HomeMy WebLinkAboutWellmark-5/4/2015 (4)Wean* Elkn Comard&ue$ 4 On1r417.aFal
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Group Name City of Waterloo
Account Key 00014392
Rating Period: 07/01/2015 to 06/30/2016
Aflerriae itiOfrenrogi
OBS #188067-18 / #188067-19
Alliance Select
Deductible: $500/$1,000;$1,000/$2,000
Coinsurance: 20% / 40%
OPM: $1,000/$2,000;$2,000/$4,000
Office Visit Copay: See OBS
BlueRx Complete
Deductible: $0 / $0
Copay: $15/$30/$60
FINAL RATES
Level
'-r>_rol
150 Single
489 Family
639 Total
alagNL
efims.
24/12 Contract
No Monthly Aggregate
Weekly Draw
Estimated Annual Premium
Fee/Contract Based on Current Enrollment
Individual Stop Loss $100,000 $118.60 $909,425
Aggregate Stop Loss 125% $2.38 $18,250
Administrative Fees - Health w/weekly settlement $26.17 $200,672
Administrative Fees - PBM $1.91 $14,646
Consultant Fee $0.00 $0
Total Administrative Fees $149.06 $1,142,992
Network Access Fee $7.82 $59,964
Single Family Annual Projection
Expected Claims $538.22 $1,345.55 $8,864,483
Administrative, NAF & Stop Loss Fees $73.04, $182.60 $1.202.969
Estimated Suggested Rates* $611.26 $1,528.15 $10,067,452
Attachment Points $672.77 $1,681.93 $11,080,551
Administrative, NAF & Stop Loss Fees $73.04, $182.60 $1.202.969
Estimated Maximum Liability to Fund* $745.81 $1,864.53
$12,283,520
*Actual results may vary. Also, rates provided include administrative costs based on the entire group population.
Individual Stop Loss includes coverage for Health and Drug and is based on a lifetime maximum of unlimited.
Aggregate Stop Loss includes coverage for Health and Drug. The maximum Aggregate reimbursement is unlimited.
Employer Signature:
Date: LI /2-7/i
Comments:
Pharmacy Fee/Contract is an estimate based on account specific member counts at the time the renewal was completed. The account will not be
billed the estimated Pharmacy administration Fee/Contract amount. Rather, the account will be billed $0.68 PMPM on its monthly invoice.
v4.1.0
Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date: 4/8/2015
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