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Home My WebLink About20053203.tiff Great-Wes`SM HEALTHCARE Great-West Life & Annuity Insurance Company Application for Group Coverage for Weld County Government Policy Number: 358610 . pp-licailt Information: Summary of Amendment: Increasing Specific Stop Loss to $125,000 - Changing inpatient mental health benefit to 10 days/yr and 20 days lifetime. Changing outpatient mental health to 20 visits. - Does this amendment include a Policyholder Name change or EIN/TIN change? ❑ Yes ® No If Yes, is this due to a merger or acquisition? ❑ Yes ❑ No Full Legal Name of Firm: Is this company subject to ERISA? ['Yes ZNo Weld County Government Company Type: State of Situs: CO fl ❑Corporation ❑Partnership Tax ID/EIN: [IS-Corp ❑Association Requested Effective Date: January 1, 2006 ❑Govenunent ❑Non-Electing Church Group ❑Public/Non-Profit ❑Limited Liability Corp. (LLC) Industry: ❑Individual/Unincorporated Business/Proprietorship SIC: ERISA Plan Number: ERISA Plan Year: For an ERISA plan,Great-West will have full discretion and authority to interpret the Plan and determine whether a claim should be paid or denied on appeal and according to the provisions of the Plan as set forth in the Summary Plan Description. /Ft2 99 msvapp(Mar-01 -2002)-Weld County Govemme-IG WLAMIDASOCOA10192005 1 ConSeni At-e,r)Aa_ 2005-3203 10 3/ S f Remove:this Plan.from Application for.Group Coverage 'State Addendum- Michigan ❑Adding ❑Deleting ❑ Changing Michigan law requires insurers to provide the following offer TO MICHIGAN SITUSED PLANS AND TO PLANS THAT INCLUDE RESIDENTS OF MICHIGAN. Please review the provision described below which we are required to offer and indicate below acceptance or rejection of the same. Although Great-West is required to offer you this provision,you are under no obligation to accept it. • Auto Accident Exclusion-if accepted,benefits will not be payable under the Plan for ['Accept Reject injuries received in an accident involving a motor vehicle if the covered person is a resident of Michigan and the accident occurs in Michigan. If rejected,benefits will be coordinated with Auto Accident coverage. DRemovethisPlanirot Application for Group Coverage State Addendum-Colorado ❑Adding ❑Delefing ❑ Changing Please review the description of a Stop-Loss provision we are required to offer and indicated below your acceptance or rejection. Acceptance may result in an increase in premium. Although Great-West is required to offer you this provision,you are under no obligation to accept it. Stop-Loss Coverage for Small Employers ❑Accept ❑Reject Colorado law requires insurers to offer Small Employers(fewer than 51 eligible employees) who self-fund their benefits Specific Stop-Loss reimbursements for claims that were incurred prior to but paid for after the termination of the Contract. If this coverage is elected,the Specific Stop-Loss benefit will be extended for 90 days from the date of termination of the Stop-Loss Contract. :Adnnnistrative Services Only (ASO) Funding: ❑Adding❑Deleting ®Ganging Aggregate Stop-Loss: ❑No ❑Yes Terminal Protection: Specific Stop-Loss: $125,000 Fixed: $ Employees $ Dependents ❑NJ= $20,000 minimum if under 50 lives Variable: Rio DNY=$25,000 minimum ❑CO =$15,000 minimum(effective 1/1/03) EFL&MD=$20,000 minimum Aggregate limitation factor: ❑10% Other: Aggregate Attachment: Pick One... Remove this Plan from Application for Group Coverage Great-West Healthcare 'Consumer Advantage PPO (Choice) -add PPO Dual-Option;plan name ['Adding❑Deleting ® Changing Li Double click for benefit information Lifetime Maximum Medical Benefits: Reimbursement Method for (all conditions) Non-network services: ❑$1,000,000 D$2,000,000 ❑$5,000,000 DAverage Contract Rate(ACR) ['Usual&Customary mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10I92005 2 I'Remove this Plan from Application for Group Coverage Great-West Healthcare Consumer Advantage PP:O (Choice) -add'PPO Dual-Option plan name ❑Adding❑Deleting `® Changing Individual Break Point/Out-of-Pocket per Calendar Family Break Point and Calendar Year Year: (choose method and amount) Deductible: An existing case may change from OOP to BP or BP to OOP only on January 1. O 2 times the individual amount elected. O 3 times the individual amount elected. ❑Network Break Point(Non-network services do not apply) ❑ ss,000 O $7,500 O $10,000 ❑ $12,500 ❑ $15,000 ❑$20,000 O $25,000 ❑ Combined Network/Non-network Out-of-Pocket ❑ $2,500 O$3,000 O$4,000 O$5,000 ❑ $7,500 O$10,000 Coinsurance Percentages: Medical Outreach: ®Covered Network Non- Out of Tier II Tier III Network* Area ❑ 100% 80% 50% 80% ❑ 100% 70% 50% 70% ❑ 100% 60% 40% 60% ❑ 90% 70% 50% 70% ❑ 80% 60% 50% 60% ❑ 70% 50% 50% 50% ❑ 70% 50% 40% 50% *Non-network services do not apply toward the breakpoint Calendar Year Deductibles: Choose Combined or Separate Deductibles ❑ Combined Tier II&III network deductible: (network/non-network) ❑ $250/250 O$250/500 O $250/1000 O $250/2000 O $500/500 O $500/1000 ❑ $500/2000 O$750/1500 O $750/3000 O $1000/2000 O $2000/3000 ❑ Separate Tier II& III network deductible : (pick a Tier II/Tier III Network deductible,then pick a Non- network deductible from same row) Tier II/Tier III-Network Non-network ❑ $250/250 O $500 ❑ $750 O $1,000 O $1,500 O $2,000 O $250/500 or ❑ $300/300 O $750 O $1,000 O $1,500 ❑ $2,000 ❑ $300/600 or ❑ $400/400 O $1,000 O $1,500 O $2,000 ❑ $3,000 O $400/800 ❑ $1,500 O $2,000 O $3,000 mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10192005 3 ❑ $500/250 ❑ $750 ❑$1,000 ❑ $1,500 0 $2,000 ❑ $500/500 ❑ $1,000 0 $1,500 ❑ $2,000 0 $3,000 ❑ $500/1,000 ❑ $1,500 ❑ $2,000 ❑ $3,000 ❑ $600/300 ❑ $1,000 ❑ $1,500 ❑ $2,000 ❑ $3,000 Not available with 70/50/50 or 70/50/40 plans ❑$750/750 ❑ $1,500 0 $2,000 ❑ $3,000 Not available with 70/50/50 or 70/50/40 plans ❑ $750/1,500 $3,000 Not available with 70/50/50 or 70/50/40 plans ❑$800/400 ❑ $1,500 ❑ $2,000 ❑ $3,000 Not available with 70/50/50 or 70/50/40 plans ❑ $1,000/500 ❑ $1,500 ❑ $2,000 ❑ $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑ $1,000/1,000 0 $2,000 ❑ $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑ $1,000/2,000 $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans Hospital per confinement deductible or outpatient surgery: Network: ❑$0 ❑$100 ❑$250 ❑$500 Non-network: ❑$100 ❑$250 ❑$500 (Non-network per confinement deductible must be equal to or greater than the network per confinement deductible.) Note: If electing Tiered Deductibles: * If Tier II deductible is$1,000—network per confinement must be$0. * If Tier II deductible is$600,$750 or$800—network per confinement deductible must be less than$500. Tier I Benefits : Preventive Care: Network: 100%with office visit copay. Non-network: Deductible and coinsurance. Lab/Xray: 100%for all providers. Network Office Visit Copay Amounts: (Choose one of the three options) mstrapp(Mar-01 -2002)-Weld County Gavernme-IGWLAMIDASOCOAI0192005 4 ❑ Primary/Specialist copay: ❑ $20❑$25 ❑$30 ❑ $35 ❑ $40 ❑ $50 ❑ Primary Care w/Specialist coinsurance: i Primary: ❑ $20 ❑ $25 CI$30 CI$35❑ $40 ; ❑ Primary Care w/higher Specialist copay: Specialist: Tier III deductible and coinsurance Primary: ❑$20O$25❑$30❑ $35 ❑ $40❑$50 Restrictions: Specialist: ❑ $30O $35 ❑ $40❑$45 ❑ $50❑ $55 $30 or$35—only available with 50%or 60%Tier III coins. $40—only available with 50%Tier III coins. o$60❑$65 Minimum Differential=$10/Maximum Differential=$25 Tier II Benefits: Standard Benefits: Optional Benefits: • Inpatient X-ray&Lab Inpatient Mental Health/Chemical Dependency: • Inpatient Hospital incl. Surgery,Anesthesia,and ❑ Covered Q Not Covered Rehabilitation • Hos ice If covered,benefit maximum calendar/lifetime days for p in-hospital conditions only: • Medical Supplies/Durable Medical Equipment ❑5/10 ® 10/20 ❑30/60 (life sustaining) • Skilled Nursing—100 days/calendar year. • Home Health Care—60 visits/calendar year. • Ambulance Tier III Benefits : mstrapp(Mar-01 -2002)-Weld County Governme-IGWLAMIDASOCOA 10192005 5 Standard Benefits: Optional Benefits: • Emergency Room Outpatient Mental Health &Chemical Dependency: O Covered O Not Covered • Outpatient Services(includes surgery,anesthesia) If covered,20 visits per calendar year max. • Outpatient X-ray and Lab: TMJ: ❑ with deductible ❑ Covered O Not Covered O without deductible If covered, $1,000 calendar year max. • Physical Therapy: Spinal Adjustment Treatment(SAT): $2,000 calendar year max. O Covered ❑ Not Covered If Covered, • Medical Supplies: (non-life sustaining) Calendar Year Max: O $500❑ $1,000 O $2,000 • Durable Medical Equipment: Family Planning: $2,500 calendar year/$10,000 lifetime max. O Covered O Not Covered • Office Surgeries/Services Outpatient Speech Hearing&Occupational Therapy: ❑ Covered O Not Covered If covered, $2000 per calendar year max. mstrapp(Mar-01 -2002)-Weld County Govemme-FGWLAMIDASOCOA10192005 6 Prescription Drugs: Prescription Drug Copay Amount Drug Deductible: Advantage Retail ❑ ❑ ❑ Applies to all prescriptions. Tier 3 -Highest Brand Name copay $60 $75 $75 $100 The family maximum is 3 Pharmacy Tier 2-Lowest Brand Name copay $30 $30 $50 $50 times the individual amount. Plan Tier 1 -Generic Drug copay $10 $10 $10 $10 DNone ❑$100 individual Mail Order ❑$150 individual Tier 3 -Highest Brand Name copay $170 $215 $215 $290 Tier 2-Lowest Brand Name copay $80 $80 $140 $140 Tier 1 -Generic Drug copay $20 $20 $20 $20 Maximum Allowable Cost- MAC C Contraceptives: ❑ Covered (standard) 90 day retail drug program-Not Covered- (disclosure required) standard I Prescription Drug Copay Amount Drug Deductible: Choice Retail ❑ ❑ ❑ Applies to Brand Name Tier 3 -Highest Brand Name copay $40 $50 $60 prescriptions only. The Pharmacy Tier 2-Lowest Brand Name copay $20 $25 $30 family maximum is 3 times Plan Tier 1 -Generic Drug copay $10 $10 $10 the individual amount. DNone Mail Order ❑$150 individual �^ Tier 3 -Highest Brand Name copay $80 $100 $120 E$250 individual Tier 2-Lowest Brand Name copay $40 $50 $60 ❑$500 individual Tier I -Generic Drug copay $20 $20 $20 Maximum Allowable Cost- MAC A Contraceptives: ❑ Covered (standard) ❑Not Covered—disclosure required 90 day retail drug program- standard Prescription Drug Copay Amount Drug Deductible: Performance Retail ❑ ❑ ❑ Applies to all prescriptions Tier 3-Highest Brand Name copay $20 $30 $40 only. The family Pharmacy- Tier 2-Lowest Brand Name copay $10 $15 $20 maximum is 3 times the 3-Tier Plan Tier 1-Generic Drug copay $5 $7 $10 individual amount. ENone Mail Order ❑$75 individual I- I Tier 3-Highest Brand Name copay $40 $60 $80 ❑$100 individual Tier 2-Lowest Brand Name copay $20 $30 $40 D$150 individual Tier 1-Generic Drug copay $10 $14 $20 Maximum Allowable Cost- MAC B Contraceptives: ❑ Covered (standard) ❑Not Covered—disclosure required 90 day retail drug program- standard ' Remove-this Plan from Application for Group Coverage Great-West Healthcare Consumer Advantage PPO (2) (Standard) - add Dual-Option plan name ❑Adding ❑Deleting Z Changing ILI Double click for benefit information mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA1019200S 