R-2021 - 05/24/2022 - AGREEMENTS - Resolutions Exhibits �<„::r•fit_';
REVIEW OF CONTRACTS
Awarding Agency: Type of Contract:
VOB Prof. Srvs.
Department: Program/Account Number:
Human Resources 126 - Emp Benefits
Awarded Contract Price: Budgeted Amount:
ONTRACT AMOUNT
Under $20,000 $500,001 - $1,000,000
$20,000 - $500,000 F7 Over $1,000,000
NOTES
Health, 3rd Party Administrator & Stop Loss Insurance, Dental Life/AD&D
Insurance, Vision Insurance, & Telemedicine Agreements
DEPARTMEtJT DIRECTOR SIGNATURE
Name: Date: 5/23/2022
NATURE
Name: Date:-/2x/22
APPROVED BY VII.L.AGE MAN R
Name: Date'.
FINAL ATO FORM ATTORNEY SIGNATURE
u � •'
Name: Date: 7 23ht
Three (3) Originals signed by other party Date/Initials 'sildog Es
Original provided to staff member for other party Date/Initials
Original provided to Official Files Date/Initials
Village of Oak Brook I Approved by Board of Trustees- Date/Initials:
HCSC GEN ASO Traditional PBM Fee Addendum 6.19
PBM Fee Schedule Addendum to the Benefit Program Application
Village of Oak Brook
Term: ;111C`11-;0,-2'21;3j:202, Employees:
Guaranteed Traditional Aggregate Pricing Arrangement D'•
Traditional Select Network and Basic Drug List
RETAIL
Brand Generic
AWP minus AWP minus
18.85% 81.80%
DISPENSING FEE
Brand Generic
$0.80 $0.80
MAIL
Brand Generic
AWP minus AWP minus
22.75% 82.25%
DISPENSING FEE: $0.00
EMENDED SUPPLY NETWORK("ESN")(N Applicable)
Brand Generic
AWP minus AWP minus
22.00%
DISPENSING FEE: $0.00
Aggregate Specialty Discount
Pricing based on Employer's use of the Prime Specialty network AWP minus:18.90%
DISPENSING FEE: $0.00
Rebate Credits to Employer:
PEPM Rebate Credits to Employer:
Employer Administration Fees: -
PBM Administration tees PEPM: $0.00
Additional Provisions:
t Employer will be billed for retail brand and retail generic prescriptions,mail brand and mail generic prescriptions,ESN brand and ESN generic,and Specialty pharmacy claims(excluding compound prescriptions)
based on the lesser of(a)U&C or(b)PBM's adjudication rate schedule(s)that is/are intended to achieve,on an aggregate calendar-year basis,the AWP discounts and Dispensing Fees shown above for all of Claim
Administrator's group customers that have purchased the above specific pricing arrangement("Groups with the Pricing Arrangement")and use the above Network(the"Employer's Contract Rates").
For purposes of setting Employer's Contract Rates and calculating whether the AWP discounts and Dispensing Fees have been achieved:
a.Brand drugs are defined as all drugs that have a Medi-Span multisource wide field equal to"M","N",or"O".
b.Generic drugs are defined as all drugs available in sufficient supply that have a Medi-Span multisource code field equal to"Y"
Employer acknowledges and agrees that Employer's Contract Rates may vary based on market influences and as necessary to achieve the AWP discounts and Dispensing Fees shown above,on an aggregate
calendar year basis,for Groups with the Pricing Arrangement that use the above Network.However,such variation for Brand products in each of the Retail,Mail,and ESN categories(on an aggregate annual basis)
may only vary by+/-3%from the applicable AWP discount shown above.
Employer will be billed the above Dispensing Fee(such Fee may be included in the amount billed to Employer)unless the Employer is billed based on the U&C price.If the Employer is billed based on the U&C
price,then the Dispensing Fee is included in such U&C price.
Employer will be billed for Compound Drug claims based on the applicable discounted rate in the Network Contract.
Employer will be billed for Foreign Claims based on an amount equal to the amount billed by the pharmacy.
Employer will be billed for out-of-network claims based on the pricing set forth in the Administrative Services Agreement and/or PBM Exhibit,as applicable.
If the AWP discounts and Dispensing Fees shown above are not achieved for a particular calendar year,for Groups with the Pricing Arrangement that use the above Network,then Employer will be credited,no
later than 180 days after the end of each calendar year during the Term,an amount calculated as follows:
-First,the total aggregate shortfall dollar amount for the calendar year for Groups with the Pricing Arrangement that use the above Network will be calculated by comparing
the actual performance of each of the above categories(Retail,Mail,ESN,and Specialty)with the corresponding AWP discounts and Dispensing Fees shown above for each
category.The amount of any performance in any category that exceeds the above AWP discounts and Dispensing Fees will be used to offset any and all shortfalls)in any or
all categories.The above aggregate shortfall,if any,is then divided by total claims for Groups with the Pricing Arrangement that use the above Network,and did not
terminate their Addendum prior to their anniversary date,for the calendar year("Per Claim Amount").Then the Per Claim Amount will be multiplied by Employer's total
claims for that calendar year to calculate the reconciliation credit.However,if Employer terminates this Addendum prior to its anniversary date and the above Guaranteed
Traditional Aggregate Pricing Arrangement is not achieved,then Employer will not be eligible to receive such credit.
-For purposes of determining if a shortfall exists,claims billed to Employer based on the U&C price will be considered to have$0.00 Dispensing Fees.
-Compound Drug claims,Foreign Claims,reversed claims,and out-of-network claims are excluded from the calculation of whether the AWP discounts and Dispensing Fees shown
above have been achieved and also are excluded from the calculation of any shortfall credit for Employer.
-If the AWP discounts and Dispensing Fees shown above are exceeded for Groups with the Pricing Arrangement that use the above Network,then Employer will not receive
any credit,and there will not be a year-end settlement.
-Under the Guaranteed Traditional Aggregate Pricing Arrangement any particular group customer's experience relative to the pricing guarantees will not determine its
eligibility for a credit.Group customer's eligibility for a credit is determined based on the aggregate experience of all group customers that have purchased the Pricing
Arrangement and use the above Network.As such,an individual group customer may have experience that does not meet,or exceeds,the AWP discounts and Dispensing
Fees shown above.In addition,when there is a reconciliation credit,it is allocated in a manner described above and not based on any particular group's experience(other
than number of claims).
1
Proprietary and Confidential Information
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator.
HCSC GEN ASO Traditional PBM Fee Addendum 6.19
PBM uses Medi-Span as the pricing source to establish AWP,for purposes of calculating whether the above AWP discounts have been achieved.
Members'cost share is the applicable copayment,deductible,and/or coinsurance,which coinsurance is calculated based on the Employer's Contract Rate or the applicable out-cf-network pricing.Zero balance
logic is not employed.
AWP discounts are based on the actual NDC-11 dispensed.
AWP discounts do not include savings from drug utilization review or other clinical or medical management programs.
The above Guaranteed Traditional Aggregate Pricing Arrangement,Rebate Credits and Administrative Fees may be subject to change if the Employer's claims include 3408 pricing.
In addition to the rights of the parties under the PBM Exhibit,if changes occur within the pharmacy benefit management marketplace which lead to a significant deviation from the current economic environment,
both parties agree to engage in good faith negotiations to amend this Addendum to make impact on both parties commercially reasonably economically neutral.If the parties cannot agree on the terms of the
amendment,either party shall be allowed to(a)proceed to dispute resolution,as set forth in the Administrative Services Agreement or(b)terminate this Addendum with 90 days prior written notice to the other
party.Failure to reach agreement on the amendment shall not be a breach of contract.
The above Guaranteed Traditional Aggregate Pricing Arrangement,Rebate Credits and Administrative Fees are based on the Network and Drug List shown above.
Unless otherwise specified in this Addendum,capitalized terms used in this Addendum shall have the meanings set forth in the Administrative Services Agreement or the PBM Exhibit,as applicable.
'Employer Payments to Claim Administrator for Covered Services provided by Network Participants are calculated based on the pricing terms set forth in this Addendum which shall remain in effect for the term
of this Addendum to the extent described in the Administrative Services Agreement.Such pricing mayor may not equal the amounts actually paid to the Network Participants or received from drug manufacturers
(e.g.,rebates),or the amounts paid or received between Claim Administrator and the PBM.Asa result,the PBM or Claim Administrator may realize positive margin on prescriptions filled at retail,mail order,ESN
or specialty pharmacies or prescription drug rebates.Employer acknowledges that it has negotiated for the specific traditional pricing terms set forth in this Addendum,and that it and its group health plan have
no right to,or legal interest in,any portion of any positive margin retained by Claim Administrator or PBM and consents to Claim Administrator's and PBM's retention of all such amounts.
Signature of Authorize urchaser
Print Name
V1, 11 /'
Title
l�
Dates
2
Proprietary and Confidential Information
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator.
Benefit Program Application ("ASO BPA")
Applicable to Administrative Services Only (ASO) Group Accounts
administered by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, hereinafter referred to as"Claim Administrator"or"BCBSIL"
Group Status: Renewing ASO Account
Group Number(s): Group Number(s): P19545 (Non- Union)
Employer Account Number(6-digits): 019545 P19546 (H S A), P56642 (Police), P56643 (Fire)
Section Number(s): 0100 (Village - Union), 0101 (Village
- Non Union), 0200 (Park District), 0300 (Retirees),
0400 (Retirees over 65), 0500 (PSEBA), 0600
(Police Union), 0800 (Union - Fire), 1000 (PSEBA- Union),
1100 (Police - Union), 8887 (COBRA), 8889 (COBRA), 8900 (COBRA)
Legal Employer Name: Village of Oak Brook
(Specify the Employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be
covered must also be named below. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED.)
ERISA Regulated Group Health Plan*: ❑ Yes ® No
Is your ERISA Plan Year*a period of 12 months beginning on the Effective Date of Coverage specified below? ❑ Yes
If not, please specify your ERISA Plan Year*: Beginning Date_/_/_ End Date_/_/_ (month/day/year)
ERISA Plan Administrator*:
Plan Administrator's Address:
If you maintain that ERISA is not applicable to your group health plan, give legal reason for exemption:
Select legal reason ; if applicable, specify other:
Is your Non-ERISA Plan Year* a period of 12 months beginning on the Anniversary Date specified below? ❑ Yes
If not, please specify your Non-ERISA Plan Year*: Beginning Date_/ / End Date / / (month/day/year)
For more information regarding ERISA, contact your Legal Advisor.
*All as defined by ERISA and/or other applicable law/regulations
Effective Date of Coverage: (Month/day/Year) 07 / 01 /2022
Anniversary Date: (Month/Day/Year) 12/ 31 /2022
Account Information F-1 NO CHANGES SEE ADDITIONAL PROVISIONS
Standard Industry Code (SIC): 8990 Employer Identification Number(EIN). 36-6009534
Address: 1200 Oak Brook Road
City: Oak Brook State: IL ZIP: 60523
Administrative Contact: Kathy Vonachen Title: Human Resources Manager
Email Address: kvonachen@oak-brook.org Phone Number: 630-368-5024 Fax Number: 630-368-
5025
Wholly Owned Subsidiaries to be covered:
Affiliated Companies to be covered: Employer Identification Number(EIN):
(Affiliated Companies must be required or permitted to be aggregated per IRS Guidelines, Employer hereby confirms that Employer, Subsidiaries and
Affiliates are treated as a single employer under Internal Revenue Code Section 414(b),or(c), or(m)or(o), or under applicable law.)
Blue Access for Employerssm ("BAEsM") Contact: Kathy Vonachen
(The BAE Contact is the Employee authorized by the Employer to access and maintain the Employer's account in BAE.)
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 1
Email Address: kvonachen@oak-brook.org Phone Number: 630-368-5024 Fax Number: 630-368-
5025
❑ The Employer or other company listed in this BPA is a public entity or governmental agency/contractor
`,roducer of Record Information Z NO CHANGES E] SEE ADDITIONAL PROVISIONS
Effective:
If applicable, the below-named producer(s) or agency(ies) is/are recognized as Employer's Producer of Record (POR) to
act as representative in negotiations with and to receive commissions from BCBSIL, Claim Administrator's corporate
subsidiaries, as applicable, for procuring Claim Administrator's claims administration services for Employer's employee
benefit program(s). This statement rescinds any and all previous POR appointments for the Employer. The POR is
authorized to perform membership transactions on behalf of the Employer. This appointment will remain in effect until
withdrawn or superseded in writing by the Employer.
Are commissions to be paid? ❑ Yes ❑ No
Producer or Agency to whom commissions are to be paid*:
Illinois Producer#:
NPN:
Address:
City: State:
Phone: Fax:
Is Producer/Agency appointed with BCBSIL? ❑ Yes ❑ No
Commissions:
❑ PCPM $ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve)
❑ Flat$ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve)
❑ Percentage of Stop Loss: %
ADDITIONAL COMMISSIONS:
*The Producer or agency name(s) above to whom commissions are to be paid must exactly match the name(s) on the appointment
application(s).
Schedule of Eligibility F-1 NO CHANGES E] SEE ADDITIONAL PROVISIONS
Employer has made the following eligibility decisions:
1. Eligible Person means:
❑ A full-time employee of the Employer.
❑ A full-time employee of the Employer who is a member of: (name of union)
❑ A part-time employee of the Employer.
❑ A retiree of the Employer. Define criteria:
® Other: Part-time employees that work at least 20 hours per week are enrolled in the Group Health Plan as of
06/30/2006 are eligible for Group Health Coverage under this plan. Part-time employees that are not enrolled as
of 06/30/2006 and future part-time will not be eligible for coverage.
Are any classes of employees to be excluded from coverage? ❑ Yes ❑ No
/f yes, please identify the classes and describe the exclusion:
2. Employee definitions:
Full-Time Employee means:
® A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent payroll
of the Employer.
❑ Other:
Part-Time Employee means:
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 2
❑ A person who is regularly scheduled to work a minimum of hours per week and who is on the permanent
payroll of the Employer.
❑ Other:
3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person:
® The date such person ceases to meet the definition of Eligible Person.
❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
❑ Other:
4. Select an effective date rule for a person who becomes an Eligible Person after the Effective Date of the Employer's
health care plan (The effective date must not be later than the 91st calendar day after the date that a newly eligible
person becomes eligible for coverage, unless otherwise permitted by applicable law).
❑ The date of employment.
® The 31 day of employment.
❑ The day of the month following month(s) of employment.
❑ The day of the month following days of employment.
❑ The day of the month following the date of employment.
❑ Other:
Is the waiting period requirement to be waived on initial group enrollment? ❑ Yes ❑ No
Are there multiple new hire waiting periods? ❑ Yes ® No
If yes, please attach eligibility and contribution details for each section.
5. Domestic partners covered: ❑ Yes ® No
If yes: a domestic partner is eligible to enroll for coverage.
If yes, are domestic partners eligible for continuation of coverage? ❑ Yes ❑ No
If yes, are dependents of domestic partners eligible to enroll for coverage? ❑ Yes ❑ No
If yes, are dependents of domestic partners eligible for continuation of coverage? ❑ Yes ❑ No
The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage
for domestic partners.
6. Civil Union Partners covered:
❑ The Employer is an Illinois county, municipality, the State of Illinois, subject to the Illinois School Code, a church
plan or other non-ERISA plan. For such Employers, a Civil Union Partner and his or her dependents are
automatically eligible to enroll for coverage and, once enrolled, eligible for continuation of coverage as described
in the Employer's Plan.
For all other Employers: ❑Yes ❑ No
If yes:A Civil Union Partner and his or her dependents are eligible to enroll for coverage.
If yes. Are Civil Union Partners and his or her dependents eligible for continuation of coverage? ❑ Yes ❑ No
The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage
for Civil Union Partners.
7. Limiting Age for covered children: Twenty-six (26) years, regardless of presence or absence of a child's financial
dependency, residency, student status, employment status, marital status, eligibility for other coverage, or any
combination of those factors. Other:
If Employer is an Illinois county, municipality, the State of Illinois, or subject to the Illinois School Code, this Limiting Age
is extended to thirty (30) years, for unmarried eligible military personnel as described in the Employer's Plan.
8. Termination of coverage upon reaching the Limiting Age:
❑ The last day of coverage is the day prior to the birthday.
® The last day of coverage is the last day of the month in which the limiting age is reached.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10121) 3
❑ The last day of coverage is the last day of the billing month.
❑ The last day of coverage is the last day of the year(12/31) in which the limiting age is reached.
❑ The last day of coverage is the day prior to the Employer's Anniversary Date.
Will coverage for a child who is medically certified as disabled and dependent on the employee terminate upon reaching
the limiting age even if the child continues to be both disabled and dependent on the employee? ❑ Yes ❑ No
However, such coverage shall be extended in accordance with any applicable federal or state law. The Employer will
notify BCBSIL of such requirements.
9. Disabled dependent: A disabled dependent means a dependent child who is medically certified as disabled and
dependent upon the Employee or his/her spouse.
To administer medical certification of disabled dependents, you may select option (a) Standard Rules or (b) Custom
Rules. BCBSIL will administer its standard process for administration of disabled dependent coverage if(a) below is
selected by Employer, or at the Employer's direction memorialized below, BCBSIL will follow a customized process if
Employerselects(b). If(b)is selected there are additional selections regarding age, proof of prior coverage, certification
review, forms, and previous medical certification approvals.
(a) ® Disabled dependent administration will follow Standard Rules.
A disabled dependent is eligible to continue coverage beyond the limiting age, provided the disability began before the
child attained the age of 26. A disabled dependent is eligible to add coverage beyond the limiting age, provided the
disability began before the child attained the age of 26, and proof of coverage as a disabled dependent is provided.
Administration of certification review is administered by BCBSIL; a disabled dependent certification form must be
submitted to BCBSIL.
(b) ❑ Disabled dependent Administration will follow Custom Rules. Please make the following sections:
Age: Please select one option regarding age of when the disability began.
❑ The disability must have begun before the child attained the age of 26.
❑ All disabled dependents are covered regardless of when the disability began.
Proof of prior coverage: Please select required or not required below:
When adding coverage, proof of prior coverage as a disabled dependent is ❑ required ❑ not required.
Certification review: Please select one option regarding the administration of certification review.
❑ Certification review is administered by BCBSIL; a disabled dependent certification form must be submitted to
BCBSIL.
❑ Certification review is administered by the Employer; there are no disabled dependent certification form
requirements.
If certification review is administered by BCBSIL, please select one option regarding forms:
❑ Utilize BCBSIL disabled dependent certification forms.
❑ Utilize custom/other disabled dependent certification forms.
If Certification Review is administered by BCBSIL, please select allowed or not allowed below:
A disabled dependent approved certification from a prior insurance carrier is ❑ allowed ❑ not allowed.
A disabled dependent approved certification from a prior BCBS policy is ❑ allowed ❑ not allowed.
10. Will extension of benefits due to temporary layoff, disability or leave of absence apply?
® Yes (specify number of days below) ❑ No
Temporary Layoff: 0 days Disability:Police & Fire by IL Statue: Other 90 days leave days
Leave of Absence: 0 days
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 4
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with an applicable
federal or state law. The Employer will notify BCBSIL of such requirements.
11. Enrollment:
Special Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents within thirty-one
(31) days of a Special Enrollment qualifying event if he/she did not previously apply prior to his/her Eligibility Date or
when otherwise eligible to do so. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage
Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to marriage or termination
of previous coverage, then no later than the first day of the Plan Month following the date of receipt of the person's
application of coverage.
An Eligible Person may apply for coverage within sixty (60) days of a Special Enrollment qualifying event in the case
either of a loss of coverage under Medicaid or a state Children's Health Insurance program, or eligibility for group
coverage where the Eligible Person is deemed qualified for group coverage assistance under a state Medicaid or CHIP
premium assistance program.
Open Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so, during the Employer's annual
Open Enrollment Period. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will
be a date mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open
Enrollment Period.
