RETIREE BENEFIT HIGHLIGHTS - Hollywood, FL

 
RETIREE BENEFIT HIGHLIGHTS - Hollywood, FL
2018 | RETIREE BENEFIT HIGHLIGHTS
RETIREE BENEFIT HIGHLIGHTS - Hollywood, FL
RETIREE BENEFIT HIGHLIGHTS - Hollywood, FL
City of Hollywood | Retiree Benefit Highlights | 2018

                                                  Table of Contents

                                                                Contact Information                                                                                                     1
                                                                      Introduction                                                                                                      2
                                                                           Notices                                                                                                      2
                                                                              Online Benefit Enrollment                                                                                 2
                                                                                 Group Insurance Eligibility                                                                            3
                                                                                    Medical Insurance                                                                                   4
                                                                                              Other Available Plan Resources                                                            4
                                                                                               Cigna – OAP In-Network Plan At-A-Glance                                                  5
                                                                                                Cigna – OAP Plan At-A-Glance                                                            6
                                                                                         Dental Insurance                                                                               7
                                                                                                 Cigna – Dental PPO Low Plan At-A-Glance                                                8
                                                                                                 Cigna – Dental PPO High Plan At-A-Glance                                             10
                                                                                         Vision Insurance                                                                             11
                                                                                                 VSP – Vision Plan Option 1 At-A-Glance                                               12
                                                                                                VSP – Vision Plan Option 2 At-A-Glance                                                14
                                                                                               VSP – Vision Plan Option 3 At-A-Glance                                                 16
                                                                                     Retiree Basic Life                                                                               17
                                                                                   Notes                                                                                         17-20

   This booklet is merely a summary of benefits. For a full description, refer to the plan document. Where conflict exists between this summary and the plan document, the plan document controls.
                   The City of Hollywood reserves the right to amend, modify or terminate the plan at any time. This booklet should not be construed as a guarantee of employment.
RETIREE BENEFIT HIGHLIGHTS - Hollywood, FL
City of Hollywood | Retiree Benefit Highlights | 2018

Contact Information

                                        Tammie Hechler                                 Phone: (954) 921-3218
       City of Hollywood
                                        Director of Human Resources                    Email: thechler@hollywoodfl.org

                                                                                       (888) 5-BenTek (523-6835)
       Online Employee Benefit Center   BenTek                                         Email: support@mybentek.com
                                                                                       www.mybentek.com/hollywood

                                                                                       Customer Service: (800) 244-6224
       Medical Insurance                Cigna
                                                                                       www.cigna.com

       Prescription Drug Coverage                                                      Customer Service: (800) 835-3784
                                        Cigna Home Delivery Pharmacy
       & Mail-Order Program                                                            www.cigna.com

                                                                                       Customer Service: (800) 244-6224
       Dental Insurance                 Cigna
                                                                                       www.cigna.com

                                                                                       Customer Service: (800) 877-7195
       Vision Insurance                 VSP
                                                                                       www.vsp.com

                                                                                       Customer Service: (800) 796-3872
       Retiree Basic Life               Symetra
                                                                                       www.symetra.com

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RETIREE BENEFIT HIGHLIGHTS - Hollywood, FL
City of Hollywood | Retiree Benefit Highlights | 2018

                                                                                     Online Benefit Enrollment
                                                                                     The City provides retirees with an online benefits enrollment platform
                                                                                     through BenTek’s Employee Benefits Center (EBC). The EBC provides
                                                                                     benefit-eligible retirees the ability to select or change insurance
                                                                                     benefits online during the annual open enrollment period, new hire
                                                                                     orientation, or qualifying events.
Introduction                                                                         Accessible 24 hours a day throughout the year, retiree may log in and
The City of Hollywood provides a comprehensive compensation package                  review comprehensive information regarding benefit plan(s) and view
including group insurance benefits. The Retiree Benefit Highlights Booklet           and print an outline of benefit elections for retiree and dependent(s).
provides a general summary of these benefit options as a convenient reference.       Retiree has access to important forms and carrier links, can report
Please refer to the City's policies or applicable collective bargaining agreements   qualifying life events and review and make changes to life insurance
and/or Certificates of Coverage for detailed descriptions of all available retiree   beneficiary designations.
benefit programs and stipulations therein. If further explanation or assistance
is needed regarding claims processing, please refer to the customer service
phone numbers under each benefit description heading or contact Human
Resources for further information.

Notices
Medicare Part D Creditable Coverage
The City of Hollywood’s prescription drug coverage(s) is considered Creditable
Coverage under Medicare Part D. If you or your dependents are or will be eligible     To Access the Employee Benefits Center:
for Medicare, you may obtain more information by requesting a Medicare Part
                                                                                           99
                                                                                            Log on to www.mybentek.com/hollywood
D Disclosure of Creditable Coverage Notice.
                                                                                           99
                                                                                            Sign in using a previously created username and password or
More information is available on the above Notices by contacting Human                         click "Create an Account" to set up a username and password.
Resources.                                                                                 9   9
                                                                                               If retiree has forgotten username and/or password, click
                                                                                               on the link “Forgot Username/Password” and follow the
                                                                                               instructions.
                                                                                           9   9
                                                                                               Once logged on, navigate to the menu in order to review
                                                                                               current elections, learn about benefit options, and make
                                                                                               elections, changes or beneficiary designations.