7 Remove this Plan from Application for Group Coverage Great-West Healthcare Consumer Advantage PPO(2) (Standard) - add Dual-'Option plan name ❑Adding ❑Deleting ® Changing Lifetime Maximum Medical Benefits: Reimbursement Method for (all conditions) Non-network services: ❑$1,000,000 O$2,000,000 ❑$5,000,000 ['Average Contract Rate(ACR) ❑Usual&Customary Individual Break Point/Out-of-Pocket per Family Break Point and Calendar Year Calendar Year: (choose method and amount) Deductible: An existing case may change from OOP to BP or BP to OOP only on January 1. ❑ 2 times the individual amount elected. ❑ 3 times the individual amount elected. ❑Network Break Point(Non-network services do not apply) O $5,000 O $7,500 O$10,000 O $12,500 O $15,000 O $20,000 O$25,000 ❑ Combined Network/Non-network Out-of-Pocket ❑ $2,500 O $3,000 O $4,000 O $5,000 ❑ $7,500 O sio,000 Coinsurance Percentages: Medical Outreach: ®Covered Network Non- Out of Tier II Tier III Network* Area ❑ 100% 80% 50% 80% ❑ 100% 70% 50% 70% ❑ 100% 60% 40% 60% ❑ 90% 70% 50% 70% ❑ 80% 60% 50% 60% ❑ 70% 50% 50% 50% ❑ 70% 50% 40% 50% *Non-network services do not apply toward the breakpoint Calendar Year Deductibles: Choose Combined or Separate Deductibles Combined Tier II&III network deductible: (network(non-network) ❑ $250/250 O $250/500 ❑ $250/1000 O $250/2000 O $500/500 O $500/1000 O $500/2000 O $750/1500 O $750/3000 ❑ $1000/2000 O $2000/3000 ❑ Separate Tier II & III network deductible : (pick a Tier II/Tier III Network deductible,then pick a Non- network deductible from same row) Tier II/Tier III-Network Non-network O $250/250 O $500 O $750 O $1,000 ❑ $1,500 ❑ $2,000 ❑ $250/500 or O $300/300 ❑ $750 O $1,000 ❑ $1,500 ❑ $2,000 mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10192005 8 ❑ $300/600 or O $400/400 ❑$1,000 O $1,500 O $2,000 O $3,000 ❑ $400/800 ❑ $1,500 O $2,000 ❑ $3,000 ❑ $500/250 ❑ $750 O $1,000 ❑ $1,500 ❑ $2,000 ❑ $500/500 ❑ $1,000 ❑ $1,500 ❑ $2,000 ❑ $3,000 ❑ $500/1,000 O $1,500 O $2,000 ❑ $3,000 ❑ $600/300 ❑ $1,000 ❑ $1,500 O $2,000 ❑ $3,000 Not available with 70/50/50 or 70/50/40 plans O $750/750 ❑ $1,500 O $2,000 O $3,000 Not available with 70/50/50 or 70/50/40 plans ❑ $750/1,500 $3,000 Not available with 70/50/50 or 70/50/40 plans O $800/400 O $1,500 O $2,000 O $3,000 Not available with 70/50/50 or 70/50/40 plans O $1,000/500 O $1,500 O $2,000 ❑ $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑ $1,000/1,000 O$2,000 O $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans ❑ $1,000/2,000 $3,000 Not available with 80/60/50,70/50/50 or 70/50/40 plans Hospital per confinement deductible or outpatient surgery: Network: ❑$0 O$100 O$250 ❑$500 Non-network: O$100 O$250 ❑$500 (Non-network per confinement deductible must be equal to or greater than the network per confinement deductible.) Note: If electing Tiered Deductibles: * If Tier II deductible is$1,000—network per confinement must be$0. * If Tier II deductible is$600,$750 or$800—network per confinement deductible must be less than$500. mstrapp(Mar-01 -2002)-Weld County Govemme-IG WLAMIDASOCOAI0192005 9 Tier I Benefits : Preventive Care: Network: 100%with office visit copay. Non-network:Deductible and coinsurance. Lab/Xray: 100%for all providers. Network Office Visit Copay Amounts: (Choose one of the three options) ❑ Primary/Specialist copay: ❑ $20❑$25 ❑$30❑ $35 ❑ $40 ❑$50 ri Primary Care wl Specialist coinsurance: I — Primary: ❑ $20 ❑$25❑ $30❑ $35 ❑ $40 Primary Care w/higher Specialist copay: Specialist: Tier III deductible and coinsurance Primary: ❑$20❑ $25 ❑ $30❑ $35 ❑ $40❑$50 Restrictions: Specialist: ❑$30O $35 ❑ $40❑ $45 ❑ $50❑ $55 $30 or$35—only available with 50%or 60%Tier III coins. $40—only available with 50%Tier III coins. O $60 O $65 1 Minimum Differential=$10/Maximum Differential=$25 Tier II Benefits: Standard Benefits: Optional Benefits: • Inpatient X-ray&Lab Inpatient Mental Health/Chemical Dependency: • Inpatient Hospital incl. Surgery,Anesthesia,and ❑ Covered ❑Not Covered Rehabilitation Hospice If covered,benefit maximum calendar/lifetime days for • in-hospital conditions only: • Medical Supplies/Durable Medical Equipment ❑ 5/10 ® 10/20 ❑30/60 (life sustaining) • Skilled Nursing— 100 days/calendar year. • Home Health Care—60 visits/calendar year. • Ambulance mstrapp(Mar-01 -2002)-Weld County Governme-IGWLAMIDASOCOA10192005 10 Tier III Benefits : Standard Benefits: Optional Benefits: • Emergency Room Outpatient Mental Health &Chemical Dependency: ❑ Covered ❑ Not Covered • Outpatient Services(includes surgery,anesthesia) If covered,20 visits per calendar year max. • Outpatient X-ray and Lab: TMJ: O with deductible O Covered O Not Covered O without deductible If covered, $1,000 calendar year max. • Physical Therapy: Spinal Adjustment Treatment(SAT): $2,000 calendar year max. O Covered O Not Covered If Covered, • Medical Supplies: (non-life sustaining) Calendar Year Max: ❑ $500❑ $1,000 ❑ $2,000 • Durable Medical Equipment: Family Planning: $2,500 calendar year/$10,000 lifetime max. O Covered O Not Covered • Office Surgeries/Services Outpatient Speech Hearing&Occupational Therapy: O Covered O Not Covered If covered, $2000 per calendar year max. mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10 11 Prescription Drugs: Prescription Drug Copay Amount Drug Deductible: Advantage Retail ❑ ❑ ❑ ❑ Applies to all prescriptions. Tier 3 -Highest Brand Name copay $60 $75 $75 $100 The family maximum is 3 Pharmacy Tier 2-Lowest Brand Name copay $30 $30 $50 $50 times the individual amount. Plan Tier 1 -Generic Drug copay $10 $10 $10 $10 DNone ❑$100 individual Mail Order D$150 individual Tier 3 -Highest Brand Name copay $170 $215 $215 $290 Tier 2-Lowest Brand Name copay $80 $80 $140 $140 Tier 1 -Generic Drug copay $20 $20 $20 $20 Maximum Allowable Cost- MAC C Contraceptives: O Covered (standard) 90 day retail drug program-❑Not Covered- (disclosure required) standard Prescription Drug Copay Amount Drug Deductible: Choice Retail O O ❑ Applies to Brand Name Tier 3 -Highest Brand Name copay $40 $50 $60 prescriptions only. The Pharmacy Tier 2-Lowest Brand Name copay $20 $25 $30 family maximum is 3 times Plan Tier 1 -Generic Drug copay $10 $10 $10 the individual amount. ❑None Mail Order D$150 individual I— I Tier 3 -Highest Brand Name copay $80 $100 $120 ❑$250 individual Tier 2-Lowest Brand Name copay $40 $50 $60 ❑$500 individual Tier 1 -Generic Drug copay $20 $20 $20 Maximum Allowable Cost- MAC A Contraceptives: 0 Covered (standard) ❑Not Covered—disclosure required 90 day retail drug program- standard Prescription Drug Copay Amount Drug Deductible: Performance Retail ❑ ❑ ❑ Applies to all prescriptions Tier 3-Highest Brand Name copay $20 $30 $40 only. The family Pharmacy Tier 2-Lowest Brand Name copay $10 $15 $20 maximum is 3 times the 3-Tier Plan Tier 1-Generic Drug copay $5 $7 $10 individual amount. ❑None Mail Order O$75 individual I Tier 3-Highest Brand Name copay $40 $60 $80 ❑$100 individual Tier 2-Lowest Brand Name copay $20 $30 $40 ❑$150 individual Tier 1-Generic Drug copay $10 $14 $20 Maximum Allowable Cost- MAC B Contraceptives: O Covered (standard) 0 Not Covered—disclosure required 90 day retail drug program- standard mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10192005 12 Network Notification Form (Formerly Network Management/Managed Care Notification Form) Form MUST be completed for all Open Access and PPO Policies accessing a TPN or Great-West Healthcare network in OK, Northeast WI,&WY markets Note that there is no minimum employee participation required to submit this form. From: _ Phone: Home Office Contact _ Home Office Contact Extension - Effective Date: Action: Carrier. Region: Platform. use... eaxar. o ae. cede. 0 Group Termination 0 Great-West Healthcare 0 National Accounts ❑Denver January 1 2006 0 New Group ❑1"GWLA ❑Midmarket ❑st Louis 0 Amendment (for TPN,Pol.Name or Pol.#change) 0 NEF(amendments only) 0 Select 0 Alta(amendments only) Product(s): - Amendment Type/(i.e.moving from TPN to Great West Healthcare)/Notes: .El PPO. ❑POS ❑Open Access Policy No.(claim no.): Policy Name: Sales Office: Claims/Member Services: 358610 Weld County Government Kennett (1.800.663.8081) Policy Street,re Address:(Address only need for new groups or TPN changes, City: t State: Zip: '1,1rS;i:� l �a�t ry'sl�$:',--�"Y$t,% .,!.. 3+�rrt•"y t.- t' art.o. 't .A,,.''` y '° n .F"xiii 4,, cra44.4. -'a''a^r� ltfr d. £ ; -,in,...--,...,-,,,,,.. .,,,A,,,,,,:-r u k ✓ t 't' t pr .T+ "Ni' i K vYl..#�`,cl k .$'d`" C +6 : -.4,-, EF ,v s ',,.. 4:!.....:, ii. ,, 4tr. 44_7, & -��p „,...r 1 ,f M+'X ; 11- ,° . t %/Al r r ;ThiP-tt2 7fi ° ,,,4,..,,,,,:70 `Yv""l Tvr,re r r, r xx . ., n ' i�'� y 7 Ai �` t ii k �I �Yyt ,4.�, ,�yr r ,'�'r E .�iw �, ��,- >�,'`s�y th, h 9 f 3 C 1 3, a tg y4gri.PZ T C M'il J^ het,,�."Mk, ,t�,---• . eas _ »�4b' =Icate' rt "- =tr •,x= 1ms. rm n,- '.�+-.. '• "a'� F-2.5::;'.. a PPO%(Waal Network Co-Pay: Network Deductible(Individual/Family) Plan Type: Check One — D Hosp-Only ❑HosplPhys Indicate"A"for add or"T"for term beside any affected networks with approximate employee count. Reminder. For TPN set up,members must reside in the TPN service area as defined on the Zip Code Report available on the Managed Care intranet websde. A-add Approx. State Network TPWBusiness code A-add Approx. State Network Area TPN/Busmess code T-term EE Count T-term EE Count Area _ It Western MO& Healthcare Preferred(formerlyMid CA "Monterey,CA Coastal Health Care/4146 MO Topeka,K6 America Health Nehvork)/4190 CA Chico,CA "Superior of CA/4124 Sx MT MT State "Interwest HealtN4171,4174 GA Dalton/Northern GA 1"Medical Network#4391 '„.: NC NC&SC State *Medcost/4198 IA NE&IA "Midlands Choice/3341 T NE NE& IA "Midlands Choice/3341 At upstate NY(Does ID Southern,ID "IPN/4160 NY not include "Multiplan/3392 ,.F, Buffalo,NY) IN Rural Indiana Sagamore/3357 Ili OH Marietta,OH "Selectnet Plus/4103 Topeka,KS& Healthcare Preferredlformerly KS k SC SC&NC State *Medcost/4198 Western MO Mid Amenca)/4190 _ KS Rural KS 'HPW4393 SD SD State "America's PPO (formerlyAraz)/4389 WPPN/Multiplan("in rural WI Rural WI/Madison " KY KY State "Center Care/4156,4172 WI Suburban only)/4159-rural/4132Madison ;,rl' Suburban LA LA/MS State "American Lifecare/4143 ' WI Fox Valley WI "Network Health Plan/4149 MS MS/LA State "American Litecare/4143 r,.', WV WV State -'Selecteet Plus/4144 Tfe a' xw 4',sxy>c ✓ 3rsA� .. as /tint 0 1 pax- us eC A< ; (y � �► arleaP ©Y1 v , PI 5 to �,.. - x,d �+wilin 18 'A3! a�+d 4 t v,w y°5[t$,,, ,, yA5,a.d,, , 3 t. nffatimer theffoHo :"Niles, ealthcafra Troricicsy.