeal The appellant must file the second level appeal within: Internal sixty
after receiving the first level appeal decision The appellant will be notified of the second level appeal decision Internal thirty
after receiving the generally within: second level appeal The appellant may request an appeal be submitted to an Independent External
one hundred twenty (120) days of
Review Organization, (IRO). This request must be submitted for the
receipt of the original denial or response to your appeal The IRO must complete the review of a non emergent claim or benefit
External
forty-five (45) days
The IRO must complete a requested expedited review of an emergent
External seventy-two
claim or benefit appeal within: *Covered Individuals have access to all documents and records used in making the decision—medical consultants used in making the decision must be disclosed. If a claim for benefits is wholly or partially denied, an Explanation of Benefits (EOB) will be furnished to the Covered Individual and the provider of services. This EOB will give the reason(s) the claim was denied. If the Covered Individual or provider of services does not agree with the claim decision or alleges that a contractual prompt payment requirement was not followed in the administration of a claim, he or she may submit an appeal. Relevant information supplied by the Covered Individual or healthcare provider should be included with the appeal. For claims denied or partially denied for not being notified, the appeal must include: the admission history and physical; the discharge summary; and the operative and pathology reports (if applicable). An appeal requested without proper documentation may not be considered. All written appeals should be sent to the Plan Administrator's address printed on the Medical/Prescription ID cards or complete the appeal form online at www.tmliebp.org. These appeal provisions shall be applicable where a provider makes a complaint that a prompt payment contract was not followed. The appealing party will be notified in writing of the results of an appeal for failure to provide Notification, and/or a denial or reduction in benefits after receipt of all necessary information to make a determination. All available medical information must be provided at no cost to the Plan. The Plan Administrator shall be under no obligation to respond to an appeal of a claim based upon complaints that have previously been addressed by a prior appeal. If the appealing party does not agree with the results of any appeal, the appeal may be elevated to the Plan's Board of Trustees. To appeal a decision to the Board of Trustees, the appealing party must send their appeal in writing to: TML IEBP Board of Trustees, 1821 Rutherford Lane, Suite 300, Austin, TX 78754-5151. Unless the appeal specifically requests that is a Board Appeal, TML IEBP shall have the discretion to consider the appeal on an internal staff basis. A committee of Trustees will schedule a meeting and hear the appeal. The appealing party may submit additional information and/or appear before the committee. The appealing party will be notified of the date, time and place the committee will meet at least five (5) days prior to the meeting date. A final decision will be made by the Board of Trustees Appeals Committee and sent to the appealing party. The Appeals Committee's final decision will be in writing and include specific references to the Plan provisions on which the decision was based. Ombudsman Services
Availability of Consumer Assistance/Ombudsman Services: There may be other resources available to help you understand the
appeals process. For questions about your appeal rights, an adverse benefit determination, or for assistance, you can contact
the Employee Benefits Security Administration at 1-866-444-EBSA (3272). Your state consumer assistance program may be able
to assist you at the Texas Consumer Health Assistance Program Texas Department of Insurance 1-855-839-2427 (1-855-TEX-
CHAP).
Provider Overpayments
The Provider agrees to refund TML IEBP all duplicate or erroneous claim payments regardless of the cause. After thirty (30) days
notice of any overpayment made by the Pool, the Provider agrees that the Pool has the right to offset unpaid refunds against
future payments.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Federal law referred to as the Health Insurance Portability and Accountability Act of 1996. HIPAA went into effect for most
group health plans on the anniversary that occurred on or after July 1, 1997. HIPAA provides individuals certain rights and
protections relating to healthcare coverage.
Refers to healthcare coverage reform and includes provisions for creditable coverage, restrictions on pre-existing condition exclusions, special enrollments and non-discrimination based on Health Status Factors; A self-funded, non-federal, governmental plan may exempt itself from HIPAA's provisions for standards relating to benefits for mothers and newborns, parity in the application of certain limits for mental health benefits, coverage for reconstructive surgery following mastectomy and coverage of Dependent students on medically necessary leave of absence. This Plan has opted out of and is exempt from these provisions. However, this Plan may comply voluntarily, in part or in whole, with some of the HIPAA requirements listed. Effective April 14, 2003, Administrative Simplification guidelines have been mandated. The administrative simplification process includes standards for electronic transactions and code sets, national identifiers (for employers, health plan and providers), Security and Electronic Signature Standards (Security Rule) and Standards for Privacy of Individually Identifiable Health Information (Privacy Rule); A self-funded, non-federal, governmental health plan cannot exempt itself from the Title II requirements. Privacy of Your Health Information
A Federal regulation, called the "Privacy Rule," requires TML Intergovernmental Employee Benefits Pool to protect the privacy
of each Covered Individual's identifiable health information. Under the Privacy Rule, TML Intergovernmental Employee Benefits
Pool may use and disclose a Covered Individual's identifiable health information only for certain permitted purposes, such as
the payment of claims under the health plan. If TML Intergovernmental Employee Benefits Pool needs to use or disclose a
Covered Individual's health information for a purpose not permitted under the Privacy Rule, TML Intergovernmental Employee
Benefits Pool must first obtain a written authorization signed by the Covered Individual.
