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Group Name
Account Key
Rating Period:
City of Waterloo
00014392
07/01/2015 to 06/30/2016
Alfemafe' Benefit
OBS #188067-17 / #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
Individual Stop Loss
Aggregate Stop Loss
Administrative Fees - Health
Administrative Fees - PBM
Network Access Fee
150 Single
489 Family
639 Total
Sfop;boss
24/12 Contract
No Monthly Aggregate
Weekly Draw
Level Fee/Contract
$100,000 $118.60
125% $2.38
w/weekly settlement
Consultant Fee
$26.17
$1.91
$0.00
Estimated Annual Premium
Based on Current Enrollment
$909,425
$18,250
$200,672
$14,646
$0
Total Administrative Fees $149.06
Single Family
Expected Claims $538.22 $1,345.55
Administrative, NAF & Stop Loss Fees $73.04 $182.60
Estimated Suggested Rates* $611.26 $1,528.15
Attachment Points $672.77 $1,681.93
Administrative, NAF & Stop Loss Fees $73.04 $182.60
Estimated Maximum Liability to Fund* $745.81 $1,864.53
$7.82
*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.
$1,142,992
$59,964
Annual Projection
$8,864,483
$1.202.969
$10,067,452
$11,080,551
$1.202.969
$12,283,520
Employer Signature:
Date: Lila 7 /A
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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