*easonfmpol eetlon,Isils r!UndeM1Vty /Bosmess4odeplum 4.:4, Y, ,.r kSk"We �l :.,v ' `iteilatndfbste� PR-eelworrilliiittmdtdiftiitfle' llOdilfgrma"flonstaohttbover llkl ' ':r (31 S. `Sit '4g' ' k'- PPO%: Network Co-Pay: Network Deductible: Plan Type: Check One _ / $ $ ee IS family O Hosp-Only ❑Hosp/Phys Indicate"A"for add or"T"for term beside any affected networks w/approximate employee count. mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10192005 13 A-add Approx. State Network Network/Business code igi A-add Approx. State Network Area NetworklBusiness code T-term EE Count a- T-term EE Count Area �y Oklahoma City- "Great-West R'* OK Tulsa&Rural Healthcare(PCC)/1473 x' Northeast Great-West Healthcare/1460—"*Not Oklahoma-PPO Necessary for Id card �, WI Wisconsin available to traveling insureds. Production. ?.,Y•. Oklahoma City B "Great-west Y";,, OK Tulsa B Rural Healthcare(PCC)/7930- Wry Wyoming Great-West Healthcare/1451-"'Not Oklahoma-POS Necessary for Id card # +; available to traveling insureds. production _",(! 1 ' ... s s {..ys aPs:{ 1"f7 iu : z .�T- . qc + :'vy xn J1 1 L4`,tz� o `2. .- s i o10 Ah �* t�.C' x['₹ 'zx �i+'s�* x�fi"(w +n` + r T�';+ e ,c,; 1 F,_ ail,*, 3. ,°`y aa. ' 'cry!,ry a 4 r, r u� x zF `4Wr, r x ell h , ea �' 1 d- l'aN �hFp.,,,;�''� .['� s - 4 e r z ;hh o *1. etwdY' Op� 'Sr 'e ��•� , �e la �� ,� r .-. 4.. c n r a K:14. sn "�.1"-V;i^ a a.. o, tw.(coin _ "17.4t it Tetairtt q:g,"a x .. P r� • aman� I. 'firs, tesafth .haam. 13Yort"�{n,�+ .-. � ,�� *.,.� .-#.' Open Access%: Network Co-Pays: Network Deductible(Individual/Family) Plan Type: Check One _ / SOP $Spec 0 Hosp-Only 0 Hosp/phys Indicate"A"for add or"T"for term beside any affected networks with approximate employee count. Reminder For TPN set up,members must reside in the TPN service area as defined on the Zip Code Report available on the Managed Care Intranet websife. A-add Approx. State Network TM/Business code A-add Approx. State Network Area TPN/Business code T-term EE Count T-term EE Count Area CA Monterey,CA "Coastal Health Care/9303 fil MT MT State "Interwest Health/9305 CA Chico,CA "Superior of CA/9311 1 NE NE& IA "Midlands Choice/9307 Upstate NY(Does IA NE&IA "Midlands Choice/9307 NY not include "Multiplan/9308 w Buffalo,NYL ID Southern,ID ••IPN/9306 �` OH Marietta,OH "Selectnet Plus/9310 KS Rural KS "HPK/9304 SD SD State "America's PPO(formerlyAraz)/9301 KY KY State "Center Care/9302 WI Rural WI "WPPN/Multiplan/9312 ill,LA LA/MS State "American Ufecare/9300 WI Fox Valley WI "Network Health Plan/9309 MS MS/LA State "American Lffecare/9300 WV WV State "Selectnet Plus/9310 _ r q+. ,,. %� Svt:, a t:etiit!tSSIN! ' S2"". .a. !, cwt 7+ n'"P r -. 'S€ i- t �y" xg" 6a � e`fA, �aaaa'n 0 40,Is arrYe��nF1'n 000 .,gusln0,s cdeto0a¢laml�s 4t S r,. . 40" a n t''a faO btYn4".'"Rv u...�ist ° k ¢h . i.. .t",.., Open Access%: Network Co-Pays: Network Deductible: Plan Type: Check One _ / $pcp $Spec $ eel$ family 0 Hosp-Only ❑Hosp/Phys Indicate"A"for add or"T"for term beside any affected networks wl approximate employee count. A-add Approx. State NetworkBusiness code 'Cµ A-add Approx. State Network Area NetworklBusiness code T-term EE Count Network mowf 1 T-term EE Count Area Oklahoma City& "Great-West 1,1k:47..". OK Tulsa&Rural Healthcare(PCC)/9220 4n. Oklahoma-PPONecessary for id card ;. production. '4,:Y. NOTES: -ALL PPO&Open Access members in TPNs and OK and UT Great-West Healthcare networks must be set up to obtain Id cards with the proper logo. -***ALL PPO members residing in NE WI,WV&WY and requiring access to Great-West Healthcare markets in NE WI,WV and WY need to be set up specifically for these networks as these networks are not available to traveling insureds. Including these Great-West Healthcare networks on the form will allow Plan Services to set up these cases to access these Great-West Healthcare networks. -Members should not have access to more than one network in a given service area. "Available to traveling insureds.Members in the specified product seeking service in these TPN service areas,as indicated in the Zip Code Report,automatically have that TPN unless noted otherwise. However,members residing in this service area must have the TPN logo on their ID cards. `Requires special notification form available from Health Care Operations x759401rebecca.dering@gwl.com -Plan Services: Please email forms re:Network Selection to Policy Apps -Feel free to Email Policy Antos with questions, (revised-5/9/05) mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10192005 14 Application For Amended'Group Coverage — Signature Pages- NOTE: This document is important.It affects your legal rights and obligations. This Application is for employee benefit coverage and/or plan administrative services provided by Great-West Life& Annuity Insurance Company(Great-West)or one of its affiliates. Other Benefits: ®None If there are any additional benefits not previously indicated,please identify them here. In the Benefit column, list coverage affected,then in Description column describe the benefit. There will be an extra cost for each additional benefit listed. You may list up to 4 additions. Benefit Description Outpatient Mental Health - 10 visits per year The Applicant understands that Great-West will provide amended Booklets,if any,electronically to the Applicant. The Applicant is responsible for distributing booklets(electronically or otherwise)to employees. The Applicant accepts and agrees that approval of the Application and the final rates,fees,and factors so determined will be based on the final enrollment and eligibility information provided to Great-West by the Applicant, including the final proportion of employees electing coverage under the contract(s)for which Application is made. Approval and final rates, fees and factors will also be subject to qualification under the current underwriting rules and practices. Underwriting rules which are used by Great-West,which include but are not limited to: • Great-West is the sole provider of medical expense benefits. • No more than 10%of eligible employees will be covered under a retiree class of benefits. • The number of employed family members related to all company officers will be less than or equal to the larger of 5 or 10%of the number of eligible employees. • The Applicant will fund at least 50%of total plan costs or 100%of employee costs. • Employee participation minimum standards that more than 75%of eligible employees will apply for coverage under the medical plan. • Dependent participation minimum standards that more than 85%of employees with eligible dependents, excluding those who elect to waive benefits(dependents covered under another plan),will apply for dependent coverage under the medical plan. State law of Colorado requires the following notice: It is unlawful to knowingly provide false,incomplete,or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,fines,denial of insurance,and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. The undersigned("the Applicant")hereby authorizes Great-West to amend the contracts and policies issued by Great-West,as specified in this Application. Such amendments to the policies,contracts,or booklets is to be effective January 1,2006. Great- West agrees to deliver the documents in a timely manner. It is the Applicants responsibility,upon receipt of the amendment to the contract or policy or the booklet,to promptly review the amendment within a reasonable time,but not to exceed 60 days from the date of the cover letter,containing the amendment,is sent to the Applicant. If the Applicant agrees and accepts the amendment,the Applicant must sign and return the amendments within 60 days from the date of the cover letter. If the Applicant disapproves,the Applicant must contact us within 60 days from the date of the cover letter. If the Applicant fails to communicate with us within the time frame specified above,it will constitute the Applicant's acceptance of the amendment as submitted. In such event,the Applicant's signature given below is also intended hereby as the Applicant's execution of the amendment Full Legal Name of the Firm: Weld County Government Effective Date: January 1,2006 By: (Printed Name) : U)_fI(/tM Ct- Je f-o mstrapp(Mar-01 -2002)-Weld County Govemme-IGWLAMIDASOCOA10192005 15 Applicant Signature: 'et /� Title: UI)I /re LJ G C C Dated: AU/3r6 mstrapp(Mar-01-2002)-Weld County Govemme-IGWLAMIDASOCOAI0192005 16 Great-West® HEALTHCARE November 15, 2005 Weld County Government 915 10th Street PO Box 758 Greeley, CO 80632 Dear Ms. Vaughn: We would like to take this opportunity to once again thank you for your business. Great-West Life &Annuity Insurance Company prides itself on providing excellent service to our customers. Enclosed are amendment/replacement contract(s)for your plan. We would appreciate your prompt review of these documents. If you agree and accept the amendment/replacement contract(s), no further action is necessary on your part. If you disapprove, then you must contact us in writing within 60 days of the date of this letter with your request for changes or alterations. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of the amendment as submitted. Should you have any questions or concerns, or would like to discuss your account, please contact your plan services representative. Sincerely, Kelly Smith Great-West Healthcare cc: Reed Smith, Group Representative— Denver Group Sales Office Great-West Healthcare refers to products and services provided by Great-West Life&Annuity Insurance Company and its subsidiaries(Alta Health&Life Insurance Company and Great-West Healthcare HMO/HCSC companies).It also refers to the group business that is underwritten by New England Life Insurance Company and Metropolitan Life Insurance Company which is currently administered by Great-West Life&Annuity Insurance Company.Great-West Life&Annuity Insurance Company is not licensed to do business in New York.Products are sold in New York by its subsidiary First Great-West Life&Annuity Insurance Company,White Plains,N.Y. 6D1,o it Gies 1 Pao %lees-3a0_. GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY Executive Offices—Greenwood Village, Colorado • (Company) Excess Loss Insurance Policy issued to Weld County Government (Policyholder) The Excess Loss Insurance Policy No. 0258610 (the prior Policy) is hereby deleted in its entirety and replaced by the attached Policy which is effective as of January 1, 2005. Notwithstanding any provisions to the contrary, this Excess Loss Insurance Policy is a continuation of excess loss insurance coverage under the deleted Policy that was in effect between the Policyholder and the Company on the date immediately prior to this Policy's effective date. Any Deficit (such term having the same meaning as defined in this Policy's applicable Rider)existing under the prior Policy will be treated as if such Deficit had incurred under this Policy during a period immediately prior to this Policy's first Policy Year and will be subject to the Company's Deficit recovery rights as set forth in the Policy's applicable provisions and/or Rider. The Company has executed this Contract at its Executive Office on November 15, 2005. GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY • toted•Ca /12C c a a." Secretary President Accepted by: Weld County Government /;Signature: Title: )fre r3/49- „r Date: /2/705-- Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of receipt. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of this Amendment/replacement to the Policies/Contracts as submitted. GREAT- EST•LIFE&. NNUIT�f INSURRAN COMP NY x • a -' „ E tine O Ft r Ts s r s �iJ� 3 a�.