                                                                                     For technical issues directly related to using the EBC please
                                                                                     call (888) 5-BenTek (523-6835) or email BenTek Support at
                                                                                     support@mybentek.com, Monday through Friday, during regular
                                                                                     business hours from 8:30 a.m. to 5:00 p.m.

                                                                                               To access group insurance benefits online, log on to:
                                                                                                      www.mybentek.com/hollywood
                                                                                     Please Note: Link must be addressed exactly as written (Due to security reasons,
                                                                                     the website cannot be accessed by Google or other search engines.)

                                                                                                                                                                        2
City of Hollywood | Retiree Benefit Highlights | 2018

Group Insurance Eligibility
  JANUARY         The City of Hollywood group insurance plan                    Disabled Dependents
      01          year is January 1 through December 31.                        Coverage for an unmarried dependent child may be continued beyond age 26 if:
                                                                                  • The dependent is physically or mentally disabled and incapable of
                                                                                    self-sustaining employment (prior to age 26); and
Dependent Eligibility                                                             • Primarily dependent upon the retiree for support; and
A dependent is defined as the legal spouse or domestic partner and/or             • The dependent is otherwise eligible for coverage under the group
dependent child(ren) of the participant, spouse or domestic partner. The term       medical plan; and
“child” includes any of the following:                                            • The dependent has been continuously insured; and
  • A natural child                                                               • Coverage with City began prior to age 26.
  • A stepchild                                                                 Proof of disability will be required upon request. Please contact Human
  • A legally adopted child                                                     Resources if further clarification is needed.
  • A newborn child (up to the age of 18 months old) of a covered
                                                                                Medicare Eligible
    dependent (Florida)
  • A child for whom legal guardianship has been awarded to the                 Prior to a non-Medicare eligible retiree reaching age 65, Cigna processes claims
    participant or the participant’s spouse or domestic partner                 as the primary insurer. Upon a retiree reaching age 65, becoming Medicare
                                                                                eligible or qualifying for early Medicare eligibility due to disability, claims are
                                                                                processed with Medicare as the primary insurer and Cigna as the secondary, if
      Dependent Age Requirements                                                the member is not actively working.

      Medical Coverage: A dependent child may be covered through                If eligible for Medicare and not actively working, it is important that the retiree
      the end of the month in which the child turns age 26. An over-age         sign up for Medicare Part A and Part B to ensure that claims are processed
      dependent may continue to be covered on the medical plan to the           correctly.
      end of the calendar year in which the child reaches age 30, if the
                                                                                Once a retiree is enrolled in Medicare Part A and Part B, the City’s medical plan
      dependent meets the following requirements:
                                                                                coverage will change from primary to secondary. This means Medicare will
        •   Unmarried with no dependents; and                                   process claims before Cigna will process claims.
        •   A Florida resident, or full-time or part-time student; and
                                                                                If a retiree missed the initial social security application period, the retiree will
        •   Otherwise uninsured; and                                            be assessed penalties by Social Security and the effective date of coverage will
        •   Not entitled to Medicare benefits under Title XVIII of the          be much later.
            Social Security Act, unless the child is disabled.
                                                                                Please note: In order to avoid penalties with Medicare, an eligible retiree must
      Dental Coverage: A dependent child may be covered through the end
                                                                                sign up for Part B when first eligible.
      of the month in which the child turns age 26.

      Vision Coverage: A dependent child may be covered through the end                              Social Security Administration
      of the month in which the child turns age 26.                                      Customer Service: (800) 772-1213 | www.socialsecurity.gov

 3
City of Hollywood | Retiree Benefit Highlights | 2018

Medical Insurance                                                                             Other Available Plan Resources
The City offers medical insurance through Cigna to benefit-eligible retirees. For             Cigna offers all enrolled retirees and dependents additional services and
information about the medical plan, please refer to the Summary of Benefits                   discounts through value added programs. For more details regarding
and Coverage document or contact Cigna's customer service. Please refer to                    other available plan resources, please refer to the summary of benefits and
the separate rate sheet for Open Access Plan (OAP) and Open Access Plus In-                   coverage document, contact Cigna’s customer service at (800) 244-6224, or
Network Plan (OAPIN) costs for your specific retiree classification.                          visit www.cigna.com.