In addition to restrictions on how TML Intergovernmental Employee Benefits Pool may use and disclose a Covered Individual's identifiable health information, the Privacy Rule gives each Covered Individual certain rights. These include the right of a Covered Individual to access his or her health information, to amend his or her health information, and to receive an accounting of certain disclosures of his or her health information. TML IEBP's Notice of Privacy Practices explains fully how TML IEBP may use and disclose a Covered Individual's identifiable health information and a Covered Individual's rights under the Privacy Rule. TML IEBP's Notice of Privacy Practices is included with each Covered Individual's enrollment information. TML IEBP's Notice of Privacy Practices also is available on TML IEBP's website at an individual may request a paper copy of the notice by calling TML IEBP's customer service number at (800) 282-5385. Security of Your Health Information
A Federal regulation, called the "Security Rule", requires TML IEBP to ensure the confidentiality, integrity and availability of a
Covered Individual's identifiable health information that TML IEBP receives, creates, maintains or transmits electronically. TML
IEBP has implemented administrative, physical and technical safeguards that meet both Federal requirements and industry
standards for the security of electronic health information.
Reservation of Rights
This is a governmental plan excluded from coverage under ERISA.
The Plan covers employees, Dependents of employees, elected officials, Dependents of elected officials, retirees, and Dependents of retirees of Pool Members who are eligible for the coverage, become covered, and continue to be covered, according to the terms of the Plan, Pool policies, and the policy of the Employer Member. Enrollment in the Group Medicare Supplement Plan requires that the Covered Individual be enrolled in Medicare Parts A and B. The terms of the Plan are described in the following pages. The Board of Trustees of the TML Intergovernmental Employee Benefits Pool reserves the right to amend this Plan if circumstances warrant and have given the Executive Director the discretionary authority to construe the terms of the plan. Important Disclaimer
The information presented in this Schedule of Benefits IS NOT a guarantee of payment.
The benefits described are subject to all plan limitations, pre-existing information, filing deadlines, exclusions and eligibility requirements. All benefits are based on the plan document language. If a Covered Individual is on continuation of coverage (COC), coverage could terminate retroactively if the individual's contribution is not made within the COC payment timeframe. If a Covered Individual is receiving care or about to receive care and is identified as not actively at work, continuation of coverage benefits may be offered, but must be accepted and paid per the continuation of coverage time guidelines for provider services to be considered for eligible benefit payment. Requests for reimbursement for a covered benefit should be sent to the Group Benefits Administrator within ninety (90) days of the date of service but not later than twelve (12) months. All inpatient and outpatient facilities are required to be licensed and/or accredited by Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), Medicare, Texas Commission on Alcohol and Drug Abuse (TCADA) or Accreditation Association for Ambulatory Health Care (AAAHC) for the bill to be considered for payment. You may be responsible for payment of all or part of any fees for healthcare services not covered by your Health Benefit Plan because the services received are provided by health care providers who are not members of the plan's provider network. Notification is required prior to receiving certain types of health care services: 1. eligibility of any individual for coverage; benefit coverage for services rendered pursuant to the Notification; or network status of the provider(s). Claims Address:
PO Box 149190 Austin, Texas 78714-9190 Customer Service:
Medical Care Management:
MTMP Retail and Mail MEDICAL BENEFITS
OUTPATIENT PRESCRIPTION DRUG BENEFIT FY11-12
MAXIMUM ALLOWABLE COST RESTAT CARD PROGRAM (MAC «PLAN»)
ALIGN/BROAD RETAIL NETWORK AND MAIL SERVICE BENEFIT OPTION
EAST TEXAS COG
Effective Date: June 1, 2012
This benefit schedule is made a part of the Plan for the purchase of outpatient prescription drugs. All charges for outpatient
prescription drugs are covered under this benefit and are not considered eligible expenses unless purchased through this program.
Generic Prescriptions Could be a Viable Savings Opportunity!
With healthcare costs continuing to rise, generic medicine might be an easy and effective way to minimize out of pocket
expenses.
1.
Generic medications are reviewed by the US Food and Drug Administration (FDA) for safety and efficacy and are manufactured under the strict standards that apply to brand-name drugs and not protected by a trademark. Generic medications create competition, which assists in keeping the costs of prescriptions competitive. Research shows that plan participants may save an average of 30% to 80% when they fill their prescriptions with a generic instead of a brand-name medication. Brand Name Drugs
Drugs produced and marketed exclusively by a particular manufacturer. The drug name is usually registered as a
trademark.
Maximum Allowable Cost (MAC A)
If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference between
the brand name and generic price in addition to the appropriate copayment for the brand name. The cost difference
between the brand name and generic price does not apply to any individual deductibles or out of pocket amounts. The
MAC differential applies to all prescriptions purchased through this program when a generic alternate is available.