(� 0CCh s {QQ.� d (� b �,a $. 5, s +� r d yin ^ '{ I�ppi t ��'po nn( , 0 0 d 80111 F ,t a 1- .IA1 APPLICATION FOR EXCESS LOSS INSURANCE Weld County Government (the Applicant) hereby applies to Great-West Life &Annuity Insurance Company for Excess Loss Insurance Policy No. 0258610 in the form attached hereto. This Policy has been approved and its terms accepted by the Applicant. ::::5:0m1 veer 15, 2005 Weld County Govern ent : By: 1 � �G nein/ rt Licensed Resident Agent: Title: 7 /Lr "1/ • • • Great4VVes tLtfe &r'Ann�it; ura a e many a� , r` d ? 5. } k i r'dMr:' , U4a £ ' E9Cet uttve '® e ..rign`s,#'rt 7 t� v 8 ' 3,� F y �'� " ,s rIt rp , 'tC.Y{ fit � "^k'b� a e t 3'f`„ ry �k° £{ . $n .,.w.r�.. EXCESS LOSS INSURANCE POLICY° Great-West Life & Annuity Insurance Company ("Company") issues this Excess Loss Insurance Policy number 0258610 to Weld County Government ("Policyholder" and/or"You") and thereby agrees to pay the benefits to the Policyholder, pursuant to provisions and conditions of the Excess Loss Insurance Policy contained and specified herein, upon receipt of satisfactory proof of loss. The consideration for coverage under this Policy is the Policyholder's application and payment of the required premium as it becomes due. The effective date of this Policy is January 1, 2005. All Policy and Agreement periods begin and end at 12:01 a.m. standard time at the Company's Executive office. This Policy is delivered in the State of Colorado and is governed by its laws. The provisions and conditions of the pages and Riders, if any, that follow will form a part of this Policy as fully as if recorded in detail above the signature placed on this Policy's cover page. The Company has executed this Policy at its Executive office on November 15, 2005. • Secretary President Excess Loss Insurance Policy (Non-Dividend Participation) Cover Page NEL-CP1(04-00) • 2 • ARTICLE - SCHEDULE OF EXCESS LOSS INSURANCE This Schedule is applicable only to the Excess Loss Insurance Policy issued to the Policyholder. . Each category, coverage basis, and optional feature of Excess Loss Insurance described herein and in each of any attached Riders (hereafter, collectively referred to as "Categorized Coverage") applies to the Policyholder only when the appropriate selection of such Categorized Coverage is indicated by the Company in the appropriate space provided. A. POLICYHOLDER'S AND PLAN'S INFORMATION, POLICY'S IMPORTANT DATES AND COVERAGE PERIODS List of Plans Included for Excess Loss Insurance Coverage under this Policy: Medical, Prescription Drugs Policy's Important Dates & Renewal Term: The Effective Date of this Policy: January 1, 2005 The Effective Date of this Amendment January 1, 2006 The Expiration Date of this Policy: End of 1-year term, subject to renewal The Anniversary Date of this Policy: Each January 1 beginning in 2006 Expense Incurral Period: • Specific: The Policy Year(s) Aggregate: The Policy Year(s) Expense Payment Period: (a) While the Policy is in effect: Specific: The Policy Year Aggregate: The Policy Year (b) After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on time: Aggregate: The Final Active Policy Year plus 15 months after the Policy ends. B. COVERED PERSONS Excess Loss Insurance is limited to Covered Benefits incurred by persons covered under Your plan: Specific Excess Loss Insurance: All persons who are validly covered pursuant to Plan's provisions. Aggregate Excess Loss Insurance: All persons who are validly covered pursuant to Plan's provisions. C. SPECIFIC EXCESS LOSS INSURANCE You are insured for the Specific Excess Loss Insurance. Specific Deductible Amount: $125,000.00 in Covered Benefits incurred by the same Covered Person (Individual Deductible) • The full specific Deductible Amount specified above will have to be re-satisfied for claims incurred prior to the termination of the Policy but which are paid after the Policy ends. Covered Benefits: Medical 1 D. AGGREGATE EXCESS LOSS INSURANCE • You are insured for the Aggregate Excess Loss Insurance. Monthly Attachment Points will be provided to you in writing. Covered Benefits: Medical, Prescription Drugs RIDER#D.1.2: Monthly Accommodation, Deficit Carryforward Type A.2 &Terminal Protection. Applicable data and points: - Number of consecutive calendar months included as Policy Months after the Policy ends: 15 months. Terminal Attachment Points will be provided to you in writing. E. PREMIUMS Monthly premium for each Categorized Coverage is determined for the premium unit method by multiplying the applicable premium rate (expressed as a dollar amount)by the applicable number of the specified premium units covered under the Plan on the first day of each Policy Month. Premium at Termination: At the end of this Policy there is a requirement for payment of a monthly premium for Terminal Protection. The premium is calculated by multiplying the applicable premium rate by the applicable number of the specified premium units on the first day of the last Policy Month preceding the terminate date of this Policy. The premium will be for the first Policy Month(s)following termination and will be payable in the first following the termination date of the Policy. If more than one type of premium unit is utilized, add all products of the multiplications for all identified types of the premium unit together to arrive at the total monthly premium for such Categorized Coverage. • F. NAME OF THIRD PARTY PLAN ADMINISTRATOR(TPA) Great-West Life &Annuity Insurance Company G. BANKING OPTIONS (identifies the frequency of your withdrawals from Your Bank Account for premiums and payment for Claims): Claims: Weekly Premium and Administration Fees: Monthly NEL-SP(07-04) • 2 TABLE OF CONTENTS • Article- Schedule of Excess Loss Insurance 4 Article- Definitions 6 Article-Specific Excess Loss 8 Article-Aggregate Excess Loss 8 Article- Limitations & Exclusions 9 Article-Termination of Policy 10 Article- Premium Provisions 10 Article-Claims Provisions 11 Article - Miscellaneous Provisions 12 Rider#D.1.2: Aggregate Excess Loss Insurance with Monthly Accommodation (with Deficit Carryforward Type A.2 &Terminal Protection) 14 • N EL-TOC(04-00) • 3 • ARTICLE - SCHEDULE OF EXCESS LOSS INSURANCE This Schedule is applicable only to the Excess Loss Insurance Policy issued to the Policyholder. Each category, coverage basis, and optional feature of Excess Loss Insurance described herein and in each of any attached Riders (hereafter, collectively referred to as "Categorized Coverage") applies to the Policyholder only when the appropriate selection of such Categorized Coverage is indicated by the Company in the appropriate space provided. A. POLICYHOLDER'S AND PLAN'S INFORMATION, POLICY'S IMPORTANT DATES AND COVERAGE PERIODS List of Plans Included for Excess Loss Insurance Coverage under this Policy: Medical, Outpatient Prescription Drugs Policy's Important Dates & Renewal Term: The Effective Date of this Policy: January 1, 2005 The Expiration Date of this Policy: End of 1-year term, subject to renewal The Anniversary Date of this Policy: Each January 1 beginning in 2006 Expense Incurral Period: Specific: The Policy Year(s) Aggregate: The Policy Year(s) Expense Payment Period: (a) While the Policy is in effect: Specific: The Policy Year Aggregate: The Policy Year (b) After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on time: Aggregate:The Final Active Policy Year plus 15 months after the Policy ends. B. COVERED PERSONS Excess Loss Insurance is limited to Covered Benefits incurred by persons covered under Your plan: Specific Excess Loss Insurance: All persons who are validly covered pursuant to Plan's provisions. Aggregate Excess Loss Insurance: All persons who are validly covered pursuant to Plan's provisions. C. SPECIFIC EXCESS LOSS INSURANCE You are insured for the Specific Excess Loss Insurance. Specific Deductible Amount: $100,000.00 in Covered Benefits incurred by the same Covered Person (Individual Deductible) The full specific Deductible Amount specified above will have to be re-satisfied for claims incurred prior to the termination of the Policy but which are paid after the Policy ends. IPCovered Benefits: Medical D. AGGREGATE EXCESS LOSS INSURANCE You are insured for the Aggregate Excess Loss Insurance. 4 • Monthly Attachment Points will be provided to you in writing. Covered Benefits: Medical, Outpatient Prescription Drugs RIDER#D.1.2: Monthly Accommodation, Deficit Carryforward Type A.2 &Terminal Protection. Applicable data and points: - Number of consecutive calendar months included as Policy Months after the Policy ends: 15 months. Terminal Attachment Points will be provided to you in writing. E. PREMIUMS Monthly premium for each Categorized Coverage is determined for the premium unit method by multiplying the applicable premium rate(expressed as a dollar amount)by the applicable number of the specified premium units covered under the Plan on the first day of each Policy Month. Premium at Termination: At the end of this Policy there is a requirement for payment of a monthly premium for Terminal Protection. The premium is calculated by multiplying the applicable premium rate by the applicable number of the specified premium units on the first day of the last Policy Month preceding the terminate date of this Policy. The premium will be for the first Policy Month(s)following termination and will be payable in the first following the termination date of the Policy. If more than one type of premium unit is utilized, add all products of the multiplications for all identified types of the premium unit together to arrive at the total monthly premium for such Categorized Coverage. F. NAME OF THIRD PARTY PLAN ADMINISTRATOR (TPA) • Great-West Life &Annuity Insurance Company G. BANKING OPTIONS (identifies the frequency of your withdrawals from Your Bank Account for premiums and payment for Claims): Claims: Weekly Premium and Administration Fees: Monthly NEL-SP(07-04) • 5 • ARTICLE - DEFINITIONS As used in this Policy and its attached Riders, unless the context specifically indicates otherwise, the following terms shall have the following meanings: ANNUAL ATTACHMENT LIMIT means the annual deductible amount for the Aggregate Excess Loss Insurance, which is the financial responsibility of the Policyholder. This amount is the Cumulative Attachment Limit for the last Policy Month of the Policy Year. This amount will be calculated at the end of the Policy Year. COVERED BENEFITS for purposes of Excess Loss Insurance coverage under this Policy: (1) to the extent not limited further under Section 2 immediately below, are limited to expenses incurred by a Covered Person, which are: (a) included in the class or classes of Covered Benefits; and (b) covered under the terms of the Plan, taking into account all of the exclusions and limitations in the Plan; and (c) incurred: (i) during the Expense Incurral Period or during the Run-in Expense Incurral Period, if applicable, and prior to the date this Policy ends; and • (d) paid during the Expense Payment Period, shown in the Schedule. Covered Benefits do not include: 1) any amount that is excluded from coverage under this Policy pursuant to Article - Limitations and Exclusions of Coverage; or 2) with respect to any Policy Year, any amount that qualifies as Covered Benefits for any previous Policy Year. (2) when used in connection with the Aggregate Excess Loss Insurance, Covered Benefits (which is also known as the Cumulative Claim Toward Attachment)do not include amounts that are considered to be Reimbursable Specific Losses, if the Specific Excess Loss Insurance is provided for in this Policy(or would have otherwise been considered Reimbursable Specific Losses, had the insurance protection under such Specific Excess Loss Insurance been continued to be in effect). COVERED PERSON means a person who is in a class or classes of persons included under Your Excess Loss Insurance Policy who is enrolled for coverage and meets the eligibility requirements set forth under the Plan. CUMULATIVE ATTACHMENT LIMIT (1) During the Policy Year while the Policy remains in effect, means for each Policy Month, the sum of the Monthly Attachment Limit for the current Policy Month plus the Monthly Attachment Limit for each of the previous Policy Months in the then current Policy Year. (2) After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on time, means: • (a) For the first Policy Month after the Policy ends, the sum of the Terminal Attachment Limit for such Policy Month plus the Cumulative Attachment Limit for the last Policy Month prior to the end of this Policy. 