          Cigna | Customer Service: (800) 244-6224 | www.cigna.com                            Healthy Rewards
                                                                                              Cigna’s Healthy Rewards is provided automatically at no additional cost and
                                                                                              offers access to discounted health and wellness programs at participating
    Summary of Benefits and Coverage                                                          providers. Member can log on to www.mycigna.com and select Healthy
    A Summary of Benefits & Coverage (SBC) for the medical plan is provided as a              Rewards to learn more about these programs or call (800) 870-3470.
    supplement to this booklet being distributed to retirees during open enrollment. The        99
                                                                                                 Vision Care
    summary is an important item in understanding the benefit options. A free paper copy        99
                                                                                                 Lasik Vision Correction Services
    of the SBC document may be requested or is available as follows:
                                                                                                99
                                                                                                 Fitness Club Discounts
                                                                                                99
                                                                                                 Nutrition Discounts
       From:                Human Resources
                                                                                                99
                                                                                                 Hearing Care
       Address:             2600 Hollywood Blvd., Ste. 206
                            Hollywood, FL 33022
                                                                                              The myCigna Mobile App
       Phone:               (954) 921-3218
                                                                                              The myCigna mobile app is an easy way to organize and access important
       At Website URL: www.mybentek.com/hollywood
                                                                                              health information. Anytime. Anywhere. Download it today from the App
                                                                                              StoreSM or Google Play™. With the myCigna mobile app, member can:
    The SBC is only a summary of the plan’s coverage. A copy of the plan document, policy,
    or certificate of coverage should be consulted to determine the governing contractual        • Find a doctor, dentist or health care facility
    provisions of the coverage. A copy of the group certificate of coverage can be reviewed      • Access maps for instant driving directions
    and obtained by contacting Human Resources.
                                                                                                 • View ID cards for the entire family
    If there are questions about the plan offerings or coverage options, please contact
    Human Resources.                                                                             • Review deductibles, account balances and claims
                                                                                                 • Compare prescription drug costs
                                                                                                 • Speed-dial Cigna Home Delivery Pharmacy™Store and organize all
                                                                                                   important contact info for doctors, hospitals, and pharmacies
                                                                                                 • Add health care professionals to contact list right from a claim or
                                                                                                   directory search
                                                                                                 • And, much more!
                                                                                              24 Hour Help Information Hotline (800) CIGNA-24
                                                                                              The Cigna 24-Hour Health Information Line provides access to helpful, reliable
                                                                                              information and assistance from qualified health information nurses on a wide
                                                                                              range of health topics 24 hours a day, any day of the year. Not sure what to do
                                                                                              when a child has a fever in the middle of the night? Not sure if treatment from
                                                                                              a doctor is necessary for an injury? There are over 1,000 topics in the Health
                                                                                              Information Library that include free audio, video and printed information on
                                                                                              aging, women’s health, nutrition, surgery and specific medical conditions to
                                                                                              help member weigh the risks and advantages of treatment options. The call is
                                                                                              free and is strictly confidential.

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City of Hollywood | Retiree Benefit Highlights | 2018

                                              Cigna – OAP In-Network Plan At-A-Glance
                                              Network                                                                      Open Access Plus
                                              Calendar Year Deductible (CYD)                                                  In-Network
                                              Single                                                                               $500
                                              Family                                                                              $1,500

            Locate a Provider                 Coinsurance
  To search for a participating provider,     Member Responsibility                                                                20%
contact Cigna's customer service or visit
www.cigna.com. When completing the            Calendar Year Out-of-Pocket Limit
  necessary search criteria, select Open      Single                                                                              $3,000
                   Access Plus network.
                                              Family                                                                              $9,000
                                              What Applies to the Out-of-Pocket Limit?                      Deductible, Coinsurance and Copays (Excludes Rx)

                                              Physician Services
                                              Primary Care Physician (PCP) Office Visit                                          $30 Copay

              Plan References                 Specialist Office Visit                                                            $40 Copay

   *Quest Diagnostics and LabCorp are         Non-Hospital Services; Freestanding Facility
the preferred labs for bloodwork through
     Cigna. When using a lab other than       Clinical Lab (Blood Work): Quest or LabCorp*                                       No Charge
   LabCorp or Quest, please confirm they      X-rays                                                                             $50 Copay
 are contracted with Cigna’s Open Access
 Plus Network prior to receiving services.    Advanced Imaging (MRI, PET, CT) – Per Scan                                         $50 Copay
                                              Outpatient Surgery at Surgical Center                                         $250 Copay Per Visit
                                              Physician Services at Surgical Center                                              No Charge
                                              Urgent Care (Per Visit)                                                            $75 Copay

                                              Hospital Services
             Important Notes                  Inpatient Hospital (Per Admission)                                                $500 Copay
• There is a separate $50/$150 calendar       Outpatient Hospital (Per Visit)                                                   $250 Copay
     year deductible to be met before Rx
                          benefits begin.     Inpatient Physician Services at Hospital                                $40 Copay + 20% After CYD

     • There is a separate $1,500/$4,500      Emergency Room (Per Visit; Waived if Admitted)                                    $200 Copay
   per plan year, Pharmacy Out of Pocket
          Limit, that does not accumulate     Mental Health/Alcohol & Substance Abuse
  towards the Medical Calendar Year Out       Inpatient Hospitalization (Per Admission)                                         $500 Copay
                           of Pocket Limit.
                                              Outpatient Services (Per Visit)                                                    $40 Copay
      • Services received by providers and
     facilities not in the Open Access Plus   Prescription Drugs (Rx)
                   Network will be denied.
                                              Calendar Year Deductible for Rx Costs                                        $50 Per Covered Person
                                              Calendar Year Out of Pocket Limit for Rx Costs              Single: $1,500                            Family: $4,500
                                              Generic                                                                          20% After CYD
                                              Preferred Brand Name                                                             20% After CYD
                                              Non-Preferred Brand Name                                                         20% After CYD
                                              Mail Order Drug (90 Day Supply)                                              $25 / $75 / $150 Copay

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City of Hollywood | Retiree Benefit Highlights | 2018

Cigna – OAP Plan At-A-Glance
Network                                                                            Open Access Plus
Calendar Year Deductible (CYD)                                  In-Network                           Out-of-Network*
Single                                                               None                                        $500
Family                                                               None                                      $1,500