Maximum Allowable Cost (MAC C)
Covered Individual will pay the appropriate copayment amount of the prescription.
Retail Covered Individual Copayments
Retail: Covered Individual OOP
Mail/Maintenance 84/90 day dispensement
(34 days supply max unless noted Biotech/SpecialtyRx 34 day dispensement
otherwise)
Covered Individual Out Of Pocket
Over the Counter Alternates:
Non-Sedating Antihistamines (Claritin®, Alavert®, Allegra®, Allegra-D®, Zyrtec®, Zyrtec-D®) per prescription Stomach and Ulcer (Prilosec®, Prevacid®, Zegerid®) per prescription Smoking Cessation (Nicorette Gum) Quantity Limit - 3 boxes per plan year MTMP Retail and Mail Retail: Covered Individual OOP
Mail/Maintenance 84/90 day dispensement
(34 days supply max unless noted Biotech/SpecialtyRx 34 day dispensement
otherwise)
Covered Individual Out Of Pocket
Align Network Value Tiered 34 day non Cost
$0.00 (up to 34 days supply) Share generic dispensement Align Network Value Tiered up to 90 day non
$9.00 (35 to 90 days supply) Cost Share generic dispensement Broad Network non Cost Share Generic
Broad and Align Network non Cost Share Best $38.00
Price Brand List Broad and Align Network non Cost Share
Non-Best Price Brand List Broad and Align Network Cost Share – see
Cost Share Copay Drugs below Specialty/Biotech Prescriptions
$100.00 for up to 34 day supply Cost Share Copay Drugs
Cost Share Drugs
Alternative Drugs
Antibiotics: Anti-Infective Agents
Minocycline® (for Dynacin®, Solodyn®) Impacts utilization on: Adoxa®, Doryx®, Dynacin®, Monodox®, Doxycycline® (for Adoxa®, Doryx®, Periostat®, Solodyn®, Oraxyl®, Oracea® Monodox®, Periostat®, Oracea®, Oraxyl®) Central Nervous System: Sedative Hypnotics
Zolpidem® Immediate Release (for Impacts utilization on: Ambien®, Ambien CR®, Edluar®, Lunesta®, Rozerem®, Sonata®, Zolpidem ER® Zaleplon® (for Sonata®) Stomach Ulcer/Reflux Drugs/Gastrointestinal/Stomach: Proton
Pump Inhibitors
Impacts utilization on: Aciphex®, Dexilant® (formerly Kapidex®), Nexium®, Lansoprazole®, Prevacid®, Prilosec®, Protonix®, Impacts utilization on: Fexofenadine®, Clarinex®, Xyzal® Impacts utilization on: Fexofenadine-D®, Clarinex-D® Nasal Steroids
Fluticasone® (for Flonase®) Impacts utilization on: Beconase AQ®, Flonase® (brand), Nasacort Generic
Flunisolide® (for Nasalide®) AQ®, Nasalide® (brand), Nasarel®, Nasonex®, Omnaris®, Rhinocort AQ®, Veramyst® Methylphenidate® Impacts utilization on: Immediate Release Amphetamine Products (Adderall®, Dexedrine®, Dextrostat®) MTMP Retail and Mail Cost Share Drugs
Alternative Drugs
Immediate Release Methylphenidate Products (Ritalin®, Foclin®) Extended Release Amphetamine Products (Adderall XR®, Dexedrine Spansules®) Extended Release Methylphenidate Products (Concerta®, Daytrana®, Metadate CD®, Ritalin LA®) Osteoporosis Drugs
Alendronate® (for Fosamax®) Impacts utilization on: Actonel®, Actonel® w/Calcium, Atelvia®, Boniva®, Fosamax®, Fosamax-D® Migraine Headaches
Sumatriptan® (for Imitrex®) Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex® (brand), Brand
Relpax®, Treximet®, Zomig®, Zomig ZMT® Overactive Bladder Drugs
Oxybutynin® Immediate Release (for Impacts utilization on: Detrol®, Detrol LA®, Ditropan® (brand), Ditropan XL®, Gelnique®, Enablex®, Oxytrol® Patches, Sanctura®, Toviaz®, Vesicare® Medication Therapy Management Program
At the time of this printing, the Value Tiered/Align Network Pharmacy Extension includes the following pharmacies:
Boomtown Drug HealthMart Pharmacy (Access Health) Brookshire Brothers Chapel Hill Pharmacy City Market Pharmacy Holmes Pharmacy Sav-On Pharmacy Hughes Pharmacy Cody Pharmacy Kenjura Pharmacy Collingsworth Pharmacy Kings Daughters Pharmacy Super Mercado's Pharmacy Davis City Pharmacy Diamond Pharmacy The Friendly Pharmacy Dillon Stores Luna's Friendly Pharmacy The Medicine Shoppe of Jasper Doc's Drugstore of Brownwood Maloney Pharmacy Doc's Drugstore of Early Med Shop Pharmacy Troup Pharmacy Medical Arts Drug (Waldie's Pharmacy) United Care Pharmacy Eagle Lake Pharmacy Medicine Chest Vista Pharmacy Medicine Shoppe of Henderson Vons Companies Inc.