Specify Open Enrollment Period: The month of June for a July 1st effective date
Late Enrol/menta An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so. Such person's Coverage Date,
family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator
and the Employer.
Select one of the provisions below:
❑ Open Enrollment— Late applicants may only apply during Open Enrollment.
❑ Late Entrant— Late applicants may apply at any time—coverage effective date is determined by the receipt date
and the rules governing off-cycle enrollments.
12. Does COBRA Auto Cancel apply? ❑ Yes ❑ No
Member's COBRA/Continuation of Coverage will be automatically cancelled at the end of the member's eligibility period.
*Not recommended for accounts with automated eligibility.
EMPLOYEECURRENT • - •
Current number of eligible subscribers at onboarding and/or annual renewal
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 5
Lines of Business (Check all applicable Z NO CHANGES [:] SEE ADDITIONAL PROVISIONS
Medical Plan Services: Consumer Driven Health Plan:
® Participating Provider Option (PPO) ❑ BlueEdgesM HCA Administrative Services (if
❑ Blue Choice Select PPO purchased, complete separate HCA BPA)
❑ Blue Choice Options ® BlueEdgesm HSA Eligible Health Plan (Vendor:
❑ Blue High Performance Networksm (Blue Other)
HPNsm)without Tiers ❑ FSA (Vendor: Select Vendor)
❑ Blue High Performance Network with Tiers ❑ HRA (Vendor: Select Vendor)
(Blue HPNT)
Prescription Drugs:
Additional Services: ® Covered under a pharmacy benefit (If selected, the
❑ Wellbeing Management PBM Fee Schedule Addendum must be attached
❑ Wellness Incentives and is part of this BPA.)
❑ Health Advocacy Solutions ❑ Covered under the medical benefit or Blue Script
❑ Mercer Health Advantage
❑ Custom Care Management Unit Pharmacy Network (Select one):
❑ Blue DirectionsSM (Private Exchange) (If
selected, the Blue Directions Addendum is ® Traditional Select Network
attached and made a part of the parties' F-1 Advantage Network
Administrative Services Agreement.) El Preferred Network (Not offered with Blue Script)
❑ Elite Network (Not offered with Blue Script)
❑ Limited Fiduciary Services for Claims and ❑ Network on PBM Fee Schedule Addendum
Appeals ❑ Other(please specify):
❑ Other Select Product PPO Drug List: Select Drug List
❑ Other Select Product Other(please specify):
❑ Other Select Product
❑ Other Select Product PPO/HSA Preventive Drug List:
❑ Other Please specify: Select Option
❑ Other Other Rx programs:
Ancillary Services: Please specify: Select Program
❑ Dental Plan Services Prescription Drug Program Clinical Programs
❑ Vision Insurance (if selected, complete a ❑ Pharmaceutical Care Management (Retrospective)
separate application) (Included with HAS)
® Stop Loss(if selected, complete separate Exhibit
to the Stop Loss Coverage Policy)
❑ Life or Disability Insurance (if selected,
complete a separate application for those
coverages)
❑ COBRA Administrative Services (if selected,
complete separate COBRA Administrative
Services Addendum to the BPA)
Mercer Health Advantage is offered by Mercer,an independent company,and is administered by Blue Cross and Blue Shield of Illinois.
Custom Care Management Unit is offered by Willis Towers Watson,an independent company,and is administered by Blue Cross and Blue Shield of Illinois.
Medical and Dental benefits and services are administered by Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve
Company,an Independent Licensee of the Blue Cross and Blue Shield Association.
Life, Disability and Vision products are issued by Dearborn Life Insurance Company,701 E.22nd St,Suite 300,Lombard,IL 60148.Blue Cross and Blue Shield of Illinois is
the trade name of Dearborn Life Insurance Company,an independent licensee of the Blue Cross and Blue Shield Association,BLUE CROSS®,BLUE SHIELD®and the Cross
and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association,an association of independent Blue Cross and Blue Shield Plans.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 6
FEE SCHEDULE
Employer shall pay amounts Claim Administrator bills Employer for benefit claims Claim Administrator processes on
Employer's behalf as well as administrative fees as set forth in this Fee Schedule.
SpecificationsPayment /1 NO CHANGES ■ SEE ADDITIONALPROVISIONS
7Employer
ayment Method: ❑ Online Bill Pay ® Electronic ❑ Auto Debit ❑ Check
ayment Period: ❑Weekly (cannot be selected if Check is selected as payment method above)
❑ Semi Monthly (cannot be selected if Check is selected as payment method above)
® Monthly
Claim Settlement Period: ® Monthly
Run-Off Period: Employer Payments are to be made for 12 months following end of Fee Schedule Period.
Standard is twelve (12) months.
Fee Schedule Period: To begin on Effective Date of Coverage and continue for 12 months. If other than 12
months, please specify: months.
Administrative Per Employee Per Month E] NO CHANGES F-1 SEE ADDITIONAL PROVISIONS
Charges
All Group
Numbers
Administrative Fee $70.89 $ $ $
Dental $ $ $ $
Limited Fiduciary Services $ $ $ $
Advanced Payment Review $ $ $ $
Health Advocacy Solutions $ $ $ $
Wellbeing Management $ $ $ $
Management of the Virtual Visits Program $ $ $ $
*Medical Drug Rebate Credit $-2.50 $ $ $
*Rebate Credit for the Prescription Drug Program $-86.97 $ $ $
Pharmaceutical Care Management(Retrospective)
(No cost if both HAS and Prescription Drug $ $ $ $
Program are elected)
Commissions: $ $ $ $
Commissions: $ $ $ $
Commissions: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Miscellaneous: $ $ $ $
Miscellaneous: $ I $ $ $
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 7
Total $-18.58 1 $ $ $
"The Rebate Credit is a per Covered Employee per month credit applied to the monthly billing statement. The Employer
and Claim Administrator have agreed to the Rebate Credit and Employer agrees that it and its group health plan have no
right to, or legal interest in, any portion of the rebates, either under the pharmacy benefit or the medical benefit, actually
provided by the Pharmacy Benefit Manager("PBM") or a pharmaceutical manufacturer to Claim Administrator and consents
to Claim Administrator's retention of all such rebates. The Rebate Credit will be provided from Claim Administrator's own
assets and may or may not equal the entire amount of rebates actually provided to Claim Administrator or expected to be
provided. Rebate Credits shall not continue after termination of the Prescription Drug Program. Employer agrees that any
Rebate Credit provision in the governing Administrative Services Agreement to the contrary is hereby superseded.
Administrative Line Item Charges
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Miscellaneous: Select Billing Frequency $
If applicable, describe other:
Miscellaneous: Select Billing Frequency $
If applicable, describe other:
Total:
Claim Administrator Provider Access Fee(s) NO CHANGES Ej SEE ADDITIONAL PROVISIONS
Group Number(s): P19545 (Non- Union) P19546 (H S A), P56642 (Police), P56643 (Fire)
® % of ADP Savings. 2.33%
❑ $ per Covered Employee per month: $
❑ Group with multiple Provider Access Fees by services (e.g., CMM, and/or PPO plans):
Group Number(s):
❑ % of ADP Savings: %
❑ $ per Covered Employee per month: $
BlueCard Program/Network access fees: Available upon request.
• Program Z NO CHANGES ■ SEE ADDITIONAL PROVISIONS
External Review Coordination: ❑ Yes ® No
/f yes, coordination fee: $700 for each external review requested by a Covered Person that the Claim Administrator
coordinates for the Employer in relation to the Employer's Plan.
Employer elects the following process:
❑ State of Illinois External Review Process ® Federal Affordable Care Act Process
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator, Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 8
Advanced Payment Review(APR): ® Yes ❑ No
APR is a suite of payment integrity offerings. Refer to the ABS. If Employer elects APR, indicate APR Savings Program
or PEPM below:
® APR Savings Program
❑ PEPM
For APR capabilities other than Reimbursement Services: If Employer elects APR Savings Program, Claim
Administrator will invoice the percentage indicated in the Fee Schedule of any recovered amounts identified by Claim
Administrator or third-party vendor other than recovery amounts received as a result of or associated with any Workers'
Compensation Law.
Reimbursement Services: ❑ Yes ❑ No If yes, Claim Administrator will retain twenty-five percent(25%) of any
recovered amounts made on third-party liability claims other than recovery amounts received as a result of or
associated with any Workers' Compensation Law.
Third-Party Law Firms Provisions (other than Reimbursement Services): ❑ Yes ❑ No Employer will pay no
more than 35% of any recovered amount made by Claim Administrator's third-party law firm or up to 35% of any
recovered amount will be deducted from the amount distributed according to established allocation processes.
Alternative Compensation Arrangements: Employer acknowledges and agrees that Claim Administrator has
Alternative Compensation Arrangements with contracted Providers, including but not limited to Accountable Care
Organizations and other Value Based Programs. Further information concerning Employer's payment for covered
services under such Arrangements is described in the Administrative Services Agreement between the Claim
Administrator and the Employer.
Virtual Visits Program: ❑ Yes ® No
/f yes, Covered Persons would be able to obtain certain Covered Services remotely via interactive video and/or
interactive audio/video (where available) capability from Virtual Visits powered by MDLIVE.
MDLIVE®is a separate company that operates and administers Virtual Visits for persons with coverage through Blue Cross and Blue Shield of Illinois.MDLIVE is solely responsible for its
operations and for those of its contracted providers.MDLIVE®and the MDLIVE logo are registered trademarks of MDLIVE,Inc.,and may not be used without permission.
Termination Administrative Charge
As applies to the Run-Off Period indicated in the Payment Specifications section above:
i. For service charges(including, but not limited to, access fees)billed on a per Covered Employee basis at the
time of termination of the Administrative Services Agreement or partial termination of Covered Employees,
the Termination Administrative Charge will be the amount equal to ten percent(10%)of the annualized charges based
on the service charges in effect as of the termination date or date of partial termination and the Plan participation of
the two (2) months immediately preceding the termination date or date of partial termination. Such aggregate amount
will be due the Claim Administrator within ten (10)days of the Claim Administrator's notification to the Employer of the
Termination Administrative Charge described herein.
ii. For service charges (including, but not limited to, access fees) billed on a basis other than per Covered
Employee at the time of termination of the Administrative Services Agreement or partial termination of
Covered Employees, the Termination Administrative Charge will be such service charges in effect at the time of
termination of the Agreement or partial termination of Covered Employees to be applied and billed by the Claim
Administrator, and paid by the Employer, in the same manner as prior to termination of the Agreement or partial
termination of Covered Employees.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 9
Other • CHANGES F-1 SEE ADDITIONAL PROVISIONS
1. Summary of Benefits &Coverage:
a. Will Claim Administrator create Summary of Benefits and Coverage (SBC)?
® Yes. Please answer question b. The SBC Addendum is attached.
❑ No. If No, then skip question b and refer to the Administrative Services Agreement for further information.
b. Will Claim Administrator distribute the (SBC)to Covered Persons?
® No. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and provide SBC to Employer in electronic format. Employer will then distribute SBC to Covered
Persons (or hire a third party to distribute) as required by law.
❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and provide SBC to Employer in electronic format. Employer will then distribute to Covered
Persons as required by law.
❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and distribute SBC to plan participants and beneficiaries via regular hardcopy mail or
electronically. Distribution Fee for hardcopy mail is $1.50 per package.
2. Massachusetts Health Care Reform Act:
Does the Employer direct Claim Administrator to provide written statements of creditable coverage to its Covered
Employees who reside, or have enrolled dependents who reside, in Massachusetts and file electronic reports to the
Massachusetts Department of Revenue in a manner consistent with the requirements under the Massachusetts Health
Care Reform Act? ® Yes ❑ No
If no:The Employer acknowledges it will provide written statements and electronic reporting to the Massachusetts
Department of Revenue if required by the Massachusetts Health Care Reform Act.
3. Alternative Care Management Program (applicable to the purchased medical management program):
® Yes ❑ No
The undersigned representative authorizes provision of alternative benefits for services rendered to Covered Persons
for Utilization Management, Case Management, including but not limited to Behavioral Health, and other health care
management programs.
4. Prior Authorization (applicable to the purchased medical management program): Employer acknowledges and
agrees to utilize Claim Administrator's standard list of services and supplies for which Prior Authorization (also called
pre-notification or preauthorization) is required.
5. Essential Health Benefits ("EHB") Election:
Employer elects EHBs based on the following:
1. ® EHBs based on a Claim Administrator state benchmark:
® Illinois ❑ Montana ❑ New Mexico ❑ Oklahoma ❑ Texas
2. ❑ EHBs based on benchmark of a state other than IL, MT, NM, OK and TX
If so, indicate the state's benchmark that Employer elects:
3. ❑ Other EHB, as determined by Employer
In the absence of an affirmative selection by Employer of its EHBs, then Employer is deemed to have elected the EHBs
based on the Illinois benchmark plan.
6. This ASO BPA is binding on both parties and is incorporated into and made a part of the Administrative Services
Agreement between the parties with both such documents to be referred to collectively as the "Agreement" unless
specified otherwise.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 10
7. Producer/Consultant Compensation:
The Employer acknowledges that if its POR acts on its behalf for purposes of purchasing services in connection with
the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is attached, the Claim
Administrator may pay the Employer's POR a commission and/or other compensation in connection with such
services under the Agreement. If the Employer desires additional information regarding commissions and/or other
compensation paid to the POR by the Claim Administrator in connection with services under the Administrative
Services Agreement, the Employer should contact its POR.
Additional Provisions: This is for a 6 month renewal through 12-31-2022
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 11
Benefit Program Application Addendum
Federal Regulatory Requirements
Starting with plan years on or after January 1, 2022, Blue Cross and Blue Shield of Illinois, a Division of Health Care Service
Corporation, a Mutual Legal Reserve Company("Claim Administrator")will offer new services and processes for ASO group
customers that are the result of new requirements imposed on group benefit plans by new federal laws and regulations,
specifically certain requirements of the Consolidated Appropriations Act of 2020 ("CAA"), including the No Surprises Act
("NSA"). As a result, the following terms apply for plan years beginning on or after January 1, 2022.
Any capitalized terms not defined here shall have the meaning stated in the Administrative Services Agreement between
Claim Administrator and Employer(the "ASA").
Transparency Requirements under the Consolidated Appropriations Act
Services that Claim Administrator will provide to Employer related to certain Transparency Requirements under the CAA
are:
Contracted Provider Data Verification
Claim Administrator will maintain a central database of Contracted Providers' demographic information, which shall include
name, address, phone number, specialty and web address ("Data Elements").
Claim Administrator will implement commercially reasonable procedures to track data updates for Contracted Providers or
confirm Provider data accuracy related to the Data Elements.
Claim Administrator will initiate an outreach to Contracted Providers to verify the accuracy of the Data Elements up to ninety
(90) days following the last recorded update or verification.
Claim Administrator will implement commercially reasonable procedures to track the receipt of updated data from a
Contracted Provider and update the central database within appropriate timeframes.
Directory of Verified Contracted Providers
Claim Administrator will provide an online Provider directory representing the Contracted Providers who render services
which may be billed to plans and policies administered by Claim Administrator. This directory shall include Providers
contracted with Claim Administrator as well as Providers contracted with any Blue Cross and Blue Shield Plan as well as
Claim Administrator and another entity performing services on behalf of Claim Administrator. The directory shall not reflect
services administered by external claims administrators or other Providers not directly contracted through Claim
Administrator.
Providers who fail to confirm the accuracy of the Data Elements may be subject to removal from the Provider directory until
they confirm the accuracy of their information.
To the extent information for the Provider directory is provided by a third-party, Claim Administrator shall not be responsible
for delays in updates to Provider data directories, or misinformation due to such delays in receiving information from third
parties.
Provider Network Status Verification
Covered Persons in plans or policies administered by Claim Administrator may seek clarification of a Provider's Network
status through Claim Administrator. Notwithstanding any terms in the ASA, Employer authorizes Claim Administrator to
communicate with Covered Persons as reasonably necessary to provide information to or responses in connection with this
section. When this clarification is sought via phone, Claim Administrator will use commercially reasonable efforts to provide
an electronic confirmation of the Provider's Network status in writing within 24 hours of the call. This verification shall be
based on the information available to Claim Administrator at the time of the request and does not represent future guarantee
of Network status.
Employer acknowledges that Claim Administrator will not issue a written confirmation of Provider Network status when
request is sought through a third-party service center.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 12
ID Cards
Claim Administrator will include up to four(4) tiers of deductible limits and out-of-pocket maximum limits for major medical
coverage on the member ID card. The limits will reflect both family and individual limits when applicable to policy, together
with in-and out-of-network limits.
For policies that include prescription drug coverage through Prime with an independent out-of-pocket or
Copayment/Deductible, up to two (2)tiers of coverage limits will be included on the ID card.
Claim Administrator will include a phone number and a website URL for consumer assistance information on ID cards issued
by Claim Administrator.
For plans that have access to a digital ID card through Blue Access for Members'" and Claim Administrator's mobile
application, the digital ID card image will be updated to reflect the necessary change for plans by plan year renewal 2022.
Claim Administrator will issue physical ID cards in accordance with its standard processes and will not re-issue physical ID
cards unless requested by Employer, in which case additional charges may apply.All newly issued physical ID cards starting
in 2022 will contain the information reflected in this section.
Surprise Billing Requirements of the No Surprises Act
Qualifying Payment Amount
As it pertains to Employer's self-funded plans, Employer acknowledges that NSA requires, among other things,that member
cost-share for certain items and services the Plan covers are calculated based on the lesser of the Provider's billed charge
or the NSA's "Qualifying Payment Amount" ("QPA"). With respect to the calculation of QPA, Employer elects to use and
adopts the QPA calculated by Claim Administrator based on Claim Administrator's self-funded business and not a QPA
customized for Employer's Plan(s).
Negotiation and Independent Dispute Resolution Process
Employer acknowledges that Claim Administrator will make on the Plan's behalf an initial payment amount on Claims
consistent with Employer's direction as established by Employer's Plan and the ASA. For non-participating Claims subject
to the NSA, a Provider may seek additional payment through a dispute process the NSA and related regulations establish.
This process may include informal negotiations with the Provider and an independent dispute resolution ("IDR") process as
described in the NSA.
Employer authorizes Claim Administrator, or for Claims for service rendered outside of Claim Administrator's service area
another Blue Cross and Blue Shield licensee, to represent the Plan with respect to any Claim with services for which a
Provider seeks to negotiate as provided by the NSA, or for which a Provider institutes IDR.
With respect to any negotiations where Claim Administrator represents the Plan to resolve any disputed Claim, Employer
expressly authorizes Claim Administrator in such negotiations to resolve any disputed Claim for an amount which Claim
Administrator determines is reasonable under the circumstances but in no event will a disputed claim be resolved for more
than QPA plus ten percent (10%)of the QPA, without approval of Employer.
Claim Administrator will maintain a summary description of its currently applicable approach to negotiation of services or
Claims subject to the dispute resolution process of the NSA. The approach will be generally the same or similar for Claims
under Employer's Plan as for similarly-situated Claims under Claim Administrator's fully insured health insurance policies.
The negotiation approach is subject to change from time to time by Claim Administrator. Information about the approach
then in effect will be made available to Employer upon reasonable request. Employer acknowledges and agrees that Claim
Administrator shall follow its then-current negotiation approach, such negotiations may not be successful, and may result in
institution of IDR without exhaustion of the full settlement authority Employer granted to Claim Administrator, which in turn
will result in additional administrative fees, as well as IDR entity fees in the event of settlement after institution of an IDR or
an IDR loss. Notwithstanding the additional administrative fee and other possible expenses, Employer expressly authorizes
Claim Administrator not to exhaust its settlement authority(up to QPA plus ten percent(10%) of the QPA) if Provider's last
offer is outside the parameters of the then-effective negotiation approach. Employer acknowledges that settling these Claims
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 13
within the settlement authority range stated here and the scope of Claim Administrator's then current negotiation approach
is in the Plan's interest.