Coinsurance
                                                                                                                                         Locate a Provider
Member Responsibility                                                    0%                                      40%
                                                                                                                                         To search for a participating provider,
Calendar Year Out-of-Pocket Limit                                                                                                        contact Cigna's customer service or visit
                                                                                                                                         www.cigna.com. When completing the
Single                                                               $1,500                                    $3,000                    necessary search criteria, select Open
Family                                                               $3,000                                    $6,000                    Access Plus network.
What Applies to the Out-of-Pocket Limit?                           Deductible, Coinsurance and Copays (Excludes Rx)

Physician Services
Primary Care Physician (PCP) Office Visit                          $40 Copay                                40% After CYD
Specialist Office Visit (No Referral Required)                     $40 Copay                                40% After CYD
                                                                                                                                         Plan References
Non-Hospital Services; Freestanding Facility                                                                                             *Out-Of-Network Balance Billing:
Clinical Lab (Blood Work): Quest or LabCorp**                      No Charge                                40% After CYD                For information regarding Out-of-
X-rays                                                             $50 Copay                                40% After CYD                Network Balance billing that may be
                                                                                                                                         charged by an out-of-network provider,
Advanced Imaging (MRI, PET, CT) – Per Scan                         $50 Copay                                40% After CYD                please refer to the Summary of Benefits
Outpatient Surgery at Surgical Center                              $50 Copay                                40% After CYD                and Coverage document.

Physician Services at Surgical Center                              $40 Copay                                 $40 Copay
                                                                                                                                         **Quest Diagnostics and LabCorp are
Urgent Care (Per Visit)                                            $40 Copay                                40% After CYD                the preferred labs for bloodwork through
                                                                                                                                         Cigna. When using a lab other than
Hospital Services                                                                                                                        LabCorp or Quest, please confirm they
                                                                                                                                         are contracted with Cigna’s Open Access
Inpatient Hospital (Per Admission)                                $250 Copay                     $750 Per Admission Deductible
                                                                                                                                         Plus Network prior to receiving services
Outpatient Hospital                                               $100 Copay                     $300 Per Admission Deductible
Inpatient Physician Services at Hospital                           No Charge                                 No Charge
Emergency Room (Per Visit; Waived if Admitted)                     $50 Copay                                 $50 Copay

Mental Health/Alcohol & Substance Abuse
Inpatient Hospitalization (Per Admission)                         $250 Copay                     $750 Per Admission Deductible           Important Notes
Outpatient Services (Per Visit)                                    No Charge                                40% After CYD                • There is a separate $50 per person
                                                                                                                                           calendar year deductible to be met
Prescription Drugs (Rx)                                                                                                                    before Rx benefits begin.
Calendar Year Deductible for Rx Costs                                              $50 Per Covered Person                                • There is a separate $1,000 / $3,000
                                                                                                                                           per calendar year, Pharmacy Out
Calendar Year Out of Pocket Limit for Rx Costs          Single: $1,000        Family: $3,000    Single: $1,000          Family: $3,000
                                                                                                                                           of Pocket Limit for in-network and
Generic                                                          20% After CYD                              50% After CYD                  out-of-network combined, that does
Preferred Brand Name                                             20% After CYD                              50% After CYD                  not accumulate towards the Medical
                                                                                                                                           Calendar Year Out of Pocket Limit.
Non-Preferred Brand Name                                         20% After CYD                              50% After CYD
Mail Order Drug (90 Day Supply)                              $20 / $50 / $80 Copay                           Not Covered

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City of Hollywood | Retiree Benefit Highlights | 2018

Dental Insurance
Cigna Dental PPO Low Plan
The City provides dental insurance through Cigna to benefit eligible-retirees.             Out-of-Network Benefits
For more detailed information about the dental plans, please refer to the
                                                                                           Out-of-network benefits are used when members receive services by a non-
separate rate sheet for Cigna Dental PPO Low and High Plan costs for your
                                                                                           participating Total PPO provider. Cigna reimburses out-of-network services
specific retiree classification.
                                                                                           based on what it determines is the Maximum Reimbursable Charge (MRC). The
In-Network Benefits                                                                        MRC is defined as the most common charge for a particular dental procedure
                                                                                           performed in a specific geographic area. If services are received from an out-
The PPO plan provides benefits for services received from in-network and out-              of-network dentist, the member will pay the out-of-network benefit plus the
of-network providers. It is also an open access plan which allows for services to          difference between the amount that Cigna reimburses (MRC) for such services
be received from any dental provider without having to select a Primary Dental             and the amount charged by the dentist. This is known as balance billing.
Provider (PDP) or obtain a referral to a specialist. The network of participating          Balance billing is in addition to any applicable plan deductible or coinsurance
dental providers the plan utilizes is the Cigna Total PPO network. These                   responsibility.
participating dental providers have contractually agreed to accept Cigna’s
contracted fee or “allowed amount.” This fee is the maximum amount a Cigna                 Calendar Year Deductible
dental provider can charge a member for a service. The member is responsible
for a Calendar Year Deductible (CYD) and then coinsurance based on the plan’s              The dental PPO Low plan requires a $25 individual or a $75 family deductible
charge limitations.                                                                        to be met for in-network or out-of-network services before most benefits will
                                                                                           begin. The deductible is waived for preventive services.
Please Note: Total DPPO dental members have the option to utilize a dentist that
participates in either Cigna’s Advantage Network or DPPO Network. However, members         Calendar Year Benefit Maximum
that use the Cigna Advantage Network will see additional cost savings from the added
                                                                                           The maximum benefit (coinsurance) the dental PPO Low plan will pay for
discount that is allowed for using an Advantage network provider. Members are
responsible for verifying whether the treating dentist is an Advantage Dentist or a DPPO
                                                                                           each covered member is $1,000 for in-network or out-of-network services
Dentist.                                                                                   combined. All services accumulate towards the benefit maximum.