Fikes Pharmacy Overton Pharmacy Waldie's Pharmacy Plaza Pharmacy Fry's Food & Drug Quality Food Centers Walter's Pharmacy Graham Pharmacy Whitehouse Pharmacy MTMP Retail and Mail
Clinical Prior Authorization
The list of conditions below may change as appropriate for the plan. For prior authorization requests, please have your
doctor/prescription prescriber call RxResults at (888) 871-4002. Your doctor/prescription prescriber will be asked a series
of questions and RxResults will then approve or deny the authorization request.
ANTIBIOTICS
MAJOR BIOTECH 9 Blood Cell Deficiency
9 Crohn's Disease Requests may be granted to patients who have
CATEGORIES
9 Cystic Fibrosis demonstrated compliance to an inhaled steroid
9 Growth Hormones and/or satisfied additional clinical criteria as
9 Hemophilia Hepatitis C determined by the prior authorization review.
9 HIV/Immune Deficiency Medications Treatment Plan Adherence is required for
9 Multiple Sclerosis authorization to be approved.
Pulmonary Arterial Hypertension Rheumatoid Arthritis TESTOSTERONE 9 ANDROGEL® (covered only for hormone
9 XOLAIR® Injection ALL PRODUCTS
replacement not for erectile dysfunction)
NON INHALERS 9 ACCOLATE®
9 ANDRODERM® 9 TESTIM® Actual lab results defining the testosterone
Covered only for asthma as a second-line drug,
level will be required. The lab report will
after an inhaled steroid. Use is excluded for
indicate whether the level is low or within
allergies and/or allergic rhinitis.
normal ranges.
Requests may be granted to patients who have
demonstrated compliance to an inhaled steroid
DIABETES
9 JANUVIA®/JANUMET® (covered for diabetes
and/or satisfied additional clinical criteria as
determined by the prior authorization review.
9 SYMLIN® Treatment Plan Adherence is required for
9 BYETTA® authorization to be approved.
9 VICTOZA® 9 ONGLYZA® 9 Attention Deficit Disorder ADHD (For
9 KOMBIGLYZE® individuals 17 years of age or older)
9 TRAJENTA® These medications may be reimbursed
These medications may be reimbursed
following satisfaction of clinical criteria as
following satisfaction of clinical criteria as
determined by prior authorization review.
determined by prior authorization review.
Narcolepsy Medications (For individuals 17
years of age or older)
9 Acne Medications (For individuals 26 years of
age and older)
Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change
without notice to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines. MTMP Retail and Mail
Step Therapy
For Clinical Authorization, doctor/prescription prescribers should call RxResults at (888) 871-4002. Your
doctor/prescription prescriber will be asked a series of questions and RxResults will then approve or deny the
authorization request.
Sample of what will occur at pharmacy
Claim is processing for Advair® & the following message will alert the pharmacist: Step Therapy after inhaled steroid
1st or Prior Authorization call (888) 871-4002.
TML IEBP Step Therapy Drug Categories
HIGH BLOOD PRESSURE (ANGIOTENSIN RECEPTOR BLOCKERS/ARB'S)
Required for members <40 years of age who have not If the member fills a medication in Category B, they will NOT need to
demonstrated adherence to an inhaled corticosteroid (ICS) start with Category A, unless they haven't used the medication for 100 (90 days of therapy in the past 120 days). If the member is beginning therapy (regardless of age), only an inhaled steroid will be approved unless otherwise approved by RxResults.
Category A
Category A
9 Inhaled Corticosteroid (ICS) - Member must 9 Any generic ACE inhibitor or ACE-combination demonstrate adherence to an inhaled steroid and/or 9 Losartan®/Losartan HCTZ® satisfy specific clinical criteria as determined by RxResults prior to obtaining a Category B medication. Category B (Only after failure with a Category A medication)
Category B (Only after failure with a Category A medication) The
doctor/prescription prescriber must provide documentation from the Covered Individual's medical record indicating that prior treatment with an ACE inhibitor resulted in a cough or angioedema. 9 ATACAND®/ATACAND HCT® 9 AVAPRO®/AVALIDE® 9 BENICAR®/BENICAR HCT® 9 COZAAR®/HYZAAR® (Brand only) 9 DIOVAN®/DIOVAN HCT® Treatment Plan Adherence is required for authorization
to be approved.