Negotiation services Claim Administrator provides shall include communicating with Provider, supplying requested
documentation as appropriate, and proposing and documenting resolution of disputed claims. Services in connection with
an IDR shall also include handling interactions with the IDR entity and Provider, supplying requested information in
connection with the IDR, and analyzing circumstances of disputed Claims to determine position on disputed Claims. On a
quarterly basis, Claim Administrator shall provide Employer with information regarding the status of negotiations and IDR
decisions.
Employer acknowledges that Claim Administrator undertakes negotiations at the direction of the Employer, undertakes such
negotiations because they are necessary to the operation of the Plan, that the compensation to be paid to Claim
Administrator for such negotiations is reasonable, and that Claim Administrator does not act as a fiduciary in accordance
with state law, or, to the extent applicable under the Employee Retirement Income Security Act of 1974 ("ERISA") in
connection with any disputed Claim. Employer is solely responsible for any amounts determined to be payable as a result
of such negotiations or awards entered through IDR on NSA-eligible items and services. Employer agrees that Claim
Administrator shall have no responsibility for or with respect to any award entered in IDR and any subsequent payment
made thereon and/or any judgment entered thereon.
In connection with Claims, items, and services that are subject to the NSA and disputed by a Provider, Employer agrees to
pay Claim Administrator the following fees:
• Fifty dollars ($50)for each Claim that is the subject of informal negotiation with a Provider(this fee will be charged
in the event the Provider, in its sole discretion, determines that it will not accept the initial payment amount); and
• An additional seventy-five dollars ($75)for each Claim where Claim Administrator represents Plan in an IDR (this
fee will be charged in the event the Provider, in its sole discretion, determines that it will initiate IDR after the informal
negotiation period); and
• All costs imposed by the IDR entity or any state, federal or local government entity in connection with an IDR.
Employer acknowledges that the fees paid for informal negotiation and IDR are reasonable and are the result of the Provider
not agreeing to the payments offered under the Plan and ASA and that the Employer consents to these fees. Claim
Administrator shall bill such amounts to Employer on Employer's invoice.
Employer acknowledges that other terms, conditions, or fees may apply with respect to any negotiations or IDR processes
performed by another Blue Cross and Blue Shield licensee.
This Addendum is incorporated into and made part of the Additional Provisions Section of the most-current ASO Benefit
Program Application (BPA) and will be effective notwithstanding anything in the Administrative Services Agreement or the
BPA to the contrary.All terms of the BPA, as amended from time-to-time,shall remain in force and effect except as otherwise
described in this Addendum.
The laws and regulations that are the subject of this Addendum are subject to additional rulemaking and interpretation. The
terms and conditions stated in this Addendum, including any associated costs/fees, may change as additional requirements
and regulatory guidance are released or as additional information becomes known. In the event of a change because
additional requirements and regulatory guidance are released or as additional information becomes known, Claim
Administrator shall provide notice to Employer and such change shall be effective sixty(60) days after such notice.
The undersigned is authorized and responsible for purchasing administrative services on Employer's behalf and has
provided the information specified in this Addendum.
Employer acknowledges that Employer, and not Claim Administrator, shall be responsible for making the necessary
adjustments to its Plan Document(s) and Summary Plan Description(s)to be consistent with Employer's election, including
any amendments to governing Plan documents.
Employer agrees to the terms set forth in this Addendum and which shall be effective for all plan years beginning on or after
January 1, 2022
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 14
Signature
Ruben Mendez
Sales Representative Signae of Authorized Purchaser
822 630-824-5197 f
District Phone & FAX Numbers Print Narqj
Brian Walsh \�i
Producer Representative Tittle
VistaNational Insurance a
Producer Firm Date
1301 West 22nd Street Suite 600
Oak Brook, IL 6052q
Producer Address
Producer Phone & FAX Numbers
Producer Email Address
36-4095485
Tax I.D. No.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 15
PROXY
The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve
Company, or any successor thereof("HCSC"), with full power of substitution, and such persons as the Board of Directors
may designate by resolution, as the undersigned's proxy to act on behalf of the undersigned at all meetings of members of
HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote
on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The
annual meeting of members is scheduled to be held each year in the HCSC corporate headquarters on the last Tuesday of
October at 12:30 p.m. Special meetings of members may be called pursuant to notice provided to the member not less than
thirty (30) nor more than sixty (60) days prior to such meetings. This proxy shall remain in effect until either revoked in
writing by the undersigned at least twenty(20) days prior to any meeting of members or by attending and voting in person
at any annual or special meeting of members.
From time to time, HCSC pays indemnification or advances expenses to its directors, officers, employees or agents
consistent with HCSC's bylaws then in force and as otherwise required by applicable law.
P19545 By:
(Non- Union)
Group No.: P19546 (H S
A), P56642
(Police),
P56643 (Fire) S
Print Signed Name Here
Sign e"and Title
Group Name: Village of Oak Brook
Address: 1200 Oak Brook Road
City: Oak Brook State: IL ZIP: 60523
Dated this �e day of
Month Year
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
IL GEN Non-ERISA ASO BPA(Rev. 10/21) 16
BlueCross B1ueSWeld The HMOs of Blue Cross and Blue Shield
0" 9of Illinois of Illinois, a Division of Health Care Service
Corporation, a Mutual Legal Reserve
Company ("BCBSIL")
Benefit Program Application ("BPA")
(All items are applicable to 151-Plus Grandfathered and Non-Grandfathered Insured Group Accounts unless otherwise
specified.)
Employer Account Number: 019545
HMO Illinois Employer Group Number(s):
HMO Illinois Section Number(s):
Blue Advantage HMO" Employer Group Number(s): B19545
0101 (Village/Non- Union), 0200{Park District) 0300
Blue Advantage HMO Section Number(s): (Reirees)0400 (Reirees 65+) 0500(PSEBA) 0501
(PSEBA)0600(Police Union) 8888(COBRA)
Employer's Legal Name: Village of Oak Brook
(Specify the Employer, the employee trust, or the association applying for coverage. Names of subsidiary or affiliated
companies to be covered must also be included below. An employee benefit plan may not be named.)
Physical Address: 1200 Oak Brook Road
City: Oak Brook State: IL Zip Code: 60523
Billing Address (if different from above):
City: State: Zip Code:
Employer Identification Number("EIN"): 36-6009534 Standard Industry Code (SIC): 8990
Wholly Owned Subsidiaries to be Covered (if additional space is needed, use the Additional Provisions section):
Affiliated Companies to be Covered (if additional space is needed, use the Additional Provisions section):
(Affiliated Companies must be required or permitted to be aggregated per IRS guidelines. Employer hereby confirms that
Employer, Subsidiaries and Affiliates are treated as a single employer under Internal Revenue Code Section 414(b), or
(c), or(m), or(o), or under applicable law.)
Administrative Contact: Kathy Vonachen Email: kvonachen(a_oak-brook.org
Phone: 630-368-5024 Fax: 630-368-5025
Blue Access for Employerss"' ("BAE""') Contact:
(The BAE Contact is the employee of the account authorized by the Employer to access and maintain its account via BAE.)
Title: HR Director/ Deputy Village Clerk Email: kvonachen(@oak-brook.orq
Phone: 630-368-5024 Fax: 630-368-5025
Policy Effective Date: 07/01/2022 Policy Anniversary Date (month/day/year): 12/31/2022
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for
employee benefit plans in the private industry. In general, all employer groups, insured or ASO, are subject to ERISA
provisions except for governmental entities, such as municipalities and public school districts, and "church plans" as
defined by the Internal Revenue Code.
ERISA Regulated Group Health Plan*: ❑ Yes ® No
If Yes, specify ERISA Plan Year* (month/day/year): Beginning Date: _/_/_ End Date:
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois.a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151PLUS-H-BPA Rev.06/21 1
ERISA Plan Sponsor*:
ERISA Plan Administrator*:
ERISA Plan Administrator's Address:
City: State: Zip Code:
ERISA Plan Administrator's Email:
Please provide your Non-ERISA Plan Month/Year:
If you contend ERISA is inapplicable to your group health plan, please give legal reason for exemption*:
❑ Federal Governmental Plan (e.g., the government of the United States or agency of the United States)
❑ Non-Federal Governmental Plan (e.g., the government of the State, an agency of the state, or the government of a
political subdivision, such as a county or agency of the State)
❑ Church Plan (complete and attach a Medical Loss Ratio Assurance form)
❑ Other, please specify:
For more information regarding ERISA, contact your Legal Advisor.
*All as defined by ERISA and/or other applicable law/regulations.
ELIGIBILITY
1. Eligible Person: Employer has decided that Eligible Person means a person who resides in the Service Area of a
Participating IPA and is:
❑ A Full-Time Employee of the Employer.
❑ A Full-Time Employee who is a member of(name of union or association):
® Other(please specify): A Full-time non-union or union emplovee of the emolover
Full-Time Employee means:
❑ An Employee of the Employer who is regularly scheduled to work a minimum of hours per week.
❑ Other(please specify):
The term "Employee"shall have the meaning set forth under ERISA and applicable law. BCBSIL reserves the right
to audit Employer's initial and ongoing eligibility determinations.
2. Civil Union Partner Coverage: A Civil Union partner, as defined in the Policy, and his or her dependents are
automatically eligible to enroll for coverage and, once enrolled, eligible for continuation of coverage as described in
the Certificate Booklet. The Employer as Policyholder is responsible for providing notice of possible tax implications
to those Insureds with coverage for Civil Union partners.
3. Domestic Partner Coverage: ❑ Yes ® No
If Employer elects Yes, a Domestic Partner, as defined in the Certificate Booklet, shall be considered eligible for
coverage. The Employer is responsible for providing notice of possible tax implications to those Insureds with
Domestic Partner Coverage.
Continuation coverage for Domestic Partners: If Employer elects coverage for Domestic Partners, Domestic
Partners are not eligible for continuation coverage under Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) as a spouse, but Employer may elect to offer continuation coverage to Domestic Partners similar to that
available to spouses under COBRA continuation. Employer shall determine eligibility for COBRA continuation for
Domestic Partners, if any. Please indicate your election below:
❑ Yes, Employer elects to offer continuation coverage to Domestic Partners, as defined in the Certificate
Booklet
® No, Employer does not elect to offer continuation coverage to Domestic Partners (Domestic Partners are not
eligible for continuation coverage)
❑ Other:
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation.a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151 PLUS-H-BPA Rev.06/21 2
4. The Limiting Age for covered children: Hereafter, Covered Children means a natural child, a stepchild, an eligible
foster child, an adopted child (including a child involved in a suit for adoption,) a child for whom the Insured is the
legal guardian, under twenty-six (26) years of age, regardless of presence or absence of a child's financial
dependency, residency, student status, employment status (if applicable under the Policy), marital status, or any
combination of those factors. Unless the Employer elects a Limiting Age over twenty-six (26), coverage will
terminate at the end of the month in which the covered child turns age twenty-six(26). If the covered child is eligible
military personnel, the Limiting Age is thirty(30) years as described in the Certificate Booklet.
To cover children age twenty-six (26)or over, you may select option (a) or(b) below:
(a) ❑ Limiting Age for covered children age twenty-six(26)or over, ❑who are married ❑who are unmarried
❑ regardless of marital status, is select one years. If the covered child is eligible military personnel,
the Limiting Age is thirty(30)years as described in the Certificate Booklet.
(b) ❑ Limiting Age for covered children who are full-time students and age twenty-six (26) or over, ❑ who
are married ❑ who unmarried ❑ regardless of marital status, is select one. If the covered child is
eligible military personnel, the Limiting Age is thirty(30)years as described in the Certificate Booklet.
For a covered child who reaches a Limiting Age over twenty-six(26), coverage will terminate:
❑ At the end of the period for which premium has been accepted.
❑ At the end of the month in which the Limiting Age is reached.
❑ At the end of the calendar year in which the Limiting Age is reached.
❑ On the Limiting Age Birthday.
❑ Other(please specify):
However, coverage shall be extended due to a leave of absence in accordance with any applicable federal or state
law.
5. Disabled Dependent: Disabled Dependent means a child who is medically certified as disabled and dependent
upon the Employee or his/her spouse(or Civil Union partner and/or Domestic Partner if Domestic Partner coverage
is elected). To administer medical certification of disabled dependents, you may select option (a) standard rules or
(b)custom rules. If(b)is selected there are additional selections regarding age, proof of prior coverage, certification
review, forms, and previous medical certification approvals.
(a) ® Disabled Dependent Administration will follow standard rules.
A disabled dependent may continue coverage beyond the limiting age, provided the disability began
before the child attained the age of twenty-six (26). A disabled dependent may add coverage beyond
the limiting age, provided the disability began before the child attained the age of twenty-six (26), and
proof of coverage as a disabled dependent is provided.
Certification Review is administered by BCBSIL; a Disabled Dependent Certification Form must be
submitted to BCBSIL.
(b) ❑ Disabled Dependent Administration will follow custom rules. Please make the following selections:
Age: Please select one(1) option regarding age of when the disability began.
❑ The disability must have begun before the child attained the age of twenty-six (26).
❑ All disabled dependents are covered regardless of when the disability began.
Proof of Prior Coverage: Please select required or not required below:
When adding coverage, proof of prior coverage as a disabled dependent is ❑ required ❑ not required.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151PLUS-H-BPA Rev.06/21 3
Certification Review: Please select one (1) option regarding administration of Certification Review.
❑ Certification Review is administered by BCBSIL; a Disabled Dependent Certification Form must
be submitted to BCBSIL.
❑ Certification Review is administered by the Employer; there are no Disabled Dependent
Certification Form requirements.
If Certification Review is administered by BCBSIL, please select one (1)option regarding forms:
❑ BCBSIL's Disabled Dependent Certification Form will be utilized.
❑ A custom/other Disabled Dependent Certification Form will be utilized.
If Certification Review is administered by BCBSIL, please select allowed or not allowed below:
An approved disabled Dependent medical certification from a prior carrier is ❑ allowed ❑ not allowed.
An approved disabled Dependent medical certification from a prior BCBS policy is ❑ allowed ❑ not
allowed.
6. Eligibility Date: All current and new Employees must satisfy the substantive eligibility criteria and required waiting
period indicated below before coverage will become effective. No waiting period may result in an effective date that
exceeds ninety-one (91) calendar days from the date that an employee becomes eligible for coverage, unless
otherwise permitted by applicable law.
If a person is added to the Policy and it is later determined that the Employer reported a Coverage Date earlier than
what would apply to the Employee or dependent, based on the waiting period and eligibility conditions the Employer
provided to BCBSIL, BCBSIL reserves the right to retroactively adjust the Coverage Date for such person.
❑ The date of employment.
® The 31 st day of employment. Note: This may not exceed ninety-one (91) calendar days.
❑ The select one day of the month following select one month(s)of employment.
❑ The select one day of the month following days (option of up to sixty(60) days) of employment.
❑ The day of the month following the date of employment.
❑ Other(please specify): Note: This may not exceed ninety-one (91) calendar days.
A full month's premium will be charged for the first month of coverage for those Employees whose Coverage Dates
fall between the first (1St) and fifteenth (15th) day of the Premium Period. No premium will be charged for the first
month of coverage for those Employees whose Coverage Dates fall between the sixteenth (16th) day and the end
of the Premium Period.
Substantive eligibility criteria.
Provide a representation below regarding the terms of any eligibility conditions (other than any applicable waiting
period already reflected above) imposed before an individual is eligible to become covered under the terms of the
plan. If any of these eligibility conditions change, Employer is required to submit a new BPA to reflect that new
information.
Check all that apply:
❑ An Orientation Period that:
1) Does not exceed one (1) month (calculated by adding one (1) calendar month and subtracting one
(1)calendar day from an Employee's start date); and
2) If used in conjunction with a waiting period, the waiting period begins on the first day after the
orientation period.
❑ A Cumulative hours of service requirement that does not exceed 1200 hours
® An hours-of-service per period (or full-time status) requirement for which a measurement period is used to
determine the status of variable-hour employees, where the measurement period:
1) Starts between the Employee's date of hire and the first(1St)day of the following month;
2) Does not exceed twelve (12) months; and
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois. Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151PLUS-H-BPA Rev.06/21 4
3) Taken together with other eligibility conditions does not result in coverage becoming effective later
than thirteen (13) months from the Employee's start date plus the number of days between a start
date and the first(1 st)day of the next calendar month(if start day is not the first(1 st)day of the month).
❑ Other substantive eligibility criteria not described above; please describe:
7. Enrollment
Special Enrollment: An Eligible Person may apply for coverage, Family Coverage or add dependents within thirty-
one (31) days of a Special Enrollment event if he/she did not apply prior to his/her Eligibility Date or when eligible
to do so. Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be the
effective date of the Special Enrollment event or, in the event of Special Enrollment due to termination of previous
coverage, the date of application for coverage. In the case of a Special Enrollment event due to loss of coverage
under Medicaid or a state children's health insurance program, however, this enrollment opportunity is not available
unless the Eligible Person requests enrollment within sixty(60) days after such coverage ends.
Open Enrollment: Specify Open Enrollment Period:The month of June for a July 1st effective date. An Eligible
Person may apply for coverage, Family Coverage or add dependents if he/she did not apply prior to his/her Eligibility
Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. Such person's
Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by
BCBSIL and the Employer. Such date shall be subsequent to the open enrollment period.
8. Extension of Benefits due to Temporary Layoff, Disability or Leave of Absence:
Temporary Layoff: 0 days; Disability: Police and Fire by IL Statue: Other 90 Days days;Leave of Absence: 0
days
❑ Other(please specify):
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable
federal or state law.
9. Funding Arrangement: ® Premium Prospective ❑ Cost Plus
10. STANDARD PREMIUM INFORMATION:
The following elections apply to both Grandfathered and Non-Grandfathered Groups:
Premium Period:
❑ The first(1 st)day of each calendar month through the last day of each calendar month. (This option applies
to all coverages if the Employer has BlueCare Dental HMOs ' Coverage.)
❑ The day of each calendar month through the day of the next calendar month. (This option is
not available for any coverage if the Employer has BlueCare Dental HMO Coverage.)
11. MINIMUM EMPLOYER CONTRIBUTION INFORMATION:
(a) The following elections apply to Grandfathered and Non-Grandfathered Groups:
Employer Contribution:
❑ One hundred percent (100°/x) of the Individual Coverage Premium and an amount equal to one
hundred percent (100%) of the Individual Coverage Premium will be contributed toward the Family
Coverage Premium.
❑ % of the Individual Coverage Premium, and % of the Family Coverage Premium.
❑ Other(please specify):
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151PLUS-H-BPA Rev.06/21 5
(b) The following applies to Grandfathered and Non-Grandfathered Groups: BCBSIL reserves the right to
change premium rates when a substantial change occurs in the number or composition of Subscribers
covered. A substantial change will be deemed to have occurred when the number of Subscribers covered
changes by ten percent (10%) or more over a thirty (30) day period or twenty-five percent (25%) or more
over a ninety(90)day period.
(c) The following applies to Non-Grandfathered Groups: BCBSIL reserves the right to take any or all of the
following actions:
1) Initial rates will be finalized for the effective date of the policy based on the Employer contribution
levels;
2) After the policy effective date, the group will be required to maintain a minimum Employer
contribution of twenty-five percent (25%). In the event the group is unable to maintain the
contribution requirements, then the rates will be adjusted accordingly; and/or
3) Non-renew or discontinue coverage unless the twenty-five percent (25%) minimum Employer
contribution is met. Employer will promptly notify BCBSIL of any change in Employer contribution.
(d) The following applies to Grandfathered Groups: It is understood that no Policy will be issued or renewed
on a contributory basis unless at least twenty-five percent (25%) of the Eligible Persons, and for Family
Coverage seventy-five percent (75)% of the Eligible Persons with Eligible dependents, have enrolled for
coverage.