6 (b) For the second Policy Month(s)after the Policy ends, the sum of the Terminal Attachment Limit • for such Policy Month plus the Cumulative Attachment Limit for the prior Policy Month. (c) For subsequent months after the Policy ends, the Cumulative Attachment Limit will be equal to the Cumulative Attachment Limit of the second month after the Policy ends. EXPENSE INCURRAL PERIOD means the period of time during which an expense covered under Your Plan must be incurred by a Covered Person to count as a Covered Benefit under this Policy. If specified in the Schedule to be applicable to Your Policy, certain covered expenses incurred during the Run-In Expense Incurral Period may also be counted as Covered benefits under the Policy. In no event shall the Expense Incurral Period extend beyond the date the Policy ends. Unless specifically stated otherwise, an expense is considered incurred on the date the service, treatment or supply is provided to a Covered Person. EXPENSE PAYMENT PERIOD means the period of time during which the Plan must actually make payment for expenses covered under Your Plan in order to count as a Covered Benefit under this Policy. Unless specifically stated otherwise, an expense is considered paid on the date a check or draft of the Company is issued for payment. MONTHLY ATTACHMENT LIMIT • means the Aggregate Excess Loss Insurance monthly deductible amount which is the financial responsibility of the Policyholder and is to be calculated as follows: (1) For each of the first three Policy Months this Policy is in effect, multiply the appropriate Monthly Attachment Point by the appropriate number of the Attachment Units on the first day of the first Policy Month. (2) For the fourth and each subsequent Policy Months this Policy is in effect, multiply the appropriate Monthly Attachment Point by the appropriate number of the Attachment Units on the first day of the second prior Policy Month. If more than one type of the Attachment Unit is utilized, add all products of the multiplications for all identified types of the Attachment Unit together to arrive at the total amount of the Monthly Attachment Limit for such Policy Month. PLAN means the self-funded employee health benefit plan or plans established and maintained by You and approved by You and the Company for purposes of this Excess Loss Insurance Policy. If so approved by the Company, the term "Plan" shall, during the period immediately prior to the date on which the self-funded plan as described in the first sentence is approved by both parties, mean either: (1) a draft Summary Plan Description(s), or a Brief Outline of Plan Benefit Design(s), or a copy(ies)of Your plan's prior benefit booklets or certificates (with modifications, if any, as so specified), whichever You have designated with the Company's acceptance to be Your self-funded Plan; or (2) magnetic or computer-readable records of plan's information maintained by the Company, which are • used by the Company as a source of information to provide claim payment and other administrative services to the Policyholder's Plan. POLICY MONTH means a calendar month during a Policy Year. POLICY YEAR • 7 Means the Policy Period which is a period beginning on the Effective Date or the most current Renewal Date • of the Policy and consisting of 12 consecutive Policy Months. The first Policy Year may contain any number of Policy Months as shown in the Schedule. For purposes of this Policy, the Policyholder's Final Active Policy Year will end on the date the Policy ends, even if this results in a Policy Year consisting of less than 12 Policy Months. REIMBURSABLE SPECIFIC LOSSES means the total Covered Benefits paid under the Plan with respect to each Covered Person less any applicable Specific Deductible Amount. TERMINAL ATTACHMENT LIMIT applies exclusively to the Aggregate Excess Loss Insurance Policy with a Rider providing Terminal Protection, and means part of the Aggregate Excess Loss Insurance deductible amount which is the financial responsibility of the Policyholder and is to be calculated monthly after the Policy ends as follows: (1) For each of the first two Policy Months after this Policy ends, multiply the appropriate Terminal Attachment Point by the appropriate number of the Attachment Units on the first day of the second prior Policy Month. (2) For the third and each subsequent Policy Months after this Policy ends, the Terminal Attachment Limit for such Policy Month is zero. If more than one type of the Attachment Unit is utilized as stated in the applicable Rider information section of the Schedule (or an Amendment), add all products of the multiplications for all identified types of the Attachment Unit together to arrive at the total amount of the Terminal Attachment Limit for such Policy Month. YOU, YOUR, POLICYHOLDER or POLICYHOLDER'S • means the Policyholder whose name is shown in the Application. NEL-DEF(07-04) ARTICLE - SPECIFIC EXCESS LOSS INSURANCE The provisions under this Article apply to You only if You are insured for the Specific Excess Loss Insurance. A. While the Policyholder's Specific Excess Loss Insurance remains in effect, the Company will pay to the Policyholder, subject to the terms, conditions and limitations of the Policy, the Specific Excess Loss Insurance reimbursement due, if any, pursuant to Article-Claims Provisions. B. Subject to the Company's Limits of Liability, the Specific Excess Loss Insurance reimbursement for any Policy Year is equal to the Reimbursable Specific Losses. NEL-SPEC(04-00) ARTICLE -AGGREGATE EXCESS LOSS INSURANCE The provisions under this Article apply to You only if You are insured for the Aggregate Excess Loss Insurance. A. While the Policyholder's Aggregate Excess Loss Insurance remains in effect, the Company will pay to the Policyholder, subject to the terms, conditions and limitations of the Policy, the Aggregate Excess Loss Insurance reimbursement due, if any, pursuant to Article-Claims Provisions. B. After the end of each Policy Year the Company will reimburse the Policyholder the amount by which the Plan's • total paid Covered Benefits during the Policy Year exceed the Annual Attachment Limit for such Policy Year. NEL-AGG(04-00) 8 ARTICLE - LIMITATIONS & EXCLUSIONS OF COVERAGE • A. This Policy is solely between the Company and the Policyholder, and shall not create any rights or legal relationship between the Company and any Covered Person or agent, assignee or beneficiary thereof. The Company's sole liability hereunder is to the Policyholder, subject to the terms, conditions and limitations of this Policy. B. Expenses incurred for or in connection with the following, as reasonably determined by the Company, will not be considered Covered Benefits under this Policy and the Company shall not be liable to reimburse the Policyholder or any person for any such expenses: (1) For expenses incurred while the Plan's coverage is not in force with respect to the Covered Person. (2) For expenses which are not covered, or are in excess of the amount payable, under the terms and provisions of the Plan. (3) For expenses to the extent the Policyholder or Plan receives any payment or receives a reduction in charges because of a claims reduction negotiation program, a coordination of benefits provision in the Plan or any right of recovery or subrogation. (4) For or in connection with procedures, drugs or treatment methods that are deemed Experimental or Investigational as defined in the Plan, except to the extent agreed to otherwise in writing in advance by the Company. (5) For any liability or obligations assumed by the Policyholder under any Contract or service agreement other than the Plan. (6) For cost of the administration of claims payments or expense of litigation with individual claimants, • service or professional providers relating or unrelating to benefits under the Plan including, but not limited to, costs of defense and liability for punitive or exemplary or extracontractual damages. (7) For liabilities, expenses, losses or fines which are based upon noncompliance or violation of any court judgment or order, any federal or state statute, rule, or regulation. (8) For premium or surcharge taxes, other assessments, or similar payment obligations regardless of what their title is and regardless of who or what entity the designated payee is, as levied by any local, state or other governmental unit against the Plan, Policyholder or Company, unless the Company has agreed in writing in advance to cover such specific payment. (9) For expenses or losses that were caused by a wrongful, criminal or tortious act of any person or entity and for which the Policyholder or Plan released such person or entity from its legal liability without just compensation to the Plan. (10) For expenses or claims paid by any person or entity other than the Company, unless the Company has agreed in writing in advance to cover such specific payment. (11) With respect to Specific Excess Loss Insurance, for expenses incurred for third party vendor prescription drug coverage; for dental, vision, or weekly indemnity(short term disability)coverage;for health conversion charges; for health care surcharges imposed by or authorized by any local, state or federal authority; and for capitation or provider bonus payments. C. Subject to the provisions of any Rider that provides Terminal Protection, after the termination of this