9 EXFORGE®/EXFORGE HCT® 9 MICARDIS®/MICARDIS HCT® 9 TEKTURNA®/TEKTURNA HCT® 9 TEKAMLO® 9 TEVETEN®/TEVETEN HCT® 9 TRIBENZOR® 9 TWYNSTA® 9 VALTURNA® 9 AZOR® Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change
without notice to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines. Important Information
TML IEBP Billing & Eligibility: (800) 282-5385 RxResults (Doctor/Prescription Prescribers Only): (888) 871-4002
MTMP Retail and Mail Drugs Covered Under This Benefit
Drugs Not Covered Under This Benefit
Dietary supplements, vitamins or formulas; Insulin or oral diabetic prescription; Growth hormones after age 15; Disposable insulin needles/syringes and physician Immunization agents, biological sera blood or blood prescribed needles/syringes; Disposable blood/urine/glucose/acetone testing 4. Male pattern baldness medications; hair growth agents (e.g. Acetest Tablets, Clinitest Tablets, Glucometer (one per calendar year), Lancets, 5. Tretinoin, all dosage forms (e.g. Retin-A, Differin, Diastix Strips, Tes-Tape and Chemstrips; Tazorac) for individuals 26 years of age or older; Diabetic supplies will be purchased with order for cosmetic agents including anti-wrinkle, Botox and oral diabetic prescription. The plan will allow skin depigmenting agents; needles, syringes, lancets and testing strips at no 6. Vitamins individually or in combination; charge if ordered within 30 days of a prescription 7. Therapeutic devices or appliances, including support at the same pharmacy; garments and other non-medicinal substances, Tretinoin all dosage forms (e.g. Retin-A, Differin, regardless of intended use; Tazorac) for Individuals through the age of 25 8. Charges for the administration or injection of any Compound medication of which at least one 9. Drugs labeled "Caution - limited by Federal Law to ingredient is a legend drug; investigational use" or experimental drugs even Any other drug which under the applicable State though a charge is made to the individual; Law may only be dispensed upon the written 10. Medications which are to be taken by or prescription of a physician or other lawful administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, Contraceptives: Oral, Extended cycle (mail order rest home, sanitarium, extended care facility, only), Transdermal patches, Contraceptive devices, convalescent hospital, nursing home or similar Levonorgestrel (Norplant), Prescription Strength premises which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals; Central Nervous System Stimulants (e.g. Adderall, 11. Emergency contraceptives; Adderall XR, Focalin, Focalin XR, Ritalin, Dexedrine, 12. Fertility medications; etc) will be covered for individuals through age 16. 13. Any prescription refilled in excess of the number (Individuals 17 years and older will require prior specified by the physician or any refill dispensed authorization through RxResults.) after one year from the physician's original order; Prescribed smoking deterrent medications 14. Prescription which an eligible individual is entitled containing nicotine or any other smoking cessation to receive without charges from any Workers' aids, all dosage forms; Compensation Laws or which is prescribed for an Growth hormones through age 15; injury or illness which is excluded from any medical Extended Release anti-depressive agents: coverage which is provided in conjunction with this Wellbutrin XL, Effexor XR; prescription benefit; Extended Release migraine prophylactic agents: Anti-obesity medications; Prescribed prenatal vitamins are not covered under Single entity legend vitamins. the Restat card. Claims for prescribed prenatal vitamins with a pregnancy diagnosis may be submitted to TML IEBP for payment consideration; Non-legend drugs other than those listed above; Lifestyle convenience prescriptions (ie: erectile dysfunction prescriptions). MTMP Retail and Mail
SpecialtyRx/Biotech Prescriptions
TML IEBP offers a Pharmacy Benefit Manager SpecialtyRx service. This service provides a convenient and cost-effective
way to order injectable drugs and supplies through Pharmacy Benefit Manager SpecialtyRx. The Specialty/Biotech copay
for a 34 day Specialty Prescription is $100.00.
To see a list of Specialty/Biotech drugs available through the Pharmacy Benefit Manager, please log in to the myTML IEBP web portal and click the "Prescription Benefits" link. SpecialtyRx is the most cost-effective way to purchase medications for Covered Individuals with chronic illnesses requiring life-sustaining medications. SpecialtyRx provides Covered Individuals with a cost-effective benefit to purchase specialty prescriptions. With SpecialtyRx, the Covered Individual will receive easy ordering and fast delivery from the Specialty Pharmacy. In addition, the Covered Individual will receive an informative care management packet. The SpecialtyRx prescription may be delivered to the physician's or Covered Individual's address. The SpecialtyRx plan provides many benefits to Covered Individuals: Single reliable source for injectable specialty prescriptions For Prior Authorization doctor/prescription prescribers call RxResults (888) 871-4002 Easy ordering with a toll-free number (877) 408-9742; 7:30am – 7:00pm CST M-F Express delivery to location of your choice either to the Covered Individual's home or provider's office (Some providers have expressed a strong opinion for the prescription to be delivered to their offices if they are required to administer the prescription.) Mail Service Prescription Option
Spend Less on Your Prescriptions!
TML Intergovernmental Employee Benefits Pool wants to remind you and your covered dependents about an important
part of your benefit plan — the CVS/Caremark Mail Service Program. Take advantage of the Caremark Mail Service
prescription benefit and you may save time and money on the medications you take each month. Getting your
prescription from the mail service pharmacy is simple with FastStart. Easy as 1-2-3!
1.