12. Essential Health Benefits ("EHB") Definition Election: Employer elects EHBs based on the Illinois benchmark.
13. Effective Date of Termination for a person who ceases to meet the definition of an Eligible Person:
® The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
❑ Other(please specify):
CURRENT ELIGIBILITY INFORMATION
Total Number of Employees (Please indicate the total number of actual Employees, not Enrollees):
1. On payroll
2. On COBRA continuation coverage
3. With retiree coverage (if applicable)
4. Who work part-time
5. Serving the new hire waiting period
6. Declining because of other group coverage (e.g., other commercial group coverage, Medicare, Medicaid,
TRICARE/Champus)
7. Declining coverage (not covered elsewhere)
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois. Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151 PLUS-H-BPA Rev.06/21 6
Premium Rates
®Yes ❑ No
Health Coverage
1. Employee only HMO Illinois $594.97 Blue Advantage HMO $
2. Employee plus one(1)dependent(i.e. HMO Illinois $1163.22 Blue Advantage HMO $
Employee plus one (1)spouse or one (1)child)
3. Employee plus two (2)or more dependents HMO Illinois $1760.63 Blue Advantage HMO $
4. Employee plus Spouse HMO Illinois $ Blue Advantage HMO $
5. Employee plus Child(ren) (i.e. Employee HMO Illinois $ Blue Advantage HMO $
plus one (1) or more children)
6. Family HMO Illinois $ Blue Advantage HMO $
Single Tier rate structure—complete item 1.
Two Tier rate structure—complete items 1. and 6.
Three Tier rate structure—complete items 1., 2., and 3.
Four Tier rate structure—complete items 1., 4., 5., and 6.
Indicate "N/A" in any rate field that does not apply
Medicare Eligible Rates(When BCBSIL is Secondary Payer)
Single Coverage HMO Illinois $594.97 Blue Advantage HMO $
Family Coverage HMO Illinois $1189.94 Blue Advantage HMO $
COST PLUS PROGRAM
❑Yes ❑ No
Service Charges:
a. Service Charges for Claim Payments:
❑ HMO Illinois: % of Claim Payments; $ per Enrollee per month for health Claim Payments.
❑ Blue Advantage HMO: % of Claim Payments; $ per Enrollee per month for health Claim Payments.
b. Physician's Services Fees:
❑ HMO Illinois: $ per month per single Enrollee; $ per month per Enrollee with one (1) or more
dependents.
❑ Blue Advantage HMO: $ per month per single Enrollee; $ per month per Enrollee with one (1) or
more dependents.
c. ❑ HMO Managed Care Fee: $ per HMO Enrollee per month.
Payment Method: ❑Transfer Payment ❑ Post Payment
If Transfer Payment, method of Transfer Payment
❑Wire Transfer ❑ Draft ❑ Electronic Fund Transfer ❑ Other(please specify):
Payment Period:
❑ Daily ❑ Weekly ❑ Bi-Weekly ❑ Monthly ❑ Other(please specify):
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois. Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151 PLUS-H-BPA Rev.06/21 7
Claim Settlement Period:
❑ Monthly ❑ Quarterly ❑ Other(please specify)
If Transfer Payment, Tentative Final Settlement Period:
Transfer Payments to be made for the following time period after termination:
❑ three (3) months ❑ six(6) months ❑ nine (9) months ❑ twelve (12) months
❑ Other(please specify):
Excess Loss—Run Off Period: months (standard is twelve (12) months)
Final Settlement: Final Settlement is to be made within days after end of Excess Loss Run-Off Period (standard
is sixty(60)days).
Employer Payments are to be made past the run-off period for all claims and adjustments.
Prescription Drug Program:
❑ Yes (the Pharmacy Benefit Manager(s) ("PBM") Fee Schedule Exhibit must be attached and is part of this BPA.)
❑ No
Rebate Credit for Drugs covered under the Pharmacy Benefit: $ per covered Employee per month
HMO Pharmacy Network (Select one (1)):
❑ Traditional Select Network
❑ Network shown on PBM Fee Schedule Exhibit
Prescription Drug Program Clinical Management Programs
❑ Medication Therapy Management(MTM) (Retrospective) $ per Enrollee per month.
Termination Administrative Charge
As applies to the Run-Off Period indicated in the Payment Specifications section below:
i. For service charges (including, but not limited to, access fees) billed on a per covered Employee basis at the
time of termination of the Policy or partial termination of covered Employees, the Termination Administrative
Charge will be the amount equal to ten percent (10%)of the annualized charges based on the service charges
in effect as of the termination date or date of partial termination and the Policy participation of the two(2)months
immediately preceding the termination date or date of partial termination. Such aggregate amount will be due
BCBSIL within ten (10)days of BCBSIL's notification to the Employer of the Termination Administrative Charge
described herein.
ii. For service charges (including, but not limited to, access fees) billed on a basis other than per covered
Employee at the time of termination of the Policy or partial termination of covered Employees, the Termination
Administrative Charge will be such service charges in effect at the time of termination of the Policy or partial
termination of covered Employees to be applied and billed by BCBSIL, and paid by the Employer, in the same
manner as prior to termination of the Policy or partial termination of covered Employees.
Termination Administrative Charges assume the continuation of the Policy benefit program(s) and the administrative
services in effect prior to termination. Should such Policy benefit program(s) and/or administrative services change, or
in the event the average Policy enrollment during the three(3) months immediately preceding termination varies by ten
percent (10%) or more from the enrollment used to determine the service charges in effect at the time of termination,
BCBSIL reserves the right to adjust the rates for service charges (including, but not limited to, access fees)to be used
to compute the Termination Administrative Charge.
EMPLOYER STATEMENTS:
1. Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of
coverage.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois. Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
I L-LG-151 PLUS-H-BPA Rev.06/21 8
2. The undersigned representative is authorized and responsible for purchasing insurance on behalf of the Employer,
has provided the information requested in this BPA and on behalf of the Employer offers to purchase the benefit
program as outlined in the proposal document submitted to the Employer by the Sales Representative. It is
understood and agreed that the actual terms and conditions of the benefit program are those contained in the
Policy.
3. This BPA is subject to acceptance by BCBSIL. Upon acceptance, BCBSIL shall issue a Policy to the Employer
and this BPA shall be incorporated and made a part of the Policy. Upon acceptance of this BPA and issuance of
the Policy, the Employer shall be referred to as the Policyholder. In the event of any conflict between the proposal
document and the Policy, the provisions of the Policy shall prevail. No coverage will begin until receipt of the first
premium by BCBSIL.
4. The undersigned representative acknowledges that any producer is acting on behalf of the Employer for purposes
of purchasing the Employer's insurance, and that if BCBSIL accepts this BPA and issues a Policy to the Employer,
BCBSIL may pay the Employer's producer a commission and/or other compensation in connection with the
issuance of such Policy. The undersigned representative further acknowledges that if the Employer desires
additional information regarding any commissions or other compensation paid to the producer by BCBSIL in
connection with the issuance of a Policy, the Employer should contact its producer.
5. The undersigned representative hereby acknowledges that the Employee Retirement Income Security Act of 1974
("ERISA"), as amended, establishes certain requirements for employee welfare benefit plans.As defined in Section
3 of ERISA, the term "employee welfare benefit plan" includes any plan, fund or program which is established or
maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund or
program was established or is maintained for the purpose of providing for its participants or their beneficiaries,
through the purchase of insurance or otherwise, medical, surgical or hospital benefits, or benefits in the event of
sickness, accident or disability.The undersigned representative further acknowledges that: (i)an employee welfare
benefit plan must be established and maintained through a separate plan document which may include the terms
hereof or incorporate the terms hereof by reference, and that (ii)an employee welfare benefit plan document may
provide for the allocation and delegation of responsibilities thereunder. However, notwithstanding anything
contained in the employee welfare benefit plan document of the Employer(or any group member if the group is an
association), the Employer agrees that no allocation or delegation of any fiduciary or non-fiduciary responsibilities
under the employee welfare benefit plan of the Employer(or any group member if the group is an_association) is
effective with respect to or accepted by BCBSIL except to the extent specifically provided and accepted in this
BPA or the Policy or otherwise accepted in writing by BCBSIL.
6. The Rebate Credit(if applicable)is a per Enrollee per month credit applied to the monthly billing statement. Rebate
Credits shall not continue after termination of the Prescription Drug Program, except as otherwise set forth in this
BPA or the PBM Fee Schedule Exhibit. (Further information about rebates, the PBM, and the Rebate Credit is
included in the governing Group Administration Document to which this BPA is attached under the section titled
"The Plan's Separate Financial Arrangements Regarding Prescription Drugs.").
OTHER PROVISIONS:
1. Reimbursement: It is understood and agreed that in the event BCBSIL makes a recovery on a third-party liability
claim, BCBSIL will retain twenty-five percent (25%) of any recovered amounts, other than recovery amounts
received as a result of, or associated with, any Workers' Compensation Law.
2. Third-Party Recovery Vendors and Law Firms Provisions (other than Reimbursement Services): BCBSIL
engages with third-party recovery vendors and law firms on a post-pay basis to identify and/or recover any potential
overpayments that may have been made to Providers.
3. Summary of Benefits and Coverage ("SBC"): The SBC Addendum is attached and made a part of the Policy.
BCBSIL will create the SBC (only for benefits BCBSIL insures under the Policy) and provide the SBC to the
Employer in electronic format. If the Employer approves of the content, Employer will then distribute the SBC to
participants and beneficiaries (or hire a third party to distribute) as required by law. If the Employer would like
changes to the SBC, it will promptly notify BCBSIL. BCBSIL will also distribute the SBC to participants and
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151PLUS-H-BPA Rev.06/21 9
beneficiaries via regular hardcopy mail or electronically in response to occasional requests received directly from
individuals. All other distribution is the responsibility of the Employer.
4. FSA purchased: ❑ Yes ® No (If yes, select vendor) (Vendor: Select Vendor)
5. Excess Loss Coverage purchased: ❑ Yes ® No (If yes, complete separate Application for Excess Loss
Coverage)
6. Blue Directions for Large Business'" purchased: ❑ Yes ® No (If yes, the Blue Directions'"" Addendum is
attached and made a part of the Policy)
7. ❑ Wellbeing Management (WBM)
ADDITIONAL PROVISIONS:
A. Grandfathered Health Plans: Employer shall provide BCBSIL with written notice prior to renewal (and during the
plan year, at least sixty(60) days advance written notice) of any changes in its Contribution Rate Based on Cost
of Coverage or Contribution Rate Based on a Formula towards the cost of any tier of coverage for any class of
Similarly Situated Individuals as such terms are described in the Affordable Care Act and applicable regulations.
Any such changes (or failure to provide timely notice thereof)can result in retroactive and/or prospective changes
by BCBSIL to the terms and conditions of coverage. In no event shall BCBSIL be responsible for any legal, tax or
other ramifications related to any benefit package of any group health insurance coverage(each hereafter a"plan")
qualifying as a "grandfathered health plan" under the Affordable Care Act and applicable regulations or any
representation regarding any plan's past, present and future grandfathered status. The grandfathered health plan
form ("Form"), if any, shall be incorporated by reference and made part of the BPA and Group Policy,and Employer
represents and warrants that such Form is true, complete, and accurate. If Employer fails to timely provide BCBSIL
with any requested grandfathered health plan information, BCBSIL may make retroactive and/or prospective
changes to the terms and conditions of coverage, including changes for compliance with state or federal laws or
regulations or interpretations thereof.
B. Retiree Only Plans and/or Excepted Benefits: If the BPA includes any retiree only plans and/or excepted
benefits, then Employer represents and warrants that one (1) or more such plans is not subject to some or all of
the provisions of Part A (Individual and Group Market Reforms) of Title XXVII of the Public Health Service Act
(and/or related provisions in the Internal Revenue Code and Employee Retirement Income Security Act) (an
"exempt plan status"). Any determination that a plan does not have exempt plan status can result in retroactive
and/or prospective changes by BCBSIL to the terms and conditions of coverage. In no event shall BCBSIL be
responsible for any legal, tax or other ramifications related to any plan's exempt plan status or any representation
regarding any plan's past, present and future exempt plan status.
C. Employer shall indemnify and hold harmless BCBSIL and its directors, officers and employees against any and all
loss, liability, damages, fines, penalties, taxes, expenses (including attorneys' fees and costs) or other costs or
obligations resulting from or arising out of any claims, lawsuits, demands, governmental inquiries or actions,
settlements or judgments brought or asserted against BCBSIL in connection with (a) any plan's grandfathered
health plan status,(b)any plan's exempt plan status, (c)any directions, actions and interpretations of the Employer,
(d) any provision of inaccurate information, (e) the SBC, (f) any plan's design (including but not limited to any
directions, actions and interpretations of the Employer, and/or (g) Employer's selection of EHB definition for the
purpose of the Patient Protection and Affordable Care Act ("ACA"). Changes in state or federal law or regulations
or interpretations thereof may change the terms and conditions of coverage.
The provisions of paragraphs A-C (directly above)shall be in addition to(and do not take the place of)the other terms and
conditions of coverage and/or administrative services between the parties.
Notwithstanding anything in the Policy or Renewal(s) to the contrary, BCBSIL reserves the right to revise our charge for
the cost of coverage (premium or other amounts) at any time if any local, state or federal legislation, regulation, rule or
guidance (or amendment or clarification thereto) is enacted or becomes effective/implemented, which would require
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois. Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151PLUS-H-BPA Rev.06/21 10
BCBSIL to pay, submit or forward, on its own behalf or on the Employer's behalf, any additional tax, surcharge, fee, or
other amount (all of which may be estimated, allocated or pro-rated amounts).
Renewals Only: If this BPA is blank, it is intentional, and this BPA is an addendum to the existing BPA. In such case, all
terms of the existing BPA as amended from time to time shall remain in force and effect. However, beginning with the
Employer's first renewal date on or after September 23, 2010, the provisions of paragraphs A-C (above) shall be part of
(and be in addition to)the terms of the existing BPA as amended from time to time.
Any reference in this BPA to eligible dependents may include Domestic Partners or Civil Union partners but will include
dependent covered children under the Limiting Age of twenty-six(26), or election made above.
Any reference in this BPA to the Limiting Age for covered children means twenty-six (26) years, or election made above,
regardless of presence or absence of a child's financial dependency, residency, student status,employment, marital status,
or any combination of those factors. If the covered child is eligible military personnel, the Limiting Age is thirty (30) years
as described in the certificate booklet.
Any reference in this BPA to the"Employee plus one(1)dependent" rate structure means "Employee plus one(1)spouse
(includes Civil Union partner and/or, if elected, Domestic Partner) or one (1)child."
Any reference in this BPA to the"Employee plus Child(ren)"rate structure means"Employee plus one(1)or more children."
No changes to plan 7/1/2022 These rates are for 6 mos good through 12/31/2/2022.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois. Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151 PLUS-H-BPA Rev.06/21 11
Ruben Mendez
Sales Representative Signaturq4f Authorized Purchaser
822 630- 824- 5197 _ ; Ila
District Phone No. Title
Brian Walsh
Producer Mnt Date
Signature of Producer Representative Wit It
VistaNational Insurance Group
Producer Firm
1301W 22nd Street
Suite 600
Oak Brook,IL 60523
Producer Address $ Amount Submitted(not required for renewals)
630-468-6503
Producer Number
36-4095485
Producer Tax ID No.
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151PLUS-H-BPA Rev.06/21 12
PROXY
The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve
Company, or any successor thereof("HCSC"), with full power of substitution, and such persons as the Board of Directors
may designate by resolution as the undersigned's proxy to act on behalf of the undersigned at all meetings of members of
HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote
on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The
annual meeting of members is scheduled to be held each year in the HCSC corporate headquarters on the last Tuesday of
October at 12:30 p.m. Special meetings of members may be called pursuant to notice provided to the member not less than
thirty (30) nor more than sixty (60) days prior to such meetings. This proxy shall remain in effect until revoked either in
writing by the undersigned at least twenty(20) days prior to any meeting of members or by attending and voting in person
at any annual or special meeting of members.
HCSC pays indemnification or advances expenses to its directors, officers, employees, or agents consistent with HCSC's
bylaws then in force and as otherwise required by applicable law.
Group No(s).: P19545 (Non-Union) P19546 (HSA) By: g�:2 S(�m M&CsP56642 (Police) P56643 (Fire) r's Name Here
Group Name: Village of Oak Brook
Address: 1200 Oak Brook Road Si ature and Title
City: Oak Brook State: IL Zip Code: 60523
Dated this: day of 0115 , _Q J
Month Year
Cut along dotted lines •
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue
Shield of Illinois,Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue
Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the
Blue Cross and Blue Shield Association
IL-LG-151 PLUS-H-BPA Rev.06/21 13
V cwtnaTM
Employer Application
Applicant Policy or Group number -
(for Aetna use only)
Company name: Village-of Oak Brook
Street address: 1200 Oak Brook Rd
City: Oak Brook
State: Illinois- Zip code: 60523
Federal tax ID number: 36 6009534
Parent company name (if applicable):
The purpose of the application is to request: X a. Issuance of new coverage
❑ b. Change in existing coverage
❑ c. Extension of existing coverage to
additional groups of employees
If offering a health plan with a deductible, is the employer, plan sponsor or a third-party funding any
of the deductible?
❑Yes. Please indicate how much: xNo
Medical Coverage Selection
Aetna Life Insurance Company,Aetna Health Inc., and/or Aetna Health Insurance Company provide or
administer medical coverage.
For employees For dependents For retirees Medical coverage
❑ ❑ ❑ Contributory
❑ ❑ ❑ Non-contributory
Are you a religious employer that meets the ❑ Yes
federal guidelines for qualification and would like
to exclude coverage for contraceptive drugs and ❑ No
devices?
If Yes, please complete the appropriate attestation form to confirm your religious exempt status.
Would you like to purchase optional ❑ Yes
coverage/reimbursement for hearing instruments
and related services for an additional premium? ❑ No
A group that has terminated with Aetna in the past 12 months for non-payment of premium must pay any
premiums owed in full before Aetna will approve a group plan application and issue health benefits.
GR-24-1 (10-19) 1 IL Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
Vision coveraee selection
Aetna Life Insurance Company provides or administers vision coverage.
For employees For dependents For retirees Aetna Vision Preferred TM
❑ ❑ ❑ Contributory
❑ ❑ ❑ Non-contributory
Dental coverage selection
Aetna Life Insurance Company provides or administers dental coverage.
For employees For dependents For retirees Dental coverage
X 11 ❑X Contributory
❑ ❑ ❑ Non-contributory
General Enrollment and Eligibility Section
Requested effective date: 7/1/2022 (Aetna will assign the actual effective date if the
application is accepted and a policy issued.)
Applicant will utilize electronic enrollment(check ❑ Yes
one): ❑ NoX
All of the regular, full-time active employees of any employer mentioned above are eligible to
participate in the coverage applied for, except the following:
(State here, by coverage, the class or classes excluded). (Please attach additional sheets as needed.)
Agent or broker certification
Agent or broker name: Brian Walsh NPN:9944184
Agency name:VISTANATIONAL TIN:36 4095485
Pay commissions to (check one):
Agent/Broker ❑ Agency X ❑ %of credit:
Phone number: 630 468 6500 Fax number:
Address:1301 W 22nd Street Suite 600 City: Oak Brook
State:IL Zip: 60523
Signature*: Email:walshb@vistanational.com
Date:
Broker admin assistant name: Cindy Bierovic Broker admin assistant e-mail:
Bierovicc@vistanational.com
*I hereby certify that I am licensed to sell Aetna products in the state of Illinois.
Agent or broker name: NPN:
Agency name: TIN:
Pay commissions to(check one):
Agent/Broker ❑ Agency ❑ %of credit:
Phone number: Fax number:
Address: City:
State: Zip:
Signature*: Email:
A group that has terminated with Aetna in the past 12 months for non-payment of premium must pay any
premiums owed in full before Aetna will approve a group plan application and issue health benefits.
GR-24-1 (10-19) 2 IL Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
Date:
Broker admin assistant name: Broker admin assistant e-mail:
*I hereby certify that I am licensed to sell Aetna products in the state of Illinois.
