Zoe Center for Pediatric and Adolescent Health, LLC
22. includes fixed charges for Embarc Benefit Protection℠, a network solution for certain high-cost gene therapy drugs arranged by eviCore. 23. assumes a deposit equivalent to one month of Insurance and Admin costs is collected at time of sale and applied as a credit to your first bill. 24. assumes Cigna Healthcare will set aside a portion of the claims funding collected throughout the year and apply these funds to claims that are paid after the policy has been terminated. Any and all surpluses in claim funding may be forfeited and retained by us as a deferred service fee, including those at the end of the claim run-out period. There will be no additional administration, insurance, or claims charges following the termination date. 25. assumes year-end accounting will be completed on an annual basis 90 days following the policy anniversary date. Any applicable refund will appear as a credit to Insurance and Admin costs in subsequent months. 26. Cigna Healthcare assumes that the group health plan or health insurance coverage to which this proposal applies will not be a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the "Act") and that it will be subject to all requirements of the Act applicable to a group health plan or health insurance coverage unless otherwise specified in writing. 27. does not include paying on behalf of the Plan the Comparative Effectiveness Research Fee required under section 4376 of the Internal Revenue Code as added by the Patient Protection and Affordable Care Act. Cigna Healthcare is prohibited from calculating, collecting and paying the fee on behalf of the Plan. 28. assumes applicable requirements of the Patient Protection and Affordable Care Act will be implemented on the effective date/renewal date unless you direct otherwise. 29. For covered mental health and substance abuse services from participating providers, Cigna Healthcare shall apply discounts available under an agreement with its affiliate, Evernorth Behavioral Health, Inc. or Evernorth Care Solutions, Inc. Zoe Center for Pediatric and Adolescent Health, LLC shall pay Cigna Healthcare 33% of the savings (billed charges less negotiated rate x .33) which shall be taken from Zoe Center for Pediatric and Adolescent Health, LLC's bank account when the claim for covered services is paid. 30. assumes that dental/vision benefits will be under a separate ASO agreement and are excepted benefits and not subject to HIPAA and ACA requirements. 31. Assumes that drugs covered under the plan's pharmacy benefit shall be administered in accordance with the following estimated pricing terms for the product Open Access Plus: ● Average Brand Discount: Average Wholesale Price - 27.24% ● Average Generic Discount: Average Wholesale Price - 83.65% ● Average Specialty Discount: Average Wholesale Price - 26.69% ● Average Dispensing Fee: $1.14 Cigna earns financial Rebates through drug manufacturer arrangements on certain drugs that are included on Cigna's prescription drug list (a/k/ a Formulary). For some of the drugs for which Cigna may earn financial Rebates, Cigna uses some portion of the financial Rebate value to adjust the Prescription Drug Charges payable by you, as the plan sponsor, and/or Members for those drugs. 32. Assumes that drugs covered under the plan's pharmacy benefit shall be administered in accordance with the following estimated pricing terms for the product Open Access Plus: ● Average Brand Discount: Average Wholesale Price - 27.24% ● Average Generic Discount: Average Wholesale Price - 83.65% ● Average Specialty Discount: Average Wholesale Price - 26.69% ● Average Dispensing Fee: $1.14 Cigna earns financial Rebates through drug manufacturer arrangements on certain drugs that are included on Cigna's prescription drug list (a/k/ a Formulary). For some of the drugs for which Cigna may earn financial Rebates, Cigna uses some portion of the financial Rebate value to adjust the Prescription Drug Charges payable by you, as the plan sponsor, and/or Members for those drugs. 33. Assumes that drugs covered under the plan's pharmacy benefit shall be administered in accordance with the following estimated pricing terms for the product HSA Open Access Plus: ● Average Brand Discount: Average Wholesale Price - 27.24% ● Average Generic Discount: Average Wholesale Price - 83.65% ● Average Specialty Discount: Average Wholesale Price - 26.69% ● Average Dispensing Fee: $1.14 Cigna earns financial Rebates through drug manufacturer arrangements on certain drugs that are included on Cigna's prescription drug list (a/k/ a Formulary). For some of the drugs for which Cigna may earn financial Rebates, Cigna uses some portion of the financial Rebate value to adjust the Prescription Drug Charges payable by you, as the plan sponsor, and/or Members for those drugs. 34. does not apply to individuals unless employed by the policyholder or an entity that participates in an association or trust that is the policyholder. ● ADDITIONAL GENERAL TERMS OF THIS PROPOSAL: 35. The information contained in this Proposal by Cigna Healthcare is proprietary and highly confidential. It is being provided with the understanding that it will not be used by the employer, its representatives or consultants for any purpose other than the evaluation of the Proposal. Under no circumstances is any of the information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used, disseminated, disclosed or otherwise communicated to any person or entity other than the employer, its representatives and consultants, and their respective employees who are directly involved in the evaluation process. 36. For Cigna Diabetes Prevention Program in Collaboration with Omada, if elected fees charged by the network provider via the claim account are as follows: $235 Enrollment fee charged via claim when the member enrolls in the program. Following Enrollment, claims will vary based on the amount of weight lost.
C. Additional Representations & Disclosures 1. The quoted rates are subject to final Underwriting approval. 2.
Each plan presented in this proposal has an actuarial value, determined by Cigna Healthcare, of 60% or greater. This determination was made using Cigna Healthcare's manual rating application which may produce an actuarial value slightly different than the official HHS calculator. Although we would expect any deviation to be small, you will have to consult with your actuarial consultant for a more precise determination of the plan's actuarial value. Cigna Healthcare does not provide actuarial certifications. 3. Cigna Healthcare may pay on your behalf any applicable state tax or assessment imposed upon your plan by drawing upon the bank account. 4. In order to implement the requested benefit design, different funding arrangements (i.e., insured, self-insured and/or HMO) involving affiliated Cigna companies may be required with respect to plan participants residing in certain states.
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