Call FastStart toll free: Members - (800) 875-0867 Hearing Impaired - (800) 231-4403 Doctors - (800) 378-5697 Call for Refill Mail Service: Members - (888) 739-7989 Let the FastStart representative know you wish to fill your prescription order through mail service. Provide the information on your benefit ID card, the names of the long-term medications you take, your doctor's name and phone number, and your mailing address. Medication Refills
Retail refills will be approved upon 75% of utilization. Mail Service refills will be approved upon 60% of utilization. Emergencies
On occasion, you may need to get a prescription filled immediately. Ask your physician to write two prescriptions, one for
a 21-day supply of medication to be filled locally and the second for the balance (up to 90 days). The 21-day supply
prescription filled locally will be covered according to the prescription drug benefit included in your Plan.
Order forms are included in your employee packets and are available from the TML Intergovernmental Employee Benefits Pool or your employer. A re-order form will accompany each order you receive. MTMP Retail and Mail
Identification Cards
Each Covered Individual will be issued an ID card. You must present your ID card to the pharmacist at the time of
purchase.
If a Covered Individual does not have the ID card at the time of purchase these steps must be followed:
Pay for the entire cost of the prescription. Obtain and complete a direct prescription drug Restat claim form. These are available from your employer or TML Intergovernmental Employee Benefits Pool. Send the Restat drug claim form with the prescription receipt directly to Restat. Restat will pay the appropriate amount, less the copayment and Maximum Allowable Cost (MAC) differential (if applicable), directly to the Covered employee usually within 30 days. Exhibit III
Level of Medical
- Waiting Period
- Cobra / State
DO NOT INCLUDE
PT OR EE THAT IS
waive - other coverage NOT ELIGIBLE
Date of Hire
waive- due to cost 2/1/2005 GS MAPPING SPECIALIST l 5/16/2001 ADMINISTRATIVE ASSISTANT 2/8/2005 FINANCIAL ASSISTANT-AP 10/10/1983 ACCOUNTING MANAGER 8/31/2001 FINANCIAL ASSISTANT-PR 5/21/2007 HOMELAND SECURITY PLANNER 2/1/2004 CONTRACT MANAGER 10/16/2012 FISCAL GRANT MANAGEMENT SPECIALIST 5/1/2010 BUS OPERATOR 6/11/2012 PROGRAM SPECIALIST 9/4/2007 BUS OPERATOR 10/1/2007 BUS OPERATOR 9/4/2007 BUS OPERATOR 10/4/2010 DIRECTOR OF FINANCE 9/4/2007 PROJECT COORDINATOR 9/4/2007 BUS OPERATOR 10/18/2010 EXECUTIVE SECRETARY 9/4/2007 BUS OPERATOR 9/4/2007 BUS OPERATOR 12/1/2004 RECEPTIONIST 5/1/2010 BUS OPERATOR 10/9/1995 ASSISTANT 9-1-1 COORDINATOR 8/20/2012 IT SERVICE ADMINISTRATOR 4/12/2001 CONTRACT SPECIALIST 2/4/2008 REGIONAL PLANNER 5/1/2010 BUS OPERATOR 9/18/2000 BUDGET MANAGER 5/29/1979 COMMUNITY CARE COORDINATO 4/1/1996 ADMINISTRATIVE ASSISTANT 5/1/2010 BUS OPERATOR 6/8/1998 MIS SPECIALIST 4/28/2008 BENEFITS COUNSELOR SUPV 9/4/2007 OPERATIONS MANAGER 6/11/2007 FINANCIAL SERVICE SPECIALIST 12/3/2007 BUS OPERATOR 4/16/2012 DIRECTOR OF AGING Exhibit III