General Agent(GA) Name: TIN:
Selling Agent ATIF L Email:LAj, Xt3
Location code:
Phone number: —0 Fax number:
Address: &9 City .
State. Zip:
GA admin assistant name: GA admin assistant e-mail:
*I hereby certify that I am licensed to sell Aetna products in the state of Illinois.
By signing the above, I certify that I am not aware of any information not disclosed by the applicant
for the products applied for in this application that may be bearing on the risk. I hereby certify that I
advised the client not to terminate any existing coverage until receiving written notice from Aetna
that the coverage applied for by this application is accepted.
Applicant acknowledgements and agreements
• You need our consent before you increase your employees' premium contribution rate.
• You can't require employees to contribute to the premium, if no contribution is now required.
• Your group policy/group agreement only covers eligible employees.You may only add additional
persons for coverage if we agree and your policy permits it.
• This application and your
— Group policy/group agreement
— Certificate of coverage
— Schedule of benefits
— Riders and amendments, if any,
detail the terms of coverage. We call these documents the plan documents.
• The documents detail all the terms of the coverage including:
— What the plan covers
— What the plan excludes
— What limits the plan has
If there is a conflict between the plan documents and any benefits comparison, summary or other
coverage description,the plan documents will govern. Any direct conflict between this form and the
plan documents will be resolved according to the terms which are most favorable to the member.
• You have selected the coverage to be offered to your employees based on written information
we've supplied.This includes your employees' coverage options including how much they'll
contribute. We have not authorized any broker,agent or consultant to modify or change the terms
of the coverage at any time.
• Some plans or programs you are buying from us may not be available in all places.
You also understand and agree to the following:
A group that has terminated with Aetna in the past 12 months for non-payment of premium must pay any
premiums owed in full before Aetna will approve a group plan application and issue health benefits.
GR-24-1 (10-19) 3 IL Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
• We may reasonably inspect payroll and other data and records related to your employee's coverage
or premium at your office during regular business hours. If we do this, we agree to give you advance
notice.The inspection will be at our expense. We have the right to reasonably inspect your records
even after your agreement with us ends.
• All our contracted providers and vendors are independent contractors.They are not agents or
employees of Aetna. We cannot guarantee the availability of any particular provider and the
providers in our network may change. We also do not guarantee any results or outcome of a
health or dental care service.
• If we request,you agree to deliver or otherwise make available to members all our paper or on-line
member documents and other plan related materials.
All statements made in this application are deemed representations and not warranties.
Important information
Any person who knowingly and with intent to injure, defraud or deceive any insurance company or
other person files an application for insurance or statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and
civil penalties.
"Aetna" is the brand name used for products and services provided by one or more of the Aetna
group of subsidiary companies.
EMPLOYER ACKNOWLEDGMENT—employer waiting period
Federal law prohibits group health plans and health insurance issuers from requiring any eligible plan
participants and beneficiaries (employees and dependents) to wait more than 90 days before their
health coverage goes into effect.
This prohibition applies to the employer/plan administrator and the insurance company. I understand
that if either party doesn't comply with the waiting period requirement, both the employer/plan
administrator and insurance company are subject to penalties
I agree to provide Aetna with the effective date information of the plan participants and beneficiaries
which takes into account the eligibility conditions and waiting period requirements under federal law.
Aetna will use the information provided to enroll plan participants and beneficiaries in the employer's
group health insurance coverage. In the event this information changes,the employer shall inform
Aetna immediately.
ELECTRONIC ENROLLMENT, BILLING/PAYMENT AND ACCESS AGREEMENT
Enrollment: As of my participation date:
1. 1 agree to keep copies (paper or electronic) of actual enrollment forms. I agree to maintain a
reasonably complete record of enrollment and eligibility information (via electronic, interactive
voice response technology and/or hard copy format), including:
• Evidence of coverage elections
A group that has terminated with Aetna in the past 12 months for non-payment of premium must pay any
premiums owed in full before Aetna will approve a group plan application and issue health benefits.
GR-24-1 (10-19) 4 IL Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
• Evidence of eligibility
• Changes to such elections and terminations
Records must be available to Aetna upon request and retained for seven years.
2. 1 agree to create and maintain records on secure information systems that can generate hard
copies of enrollments or changes maintained on electronic information systems. Any hard copy
records generated pursuant to this provision shall meet reasonable standards of availability,
authenticity, non-repudiation and integrity.
3. 1 agree that all enrollment and eligibility information presented to Aetna is accurate and timely
updated. I acknowledge that Aetna can and will rely on such information in determining
whether an individual is eligible for benefits under the plan. I agree to pay Aetna promptly any
applicable back premiums as the result of a discrepancy between the enrollee information and
the actual information presented by the enrollee.The premium due to Aetna starts accruing as
of the date on which the enrollee's information changed.
4. If my plan is an insured plan, I agree to either:
• Use Aetna-supplied forms in paper format or electronic format,or
• Incorporate the following four points into my enrollment materials:
– Names of the Aetna company offering the insurance coverage
– State-specific fraud warning statement
– A statement that the terms of the insurance documents will govern the member's rights
and responsibilities
– An acknowledgment that participating providers are not agents or employees of Aetna
and that network composition can change
Signature section
I hereby apply for the coverage(s) indicated above. I certify that all information provided in this
application is accurate and complete. I understand that this application will become part of the group
agreement and/or group policy issued by Aetna. By my signature below, I agree to be bound by the
terms and conditions of that group agreement and/or group policy. I understand that Aetna may
choose not to accept this application, subject to any state requirements.
Signed at (location):
City, State 4plicant(Company name)
By: — )�- flace- M-nnnQe-/-
Autheapplicant signature Official titl
05 ^a 6-1�20Q2
Witness Date
A group that has terminated with Aetna in the past 12 months for non-payment of premium must pay any
premiums owed in full before Aetna will approve a group plan application and issue health benefits.
GR-24-1 (10-19) 5 IL Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
Your premium purchases insurance coverage from Aetna, as well as the services of any Aetna-
appointed licensed independent agent or broker identified in the application for group coverage.
Aetna has various programs for compensating producers (agents, brokers and consultants). If you
would like information regarding compensation programs for which your producer is eligible,
payments (if any)which Aetna has made to your producer, or other material relationships your
producer may have with Aetna,you may contact your producer or your Aetna account representative.
Information regarding Aetna's programs for compensating producers is also available at
www.aetna.com.
We appreciate your business and the opportunity to serve you.
Please keep a copy of this application for your records. If Aetna accepts this application, it becomes
part of the issued group agreement and/or group policy.
A group that has terminated with Aetna in the past 12 months for non-payment of premium must pay any
premiums owed in full before Aetna will approve a group plan application and issue health benefits.
GR-24-1 (10-19) 6 IL Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
BlueCross BlueShield
x of Illinois
EXHIBIT TO THE
STOP LOSS COVERAGE POLICY
Employer Group Name: Village of Oak Brook
Employer Group Address: 1200 Oak Brook Road
City: Oak Brook State of Situs: IL Zip Code: 60523
Account Number: 019545
Employer Group Number(s): P19545 (Non-Union) P56642 (Police) P56643 (Fire) P19546 (H
A_
Current Effective Date of Policy 07/01/2022
Current Policy Period: These specifications are for the Policy Period commencing on 07/01/2022 and ending on 12/31/202
The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in
full force and effect until the earliest of the following dates: (1)The last day of the Policy Period; (2)The date the Policy
terminates; or(3)The date this Exhibit is superseded in whole or in part by a later executed Exhibit.
A. Aggregate Stop Loss Coverage: ® Yes ❑ No
If yes, complete items 1. through 9. below.
1. ❑ New Coverage ® Renewal of Existing Coverage
2. Stop Loss Coverage during the current Policy Period:
❑ New Coverage(Select one from below):
❑ Incurred and paid during the Claims incurred and paid from to
Policy Period:
❑ Run-in coverage: Claims incurred from to
and Claims paid from to
If coverage is for claims incurred prior to the effective date of the Policy and paid by
Policyholder's prior claim administrator, then such claims must be reported by the Policyholder to
the Company(Blue Cross and Blue Shield of Illinois, a Division of Health Care Service
Corporation, a Mutual Legal Reserve Company) and paid by the Policyholder's prior claim
administrator by the end of the current Policy Period.
® Renewal of Existing Coverage:
® Claim Administrator's Claims: Claims incurred on or after the original Effective Date of Policy and paid
during the Policy Period.
3. Aggregate Stop Loss Coverage shall apply to:
❑ Medical Claims ❑ Vision Claims
® Outpatient Prescription Drug Claims with Company's Pharmacy Benefit Manager ❑ Dental Claims
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association
GA-10-4.1 HCSC APP Rev. 06/20
❑ Outpatient Prescription Drug Claims with Policyholder's Pharmacy Benefit Manager:
❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
❑ Other(please specify):
4. Average Claim Value: 1679.83 (per Employee per month)
® Includes Claim Administrator's Provider Access Fee
El Excludes Claim Administrator's Provider Access Fee
Attachment Factor: 125% of the Average Claim Value
5. Aggregate Attachment Claim Liability:
a. Employer's Claim Liability for each Policy Period shall be the sum of the Monthly amounts obtained by
multiplying the number of Individual and Family Coverage Units for each Month by the following factor:
$2099.79 for each Coverage Unit
$ for each Family Coverage Unit
6. Aggregate Stop Loss Coverage includes coverage of Run-Off Paid Claims: ® Yes ❑ No
Run-Off Attachment Claim Liability Factors:
Employer's Run-Off Claim Liability shall be an amount equal to 15% of the annualized Employer Claim Liability
based on the participation of the two (2) calendar months immediately preceding termination. Settlement for the
final accounting period will be described in the section of the Policy entitled SETTLEMENTS.
7. Aggregate Stop Loss Claims:
a. The amount of Paid Claims during the current Policy Period, less Individual (Specific) Stop Loss Claims if
any, that exceeds the Aggregate Point of Attachment. The Aggregate Point of Attachment shall equal the
sum of the Employer's Claim Liability amounts calculated Monthly as described in item A.S. above for the
current Policy Period. However, for the current Policy Period the minimum Aggregate Point of Attachment
shall be $1213257.
b. The following applies if the answer to item A.6. above is "Yes" (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of the current Policy Period, Aggregate Stop Loss Coverage shall
equal the amount of Final Settlement Paid Claims that exceed the Final Settlement Aggregate Point of
Attachment. Final Settlement Paid Claims shall equal the sum of the Paid Claims during the Final Policy
Period and the Paid Claims during the Run-Off Period, less Individual (Specific) Stop Loss Claims, if any.
The Final Settlement Point of Attachment shall equal the sum of the Employer's Claim Liability amount for
the Final Policy Period and the Employer's Run-Off Claim Liability calculated as described in items A.S. and
A.6. above. However, for the Final Settlement Period the minimum Aggregate Point of Attachment shall be
the minimum Aggregate Point of Attachment in item A.7.a. above increased by 15%.
c. The amount of"Run-in" Claims that is excluded from Individual (Specific) Stop Loss Coverage in item B.2.
is also not eligible for Aggregate Stop Loss coverage.
8. Stop Loss Premium (Select one):
® Annual Premium (Due on the first day of the current Policy Period): $15962.
The following applies if the answer to item A.6. above is "Yes" (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy Period, an
additional premium amount equal to 15% of the Annual Premium will be due within ten (10)calendar days of
receipt of the billing.
❑ Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family
Coverage Units for a particular Month by:
$ for each Coverage Unit
$ for each Family Coverage Unit
2
GA-10-4.1 HCSC APP Rev. 06/20
The following applies if the answer to item A.6. above is "Yes" (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of the current Policy Period, an additional Premium amount equal to
15% of the annualized Premium based on the participation of the two (2) months immediately preceding
termination will be due within ten (10)calendar days of receipt of the billing.
9. The premium is based upon a current membership of 29 Individual Coverage Units and 78 Family Coverage
Units.
B. Individual (Specific) Stop Loss Coverage: ® Yes ❑ No
If yes, complete items 1. through 6. below.
1. ❑ New Coverage ® Renewal of Existing Coverage
2. Stop Loss Coverage during the current Policy Period:
❑ New Coverage (Select one from below):
❑ Incurred and paid Claims incurred and paid from to
during the Policy
Period:
❑ Run-in coverage: Claims incurred from to
and Claims paid from to
If coverage is for claims incurred prior to the effective date of the Policy and paid by Policyholder's prior
claim administrator, then such claims must be reported by the Policyholder to the Company(Blue Cross
and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve
Company) paid by the Policyholder's prior claim administrator by the end of the current Policy Period.
® Renewal of Existing Coverage:
® Claim Administrator's Claims: Claims incurred on or after the original Effective Date of Policy and paid
during the Policy Period.
3. Individual (Specific) Stop Loss Coverage shall apply to:
® Medical Claims ❑ Vision Claims
® Outpatient Prescription Drug Claims with Company's Pharmacy Benefit Manager ❑ Dental Claims
❑ Outpatient Prescription Drug Claims with Policyholder's Pharmacy Benefit Manager:
❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
❑ Other(please specify):
4. Individual (Specific) Stop Loss Claims
For each other Covered Person:
a. Individual (Specific) Stop Loss Coverage equals the amount of Paid Claims for a Covered Person
during the current Policy Period in excess of the Individual Point of Attachment of$85000 per Covered
Person. Such amount shall apply for the current Policy Period.
Point of Attachment ® Includes Claim Administrator's Provider Access Fee
❑ Excludes Claim Administrator's Provider Access Fee
3
GA-10-4.1 HCSC APP Rev. 06/20
b. Employer's Claim Liability equals the sum of Paid Claims for a Covered Person during the current Policy
Period up to the Point of Attachment specified in item B.4.a. above.
5. Individual (Specific)Stop Loss Coverage includes coverage of Run-Off Paid Claims: ® Yes ❑ No
The following applies if the answer to item B.S. above is "Yes" (Individual Stop Loss Coverage includes coverage
of Run-Off Paid Claims):
a. In the event of termination at the end of the current Policy Period, Individual (Specific) Stop Loss
Coverage shall equal the amount of Final Settlement Paid Claims that exceed the Point of Attachment
specified in B.4. above. Final Settlement Paid Claims shall equal the sum of Paid Claims for a Covered
Person during the Final Policy Period and the Run-Off Period (beginning on and ending on
b. In the event of termination at the end of the current Policy Period, Employer's Final Settlement Claim
Liability equals the sum of Paid Claims for a Covered Person during the Final Policy Period and Run-
Off Period up to the Point of Attachment specified in item BA.a. above.
Settlement for the final accounting period will be described in the section of the Policy entitled
SETTLEMENTS.
6. Stop Loss Premium (select one):
❑ Annual Premium (Due on the first day of the current Policy Period): $
The following applies if the answer to item B.S. is "Yes" (Individual (Specific)Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy Period, an
additional premium amount equal to 20% of the Annual Premium will due within ten (10)calendar days of
receipt of the billing.
® Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family
Coverage Units for a particular Month by:
$400.81 for each Coverage Unit
$ for each Family Coverage Unit
The following applies if the answer to item B.S. above is "Yes" (Individual (Specific)Stop Loss Coverage
includes coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy
Period, an additional premium amount equal to 20% of the annualized Premium based on the participation of
the two (2) months immediately preceding termination will be due within ten (10) calendar days of receipt of
the billing.
7. The premium is based upon a current membership of 29 Individual Coverage Units and 78 Family Coverage Units.
Additional Provisions:
Retirees Covered: Yes ® No ❑
The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on behalf
of the Employer. It is understood that the actual terms and conditions of coverage are those contained in this Exhibit and
the Stop Loss Coverage Policy into which this Exhibit shall be incorporated at the time of acceptance by Blue Cross and
Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ("HCSC"). Upon
acceptance, HCSC shall issue a Stop Loss Coverage Policy to the Employer. Upon acceptance of this Exhibit and issuance
of the Stop Loss Coverage Policy, the Employer shall be referred to as the "Policyholder."
Ruben Mendez
4
GA-10-4.1 HCSC APP Rev.06/20
Gr�S �um�ErS� 1�ll�y�r
Sales Representative Signature of Authorized Purchaser
Brian Buzecky
Name of Underwriter Title of AAorized Purchaser
VS "
Signature of Underwriter Date
INTERNAL USE ONLY Date Application approved by Underwriting:
Name of Underwriter:
5
GA-10-4.1 HCSC APP Rev. 06/20
VILLAGE OF OAK BROOK
vcwtna- Fire Union Employees
Effective Date:07-01-2022
Dental Benefits Summary
Passive PPO
With PPOII`and ExtendSM Networks
Annual Deductible*
Individual $50
Family $150
Preventive Services 100%
Basic Services 80%
Major Services 50%
Annual Benefit Maximum $1500
Office Visit Copay N/A
Orthodontic Services(Adult and Child) 50%
Orthodontic Deductible None
Orthodontic Lifetime Maximum $2000
*The deductible applies to: Basic&Major services only
Partial List of Services Passive PPO
With PPOII and ExtendSM Networks
Preventive
Oral examinations(a) 100%
Cleanings(a)Adult/Child 100%
Fluoride(a) 100%
Sealants(permanent molars only)(a) 100%
Bitewing Images(a) 100%
Full mouth series Images(a) 100%
Space Maintainers 100%
Basic
Root canal therapy
Anterior teeth/Bicuspid teeth 80%
Root canal therapy,molar teeth 80%
Scaling and root planing(a) 80%
Gingivectomy(a)* 80%
Amalgam(silver)fillings 80%
Composite fillings 80%
Pagel
VILLAGE OF OAK BROOK
Vcwtna- Fire Union Employees
Effective Date:07-01-2022
Dental Benefits Summary
Stainless steel crowns 80%
Incision and drainage of abscess* 80%
Uncomplicated extractions 80%
Surgical removal of erupted tooth* 80%
Surgical removal of impacted tooth(soft tissue)* 80%
Osseous surgery(a)* 80%
Surgical removal of impacted tooth(partial bony/full bony)* 80%
General anesthesia/intravenous sedation* 80%
Crown Lengthening 80%
Major
Inlays 50%
Onlays 50%
Crowns 50%
Full&partial dentures 50%
Pontics 50%
Denture repairs 50%
Crown Build-Ups 50%
Implants 50%
*Certain services may be covered under the Medical Plan.Contact Member Services for more details.
(a)Frequency and/or age limitations may apply to these services. These limits are described in the bookledcertificate.
Other Important Information
This Aetna Dental®Preferred Provider Organization(PPO)benefits summary is provided by Aetna Life Insurance
Company for some of the more frequently performed dental procedures.
Under the Dental Preferred Provider Organization(PPO)plan,you may choose at the time of service either a PPO
participating dentist or any nonparticipating dentist. With the PPO plan, savings are possible because the participating
dentists have agreed to provide care for covered services at negotiated rates. Non-participating benefits are subject to
recognized charge limits.
Out-of-Network plan payments are based on the 90th percentile of prevailing charges for the geographic area.
Emergency Dental Care
If you need emergency dental care for the palliative treatment(pain relieving, stabilizing) of a dental emergency,you are
covered 24 hours a day, 7 days a week.
Page2
VILLAGE OF OAK BROOK
vcwtna- Fire Union Employees
Effective Date:07-01-2022
Dental Benefits Summary
When emergency services are provided by a participating PPO dentist,your co-payment/coinsurance amount will be based
on a negotiated fee schedule. When emergency services are provided by a non-participating dentist,you will be
responsible for the difference between the plan payment and the dentist's usual charge. Refer to your plan documents for
details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to
verify appropriateness of treatment.
Partial List of Exclusions and Limitations* -Coverage is not provided for the following:
1.Services or supplies that are covered in whole or in part:
(a) under any other part of this Dental Care Plan; or
(b) under any other plan of group benefits provided by or through your employer.
2. Services and supplies to diagnose or treat a disease or injury that is not:
(a)a non-occupational disease;or
(b)a non-occupational injury.