                                                                                                    Cigna | Customer Service: (800) 244-6224 | www.cigna.com

 7
City of Hollywood | Retiree Benefit Highlights | 2018

Cigna – Dental PPO Low Plan At-A-Glance
Network                                                                          Cigna Total DPPO
Calendar Year Deductible (CYD)                                  In-Network and Out-of-Network Combined
Per Member                                                                                $25
Per Family                                                                                $75

Calendar Year Benefit Maximum
                                                                                                                                 Locate a Provider
Per Member (Includes Class I Services)                                                   $1,000
                                                                                                                                 To search for a participating provider,
Class I Services: Diagnostic & Preventive Care                    In-Network                      Out-of-Network*                contact Cigna's customer service or visit
                                                                                                                                 www.cigna.com. When completing the
Routine Oral Exam (2 Per Calendar Year)                                                                                          necessary search criteria, select Cigna
Routine Cleanings (2 Per Calendar Year)                                                               Plan Pays: 80%             Dental PPO or EPO network.
                                                                  Plan Pays: 100%
                                                                                                     Deductible Waived
Bitewing X-rays (2 Per Calendar Year)                            Deductible Waived
                                                                                                  (Subject to Balance Billing)
Complete X-rays (1 Set Every 36 Consecutive Months)

Class II Services: Basic Restorative Care
Fillings
Simple Extractions
                                                                                                                                 Plan References
                                                                                                                                 *Out-Of-Network Balance Billing: For
Endodontics (Root Canal Therapy)                                                                  Plan Pays: 70% After CYD
                                                              Plan Pays: 80% After CYD                                           information regarding out-of-network
Periodontics                                                                                      (Subject to Balance Billing)   balance billing that may be charged
                                                                                                                                 by an out-of-network provider for
General Anesthesia/Intravenous Sedation (Limitations Apply)
                                                                                                                                 services rendered, please refer to the
Oral Surgery                                                                                                                     Out-of-Network Benefits section on the
                                                                                                                                 previous page.
Class III Services: Major Restorative Care
Crowns
                                                                                                  Plan Pays: 50% After CYD
Dentures                                                      Plan Pays: 50% After CYD
                                                                                                  (Subject to Balance Billing)
Bridges

Class IV Services: Orthodontia                                                                                                   Important Notes
Lifetime Maximum                                                                         $1,000                                  • It is recommended for members to
                                                                                                                                   request their provider to obtain a
                                                                                                  Plan Pays: 50% After CYD         Predetermination of Benefits when
Benefit (Child(ren) Up To Age 19)                             Plan Pays: 50% After CYD
                                                                                                  (Subject to Balance Billing)
                                                                                                                                   services are expected to exceed $200
                                                                                                                                   in costs.
                                                                                                                                 • Each covered family member may
                                                                                                                                   receive two (2) routine cleanings per
                                                                                                                                   calendar year under the preventive
                                                                                                                                   benefit.
                                                                                                                                 • Late entrant provisions, age limitations
                                                                                                                                   and waiting periods may apply.

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City of Hollywood | Retiree Benefit Highlights | 2018

Dental Insurance
Cigna Dental PPO High Plan
The City offers dental insurance through Cigna to benefit-eligible retirees. For           Out-of-Network Benefits
more detailed information about the dental plans, please refer to the separate
                                                                                           Out-of-network benefits are used when members receive services by a non-
rate sheet for Cigna Dental PPO Low and High Plan costs for your specific retiree
                                                                                           participating Total PPO provider. Cigna reimburses out-of-network services
classification.
                                                                                           based on what it determines is the Maximum Reimbursable Charge (MRC). The
In-Network Benefits                                                                        MRC is defined as the most common charge for a particular dental procedure
                                                                                           performed in a specific geographic area. If services are received from an out-
The PPO plan provides benefits for services received from in-network and out-              of-network dentist, the member will pay the out-of-network benefit plus the
of-network providers. It is also an open access plan which allows for services to          difference between the amount that Cigna reimburses (MRC) for such services
be received from any dental provider without having to select a Primary Dental             and the amount charged by the dentist. This is known as balance billing.
Provider (PDP) or obtain a referral to a specialist. The network of participating          Balance billing is in addition to any applicable plan deductible or coinsurance
dental providers the plan utilizes is the Cigna Total PPO network. These                   responsibility.
participating dental providers have contractually agreed to accept Cigna’s
contracted fee or “allowed amount.” This fee is the maximum amount a Cigna                 Calendar Year Deductible
dental provider can charge a member for a service. The member is responsible
                                                                                           The dental PPO High plan requires a $25 individual or a $75 family deductible
for a Calendar Year Deductible (CYD) and then coinsurance based on the plan’s
                                                                                           to be met for in-network or out-of-network services before most benefits will
charge limitations.
                                                                                           begin. The deductible is waived for preventive services.
Please Note: Total DPPO dental members have the option to utilize a dentist that
participates in either Cigna’s Advantage Network or DPPO Network. However, members         Calendar Year Benefit Maximum
that use the Cigna Advantage Network will see additional cost savings from the added       The maximum benefit (coinsurance) the dental PPO High plan will pay for
discount that is allowed for using an Advantage network provider. Members are
                                                                                           each covered member is $2,000 for in-network or out-of-network services
responsible for verifying whether the treating dentist is an Advantage Dentist or a DPPO
Dentist.
                                                                                           combined. All services accumulate towards the benefit maximum.