Policy, the Company will not be liable for any further payments under this Policy regardless of the date that the underlying benefit claim was incurred or submitted to the Company, provided that the Company has not • intentionally delayed processing the claim. NEL-EX(04-00) 9 • ARTICLE -TERMINATION OF POLICY The Policy and all coverages hereunder will terminate upon the earliest of the following dates. A. Except as provided under the Grace Period Section under Article- Premium Provisions, at the end of any period for which the last premium is paid. • B. Except to the extent of coverage provided under the Terminal Aggregate Liability Protection feature as described in the appropriate Rider, if such Rider applies to You, the date the Policy ends. C. The date of termination of the Plan. D. The date of cancellation of the administrative services agreement between the Policyholder and the Company. E. If any state or other jurisdiction enacts a law which prohibits the continuance of this Policy, or the existing law is interpreted to so prohibit the continuance of this Policy, as reasonably determined by the Company, the Policy shall terminate automatically as to such time or jurisdiction on the effective date of such law or interpretation. F. The Policyholder may terminate this Policy at any time by giving written notice to the Company at least 31 days in advance of such date. G. The Company may terminate this Policy: (1) On any Expiration Date of the Policy, by giving written notice to the Policyholder at least 31 days prior • to such date; (2) Immediately upon written notice to the Policyholder in the event the Policyholder files a petition for bankruptcy or for voluntary reorganization for the benefit of creditors, or is the subject of an involuntary petition for bankruptcy. However, such termination will not relieve the Company from its liability existing prior to the date of termination; (3) Immediately upon written notice to the Policyholder of the discovery of the Policyholder's material misrepresentation which affects the insurability of the risk; (4) Retroactively to the Policy Effective Date or the latest Renewal Date as applicable, upon written notice to the Policyholder, if it is discovered that the Policy was obtained or was renewed through fraudulent statements, omissions or concealment of facts material to the acceptance of the risk assumed by the Company; (5) Immediately and without notice upon failure of the Policyholder to comply with any material term of this Policy; and (6) Immediately and without notice upon Company's receipt of information that the Policyholder has failed to fund its Bank Account established to pay benefits under its Plan. If this Policy terminates for any reason, the Policyholder shall remain liable for any unpaid amounts that have accrued under this Policy including amounts accrued during the grace period. NEL-TP(04-00) • ARTICLE - PREMIUM PROVISIONS A. PREMIUM DUE DATE AND PAYMENT: The first premium is due on the Effective Date of this Policy. Future premiums are due on the first day of each Policy Month. The Policyholder will make funds available in its Transfer Account, as specified in the Administrative Services Contract, that are sufficient to honor all of the Policyholder's obligations under this Policy while it is in force. 10 • B. GRACE PERIOD: A Grace Period of 31 days from the due date will be allowed for the payment of each premium after the first premium payment. During the Grace Period, the coverage will remain in effect provided that the premium is paid before the end of the Grace Period. If the Policyholder does not pay the premium due this Policy will terminate without further notice retroactively to the date for which premiums were last paid. C. COMPUTATION OF PREMIUMS: The total monthly premium is the sum of all Categorized Coverages together, as applicable to the Policyholder. D. PREMIUM REFUNDS: Any error in or correction to any premium paid must be reported to the Company promptly. The premiums will be adjusted retroactively to reflect the changes. For a decrease in premium, or termination of insurance, a credit will be given only for the 2-month period prior to receipt of such notice. No premium refunds will be owed or made to the Policyholder or any person if an error or a correction in paid premium is failed to be reported to the Company within this time limit. E. CHANGES IN RATES, FACTORS, CALCULATION OF MONTHLY ATTACHMENT LIMIT AND POINTS: The Company reserves the right to change any premium rates, factors, Monthly Attachment Limit calculation, points and Specific Deductible Amount(s)on any of the following dates: (1) On the date when the terms of this Policy are changed; (2) On any Anniversary Date of the Policy(however, any such change which represents an increase in rates, factors, points or Specific Deductible Amount(s), will not become effective until after the date which is 30 days after the Company has given written notice to the Policyholder informing the Policyholder of the increase); (3) On the effective date of any change to the Plan that materially affects benefits provided under the Plan; • (4) On the first day of a month, regardless of Policy Year, following a change in Policyholder's primary business or in Policyholder's geographical location; (5) On the date the Policyholder adds to or deletes from this Policy a subsidiary or affiliated companies or divisions. The addition or deletion may only occur with the Company's prior approval; (6) On the first day of a month following a change in the number of Covered Persons under the Plan if such change exceeds 10% from the prior month or 20%over any three consecutive months regardless of Policy Year; and (7) On any date that the Policyholder requests the addition of a Covered Person who should have been included as a Covered Person earlier, such change to be retroactive to the date the Covered Person should have been included; provided, however, that Company reserves the right to consider that such Covered Person shall be included under this Policy no earlier than 2 months prior to the Policyholder's request to add the person(s). ARTICLE - CLAIMS PROVISIONS A. NOTICE OF CLAIM: The Policyholder shall give written notice of claims to the Company in a form satisfactory to the Company. If the Policyholder designates the Company as TPA, the Policyholder's notice and proof of claim submission duty is considered to have been delegated to the Company. The Policyholder's such duty is thereby waived. B. PAYMENT OF CLAIMS: Contingent upon the Company's receipt of the Policyholder's timely submitted notice and satisfactory proof of claim as described in Section A. above, the Company will thereafter pay the • Policyholder any Excess Loss insurance reimbursement due within a reasonable time, but not to exceed 60 working days. C. ADJUDICATION OF CLAIMS: The Company shall have no obligation under this Policy for the settlement or adjustment of claims filed by Covered Persons under the Policyholder's Plan. The Policyholder shall always have the final right to determine the availability or extent of benefits payable under its Plan and the 11 Company shall always have the final right to determine the availability and extent of coverage to the • Policyholder under this Policy. D. RECOVERY OF OVERPAYMENT: If the Company reimbursed You more than it should have, the Company has the right to recover the excess amount directly from you. The provisions in this Section D. shall survive beyond the termination of this Policy. E. INSOLVENCY: In the event of the insolvency or bankruptcy of the Policyholder, all reimbursements made or becoming due after the effective date of this Policy shall be payable by the Company on the basis of the amount of liability of the Plan under the terms and conditions of this Policy as finally determined in the liquidation or receivership proceeding without diminution because of the insolvency or bankruptcy of the Policyholder. Such amount shall be paid directly to the Policyholder or its liquidators, receiver, or other statutory successor. The Company shall be discharged from its obligations under this Policy to the extent of such payments. Nothing in this Section shall increase the Company's liability beyond that which would have existed had the Policyholder not become insolvent or bankrupt. NEL-TP(04-00) ARTICLE - MISCELLANEOUS PROVISIONS A. ENTIRE CONTRACT: The Contractholder shall make any and all such premium payments separate and apart from the payments due under this Contract and in the manner set forth in the applicable Policy. • In the event of a conflict between the provisions of the Plan and the provisions of this Policy, the latter shall prevail. The Company has relied upon the underwriting information provided by the Policyholder or its authorized representative in the issuance of this Policy and the Policyholder represents such information as accurate. Should subsequent information become known which, if known prior to the issuance of this Policy, would affect the rate(s), attachment point(s), deductible(s), attachment limit(s), claim limit(s)or terms and conditions for coverage hereunder, the Company shall have the right to revise the rate(s), attachment point(s), deductible(s), attachment limit(s), claim limit(s), or terms or conditions as of the effective date of issuance of this Policy or, at the option of the Company as of the next premium due date, by providing written notice to the Policyholder. B. DATA REQUIRED: The Policyholder shall maintain adequate records regarding administration of the Plan covered under this Excess Loss Insurance Policy. The Policyholder must maintain records of all Covered Persons under the Plan during the period the Policy is in effect and for a period of five years after the end of the Policy. Upon request by the Company, the Policyholder shall make available to the Company any such records and information deemed necessary for the Company's administration of this Excess Loss Insurance Policy. The Company may periodically examine any of the Policyholder's records relating to the coverage under this Policy and any claims filed under the Plan, and as a result of any examination of the Policyholder's records shall be entitled to readjust premiums, attachment points, deductibles, attachment limits, claim limits or reimbursements paid as may be necessary to reflect the true intent of this Policy. This provision shall survive the termination of this Policy. C. CLERICAL ERROR: Clerical error whether by the Policyholder or by the Company in keeping any records pertaining to the coverage will not invalidate coverage otherwise validly in force nor continue coverage otherwise validly terminated, but no such error shall expand the Company's obligations under this Policy. D. NOTICE: All notices and communications required under the terms of this Policy shall be given in writing by one party addressed to the other. • E. HOLD HARMLESS: It is understood that the only parties to this Policy are the Company and the Policyholder. No express or implied interest or rights are created under this Policy for any other persons or entities, whether they are providers or the Policyholder's employees, former employees, their dependents, heirs or assignees; and no third-party beneficiary status is conferred upon such persons or entities. 