3. Services not listed in the Dental Care Schedule that applies,unless otherwise specified in the Booklet-Certificate.
4. Those for replacement of a lost,missing or stolen appliance,and those for replacement of appliances that have been
damaged due to abuse,misuse or neglect.
5. Those for plastic,reconstructive or cosmetic surgery,or other dental services or supplies,that are primarily intended to
improve,alter or enhance appearance. This applies whether or not the services and supplies are for psychological or
emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.
6. Those for or in connection with services,procedures,drugs or other supplies that are determined by Aetna to be
experimental or still under clinical investigation by health professionals.
7. Those for dentures,crowns,inlays,onlays,bridgework,or other appliances or services used for the purpose of
splinting,to alter vertical dimension,to restore occlusion,or to correct attrition,abrasion or erosion.
8. Those for any of the following services(Does not apply to the DMO plan in TX):
(a)an appliance or modification of one if an impression for it was made before the person became a covered
person;
(b)a crown,bridge,or cast or processed restoration if a tooth was prepared for it before the person became a
covered person;or
(c)root canal therapy if the pulp chamber for it was opened before the person became a covered person.
9. Services that Aetna defines as not necessary for the diagnosis,care or treatment of the condition involved. This applies
even if they are prescribed,recommended or approved by the attending physician or dentist.
10. Those for services intended for treatment of any jaw joint disorder,unless otherwise specified in the
Booklet-Certificate.
I
11. Those for space maintainers,except when needed to preserve space resulting from the premature loss of deciduous
teeth.
12. Those for orthodontic treatment,unless otherwise specified in the Booklet-Certificate.
Page3
li
VILLAGE OF OAK BROOK
vcwtna- Fire Union Employees
Effective Date:07-01-2022
Dental Benefits Summary
13. Those for general anesthesia and intravenous sedation,unless specifically covered. For plans that cover these
services,they will not be eligible for benefits unless done in conjunction with another necessary covered service.
14. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride
may be done by a licensed dental hygienist. In this case,the treatment must be given under the supervision and guidance
of a dentist.
15. Those in connection with a service given to a person age 5 or older if that person becomes a covered person other
than:
(a)during the first 31 days the person is eligible for this coverage, or
(b)as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to
charges incurred:
(i)after the end of the 12-month period starting on the date the person became a covered person; or
(ii)as a result of accidental injuries sustained while the person was a covered person; or
(iii)for a primary care service in the Dental Care Schedule that applies as shown under the headings
Visits and Exams, and X-rays and Pathology.
16. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the
services shown in the Dental Care Schedule that applies.
17. Those for a crown,cast or processed restoration unless:
(a) it is treatment for decay or traumatic injury,and teeth cannot be restored with a filling material; or
(b) the tooth is an abutment to a covered partial denture or fixed bridge.
18. Those for pontics,crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in
the Booklet-Certificate.
19. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons,unless otherwise specified in the
Booklet-Certificate.
20. Services needed solely in connection with non-covered services.
21. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services.
Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the
coverage.
*This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.
Your Dental Care Plan Coverage Is Subject to the Following Rules:
Replacement Rule
The replacement of, addition to; or modification of: existing dentures; crowns; casts or processed restorations;removable
denture; fixed bridgework; or other prosthetic services is covered only if one of the following terms is met:
The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or
bridgework was installed. This coverage must have been in force for the covered person when the extraction took place.
Page4
VILLAGE OF OAK BROOK
vcwtna- Fire Union Employees
Effective Date:07-01-2022
Dental Benefits Summary
The existing denture,crown; cast or processed restoration,removable denture,bridgework,or other prosthetic service
cannot be made serviceable,and was installed at least 8 years before its replacement.
The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is
covered,and cannot be made permanent, and replacement by a permanent denture is required. The replacement must take
place within 12 months from the date of initial installation of the immediate temporary denture.
The extraction of a third molar does not qualify.Any such appliance or fixed bridge must include the replacement of an
extracted tooth or teeth.
Tooth Missing But Not Replaced Rule
Coverage for the first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the
requirements that such removable dentures; fixed bridgework and other prosthetic services are(i)needed to replace one or
more natural teeth that were removed while this policy was in force for the covered person; and(ii)are not abutments to a
partial denture;removable bridge; or fixed bridge installed during the prior 8 years.
Alternate Treatment Rule If more than one service can be used to treat a covered person's dental condition,Aetna may
decide to authorize coverage only for a less costly covered service provided that all of the following terms are met:
(a) the service must be listed on the Dental Care Schedule;
(b) the service selected must be deemed by the dental profession to be an appropriate method of treatment; and
(c)the service selected must meet broadly accepted national standards of dental practice.
If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service
than that for which coverage is approved,the specific copayment for such service will consist of:
(a) the copayment for the approved less costly service;plus
(b) the difference in cost between the approved less costly service and the more costly covered service.
Finding Participating Providers
Consult Aetna Dentals online provider search for the most current provider listings.Participating providers are
independent contractors in private practice and are neither employees nor agents of Aetna Dental or its affiliates. The
availability of any particular provider cannot be guaranteed,and provider network composition is subject to change
without notice. For the most current information,please contact the selected provider or Aetna Member Services at the
toll-free number on your online ID card,or use our Internet-based provider search available at www.aetna.com.
Specific products may not be available on both a self-funded and insured basis. The information in this document is
subject to change without notice. In case of a conflict between your plan documents and this information,the plan
documents will govern.
In the event of a problem with coverage,members should contact Member Services at the toll-free number on their online
ID cards for information on how to utilize the grievance procedure when appropriate.
Pages
VILLAGE OF OAK BROOK
vcwtna- Fire Union Employees
Effective Date:07-01-2022
Dental Benefits Summary
All member care and related decisions are the sole responsibility of participating providers.Aetna Dental does not provide
health care services and,therefore,cannot guarantee any results or outcomes.
Dental plans are provided or administered by Aetna Life Insurance Company,Aetna Dental Inc.,Aetna Dental of
California Inc. and/or Aetna Health Inc.
Telehealth Services: the plan will reimburse the treating or consulting provider for the diagnosis,consultation, or treatment
of an enrollee via telehealth on the same basis and to the same extent that the plan would reimburse the same covered
in-person service.
In Texas,the Dental Preferred Provider Organization(PPO)is known as the Participating Dental Network(PDN),and is
administered by Aetna Life Insurance Company.
This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a
partial,general description of plan or program benefits and does not constitute a contract. The availability of a plan or
program may vary by geographic service area. Certain dental plans are available only for groups of a certain size in
accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions. Consult the plan
documents(Schedule of Benefits,Certificate/Evidence of Coverage,Booklet,Booklet-Certificate,Group Agreement,
Group Policy)to determine governing contractual provisions,including procedures,exclusions and limitations relating to
your plan.
Aetna complies with applicable Federal civil rights laws and does not discriminate,exclude or treat people differently
based on their race,color,national origin, sex,age,or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter,written information in other formats,translation or other services,call 877-238-6200.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above,
you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O.Box 14462,Lexington,KY 40512(CA HMO customers: PO Box 24030 Fresno,CA 93779),
1-800-648-7817,TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
CRCoordinator@aetna.com.
You can also file a civil rights complaint with the U.S.Department of Health and Human Services,Office for Civil Rights
Complaint Portal,available at https:Hocrportal.hhs.gov/ocr/portal/lobby.jsf,or at: U.S. Department of Health and Human
Services,200 Independence Avenue SW.,Room 509F,HHH Building,Washington,DC 20201,or at 1-800-368-1019,
800-537-7697(TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company, Coventry Health Careplans and their affiliates(Aetna).
Page6
�►a�tna� VILLAGE OF OAK BROOK
Fire Union Employees
Effective Date:07-01-2022
Dental Benefits Summary
TTY:711
English To access language services at no cost to you,call the number on your ID card.
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to identitetit.
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indicat a la seva targeta d'identificaci6.
Cebuano Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran,tawagi ang
numero nga anaa sa imong kard sa ID.
Chamorro Para un hago' i setbision lengguahi ni dibatde para hagu,agang i numiru gi iyo-mu
kard aidentifikasion.
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nampa mei mak won noum ena katen ID
Cushitic-Oromo
Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa
eenyummaa (ID) kee irraa jiruun bilbili.
Dutch Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.
French Pour acceder gratuitement aux services linguistiques,veuillez composer le numero
indique sur votre carte d'assurance sante.
French Creole Pou ou jwenn sevis gratis nan tang ou, rele nimewo telefon ki sou kat idantifikasyon
(Haitian) asirans sante ou.
German Um auf den fur Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die
Nummer auf Ihrer ID-Karte an.
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Page7
;x'i r:72 i
VILLAGE OF OAK BROOK
#*cwtna M Fire Union Employees
Effective Date:07-01-2022
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aana me a awe awe e o'o e a aku i ka helu kelepona ma kau
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koj daim npav ID.
Igbo Inweta enyemaka asusu na akwughi ugwo obula, kpoo nomba no na kaadi njirimara
gi
Ilocano Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti
numero nga adda ayan ti ID kardmo.
Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor
Indonesian telepon di kartu asuransi Anda.
Italian Per accedere ai servizi linguistici senza alcun costo per lei,chiami it numero sulla
tessera identificativa.
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ntilga i kat yong matibla
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kaat in ID eo am.
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kuany ne namba de abac t5 ne ID kard duan de tilt de nyin de panakim kju.
Norwegian For tilgang til kostnadsfri spraktjenester, ring nummeret pa ID-kortet ditt.
Page8
r ,ariet
�►a�tna- VILLAGE OF OAK BROOK
Fire Union Employees
Effective Date:07-01-2022
Pennsylvanian- Dental Benefits Summary
Dutch Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
Persian Farsi y �y La ���LWt�;�,lS�,9,e lw 1�"9 a l�6 I,,�,Aq jL j uLa.1i Aj�„J w�L,i
Polish Aby uzyskac dostgp do bezpfatnych usfug jgzykowych, nale2y zadzwonic pod numer
podany na karcie identyfikacyjnej.
Portuguese Para aceder aos servigos linguisticos gratuitamente, ligue para o numero indicado
no seu cartao de identificagao.
Punjabi
Romanian Pentru a accesa gratuit serviciile de limbs,apelati numarul de pe cardul de membru.
Russian AAA Toro yTo6bi 6ecnnaTHO nolly4VlTb nOMOuAb nepeBoggMKa, n03B0HWTe no
TeneOOHy, npNBeAeHHOMy Ha BaweO mgeHT140WKa4M0HH0N Kapre.
Samoan Mo le mauaina o 'au'aunaga tau gagana a aunoa ma se totogi, vala'au le numera i
luga o lau pepa ID.
Serbo-Croatian Za besplatne prevodilacke usluge pozovite broj naveden na Vagoj identifikacionoj
ka rtici.
Spanish Para acceder a los servicios linguisticos sin costo alguno, Ilame al numero que figura
en su tarjeta de identificacion.
Sudanic Fulfulde Heeba a naasta nder ekkitol jaangirde woldeji walla yobugo, ewnu lamba je Cron
windi ha do derowol maada.
Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya
kitambulisho.
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Syriac-Assyrian
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numero sa iyong ID card.
Telugu o�
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telefoni ki he fika 'oku ha atu 'i ho'o ID kaati.
Turkish Dil hizmetlerine 0cretsiz olarak eri§mek i4in kimlik kartinizdaki numarayi arayin.
Ukrainian Uo6 6e3KOWTOBHj OTpNMaTH MOBHi nocnym,3aA3BOHITb 3a HOMepoM, 13Ka3aHNM Ha
BawiV igeHTW1 iKaNHiA KapT4i.
Urdu JL5 ..v ' z�� , �,LS ID ,, , ul x,.15 , \;Lw.) `� .S;
Vietnamese
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cua quy vi.
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Yoruba Lati rayesi awon ise ede fun o lofee, pe nomba to wa lori kaadi idanimo re.
Page9
1►aetna Shannon O Toole
Aetna Inc.
333 W Wacker Dr.
Chicago,IL 60606
Phone: 3129283047:
E-mail: OTooleS2@aetna.com
Vista National Insurance Group Inc
1301 W 22nd Street
Suite 600
Oak Brook,IL 60523
Phone: 6304686500:
Fax: (630) 468-6600
March 23, 2022
Dear Siror Madam:
Thank you forgiving us the opportunity to presentthis proposal. We believe you will find the proposal addresses all primary
aspects of your requested benefits package. Based on your quote,this proposal includes the following components:
Executive Summary—Our response to the current business climate
Financial Information —rate details
Quote Conditions —general quotation assumptions and disclosures
Plan and Benefit Information —detailed plan designsforthe rates and premium illustrated in this proposal
Census Summary —recap of census information entered for the quote
Sitematch Information —medical/dental product availability
Sincerely,
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
EXECUTIVE SUMMARY
Aetna has helped protect people againstthe risks and uncertainties of life for over 150 years. Westriveto
continually evolve in orderto meet the changing needs of our customers while keeping true to our values. To
accomplish this,our strategic vision centers on the following areas for all of our products and services:
Integration -Information -Innovation
Through the increased use of integrated data analysis,predictive modeling,integrated care services,and
technology initiatives,we can identify and assist members who may benefitfrom services today or may likely
need services in the future.
Sincethis enables us to develop amore complete picture of customer and member needs,we can help our
customers control costs,enjoyeasier administration,and provide their employees with access to informationto
help them become better educated about their benefits and thevalue inherentin those benefits. The balance of
thissummary will explain howweare able to accomplish this for you.
Aetna Dental/Medical Integration®(DMI)
This Industry leading program is automatically included atno additional charge for employers who haveboth
Aetna dental and our medical coverage.The DMI program is comprised ofenhanced benefits,including an extra
cleaning,full coverage for certain periodontal services and avariety ofoutreach methods to at-risk members who
are not currently seeking dental care.Ask about the Aetna Dental/Medical Integration program and let us help
you avoid potential costs and risksthatcould negatively impacts person's overall well-being.
Integrated Health and Disability (IHD)
High-impactconditions are affecting employees and productivity at an increasing rate.Research has also shown
that employeeswho filedisability claims haveamuch highermedical spend onaveragethan employeeswho do
notfile disability claims.Recognizing this,ourservices includeafree,closely integrated medical anddisability
case management process that provides focused case management and individualized contact for claimants
who haveour medical and disability plans.
With Integrated Health and Disability(IHD),we use ourrich data management tools to help predictwhen
disabilities may occur and take early steps toward disability prevention. When a disability does occur,ourteam
of skilled clinicians works together to co-manage cases and refer members to applicable medical management
programs. By focusing on getting employees back to health and work,our clinicians workto improve outcomes
-to everyone's advantage.
Single Source for a Comprehensive Benefits Package
Our integrated product portfolio and services enable customers to assemble a robust benefits package through a
singlesource. We can offer customers the advantage of efficiencies and ease of administration as a direct result
of using a single source for their total benefits needs. Efficiencies also extend to members. By offering awide-
ranging benefits package through one carrier,members need only access one set of information toolsto learn
more about the benefits and services available to them,thereby reaping the advantages of simplification.In this
manner,members are encouraged to use their benefits more extensively-another key advantage for the
customer.
Leadership in Consumer-Directed Health Care
Navigating the newworld of consumer-directed health planscalls for a company with a strong history of
innovation and the right expertise for the times. Aetna is an established leaderin providing value-added,
consumer-directed health plans. Sincethe launch of our first generation of consumer-directed plans in
September of 2001, (we were thefirst national carrierto offerthese),we have firmly positioned ourselves as a
leaderand innovator in consumer-directed health plans.
Our portfolioof consumer-directed products features a variety of plan designsthatinclude integrated health
savings accounts(HSAs),health reimbursement accounts(HRAs)and flexible spending accounts(FSAs). With
each product comes access to innovative decision-making tools to help members make informed decisions
about their care.
Proactive Approach to Medical Management
A clearexample of how Integration,Information and Innovation benefit our customers is in thearea of medical
management. Ultimately, itis the individual treating physicianwho manages thepatient's care. However,we
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
believe we play an important role by helping members and physicians access information and covered services
to maximize the potential of successful treatment outcomes.
The emphasis is on member empowerment and strong,early,and effective disease and case management
programs as well as the continuum of care for the patient, stressing concurrent review and discharge planning for
hospitalizations and case management.
Active Measures to Help Control Benefits Cost
To counterthe nationally escalating costof benefits,we continueto explore innovativeways to help control costs
whileensuring members have access to information resources andtechnology. As a result,we h ave instituted a
series of measures in an effortto meet the industry-wide challengeof holding premiums and fees down while
offering members comprehensive coverage. We believe improvements in health care and outcomes lead to
better control of health care costs. Likeourpredictive modeling and MedQuerys"tools,our case management
and disease management programs are designed to allow us to identify at-risk populations proactively,and to
provide real-time assistanceto help coordinate,facilitate and improvequality of care. This also helps our
members better understand and comply with theircare regimen. We can help improve members' health and
assist controlling health care costs by increasing memberaccess to information through programs and
technology such as Informed Healthr Line,Aetna InteliHealthr,and Aetna Navigator
Decision-making Support for Members
We seek to engagemembers in making informed,quality health caredecisions. Webelievethat ourmembers
are best served when provided with tools that promote their understanding oftheirown health needs and
empowerthem to participate-and connect-with theirphysicians in themedical treatment process.
Our suite of technological tools allows us to offer employees increased engagement and accountability for their
health plan.
Customer-focused, Leading Edge Technology
We are delivering on o ur p romise to provide customers with the most comprehensive suite of tools and services
offered by today's technology. Whether itis reducing the time for claimpayments to physicians,providing
members with 24-houraccessto personalized benefits information or offering customers the ease of online
benefits administration,we are taking advantage of technology to enhance the services we provide to our
customers.
In general,we hold a tech n o I ogy ed g e i n electronic reporting,web-based member tools,consumer-directed
information tools,data managementand predictive modeling,and electronic claim adjudication. Whereothers
focus solely on discounts,we also consider technology a means to allow members to take control ofthe demand
side ofthe total costequation for our customers.
Comprehensive and Extensive Networks
Access to care is a paramount consideration for customers in theselection ofacompany thatcan best provide
widespread medical delivery networks for their employees. Recognizing the importance of this principle,our
uncompromising focus on providing access to care in as many geographic locations as possible is an advantage
that distinguishes our services in the marketplace. Our inclusive network strategy allows us to offer our
customers and their employees one of the most comprehensive networks available in the industry,regardless of
product. Our underlying philosophy for network development is to promote access to stable provider networks
with cost-effective,high-quality providers. Our goal is to build relationships with our providers that promote a
positive impact on member care and enhance customer satisfaction. Our strategy incorporates three basic
underlying concepts:access,cost appropriateness,and quality.
Innovating to Meet the Evolving Needs of our Customers
Flexible, cost-effective dental plans -With over 35 years'experience in the dental marketplace,we offer a
wide array of products. We can provide the advantages of a managed dental plan and still offer employees the
option to choose any licensed dentistfrom our extensive national network. Members of all dental plans are able
to access a variety of our internettools such as Aetna Navigator,DocFindr and InteliHealth Dental.
Benefits for part-time and temporary employees -Our Aetna Affordable Health Choicess"plans provide
limited benefits to employees who have historically been unable to access employee benefits,offering affordable
medical,dental,life, disability,vision and pharmacy coverage administered through payroll deduction. We have
created affordable benefits packages that help employers reducetheir costs of recruitment,hiring,and training
employees as well as creating a way to retain these employees longer.
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Conclusion
We harness the power of information to help our customers and their employees make better, more informed
decisions. The result is our customers have the ability to control costs more effectively,and their employees
have more information to help them stay healthier and more productive.
We can gather aggregated data and integrate it across our areas of service to get a more complete picture of
each customer's overall needs. We use this information to select and develop plans and optionsthat are best
suited to the customer and their workforce.