7/1/2002 HOMELAND SECURITY COORDINATOR 10/29/2012 WSIT TEAM LEADER 5/29/2012 CASE WORKER 10/16/2012 FISCAL GRANT MANAGEMENT SPECIALIST 11/16/2008 DISPATCH 9/4/2007 BUS OPERATOR 9/4/2007 DISPATCH 6/7/2011 9-1-1 SUPPORT SPECIALIST 2/18/2011 BUS OPERATOR 5/7/2002 CONTRACT SPECIALIST 12/1/1999 SECTION CHIEF - CONTRACTS 6/13/1979 ADMIN SUPPORT TECH 3/5/2007 9-1-1 TECHNOLOGY COORDINA 6/1/2000 ECONOMIC DEV MANAGER 9/8/1997 PROGRAM MONITOR 1/16/2006 BENEFITS COUNSELOR 2/11/2008 DIRECTOR OF HUMAN RESOURCES 10/1/2011 GIS ANALYST 8/4/2008 CONTRACT MANAGER ASSIST 12/1/2009 CONTRACT SPECIALIST 10/18/2010 DISPATCH 1/1/2008 GS MAPPING SPECIALIST l 2/15/2010 DIRECTOR CRIMINAL JUSTICE 12/3/1979 SECTION CHIEF-MONITORING 9/4/2007 BUS OPERATOR 3/20/2012 PUBLIC EDUCATION TRAINER 1/16/2013 RECEPTIONIST 9/4/2007 FISCAL GRANT SUPPORT SPECIALIST 1/31/1994 EXECUTIVE ASSISTANT 6/14/2012 OMBUDSMAN 5/1/2010 BUS OPERATOR 11/16/2008 I,R & A SPECIALIST 5/14/2007 EXECUTIVE DIRECTOR 10/16/2012 WF SYSTEM IMPROVE TEAM LEAD 7/13/1987 SECTION CHIEF-PLANNING 6/11/2012 BENEFITS COUNSELOR 1/1/2004 CASE WORKER I 4/13/2009 DIRECTOR OF TRANSPORTATION 8/16/2001 PROGRAM MONITOR TML IEBP - HB 2015 Report
Exhibit IV
East Texas COG - PEASTTE1 Claims Paid 6/1/2010 Through 5/31/2011 Enrollee
Dependent
Rx Mail Order
Claims & RX
Loss Ratio
TML IEBP - HB 2015 Report
Exhibit IV
East Texas COG - PEASTTE1 Claims Paid 6/1/2011 Through 5/31/2012 Group Name
Start Date
Sex Status
Total Paid
Diag 1 Diag 1 Desc
Diag 1 Paid
Diag 2 Diag 2 Desc
Diag 2 Paid
Diag 3 Diag 3 Desc
Diag 3 Paid
Diag 4 Diag 4 Desc
Diag 4 Paid
Diag 5 Diag 5 Desc
Diag 5 Paid
Oth Diag Paid
Plan Desc
06/01/2011 05/31/2012 ATRIAL FIBRILLATION ANAL & RECTAL POLYP INT HEMORRHOID W/O ABN FIND-STOOL CONTENTS CHRONIC DIASTOLIC HF $2362.36 CTbGO0F* Standard Plan 06/01/2011 05/31/2012 $7810.07 $29187.49 CHR MAXILLARY SINUSITIS CHR FRONTAL SINUSITIS ESOPHAGEAL REFLUX CHRONIC SINUSITIS NOS $6419.34 CTbGO0F* Standard Plan 06/01/2011 05/31/2012 $639.50 $11646.66 CLSD FX LAT MALLEOLUS CL FX DISTAL RADIUS NEC DYSTHYMIC DISORDER COR AS-NATIVE VESSEL CLSD FX RAD W ULNA NOS $3377.55 CTbGO0F* Standard Plan 06/01/2011 05/31/2012 $1939.08 $28513.26 HYPERTENSION NOS DM2/NOS UNCOMP NSU INCISIONAL HERNIA CHF NOS $13790.00 $1707.23 CTbGO0F* Standard Plan 06/01/2011 05/31/2012 $158.81 $27996.52 URETERAL CALCULUS HYPERTENSION NOS GB CALCULUS W CHOL NEC $18819.43 CTbGO0F* Standard Plan 06/01/2011 05/31/2012 $534.29 $19223.95 HYPERTENSION NOS RHEUMATOID ARTHRITIS LOC OA NOS-LOWER LEG $14798.06 V4962 OTH FINGER AMP STATUS LOC PRIMARY OA-LOWER LEG $1597.37 CTbGO0F* Standard Plan December 07, 2012 EAST TEXAS COUNCIL OF GOVERNMENTS The TML Intergovernmental Employee Benefits Pool believes it is important to keep Members informed throughout the year of their group healthcare utilization as well as the healthcare utilization of the entire Pool. This information is important to decisions made regarding future contribution rates. The information outlined below shows your year-to-date experience. The Pool's administrative expenses are about 15%. Therefore, a loss ratio above 85% means that claims for your entity are exceeding contributions.