12 Based on the above understanding, except for a claim, demand or lawsuit arising out of the Company's • tortious or wrongful act committed directly against the Policyholder's employees or their dependents, the Company shall have no liability under this Policy, and the Policyholder agrees to hold harmless and indemnify the Company against any and all such loss, damage, and expense including court costs and attorney's fees, resulting from or arising out of claims, demands, or lawsuits brought against the Company by such employees, their dependents, heirs or assignees, and to claims for paid claim or surcharge taxes by any local, state or other governmental unit or other assessments (except for taxes on insurance premiums received under this Policy as described in Article- Premium Provisions) made against the Company by any governmental unit. F. AMENDMENT TO THE PLAN: No change in benefits payable under the Plan or any Amendment to the Plan will be binding on the Company until such change or Amendment is approved in writing by the Company. In the event the Company does not approve a Plan Amendment, liability will be limited to the Plan provisions in effect prior to the change or Amendment. G. CONFORMITY WITH THE LAW: If any provision of this Policy at time of issue is contrary to any law to which it is subject, that provision is changed to meet the law's minimum requirements. H. LEGAL ACTION: No action at law or in equity shall be brought to recover on this Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the Policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished. I. AMENDMENTS TO THE POLICY: Only the President, a Vice President, the Secretary or an Assistant Secretary of the Company have the authority to alter this Policy, or to waive any of the Company's rights or requirements and then only in writing. No such alteration to this Policy shall be valid unless amended on or attached to this Policy. Notwithstanding anything in this Policy to the contrary, Company reserves the right to amend the Policy at any time on 90 days advance written notice, such Amendment to be effective at the • expiration of said 90 days. J. OFFSET: The Company shall be entitled to offset payments due to the Policyholder under this Policy against premiums due and unpaid by the Policyholder to the Company. K. ASSIGNMENT: Any assignments of this Policy or of any rights hereunder shall be void and of no force or effect. L. NOT WORKERS'COMPENSATION: The coverage provided under this Policy applies only to benefits under Your Plan of benefits for non-occupational accidents or illnesses. It is not the intent of this Policy to provide benefits or coverage under any Plan in lieu of Workers'Compensation Insurance. NEL-TP(04-00) • 13 • Rider#D.1.2: Aggregate Excess Loss Insurance With Monthly Accommodation (With Deficit Carryforward Type A.2 &Terminal Protection) This Rider applies to You only if it is so specified in the Schedule or otherwise added by Amendment. This Rider forms a part of Excess Loss Insurance Policy number: 0258610 to which it is attached and modifies the Policy to the extent provided below. All the terms and conditions of the Policy, not in conflict with this Rider, remain in effect Article-Aggregate Excess Loss Insurance, Section B is superseded by the following provisions: A. Definitions: As used in this Rider, the following terms shall have the following meanings: (1) "Deficit"for any Policy Year shall mean the amount of the Aggregate Excess Loss Insurance Reimbursement that the Company pays or is liable to pay to the Policyholder which equals the result of the Plan's total paid Covered Benefits during the Policy Year minus the Cumulative Attachment Limit of the last Policy Month of the Policy Year. Subject to A.2. below, a Deficit occurring during any Policy Year will be carried forward for recovery from the Policyholder by the Company in any subsequent Policy Year in which there is a Surplus. (2) "Recoverable Deficit"for a Policy Year shall mean the limited amount of a Deficit, from that Policy Year, which can be carried forward from one Policy Year to any following Policy Year for recovery. For purposes of this Rider, the Recoverable Deficit for a Policy Year will not exceed 10% of the Cumulative Attachment Limit of the last Policy Month of the Policy Year from which such Deficit is being carried • forward. However, if the Policy ends on a date other than the last day of the Policy Year, there will be no limit on the amount of the Recoverable Deficit, which was incurred in a Policy Year prior to the final Active Policy Year. (3) "Active Policy Year" shall mean any Policy Year prior to the date this Policy ends. (4) If this Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on time, this Rider shall include the"Policy Year After the Policy Ends,"which shall contain the consecutive number of calendar months (which shall be deemed Policy Months)as specified in the Schedule's section with information designed for this Rider or in an Amendment, and shall begin on the date immediately after the final Active Policy Year ends. B. During the Active Policy Year: (1) After the end of each Policy Month, except for the Policy Month specified in B.2. below: (a) The Company will reimburse the Policyholder the amount by which (i)the result of the Plan's total paid Covered Benefits for the Policy Year to date minus the amount of any reimbursement previously paid to the Policyholder during the Policy Year and which the Policyholder has not repaid, exceeds (ii)the Cumulative Attachment Limit for such Policy Month. (b) If the amount calculated pursuant to B.1.a. above is less than zero, the Policyholder shall pay the Company the sum of(i)the total reimbursement previously paid to the Policyholder during the Policy Year less any amount the Policyholder has repaid, plus (ii) the Recoverable Deficit from all previous Policy Years which the Policyholder has not repaid. (c) In no event shall the amount the Policyholder is required to pay the Company in B.1.b. above • exceed the amount by which the amount in B.1.a.(ii) is greater than the resultant amount in B.1.a.(i). (2) If the date the Policy ends does not coincide with the Policy Expiration Date, after the end of the Policy Month in which the Policy ends: 14 (a) The Company will reimburse the Policyholder the amount by which (i)the result of the Plan's total • paid Covered Benefits for the final two Active Policy Year to date minus the amount of any reimbursement previously paid to the Policyholder during the final two Active Policy Year and which the Policyholder has not repaid, exceeds (ii)the sum of the Cumulative Attachment Limit for such Policy Month plus the Cumulative Attachment Limit for the last Policy Month of the Policy Year prior to the final Active Policy Year. (b) If the amount calculated pursuant to B.2.a. above is less than zero, the Policyholder shall pay the Company the sum of(i)the total reimbursement previously paid to the Policyholder during the final two Active Policy Years less any amount the Policyholder has repaid, plus (H)the Recoverable Deficit from all previous Policy Years which the Policyholder has not repaid. (c) In no event shall the amount the Policyholder is required to pay the Company in B.2.b. above exceed the amount by which the sum in B.2.a.(ii) is greater than the resultant amount in B.2.a.(i). C. During the Policy Year After the Policy Ends: (1) If the date the Policy ends coincides with the Policy Expiration Date: After the end of the second Policy Month of the Policy Year After the Policy Ends and any subsequent Policy Month thereafter: (a) The Company will reimburse the Policyholder the amount by which (i)the result of the Plan's total paid Covered Benefits during the final Active Policy Year and the Policy Year After the Policy Ends to date minus the amount of any reimbursement previously paid to the Policyholder during the final Active Policy Year and the Policy Year After the Policy Ends and which the Policyholder has not repaid, exceeds (ii)the Cumulative Attachment Limit for such Policy Month. (b) If the result as calculated pursuant to C.1.a. above is less than zero, the Policyholder shall pay • the Company the sum of(i)the total reimbursement previously paid to the Policyholder during the final Active Policy Year and the Policy Year After the Policy Ends less any amount the Policyholder has repaid, plus (ii)the Recoverable Deficit from all previous Policy Years which the Policyholder has not repaid. (c) In no event shall the amount the Policyholder is required to pay the Company in C.1.b. above exceed the amount by which the amount in C.1.a.(ii) is greater than the resultant amount in C.1.a.(i). (2) If the date the Policy ends does not coincide with the Policy Expiration Date: After the end of the second Policy Month of the Policy Year After the Policy Ends and any subsequent Policy Month thereafter: (a) The Company will reimburse the Policyholder the amount by which (i)the result of the Plan's total paid Covered Benefits during the final two Active Policy Years and the Policy Year After the Policy Ends to date minus the amount of any reimbursement previously paid to the Policyholder during the final two Active Policy Years and the Policy Year After the Policy Ends and which the Policyholder has not repaid, exceeds (ii)the sum of the Cumulative Attachment Limit for such Policy Month plus the Cumulative Attachment Limit for the last Policy Month of the Policy Year prior to the final Active Policy Year. (b) If the result as calculated pursuant to C.2.a. above is less than zero, the Policyholder shall pay the Company the sum of(i)the total reimbursement previously paid to the Policyholder during the final two Active Policy Year and the Policy Year After the Policy Ends less any amount the Policyholder has repaid, plus (H)the Recoverable Deficit from all previous Policy Years which the Policyholder has not repaid. • (c) In no event shall the amount the Policyholder is required to pay the Company in C.2.b. above exceed the amount by which the sum in C.2.a.(ii) is greater than the resultant amount in C.2.a.