                                                                                                    Cigna | Customer Service: (800) 244-6224 | www.cigna.com

 9
City of Hollywood | Retiree Benefit Highlights | 2018

Cigna – Dental PPO High Plan At-A-Glance
Network                                                                          Cigna Total DPPO
Calendar Year Deductible (CYD)                                  In-Network and Out-of-Network Combined
Per Member                                                                                $25
Per Family                                                                                $75

Calendar Year Benefit Maximum
                                                                                                                                 Locate a Provider
Per Member (Includes Class I Services)                                                   $2,000
                                                                                                                                 To search for a participating provider,
Class I Services: Diagnostic & Preventive Care                    In-Network                      Out-of-Network*                contact Cigna's customer service or visit
                                                                                                                                 www.cigna.com. When completing the
Routine Oral Exam (2 Per Calendar Year)                                                                                          necessary search criteria, select Cigna
Routine Cleanings (2 Per Calendar Year)                                                               Plan Pays: 80%             Dental PPO or EPO network.
                                                                  Plan Pays: 100%
                                                                                                     Deductible Waived
Bitewing X-rays (2 Per Calendar Year)                            Deductible Waived
                                                                                                  (Subject to Balance Billing)
Complete X-rays (1 Set Every 36 Consecutive Months)

Class II Services: Basic Restorative Care
Fillings
Simple Extractions
                                                                                                                                 Plan References
                                                                                                                                 *Out-Of-Network Balance Billing: For
Endodontics (Root Canal Therapy)                                                                  Plan Pays: 70% After CYD
                                                              Plan Pays: 80% After CYD                                           information regarding out-of-network
Periodontics                                                                                      (Subject to Balance Billing)   balance billing that may be charged
                                                                                                                                 by an out-of-network provider for
General Anesthesia/Intravenous Sedation (Limitations Apply)
                                                                                                                                 services rendered, please refer to the
Oral Surgery                                                                                                                     Out-of-Network Benefits section on the
                                                                                                                                 previous page.
Class III Services: Major Restorative Care
Crowns
                                                                                                  Plan Pays: 50% After CYD
Dentures                                                      Plan Pays: 50% After CYD
                                                                                                  (Subject to Balance Billing)
Bridges

Class IV Services: Orthodontia                                                                                                   Important Notes
Lifetime Maximum                                                                         $2,000                                  • It is recommended for members to
                                                                                                                                   request their provider to obtain a
                                                                                                  Plan Pays: 50% After CYD         Predetermination of Benefits when
Benefit (Child(ren) Up To Age 19)                             Plan Pays: 50% After CYD
                                                                                                  (Subject to Balance Billing)
                                                                                                                                   services are expected to exceed $200
                                                                                                                                   in costs.
                                                                                                                                 • Each covered family member may
                                                                                                                                   receive two (2) routine cleanings per
                                                                                                                                   calendar year under the preventive
                                                                                                                                   benefit.
                                                                                                                                 • Late entrant provisions, age limitations
                                                                                                                                   and waiting periods may apply.

                                                                                                                                                                       10
City of Hollywood | Retiree Benefit Highlights | 2018

Vision Insurance
Vision Service Plan Option 1
The City offers vision insurance through Vision Service Plan (VSP) to benefit-    Out-of-Network Benefits
eligible retirees. For more detailed information about the vision plans, please
                                                                                  Retiree and covered dependent(s) may also choose to receive services from
refer to the separate rate sheet for Vision Service Plan Option 1, Option 2 and
                                                                                  vision providers who do not participate in the VSP Choice Network. When going
Option 3 Plan costs for your specific retiree classification.
                                                                                  out of network, the provider will require payment at the time of appointment.
In-Network Benefits                                                               VSP will then reimburse based on the plan’s out-of-network reimbursement
                                                                                  schedule upon receipt of proof of services rendered.
The vision plan offers retiree and covered dependent(s) coverage for routine
eye care, including eye exams, eyeglasses (lenses and frames) or contact          Calendar Year Deductible
lenses. To schedule an appointment, covered retiree and dependent(s) can
                                                                                  There is no plan year deductible.
select any network provider who participates in the VSP Choice network. At
the time of service, routine vision examinations and basic optical needs will     Calendar Year Out-of-Pocket Maximum
be covered as shown on the plan’s schedule of benefits. Cosmetic services and
upgrades will be additional if chosen at the time of the appointment.             There is no out-of-pocket maximum. However, there are benefit reimbursement
                                                                                  maximums for certain services.