Enrollee
Rx Mail Order
Claims & RX
Loss Ratio
Loss Ratio
1821 Rutherford Lane, Suite #300, Austin, TX 78754-5151 (800) 348-7879 www.tmliebp.org Service Team Fax: (512) 719-6505 or (512) 719-6586 Executive Fax: (512) 719-6509 TML IEBP - HB 2015 Report
Exhibit IV
East Texas COG - PEASTTE1 Claims Paid 2/1/2012 Through 1/31/2013 Group Name
Start Date
Sex Status
Total Paid
Diag 1 Diag 1 Desc
Diag 1 Paid
Diag 2 Diag 2 Desc
Diag 2 Paid
CERVICAL SPONDYLOSIS TOBACCO USE DISORDER JT DERANG NEC-SHOULDER JT DERANG NOS-SHOULDER DM2/NOS UNCOMP NSU PNEUMONIA ORGANISM NOS INFLAM BREAST DISEASE HX NARCOTIC ALLERGY TML IEBP - HB 2015 Report
Exhibit IV
East Texas COG - PEASTTE1 Claims Paid 2/1/2012 Through 1/31/2013 Diag 3 Desc
Diag 3 Paid
Diag 4 Diag 4 Desc
Diag 4 Paid
Diag 5 Diag 5 Desc
Diag 5 Paid
Oth Diag Paid
Plan Desc
HYPERTENSION NOS BRACHIAL NEURITIS NOS $2764.17 STbGO0F0 Standard Plan CLSD ANT DISLOC HUMERUS RECUR DISLOCAT-SHOULDER PHYSICAL THERAPY NEC $4566.87 STbGO0F0 Standard Plan HYPERTENSION NOS HYPERLIPIDEMIA NEC & NOS OBSTRUCTIVE SLEEP APNEA $1770.78 STbGO0F0 Standard Plan BREAST HYPERTROPHY JOINT PAIN-SHOULDER $831.09 STbGO0F0 Standard Plan
Source: http://www.etcog.org/userfiles/file/rfps/etcog/grouphealthinsurance.pdf
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Actos de libertad: pensando en clave electiva* Ponencia inédita presentada en el III Congreso Iberoamericano de Pensamiento. Holguín, 2006. Por EDELBERTO LEIVA LAJARA ACTO PRIMERO: ÍNTIMA LIBERTAD Estamos demasiado acostumbrados -patrones culturales por medio- a las manifestaciones físicas de la audacia. Yo no pretendo una ingenua exaltación a priori de la actitud contemplativa -por sí mismo el pensar supone un hacer pluridimensional que lo complemente y le dé existencia en el mundo material-, sino una reflexión íntima en torno al siguiente problema: hasta dónde el principio de toda emancipación radica en un primer acto de liberación interior. El fundamento lo ofrece la historia de nuestro pensamiento, cuya lección primera y mayor parece ser, en efecto, que si no somos libres en el pensar, sencillamente no somos libres. Que no hayamos creado sistemas, doctrinas o modelos de pensamiento que hayan llenado épocas en la historia universal, no es un argumento en contra. En buena lid, en el caso cubano, parece ser la clave de todo. A diferencia de otros pueblos en algunas etapas históricas, no hemos pretendido la suma definitoria del conocimiento humano. En nuestro fuero interno, hemos sido lo suficientemente libres para no aspirar a ello, y es posible que haya sido lo mejor para todos. Sería magnífico que siguiera siendo así en el futuro, porque ello implica el reconocimiento de la singularidad e irrepetibilidad de esa escurridiza cualidad que llamamos lo cubano, inaprensible con frecuencia para ese otro, también singular e irrepetible, proveniente de cualquier lugar del mundo. . No se entienda lo anterior como una apología de la incomunicación, o la negación de un fondo de valores comunes a la humanidad y por tanto susceptibles de servir de fundamento a los más disímiles proyectos sociales, políticos o culturales. Tampoco -¡mucho menos!- como un ejemplo más de esa recurrente inclinación a la postura Cuba=ombligo del mundo que por momentos lacera nuestra integridad de pueblo. Es mucho más sencillo. Es una posición de humildad sustentada por la convicción de que no es posible inventar lo que siempre, como grupo humano, hemos rechazado: los grandes sistemas de pensamiento que pretenden explicarlo todo, así sea en sus versiones originales o en trasnochadas interpretaciones de apologetas. Pero vayamos a lo esencial, a la importancia del acto electivo como fundamento de libertad, entendido como posibilidad de asumir una de las opciones viables en un momento dado. Es ingenuo presuponer una libertad absoluta de elección, ajena al estado concreto de la sociedad, la cultura, la política, la economía. El entramado profundamente complejo de una comunidad, sin dudas, condiciona la elección. Cada punto de partida genera un espectro de opciones, más o menos amplias, más o menos viables, y puede darse por demostrado -si la historia en realidad demuestra algo- que son muy raros, casi inexistentes en realidad, los casos en que sólo era posible hacer lo que se hizo y del modo en que se hizo. Por lo demás, las vías por las cuales unas variantes se imponen sobre otras se definen a partir de una multicausalidad ya hoy comúnmente aceptada por la comunidad de estudiosos de las sociedades humanas. Pero también sabemos que todo lo que el ser humano es capaz de crear, en cualquier ámbito, es primero pensado. Lo son los proyectos sociales, y para entenderlos, en el caso cubano, es imprescindible comprender las claves de nuestro modo de pensar, que son claves electivas. Que es decir, de libertad. ACTO SEGUNDO: LA APELACIÓN A LOS ORÍGENES Los cubanos acudimos con asiduidad a la historia como argumento para validar o deslegitimar opiniones y proyectos. Si le concedemos, como nación, una importancia tan significativa al pasado, amerita sin dudas remitirnos a él para rastrear los orígenes de lo que nos ocupa, inserto en lo específico de lo cubano, y por tanto
Bjp-2014-158931 1.6
The British Journal of Psychiatry1–6. doi: 10.1192/bjp.bp.114.158931 Shared treatment decision-making andempowerment-related outcomes in psychosis:systematic review and meta-analysisDiana Stovell, Anthony P. Morrison, Margarita Panayiotou and Paul Hutton BackgroundIn the UK almost 60% of people with a diagnosis of shared decision-making were found on indices of treatment-