Along with powerful data,our philosophy is to deliver outstanding serviceto customers and their employees as
defined by the quality ofeach interaction and service experience. We accomplish this by:
-Focusing on improving key processes thataffect ourcustomers
-Deploying technology to further improve service and operating efficiencies
-Focusing on continually increasing the quality ofthetotal experience for our customers
We appreciate the opportunity to demonstrate how we can meet your needs through usin g th a power of
Integration,Information and Innovation.
vaetna- VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
DENTAL RATES/FEES & COSTS
Option: 1
Policy Period: 12 months
Product Pkg: PPOD
Specialty Networks: None
Subgroup: All Other Employees
Location(s): AZ, FL, IL, IN, TN
Funding: Prospective
Non-Student Age: 26 Student Age: 26
Our quoted rates are guaranteed for 36 months beginning on 07/01/2022.
The flat rate guarantee is subject to the same terms and conditions as stated on the Quote Conditions section of your
proposal.
Aetna reserves the right to revoke the flat rate guarantee if there is change in the total base eligible and or/enrolled lives
of+/-10% during the guarantee period.
Annual rate exhibits and benefit summaries will be delivered approximately 60-90 days prior to your anniversary date.
No reporting will be available.
PPO PPO
Plan Feature In Network Out of Network Tier Lives Rate Monthly Cost
Coins-Preventive 100% 100% Single 39 38.69
Coins-Basic 80% 80% Two Party 50 70.10
Coins-Major 50% 50% Family 49 134.88
Endo/Perio 3 80% 80% 138 11,623.03
Endo/Perio Other 80% 80%
General Anesthesia 80% 80%
(Buy Up)
Deductible $50 $50
Ded Applicability B,M B,M
Fam Deductible 3X 3X
CYMax $1,500 $1,500
R&C Percentile N/A 90th
Extend Network Include N/A
Waiting Period None None
Ortho Elig Adult&Child Adult&Child
Ortho Coins 50% 50%
Ortho LT Max $3,000 $3,000
Removal of Ortho Exclusion Exclusion
Work in Progress applies applies
Exclusion(Buy Up)
Dental Implants(Buy 50% 50% Signature/Date:
up)
Crown Build Ups 50% 50%
Crown Lengthening 80% 80%
Fluoride Increase Age To age 19 To age 19
Limit
Sealants Remove To age 16 To age 16
Age Limit
Posterior Composite Covered Covered
Prosthetic 8 Years 8 Years
Replacement
Annual Coin increase Does not apply Does not apply
Increase applies to Does not apply Does not apply
Incentive Annual Max Does not apply Does not apply
Increase Amount
Incentive Number of Does not apply Does not apply
Increase
Penalty if No Visit Does not apply Does not apply
03232022 Quote ID: 3354735 page 1
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
ovae`na VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Option: 1
Policy Period: 12 months
Product Pkg: PPOD
Specialty Networks: None
Subgroup: Fire Union
Location(s): IL
Funding: Prospective
Non-Student Age: 26 Student Age: 26
Our quoted rates are guaranteed for 36 months beginning on 07/01/2022.
The flat rate guarantee is subject to the same terms and conditions as stated on the Quote Conditions section of your
proposal.
Aetna reserves the right to revoke the flat rate guarantee if there is change in the total base eligible and or/enrolled lives
of+/-10% during the guarantee period.
Annual rate exhibits and benefit summaries will be delivered approximately 60-90 days prior to your anniversary date.
No reporting will be available.
PPO PPO
Plan Feature In Network Out of Network Tier Lives Rate Monthly Cost
Coins-Preventive 100% 1000/. Single 13 38.69
Coins-Basic 80% 80% Two Party 7 70.10
Coins-Major 50% 50% Family 26 134.88
Endo/Perio 3 80% 80% 46 4,501
Endo/Perio Other 80% 80%
General Anesthesia 80% 80%
(Buy Up)
Deductible $50 $50
Ded Applicability B,M B,M
Fam Deductible 3X 3X
CYMax $1,500 $1,500
R&C Percentile N/A 90th
Extend Network Include N/A
Waiting Period None None
Ortho Elig Adult&Child Adult&Child
Ortho Coins 50% 50%
Ortho LT Max $2,000 $2,000
Removal of Ortho Exclusion Exclusion
Work in Progress applies applies
Exclusion(Buy Up)
Dental Implants(Buy 50% 50%
up)
Crown Build Ups 50% 50%
Crown Lengthening 80% 80%
Fluoride Increase Age To age 19 To age 19
Limit
Sealants Remove To age 16 To age 16
Age Limit
Posterior Composite Covered Covered
Prosthetic 8 Years 8 Years
Replacement
Annual Coin increase Does not apply Does not apply
Increase applies to Does not apply Does not apply
Incentive Annual Max Does not apply Does not apply
I ncrease Amount
Incentive Number of Does not apply Does not apply
Increase
Penalty if No Visit Does not apply Does not apply
For members residing in Texas,a)PDN substitutesthe referenceto PPO Dental,b)if a PDN plan is shown,your In-and Out-of Network benefits are the In-Network
benefits shownabove.
In Virginia,the DMO®Plan is known as the DNO(Dental Network Only)Plan.
The Patient Protection and Affordable Care Act imposesa new fee/assessment,the Health Insurer Fee(HI F).This rate quote includes an allocation of 0.01%for HIF.
03232022 Quote ID: 3354735 page 2
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
QUOTE CONDITIONS
GENERAL
The quotes in this proposal are non-binding and do not constitute an offer of coverage. Any offer is subject to final underwriting
review by us, as permitted by applicable law,we reserve the right notto extend an offer orto change pricing and/or other terms
specified in this proposal based on that review.
Quotes have been based on the information entered into our Internet-based quoting system. Additional information maybe
required to complete the underwriting and installation process. Rates and/or product availability may change if any of the following
occur:
• Participation assumptions are not met or there is a change in the contribution strategy
•Actual enrolled census deviates from information provided
•The number of eligible lives and/or participation changes atany time priorto the next rate change
•The information provided to us is incorrect or incomplete
•Medical conditions are reviewed where permitted
• Benefit levels change from those specified in this proposal
•There is an increase in number of retired enrollees
•There is an increase in COBRA enrollees.
Plans summarized in this proposal are subject to additionalterms,conditions and limitations specified inapplicable coverage
contracts. Copies of coverage contracts are available upon request.
All ourstandard plan provisions,definitions,terms and conditions of coverage,exclusions and limitations,and claim paymen for
administrative practices will apply fo r items not specifically outlined in the proposal.
Changes to product availability,actuarial factors,and state/federal laws may alter the proposal atthetime of final underwriting and
installation.
Quotes are based on the assumptions that all information provided to us is correct and complete,thatthe employer is a legitimate
employer group,and thatthe group is in sound financial condition.
The contract situs is assumed to be the state/s of IL.
No commissions will be paid on coverage unless the agent is properly licensed and appointed prior to the initial coverage date.
We have various programs for compensating agents,brokers and consultants. If you would like information regarding
compensation programs forwhich your producer is eligible,payments(if any)which we have made to your producer,or other
material relationshipsyourproducer may have with us,you may contactyourproducer oryour account representative. Information
regarding our programs for compensating producers is also available at:www.aetna.com.
Notification of acceptance of the proposal must be communicated in writing to us no later than 30 days prior to the effective date.
Otherwise,late acceptance may cause a delay in contract issue,online ID card generation,and other pertinent insurance
information. Late submission may also result in an invalid proposal and require postponement of the effective date.
Dependent children can be covered through aspecified age and extended through a later specified age if full-time student. The
ages vary by state.
This proposal assumes thatwe will be the sole carrier exceptwhere we will allow a competitor's plan alongwith our medical plan.
03232022 Quote ID: 3354735 page 3
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Participation,eligibility,and contribution results mustmeet our minimum requirements and applicable state requirements for the
employer to be eligible under the quoted plans. As permitted by applicable law,coverage maybe terminated ornon-renewed if
these participation,eligibility and contribution requirements are not met at any point in thefuture.
All proposals are only available to corporations,sole proprietorships,and partnerships. Associations,Taft-Hartley Groups,
MEWAs, PEOs (Professional Employer Organizations/Employee Leasing Firms),or multiple employer groups of any kind are not
eligiblefor coverage through this rating application. Closed groups are noteligible.
Except in Arizona,Coverage is for full-time employees working a minimum of 25 hours per week. Temporary and seasonal
employees as well as 1099 independent contractors are not eligible for coverage. The benefits described in this proposal must be
offered to all eligible employees.
This proposal assumes that late enrollees will not be covered until the next regularly scheduled open enrollment period after
individual application has been made. Special enrollment rules may apply with respectto late enrollees experiencing certain life
events.
New employees must complete the waiting period designated by their employer prior to enrolling in one of our plans. Thewaiting
period must be consistently applied within a class of employees.
Employees declining coverage maybe required understate law to complete a waiver of coverage form.
New eligible dependents or employees must be added within 31 calendar days of their eligibility date or such other period as may
be required by applicable law.
In accordancewith theterms of the Group Agreement, rates and other adjustments maybe made to the quotation with a 30-day
notice unless otherwise required by state regulations.
State and Federal legislation/regulations,including HIPAA,take precedence over any and all quote conditions.
Rates maybe affected if there is material change in the plan of benefits offered ora change in claim payment requirements,
procedures,account structures,or any other changes affecting the manner or cost of paying benefits that is initiated by the
customer or required because of legislative or regulatory action.
Late payment charges maybe assessed after the expiration of a 31-day grace period.
03232022 Quote ID: 3354735 page 4
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
QUOTE CONDITIONS
DENTAL INSURANCE"
Quoting and Pricing Information
Coverage is assumed to be effective on 07/01/2022. Initial rates assume a 12-month contract year. Final rates will be
guaranteed for 36 months provided there is not a change in the total base eligible and/or enrolled lives ofplus/minus 10
percentwith in the first year. Should this occur,Aetna reserves the rig htto re-underwrite the customer as anew group
where permitted by applicable law. Proposed rates are also subject to changed ueto any state rate filing requirements,
approvals,or adjustments based on regulatory determinations.
Plans are available to groups of two to 25 eligible employees if packaged with amedical plan. Plans are available to
groups of 26 or more eligible employees on a standalone basis. Orthodontia coverage is available to groups with 10 or
more eligible employees.
For some plans,coverage may not be available for employees and their dependents located outside specified service
area boundaries.
Dependent children can becovered through a specified ageand extended throughalater specified ageifattending
school on a regular basis. The ages vary by state.
Plans and rates shown in this quote are based on thegroup having an existing,in-force Dental plan. We reserve the right
to change the proposed plan and rates ifthis is notthe case.
PPO Max plans out-of-network benefits are limited to in-network negotiated fees.
Employees in AZ,CA,GA, MA, MD, MO,NC, NJ and TX must either live or work within the approved DMO®
service area to be eligible to enroll in the DMOO.
DMO and DMO Select are not an available option in AK,AL, AR, GU, LA, ME, MS, MT, ND, NH, PR, SC, SD, VI, VT and
WY.
Limited(varying by state) DMO Non-Participating benefits are included forplans contracts written in:CT,IL, KY, MA and
OH and for plan contracts written and members residing in OK.
Participation Requirements:
Plans and rates shown in this quote are based on employee participation of 60%-89% in the dental plan. Aetna
reservesthe rightto change the proposed plan and rates or decline coverage if this is notthecase.
Rates shown in this quote are based on a commission level ofno commissions.
Employee and Dependent Information
Coverage for retirees is notavailablefor groupswith lessthan 51 eligible employees. Forgroupswith 51 ormoreeligible
employees,retirees cannot compose more than 20 percent of the total number of eligible employees.
Late Entrant exclusions do not apply for DMO contracts written in the State of Texas.
Late Entrant exclusions do notapplyto contracts written in thestate of Maine and to Maine residents.
Colorado: Fully Insured Dental new business cases when the contract is issued in CO -- Pediatric Dental Coverage
This policy DOES NOT include coverage of pediatric dental services as required underfederal law.Coverage of pediatric denta I
services is available for purchase in the State of Colorado,and can be purchased as a stand-alone plan oras a covered benefit in
another health plan.Please contactyour insurance carrier,agent,or Con nectfor Health Colorado to purchase either a plan that
includes pediatric dental coverage,oran Exchange-qualified stand-alone dental plan that includes pediatricdental coverage.
Florida DMO Quotes-Any employer,group,ororganizationthatpays or contributes to the premium of group health insurance
plan or dental service plan corporation which provides dental coverage only upon the condition that services be rendered by an
exclusive list of dentists o r g roups of dentists shall provide an alternative to en able the insured to have a free choice of dentist.The
employer,group,or organization shall pay or contribute an equal dollar amount toward either alternative elected by the insured.
The provisions of this section do not req uirethecommingling of costs and claims experience between the two alternative plan s.
Massachusetts --Minimum Creditable Coverage
03232022 Quote ID: 3354735 page 5
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
This dental plan,alone,does not meet Minimum Creditable Coverage standards and will not satisfy the individual mandatethatyou
have health insurance.
As of January 1,2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents,eighteen(18)years of
age and older,must have health coverage that meets Minimum Creditable Coverage standards setby the Commonwealth Health
Insurance Connector,unless waived fromthehealth insurance requirement based on affordability orindividual hardship. Formore
information call the Con nector at 1-877-MA-ENROLL or visitthe Conn ectorwebs ite(www.mahealthcon nector.org).
This plan is notintended to provide comprehensive health coverageand does notmeet Minimum Creditable Coverage standards,
even if it does include services that are notavailable in the insured's otherhealth plans.
If you havequestions aboutthis notice,you may contactthe Division of Insurance by calling(617)521-7794 orvisiting its website
at www.mass.gov/doi.
*Not applicableto Vital Savings byAetnasm. Please reference the Vital Savings by AetnasM Program Summary and Fee Sheet for
Vital Savings byAetnasM quote conditions.
Attention customers with Massachusetts residents: You should beaware that our network ofpreferred providers in
Massachusetts has providers mainlyin the following counties:Barnstable,Berkshire,Bristol,Essex,Hampden,Hampshire,
Middlesex,Norfolk,Plymouth,Suffolk and Worcester.Members'out of pocket expenses will behigherifthey do notseean in-
network providerand,in some plans,benefits may notbe available at all for out-of-network providers.
New York - Fully Insured Dental new business cases when the contract is issued in NY
For contributory plans,New York state insurance law says, employers must insure not less than 50% of eligible employees or,if
less,5 or more of such employees.To ensure compliancewith this law,Aetna requires New York customers to provide updated
employee census information on an annual basis.
NY,CO and NJ:
Producers(Brokers,Agents Consultants):Licensed and appointed producers may earn compensation in the form of commission
on the sale of this product.The amount of compensation varies depending on a number of factors,including customer segment
and the products selected.Aetna offers additional bonus programs to its producers,which may also apply.Please consult your
broker for additional information concerning his/her compensation forthissale,including commission and any applicable bonus
programs.The producer is prohibited by law from altering the amount ofcompensation received from Aetna based in whole or in
part on thesale.
Salaried employees may earn compensation on thesale ofAetna products based on theservices they provide,including
providing quotes on,and explanations of,Aetna products.The compensation varies depending on a number of factors,
including customer segment and products selected.Combining all factors,and excluding limited-benefitplans,
compensation for each productquoted averages lessthan 0.80%ofthe total first year annual premium. Aetna offers
additional bonus programs,which may also apply.Neither Aetna northeemployee has material ownership interestsin the
other.The employee may not alter the amount of compensation received from Aetna.You may obtain additional
information aboutthe compensation expected to bereceived by eligible employees,based in wholeorin parton thesaleof
an Aetna product,or alternative options presented,by contacting Aetna at https://www.aetna.com/about-aetna-
insurance/contact-us/forms/emp lover/transparencv.html.
Washington—Temporomandibular Joint(TMJ) Disorders:
A Non-surgical TMJ offering is available for purchase resulting in rateimpactto all DMO &PPO non-small group businesswith a
Washington contractstate. If purchased,aTMJ $1000 annual maximum and,$5000 lifetime maximum applies to dental services
related to the treatment of TMJ disorders.To ensure compliance with this State Mandate,Aetna requires Washington customers to
complete an acceptance/denial of purchase for Non-Surgical TMJ coverage at the time ofsale.
Dental EOB's: We make EOGs available through oursecureNavigatorwebsitefor subscribers who have registered to use
Navigatorand forwhomwe have a valid email address.We send members an email when a new EOB is available.All other
members receive paper EOBs. If a member receiving EOBs electronically prefers paper EOBs,they can get them by telling us that
is their preference.
03232022 Quote ID: 3354735 page 6
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Patient Protection and Affordable Care Act— Fees and Assessments
The Patient Protection and Affordable Care Act imposes a Health Insurer Fee(the"Fee"). The Fee became effective on January 1,
2014. The Fee will be suspended for 2017, but reinstated starting in 2018. This rate quote includes,where permitted,the
estimated proportionate allocation of the Fee for the years where the Fee is applicable.
Aetna reserves the rightto modify these rates,or otherwise recoup such Fee if estimates are material ly insufficient.
Health Insurer Fee
Health Insurance Providers Fee(HIF)is a recurring,annual,industry fee assessed based on each insurer's share of thefully
insured market,as determined by the IRS.
Per the Omnibus bill signed on December 20, 2019, HIF has been repealed for2021 and beyond.
This rate quote includes,as applicable,an estimated proportionate allocation of expenses associated with the HIF. Aetna reserves
the rightto modify these rates,or otherwise recoup such fees,based on future regulatory guidance or subsequentstate regulatory
approval.
Dental PPOII - Dental PPO 11 is a vendor based program thatoffers access to contracted rates fordental claims that may
otherwise be paid at billed charges undertheout-of-network portion ofthe Dental PPO plan.Thethird party vendors participating in
the Dental PPO 11 Program network are considered participating providers and services rendered by such providers will be
reimbursed in accordancewith theterms of the Customer's plan as in-network service.
ExtendsM Network- Extends^^is a network that is availablewith the Dental PPOII programto expand in-network access even
further. Extend offers access to contracted providers ata discount less than the Dental PPO and Dental PPO ll,that would
otherwise be paid at billed charges as an out-of-network claim on the Dental PPO plan. Therefore,member's out ofpocketsavings
are maintained or enhanced. Providers in the Extend network are participating providers and their services will be reimbursed in
accordancewith theterms of the Customer's plan at the in-network level.
Dental Out of Network Savings Program —Dental Out of Network Savings program is availablefor Indemnity and PPO dental
plans thatdetermine the Recognized Chargeforout-of-network services based on FAIR Health data; it is not,however,available
fordental benefits thatare embedded with a medical plan. Aetna contracts with third-party network vendors that,in turn,have
contracted with dentists who have agreed to charge discounted rates. Those dentists are still considered o ut-of-netwo rk providers,
and the services they provide will be covered in accordancewith your plan's benefits for out-of-network services.
Proposals for Aetna Dental PPO (including the Freedom-of-Choice plan design and Texas PDN)may not be offered to groups
that haveAssurant Employee Benefits orSunlife as the incumbent Dental PPO carrier,unless theAetna Dental PPO is quoted and
sold along with an Aetna Medical plan.
03232022 Quote ID: 3354735 page 7
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
CENSUS SUMMARY
Dental Summary*
Age Single Two Party Family Waived
M F M F M F M F
<30 7 3 1 0 0 0 0 0
30-34 5 1 4 0 5 1 0 0
35-39 4 1 4 1 9 0 0 0
40-44 2 1 2 1 7 2 0 0
45-49 4 1 1 0 16 5 0 0
50-54 2 1 1 2 11 1 4 1 0 0
55-59 1 0 4 2 8 3 0 0
60-64 2 1 1 2 5 1 3 0 0
65+ 12 1 4 20 7 0 0 0 0
The numberof lives represents all lives submitted in this quote. Please see theapplicable Benefit,Rate&Premium Information page forthe
eligible lives quoted.
03232022 Quote ID: 3354735 page 8
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
SELECTED PRODUCTS/PROGRAMS SITEMATCH SUMMARY
Sitematch summary information included in this proposal maybe limited to the group headquarters state.