                                                                                             VSP | Customer Service: (800) 877-7195 | www.vsp.com

11
City of Hollywood | Retiree Benefit Highlights | 2018

VSP – Vision Plan Option 1 At-A-Glance
Network                                                                             VSP Choice
Services                                                        In-Network                           Out-of-Network
Eye Exam                                                           $10 Copay                       Up to $45 Reimbursement
                                                                                                   Reimbursement Based on     Locate a Provider
Materials                                                          $25 Copay
                                                                                                       Type of Service
                                                                                                                              To search for a participating provider,
Frequency of Services                                                                                                         contact VSP's customer service or visit
                                                                                                                              www.vsp.com. When completing the
Examination                                                                            12 Months                              necessary search criteria, select VSP
                                                                                                                              Choice network.
Lenses                                                                                 12 Months
Frames                                                                                 24 Months

Contact Lenses                                                                         12 Months

Lenses
Single                                                                                             Up to $30 Reimbursement    Plan References
                                                               Covered at 100%                                                *Contact lenses are in lieu of spectacle
Bifocal                                                                                            Up to $50 Reimbursement
                                                           After $25 Materials Copay                                          lenses and a frame
Trifocal                                                                                           Up to $65 Reimbursement

Frames
                                                        $100 Allowance on Any Frame or
                                                         $120 if Part of the "Collection"
Allowance                                                                                          Up to $70 Reimbursement
                                                        Frame Options. 20% Discount on
                                                        Any Amount Over the Allowance.                                        Important Notes
                                                                                                                              • Member options, such as LASIK, UV
Contact Lenses*                                                                                                                 coating, progressive lenses, etc. are not
Non-Elective (Medically Necessary)                              Covered at 100%                    Up to $210 Reimbursement     covered in full, but may be available at
                                                                                                                                a discount.
                                                          $100 Allowance with a $60
Elective (Fitting, Follow-up & Lenses)                     Maximum Copay for the                   Up to $105 Reimbursement
                                                             Contact Lense Exam.

                                                                                                                                                                     12
City of Hollywood | Retiree Benefit Highlights | 2018

Vision Insurance
Vision Service Plan Option 2
The City offers vision insurance through Vision Service Plan (VSP) to benefit-    Out-of-Network Benefits
eligible retirees. For more detailed information about the vision plans, please
                                                                                  Retirees and covered dependent(s) may also choose to receive services from
refer to the separate rate sheet for Vision Service Plan Option 1, Option 2 and
                                                                                  vision providers who do not participate in the VSP Choice Network. When going
Option 3 Plan costs for your specific retiree classification.
                                                                                  out of network, the provider will require payment at the time of appointment.
In-Network Benefits                                                               VSP will then reimburse based on the plan’s out-of-network reimbursement
                                                                                  schedule upon receipt of proof of services rendered.
The vision plan offers retiree and covered dependent(s) coverage for routine
eye care, including eye exams, eyeglasses (lenses and frames) or contact          Calendar Year Deductible
lenses. To schedule an appointment, covered retiree and dependent(s) can
                                                                                  There is no plan year deductible.
select any network provider who participates in the VSP Choice network. At
the time of service, routine vision examinations and basic optical needs will     Calendar Year Out-of-Pocket Maximum
be covered as shown on the plan’s schedule of benefits. Cosmetic services and
upgrades will be additional if chosen at the time of the appointment.             There is no out-of-pocket maximum. However, there are benefit reimbursement
                                                                                  maximums for certain services.

                                                                                             VSP | Customer Service: (800) 877-7195 | www.vsp.com

13
City of Hollywood | Retiree Benefit Highlights | 2018

VSP – Vision Plan Option 2 At-A-Glance
Network                                                                             VSP Choice
Services                                                        In-Network                            Out-of-Network
Eye Exam                                                           $10 Copay                        Up to $45 Reimbursement
                                                                                                    Reimbursement Based on     Locate a Provider
Materials                                                          $20 Copay
                                                                                                        Type of Service
                                                                                                                               To search for a participating provider,
Frequency of Services                                                                                                          contact VSP's customer service or visit
                                                                                                                               www.vsp.com. When completing the
Examination                                                                             12 Months                              necessary search criteria, select VSP
                                                                                                                               Choice network.
Lenses                                                                                  12 Months
Frames                                                                                  24 Months

Contact Lenses                                                                          12 Months

Lenses
Single                                                                                              Up to $30 Reimbursement    Plan References
                                                                Covered at 100%                                                *Contact lenses are in lieu of spectacle
Bifocal                                                                                             Up to $50 Reimbursement
                                                            After $20 Materials Copay                                          lenses and a frame
Trifocal                                                                                            Up to $65 Reimbursement

Frames
                                                          $130 Allowance on Any Frame
                                                         or $150 Allowance if Part of the
Allowance                                                "Collection" Frame Option. 20%             Up to $70 Reimbursement
                                                        Discount for Any Amount Over the                                       Important Notes
                                                                    Allowance.
                                                                                                                               • Member options, such as LASIK, UV
                                                                                                                                 coating, progressive lenses, etc. are not
Contact Lenses*                                                                                                                  covered in full, but may be available at
Non-Elective (Medically Necessary)                              Covered at 100%                     Up to $210 Reimbursement     a discount.
                                                           $130 Allowance with a $20
Elective (Fitting, Follow-up & Lenses)                      Maximum Copay for the                   Up to $105 Reimbursement
                                                              Contact Lense Exam.

