Zoe Center for Pediatric and Adolescent Health, LLC
Detailed Rates : Level Funding Q3P2 Triple Option Plan: Q3 OAP BASE
Product: Open Access Plus
Subs
Admin Fee Individual Stop Loss
Aggregate Stop Loss
Fixed Costs Claims Funding
Total Costs
Employee
88
$36.60 $78.68 $65.14 $107.23
$97.02 $208.59 $172.69 $284.26
$16.60 $35.69 $29.55 $48.64
$150.22 $322.96 $267.38 $440.13
$374.22 $804.56 $666.10 $1,096.45
$524.44 $1,127.52 $933.48 $1,536.58
Emp + Spouse Emp + Child(ren) Emp + Family Monthly Cost
1
9 0
98
$3,885.74
$10,300.56
$1,762.44
$15,948.74
$39,730.82
$55,679.56
Plan: Q3 OAP BUYUP
Product: Open Access Plus
Subs
Admin Fee Individual Stop Loss
Aggregate Stop Loss
Fixed Costs Claims Funding
Total Costs
Employee
30
$36.87 $79.27 $65.62 $108.03 $1,785.59
$101.57 $218.39 $180.80 $297.61 $4,919.11
$18.90 $40.64 $33.65 $55.38 $915.37
$157.34 $338.30 $280.07 $461.02
$426.13 $916.18 $758.51
$583.47 $1,254.48 $1,038.58 $1,709.58
Emp + Spouse Emp + Child(ren) Emp + Family Monthly Cost Plan: Q3 HSA
2 3 3
$1,248.56
38
$7,620.07
$20,637.47
$28,257.54
Product: HSA Open Access Plus
Subs
Admin Fee Individual Stop Loss
Aggregate Stop Loss
Fixed Costs Claims Funding
Total Costs
Employee
0 0 0 0
$40.87 $87.86 $72.74 $119.74
$97.90 $210.48 $174.25 $286.83
$11.58
$150.35 $323.23 $267.59 $440.49
$260.95 $561.05 $464.50 $764.60
$411.30 $884.28 $732.09 $1,205.09
Emp + Spouse Emp + Child(ren) Emp + Family Monthly Cost
$24.89 $20.60 $33.92
0
$0.63
$1.51
$0.18
$2.32
$4.03
$6.36
Cost Summary
Admin Fee Individual Stop Loss
Aggregate Stop Loss
Fixed Costs Claims Funding
Total Costs
Monthly Total Annual Total
$5,671.96
$15,221.18
$2,677.99 $32,135.87
$23,571.13
$60,372.32
$83,943.46
$68,063.54
$182,654.20
$282,853.61
$724,467.89 $1,007,321.52
Funding Details Individual Stop Loss Limit (Medical & Rx)
$40,000
Corridor Factor (Total)
110%
Surplus Share
1/2 retained by Cigna Healthcare, 1/2 returned to the Employer
Benefit Advisor Fees / Commissions
$40.00 PEPM
The quoted rates are subject to final Underwriting approval.
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