DENTAL
Employee Subgroup: All Other Employees
Option: 1
With Network Access
Product/Program State Net ID Network Name Employees Totals
PPOD AZ 1872 Arizona 1
PPOD FL 1848 Southeastern Florida 1
PPOD FL 1849 Tampa& So.West Florida 1
PPOD IL 1863 Chicago&No. Illinois 133
PPOD IN 1859 Northwestern Indiana 1
PPOD TN 1851 Tennessee 1
Total Employees With PPOD Network Access 138
Without Network Access
State Employees Totals
Total Employees Without Network Access 0
Network Access Summary
Product/Program Access Percent
PPOD 100%
Without Network Access 0%
Formembers residing inthestate of Texas, PDN substitutes the referenceto PPO Dental.
0323/2022 Quote ID: 3354735 page 9
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Employee Subgroup: Fire Union
Option: 1
With Network Access
Product/Program State Net ID Network Name Employees Totals
PPOD IL 1863 Chicago&No. Illinois 46
Total Employees With PPOD Network Access 46
Without Network Access
State Employees Totals
Total Employees Without Network Access 0
Network Access Summary
Product/Program Access Percent
PPOD 100%
Without Network Access 0%
Formembers residing inthestate of Texas, PDN substitutes the referenceto PPO Dental.
03232022 Quote ID: 3354735 page 10
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
PPO DENTAL PLAN DESIGN AND BENEFITS
For Option: 1
For Subgroup:All Other Employees
Network/Service Area:Arizona,Chicago&No.Illinois,Northwestern Indiana,Southeastern Florida,Tampa&So.West Florida, Tennessee
Plan Features In-Network Benefits Out-of-Network Benefits
Annual Deductible $50 $50
The deductiblefor PPO/PDN The deductiblefor
Dental benefits applies to Basic PPO/PDN Dental benefits
and Major Services. applies to Basic and Major
Services.
Family Deductible 3X Individual 3X Individual
Calendar Year Maximum $1,500 $1,500
Coverage Levels
Preventive& Diagnostic 100% 100%
Basic Restorative 80% 80%
Major Restorative 50% 50%
Endo/Perio 3„ 80% 80%
Endo/Perio Other 80% 80%
Annual Coinsurance lncreaseforSubsequentYears Does not apply Does not apply
"`Annual Coinsurance Increase Does notapply Does notapply
Annual Maximum Increasefor Subsequent Years Does notapply Does not apply
Number of Increases Does notapply Does notapply
Annual Maximum Year 2 Does not apply Does notapply
Annual Maximum Year 3 Does not apply Does not apply
Annual Maximum Year 4 Does not apply Does notapply
Penalty for No Visit Does notapply Does notapply
R&C Percentile 90th
Extend Network Include
Orthodontics
Orthodontia Eligibility Adults and Dependent Children Adults and Dependent
Children
Orthodontia Coinsurance 50% Coinsurance 50% Coinsurance
Removal of Orthodontia Work in Progress Exclusion(Buy Up) Standard Exclusions Apply Standard Exclusions Apply
Visits and Exams
Oral examination visit-(limited to 2 routine and 2 other exams 100% 100%
per year)
Prophylaxis,including scaling and polishing (2 per year) 100% 100%
Fluoride(1 application peryear) 100% 100%
Sealants (1 treatment pertooth every 3 years on permanent 100% 100%
molars only)
X-rays
Bitewing x-rays(1 set per year) 100% 100%
Full mouth series(1 set every 3 years) 100% 100%
Periapical x-rays 100% 100%
Endodontics
Pulpotomy 80% 80%
Root canal therapy,anterior or bicuspid tooth,with x-rays and 80% 80%
cultures
Apicoectomy 80% 80%
Root canal therapy,molar teeth,with x-rays and cultures 80% 80%
Minor Restorations
Amalgam (silver)fillings 80% 80%
Composite fillings 80% 80%
Stainless steel crowns 80% 80%
Periodontics
Scaling and root planing (4 separate quad rants every 2 years) 80% 80%
Gingivectomy(1 per quadrantevery 3 years) 80% 80%
" Osseous surgery(1 per q uad rant every 3 years) 80% 80%
Crown Lengthening 80% 80%
03232022 Quote ID: 3354735 page 11
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Plan Features In-Network Benefits Out-of-Network Benefits
Oral Surgery
Incisionand drainageof abscess 80% 80%
Uncomplicated extractions 80% 80%
Surgical removal of erupted tooth 80% 80%
Surgical removal of impacted tooth(softtissue) 80% 80%
* Surgical removal of impacted tooth(full or partial bony) 80% 80%
Prosthodontics/Major Restorations
In lays/On lays 50% 50%
Crowns 50% 50%
Crown Build Ups 50% 50%
Bridges 50% 50%
Full& partial dentures 50% 50%
Denture repairs 50% 50%
Pontics 50% 50%
Dental Implants(Buy Up) 50% 50%
Fluoride Increase Age Limit To age 19 To age 19
Sealants Remove Age Limit To age 16 To age 16
Posterior Composite Covered Covered
Prosthetic Replacement 8 Years 8 Years
Anesthesia
General Anesthesia/IV Sedation 80% 80%
Space Maintainers 100% 100%
Dental Dependent Age Selections
Non Stud entAge: 26 26
Student Age: 26 26
Non Student: DependentAge Termination of Coverage End of Month End of Month
Student: DependentAge Termination of Coverage End of Month End of Month
Contribution
Voluntary No No
Emp to yeeContri bution 20% 20%
For members residing in Texas,a)PDN substitutes the reference to PPO Dental, b)your In-and Out-of Network benefits are the
In-Network benefits shown above.
*** Maximum of 3 annual coinsurance increases up to a maximum of 100%/100%/70%. Please noteth at coinsurance maximums
may vary or be lower in some states.
03/23/2022 Quote ID: 3354735 page 12
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
PPO DENTAL PLAN DESIGN AND BENEFITS
For Option:1
For Subgroup: Fire Union
Network/Service Area:Chicago&No.Illinois
Plan Features In-Network Benefits Out-of-Network Benefits
Annual Deductible $50 $50
The deductiblefor PPO/PDN The deductiblefor
Dental benefits applies to Basic PPO/PDN Dental benefits
and Major Services. applies to Basic and Major
Services.
Family Deductible 3X Individual 3X Individual
Calendar Year Maximum $1,500 $1,500
Coverage Levels
Preventive& Diagnostic 100% 100%
Basic Restorative 80% 80%
Major Restorative 50% 50%
Endo/Perio 3' 80% 80%
Endo/Perio Other 80% 80%
Annual Coinsurance Increase for Subsequent Years Does not apply Does not apply
"`Annual Coinsurance Increase Does not apply Does not apply
Annual Maximum Increasefor Subsequent Years Does not apply Does notapply
Number of Increases Does notapply Does notapply
Annual Maximum Year 2 Does notapply Does notapply
Annual Maximum Year 3 Does not apply Does notapply
Annual Maximum Year 4 Does not apply Does not apply
Penalty for No Visit Does notapply Does not apply
R&C Percentile 90th
Extend Network Include
Orthodontics
Orthodontia Eligibility Adults and Dependent Children Adults and Dependent
Children
Orthodontia Coinsurance 50% Coinsurance 50% Coinsurance
Orthodontia Lifetime Maximum $2,000 $2,000
Removal of Orthodontia Work in Progress Exclusion(Buy Up) Standard Exclusions Apply Standard Exclusions Apply
Visits and Exams
Oral examination visit-(limited to 2 routineand 2 otherexams 100% 100%
per year)
Prophylaxis,including scaling and polishing(2peryear) 100% 100%
Fluoride(1 application peryear) 100% 100%
Sealants (1 treatment per tooth every 3 years on permanent 100% 100%
molars only)
X-rays
Bitewing x-rays(1 set per year) 100% 100%
Full mouth series(1 set every 3 years) 100% 100%
Periapical x-rays 100% 100%
Endodontics
Pulpotomy 80% 80%
Rootcanal therapy,anterior or bicuspid tooth,with x-rays and 80% 80%
cultures
Apicoectomy 80% 80%
" Rootcanal therapy,molarteeth,with x-rays and cultures 80% 80%
Minor Restorations
Amalgam (silver)fillings 80% 80%
Composite fillings 80% 80%
Stainless steel crowns 80% 80%
Periodontics
Scaling and rootplaning(4 separate quadrants every years) 80% 80%
Gingivectomy(1 perquadrantevery 3 years) 80% 80%
Osseous surgery(1 per quadrantevery 3 years) 80% 80%
Crown Lengthening 80% 80%
03232022 Quote ID: 3354735 page 13
Filing Info: AQCAZProposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Plan Features In-Network Benefits Out-of-Network Benefits
Oral Surgery
Incisionand drainage of abscess 80% 80%
Uncomplicated extractions 80% 80%
Surgical removal of erupted tooth 80% 80%
Surgical removal of impacted tooth(softtissue) 80% 80%
Surgical removal of impacted tooth(full or partial bony) 80% 80%
Prosthodontics/Major Restorations
Inlays/Onlays 50% 50%
Crowns 50% 50%
Crown Build Ups 50% 50%
Bridges 50% 50%
Full& partial dentures 50% 50%
Denture repairs 50% 50%
Po n ti cs 50% 50%
Dental Implants(Buy Up) 50% 50%
Fluoride Increase Age Limit To age 19 To age 19
Sealants Remove Age Limit To age 16 To age 16
Posterior Composite Covered Covered
Prosthetic Replacement 8 Years 8 Years
Anesthesia
General Anesthesia/IV Sedation 80% 80%
Space Maintainers 100% 100%
Dental Dependent Age Selections
No n Stud en t Ag e: 26 26
Student Age: 26 26
Non Student: Dependent Age Termination of Coverage End of Month End of Month
Student: DependentAge Termination of Coverage End of Month End of Month
Contribution
Voluntary No No
Employee Contribution 20% 20%
Formembers residing in Texas,a)PDN substitutes the reference to PPO Dental, b)your In-and Out-of Network benefits are the
In-Network benefits shown above.
"` Maximum of 3 annual coinsurance increases up to a maximum of 100%/100%/70%. Please noteth at coinsurance maximums
may vary or be lower in somestates.
03232022 Quote ID: 3354735 page 14
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
DENTAL LIMITATIONS &EXCLUSIONS*
Oral exams are limited to four per yearfor DMO dental plans,and two routine andtwo otherexams peryearforPPO and Indemn ity dental plans.
Undera DMO dental plan,services performed by specialists,including general anesthesia,are eligible for coverage onlywhen prescribed bythe
primary care dentist and authorized by Aetna. Copayments underthe DMO plan are based on the dentist's reasonable and customary fees.
Emergency Dental Care
Undera DMO dental plan,if you need emergency dental care forthe palliative treatment(pain relieving,stabilizing)of a de ntal emergency,you are
covered 24 hours a day,7 days a week. You should contactyour Primary Care Dentist to receive treatment. If you are unable to contactyour
PCD,contact Member Services for assistance in locating a dentist.Referto your plan documents fordetails.Subject to state requirements.Out-of-
area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.
When emergency services are provided by a participating PPO dentist,your co-payment/coinsurance amount will be based on a negotiated fee
schedule. When emergency services are provided by anon-participating dentist,you will be responsible forthe difference between the plan
payment and the dentist's usual charge.Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental
care maybe reviewed by our dental consultants to verify appropriateness of treatment.
Under an Indemnity dental plan,benefits payable are limited to the prevailing(usual and customary)charge level,as determined by Aetna per the
terms of your benefit plan.
*Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care maybe reviewed by our dental
consultants to verify appropriateness of treatment.
Some of the Services not covered under the plan are:
1. Those for services or supplies which are covered in whole or in part:
(a)Under any other part of this Dental Care Plan;or
(b)Under any other plan of group benefits provided by or through your employer.
2. Those for services and supplies to diagnose or treat a disease or injury that is not:
(a)A non-occupational disease;or
(b)A non-occupational injury.
3. Those forservices not listed in the Dental Care Schedule that applies;unless otherwise specified in the Booklet-Certificate.
4. Those for replacement of a lost;missing;or stolen appliance;and those for replacement of appliances that have been damaged due to abuse;
misuse;or neglect.
5. Those for:plastic;reconstructive;orcosmetic surgery;orotherdental services orsupplies which are primarily intended to improve;alter;or
enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns
and pontics will always be considered cosmetic.
6. Those for;or in connection with:services;procedures;drugs;or other supplies that are determined by Aetnato be experimental;orstill under
clinical investigation by health professionals.
7. Those for:dentures;crowns;inlays;onlays;bridgework;or other appliances or services used forthe purpose of splinting;to alter vertical
dimension to restore occlusion;or correcting attrition;abrasion;or erosion.
8. Those for any of the following services:
(a)An appliance;or modification of one;if an impression for it was made before the person became a covered person;
(b)A crown; bridge;or cast or processed restoration;if a tooth was prepared for it before the person became a covered person;
(c)Root canal therapy;if the pulp chamber for it was opened before the person became covered person.
9. Those forservices that Aetna defines as not necessary forthe diagnosis;care;ortreatment of the condition involved. This applies even if they
are prescribed;recommended;or approved by the attending physician or Dentist.
10.Those for services intended fortreatment of any Jaw Joint Disorder;unless otherwise specified in the Booklet-Certificate.
11.Those for Space Maintainers except when needed to preserve space resulting from the premature loss of deciduous teeth.
12.Those for orthodontic treatment;unless otherwise specified in the Booklet-Certificate.
13.Those for general anesthesia and intravenous sedation unless specifically covered. For plans which cover these services,they will not be
eligible for benefits unless done in conjunction with another necessary covered service.
14.Those for treatment by other than a Dentist;exceptthat scaling or cleaning of teeth and topical application of fluoride maybe done by a
licensed dental hygienist. In this case,the treatment must be given underthe supervision and guidance of a Dentist.
15.Those in connection with a service given to a person age five or more if that person becomes a covered person other than:(a)during the first
31 days the person is eligible forth is coverage;or(b)as prescribed for any period of open enrollment agreed to by the Employer and Aetna. This
does not apply to charges incurred:
(a)Afterthe end of the twelve month period starting on the date the person became a covered person;or
(b)As a result of accidental injuries sustained while the person was a Covered Person;or
(c)For a Primary Care Service in the Dental Care Schedule that applies shown underthe headings Visits and Exams;and X-rays and Pathology.
16.Those for services given by a Non-Par Dental Provider to the extent that the charges exceed the amount payable for the services shown in the
Dental Care Schedule that applies.
17.Those fora crown;cast;or processed restoration unless:
(a)It is treatment fordecay ortraumatic injury and teeth cannot be restoredwith a filling material;or
(b)The tooth is an abutment to a covered partial denture or fixed bridge.
18.Those forpontics;crowns;castor processed restorations made with high noble metals;unless otherwise specified in the Booklet-Certificate.
19.Those for surgical removal of impacted wisdom teeth only for orthodontic reasons;unless otherwise specified in the Booklet-Certificate.
20.Those for services needed solely in connection with non-covered services.
21.Those forservices done where there is no evidence of pathology;dysfunction;ordisease otherthan covered preventive se rvices
03232022 Quote ID: 3354735 page 15
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage.
Dental Care Plan coverage is subiectto the following rules:
Replacement Rule:The replacement of;addition to;or modification of:existing dentures;crowns;casts or processed restorations;removable
bridges;orfixed bridgework is covered only if one of the following terms is met:
(a)The replacement oraddition of teeth is required to replace oneor more teeth extracted afterthe existing denture orbridgeworkwas installed.
Dental Care Plan coverage must have been in force forthe covered personwhen the extraction took place.
(b)The existing denture;crown;cast orprocessed restoration;removable bridge;orbridgewo rk cannot be made serviceable;andwas installed at
least five years undera DMO dental plan and at least eight years undera PPO or Indemnity dental plan before its replacement. However,if under
a PPO or Indemnity dental plan a prosthetic replacement buy up is selected,then its replacement is at least five years.
(c)The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered;and cannot be
made permanent;and replacement by a permanent denture is required. The replacement must take place within 12 months from the date of initial
installation of the immediate temporary denture.
Tooth Missing But Not Replaced Rule:Coverage forthe first installation of removable dentures;removable bridges;and fixed bridgework is subject
to the requirements that such dentures;removable bridges;andfixed bridgework are(i)needed to replace oneormore natural teeth thatwere
removed while this policywas in force for the covered person;and(ii)are not abutments to a partial denture;removable bridge;orfixed bridge
installed at least five years undera DMO dental plan and eight years undera PPO or Indemnity dental plan before its replace ment. This rule not
applicable to California and Texas members. However,if undera PPO or Indemnity dental plan a prosthetic replacement buy up is selected,then
its replacement is at least five years.
Alternate Treatment Rule:If more than one service can be used to treat a covered person's dental condition;Aetna may decideto authorize
coverage only fora less costly covered service provided that all of the following terms are met:
(a)The service must be listed on the Dental Care Schedule;
(b)The service selected must be deemed bythe dental profession to be an a pprop date method of treatment;and
(c)The service selected must meet broadly accepted national standards of dental practice.
If treatment is being given by a Par Dental Providerand the covered person asks fora more costly covered service than that forwhich coverage is
approved;the specific Copayment forsuch service will consist of:
(a)The Copayment forthe approved less costly service;plus
(b)The difference in cost between the approved less costly service and the more costly covered service.
Consult Aetna's on-line provider directory for the most current provider listings. Participating providers are independent contractors in private
practice and are neither employees nor agents of Aetna or its affiliates. The availability of any particular provider cannotbe guaranteed for referred
or in-network benefits,and provider network composition is subject to change without notice. Not every provider listed in the directory will be
accepting new patients. Although Aetna has identified providers who were not accepting patients as known to Aetna at the time this provider
directory was created,the status of a provider's practice may have changed. For the most current information,please contact the selected provider
or Member Services at the toll-free number on your online ID card.
This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial,general description
of plan or program benefits and does not constitute a contractor any part of one. Fora complete description of the benefits available to you,
including procedures,exclusions and limitations,please requesta copy of yourspecific plan documents,which may include the Group Insurance
Certificate or Booklet,Group Insurance Policy and any applicable riders to your plan. All the terms and conditions of your plan or program are
subject to and governed by applicable contracts,laws,regulations and policies. The availability of a plan or program may vary by geog raphic
service area,and not all plans or programs are available in all areas. All benefits are subject to coordination of benefits.
Specific products may not be available on both a self-funded and insured basis. The information in this document is subject to change without
notice. In case of a conflict between your plan documents and this information,the plan documents will gove m.
In the event of a problem with coverage,members should contact Member Services at the toll-free number on their online ID cards for information
on howto utilize the grievance procedure when appropriate.
All membercare and related decisions are the sole responsibility of participating providers. Aetna does not provide health care services and,
therefore,cannot guarantee any results oroutcomes.
Dental benefits are provided oradministered by: Aetna Life Insurance Company,Aetna Dental of Ca lifomia Inc.,Aetna Health Inc.and Aetna
Dental Inc.
In Arizona,Advantage Dental,Basic Dental and Family Preventive Dental Plans are provided oradministered by Aetna Health Inc.;PPO and
Indemnity Dental plans are provided oradministered by Aetna Life Insurance Company.
For members residing in the state of Texas,PDN substitutes the reference to PPO Dental.
In Virginia,the DMO®Plan is known as the DNO (Dental Network Only)Plan.
*Not applicable to Vital Savings byAetnaSm
03232022 Quote ID: 3354735 page 16
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584
VILLAGE OF OAK BROOK
Industry Code: 9111
Proposed Effective Date: 07/01/2022
For members of a 100/0/0 plan: Replacement rule,Tooth Missing but not Replaced rule,Alternate Treatment rule,and Emergency Dental Care
may not apply.
03232022 Quote ID: 3354735 page 17
Filing Info: AQC AZ Proposal-1(12/01) Proposal ID: 575584