                                                                                                                                                                      14
City of Hollywood | Retiree Benefit Highlights | 2018

Vision Insurance
Vision Service Plan Option 3
The City offers vision insurance through Vision Service Plan (VSP) to benefit-    Out-of-Network Benefits
eligible retirees. For more detailed information about the vision plans, please
                                                                                  Retiree and covered dependent(s) may also choose to receive services from
refer to the separate rate sheet for Vision Service Plan Option 1, Option 2 and
                                                                                  vision providers who do not participate in the VSP Choice Network. When going
Option 3 Plan costs for your specific retiree classification.
                                                                                  out of network, the provider will require payment at the time of appointment.
In-Network Benefits                                                               VSP will then reimburse based on the plan’s out-of-network reimbursement
                                                                                  schedule upon receipt of proof of services rendered.
The vision plan offers retiree and covered dependent(s) coverage for routine
eye care, including eye exams, eyeglasses (lenses and frames) or contact          Calendar Year Deductible
lenses. To schedule an appointment, covered retiree and dependent(s) can
                                                                                  There is no plan year deductible.
select any network provider who participates in the VSP Choice network. At
the time of service, routine vision examinations and basic optical needs will     Calendar Year Out-of-Pocket Maximum
be covered as shown on the plan’s schedule of benefits. Cosmetic services and
upgrades will be additional if chosen at the time of the appointment.             There is no out-of-pocket maximum. However, there are benefit reimbursement
                                                                                  maximums for certain services.

                                                                                             VSP | Customer Service: (800) 877-7195 | www.vsp.com

15
City of Hollywood | Retiree Benefit Highlights | 2018

VSP – Vision Plan Option 3 At-A-Glance
Network                                                                             VSP Choice
Services                                                        In-Network                            Out-of-Network
Eye Exam                                                           $10 Copay                        Up to $45 Reimbursement
                                                                                                    Reimbursement Based on     Locate a Provider
Materials                                                          $10 Copay
                                                                                                        Type of Service
                                                                                                                               To search for a participating provider,
Frequency of Services                                                                                                          contact VSP's customer service or visit
                                                                                                                               www.vsp.com. When completing the
Examination                                                                             12 Months                              necessary search criteria, select VSP
                                                                                                                               Choice network.
Lenses                                                                                  12 Months
Frames                                                                                  24 Months

Contact Lenses                                                                          12 Months

Lenses
Single                                                                                              Up to $30 Reimbursement    Plan References
                                                                Covered at 100%                                                *Contact lenses are in lieu of spectacle
Bifocal                                                                                             Up to $50 Reimbursement
                                                            After $10 Materials Copay                                          lenses and a frame
Trifocal                                                                                            Up to $65 Reimbursement

Frames
                                                          $150 Allowance on Any Frame
                                                         or $170 Allowance if Part of the
Allowance                                                "Collection" Frame Option. 20%             Up to $70 Reimbursement
                                                        Discount for Any Amount Over the                                       Important Notes
                                                                    Allowance.
                                                                                                                               • Member options, such as LASIK, UV
                                                                                                                                 coating, progressive lenses, etc. are not
Contact Lenses*                                                                                                                  covered in full, but may be available at
Non-Elective (Medically Necessary)                              Covered at 100%                     Up to $210 Reimbursement     a discount.
                                                           $150 Allowance with a $10
Elective (Fitting, Follow-up & Lenses)                      Maximum Copay for the                   Up to $105 Reimbursement
                                                              Contact Lense Exam.

                                                                                                                                                                      16
City of Hollywood | Retiree Benefit Highlights | 2018

Retiree Basic Life                                                                 Notes
The City offers Basic Term Life Insurance to eligible retirees who elected life    Use this section to make notes regarding personal benefit plans or to keep track
insurance at the time of retirement through Symetra. The retiree Basic Term        of important information such as doctor’s names and addresses or prescription
Life Insurance amount is a set benefit of $5,000. Cost for coverage is $3.00 per   medications.
$1,000.

                                Retiree Life
     $5,000      X      $3.00       /      $1,000       =        $15.00
     Volume              Rate                                  Monthly Cost

  Always remember to keep beneficiary forms updated. Retiree
  may update beneficiary information at anytime through the
   Human Resources Department or by logging onto BenTek at
              www.mybentek.com/hollywood.

      Symetra | Customer Service: (800) 796-3872 | www.symetra.com

17
City of Hollywood | Retiree Benefit Highlights | 2018

Notes
Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor’s names and addresses or prescription medications.

                                                                                                                                                                      18
City of Hollywood | Retiree Benefit Highlights | 2018

Notes
Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor’s names and addresses or prescription medications.

19
City of Hollywood | Retiree Benefit Highlights | 2018

Notes
Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor’s names and addresses or prescription medications.

                                                                                                                                                                      20
4200 Northcorp Parkway, Suite 185
       Palm Beach Gardens, Florida 33410
Toll Free: (800) 244-3696 | Fax: (561) 626-6970
                                                                                    FINAL
             www.gehringgroup.com                 Last Modified: November 4, 2017 9:57 AM
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