(i). N EL-RD 1.2(04-00) 15 GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY • Executive Offices—Greenwood Village, Colorado (Company) • Excess Loss Insurance Policy issued to Weld County Government (Policyholder) The above Excess Loss Policy No. 0258610 is amended as follows: SPECIFIC EXCESS LOSS LEVEL The previously issued Policy section entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE is hereby deleted and replaced by the attached Policy section entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE, to reflect the change to the section entitled Specific Excess Loss Insurance. This Amendment overrides anything to the contrary contained in the Policy/Contract. All Policy/Contract provisions not addressed by this Amendment shall remain in full force and effect. Where a conflict exists between the Amendment provision and a Policy/Contract provision, the Amendment provision shall control. This Amendment is effective on and after January 1, 2006. The Company has executed this Amendment at its Executive Office on November 15, 2005. GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY • Secretary President Accepted by: Weld County Government Signature: Title: Date: Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of receipt. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of this Amendment/replacement to the Policies/Contracts as submitted. • 1 GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY • Executive Offices—Greenwood Village, Colorado (Company) Administrative Services Contract issued to Weld County Government (Contractholder) The above Administrative Services Contract No. 0258610 is amended as follows: MEMBER CARE MANAGEMENT APPENDIX The Appendix entitled Member Care Management is deleted and replaced with the attached Medical Outreach Program Appendix and is made part of the contract. This Amendment overrides anything to the contrary contained in the Policy/Contract. All Policy/Contract provisions not addressed by this Amendment shall remain in full force and effect. Where a conflict exists between the Amendment provision and a Policy/Contract provision, the Amendment provision shall control. This Amendment is effective on and after January 1, 2006. The Company has executed this Amendment at its Executive Office on November 15, 2005. GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY filak.* Ro For the Actuary Accepted by: Weld County Government Signature: Title: Date: Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of receipt. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of this Amendment/replacement to the Policies/Contracts as submitted. • 1 • AGREEMENT INSTRUCTIONS FOR GUARANTY ASSOCIATION NOTICES AND OTHER STATE REQUIRED NOTICES The enclosed State Guaranty Association Notices are considered to be a part of the employee booklet. These Notices describe the protection a resident receives through the Association. Under state law, a copy of the Notice must be given to each employee who elects coverage under this Plan and resides in a state for which a Notice has been provided. General Instructions for State Notices -Agreements: • State Notices must be provided to all employees enrolling in your Plan—based on the employee's state of residence. • Please review the documents attached to this sheet and provide copies to enrolling employees according to the state in which he/she resides. •A Notice is required if the Contractholder is sitused in that state or has residents of that state. • • 1 • CALIFORNIA GUARANTEE ASSOCIATION ACT -SUMMARY CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION ACT SUMMARY DOCUMENT AND DISCLAIMER Residents of California who purchase life and health insurance and annuities should know that the Insurance companies licensed in this state to write this type of insurance are members of the California Life and Health Insurance Guarantee Association (CLHIGA). The purpose of this Association is to assure that Policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guarantee Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases,to keep coverage in force. The valuable extra protection provided through the Association is not unlimited, as noted below, and is not a substitute for consumers'care in selecting insurers. The California Life and Health Insurance Guarantee Association may not provide coverage for this Policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in California. You should not rely on coverage by the California Health Insurance Guarantee Association in selecting an insurance company or in selecting an insurance Policy. Coverage is NOT provided for your Policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable Contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Guarantee Association to induce you to purchase any kind of insurance Policy. Policyholders with additional questions should first contact their insurer or agent, and may then contact: • Executive Director California Life and Health Insurance Guarantee Association P. O. Box 16860 Beverly Hills, CA 90209-3319 (323) 782-0182 Consumer Service Division California Department of Insurance 300 South Spring Street Los Angeles, CA 90013 (800)927-4357 or(213)897-8921 Below is a brief summary of this law's coverages, exclusions and limits.This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the right or obligations of the Association. COVERAGE Generally, individuals will be protected by the California Life and Health Insurance Guarantee Association if they live in this state and hold a life or health insurance Contract, or an annuity, or if they are insured under a group insurance Contract, issued by a member insurer.The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. • EXCLUSIONS FROM COVERAGE However, persons holding such Policies are not protected by this Guarantee Association if: • Their insurer was not authorized to do business in this state when it issued the Policy or Contract. 2 • Their Policy was issued by a health care service plan (HMO, Blue Cross, Blue Shield), a charitable • organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society. • They are eligible for protection under the laws of another state. This may occur when the insolvent insurer was incorporated in another state whose guarantee association protects insureds who live outside that state. The Guarantee Association also does not provide coverage for: • Unallocated annuity Contracts; that is, Contracts which are not issued to and owned by an individual and which guarantee rights to group Contract holders, not individuals. • Employer and association plans, to the extent they are self-funded or uninsured. • Synthetic guaranteed interest Contracts. • Any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable Contract sold by prospectus. • Any Policy of reinsurance unless an assumption certificate was issued. • Interest rate yields that exceed an average rate. • Any portion of a Contract that provides dividends or experience rating credits. LIMITS ON AMOUNTS OF COVERAGE The Act limits the Association to pay benefits as follows: • for Life and Annuity Benefits: • - 80%of what the life insurance company would owe under a life Policy or annuity Contract up to: - $100,000 in cash surrender values; - $100,000 in present value of annuities; or • - $250,000 in life insurance death benefits. - A maximum of$250,000 for any one insured life no matter how many Policies and Contracts there were with the same company, even if the Policies provided different types of coverages. - for Health Benefits, a maximum of$200,000 of the contractual obligations that the health insurance company would owe were it not insolvent. The maximum may increase or decrease annually based upon changes in the health care cost component of the consumer price index. PREMIUM SURCHARGE Member insurers are required to recoup assessments paid to the Association by way of a surcharge on premiums charged for insurance Policies to which the Act applies. • 3 • COLORADO PROTECTION ASSOCIATION ACT SUMMARY OF THE COLORADO LIFE AND HEALTH INSURANCE PROTECTION ASSOCIATION ACT AND NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS INTRODUCTION Residents of Colorado who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Life and Health Insurance Protection Association. The purpose of this Association is to assure that Policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in Colorado and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Association is limited, however. And, as noted below, this protection is not a substitute for consumers'care in selecting companies that are well-managed and financially stable. IMPORTANT DISCLAIMER The Life and Health Insurance Protection Association may not provide coverage for this Policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require residency in Colorado. You should not rely on coverage by the Life and Health Protection Association in selecting an • insurance company or in selecting an insurance Policy. Coverage is NOT provided for a Policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies or their agents are prohibited by law from using the existence of the Association to induce you to purchase any kind of insurance Policy. SUMMARY The state law that provides for this safety-net coverage is called the Life and Health Insurance Protection Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Association. COVERAGE Generally, individuals will be protected by the Life and Health Insurance Protection Association if they live in this state and hold a life or health insurance Contract, or an annuity, or if they hold certificates under a group life or health insurance Contract or annuity, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. This Information is Provided By: • Life and Health Insurance Colorado Division of Insurance Protection Association 1560 Broadway, Suite 850 P.O. Box 480025 Denver, Colorado 80202 Denver, Colorado 80248-0025 (303)894-7499 (303)292-5022 4 • EXCLUSIONS FROM COVERAGE Persons holding such Policies or Contracts are notprotected by this Association if: • they are not residents of the State of Colorado, except under certain very specific circumstances; • the insurer was not authorized or licensed to do business in Colorado at the time the Policy or Contract was issued; • their Policy was issued by a nonprofit hospital or medical service organization (e.g., the"Blues"), an HMO, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the Policyholder is subject to future assessments, or by an insurance exchange. The Association also does not provide coverage for: • any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has assumed the risk; • any Policy of reinsurance(unless an assumption certificate was issued); • plans of employers, associations or similar entities to the extent they are self-funded or uninsured (that is, not insured by an insurance company, even if an insurance company administers them); • interest rate yields that exceed an average rate; • dividends; • experience rating credits; • credits given in connection with the administration of a Policy or Contract; • annuity Contracts or group annuity certificates not owned by an individual unless and to the extent guaranteed to an individual by the insurer; • annuity Contracts or group annuity certificates used by nonprofit insurance companies to provide retirement benefits for nonprofit educational institutions and their employees; • Policies, Contracts, certificates or subscriber agreements issued by a prepaid dental care plan; • sickness and accident insurance when written by a property and casualty insurer as part of an • automobile insurance Contract; • unallocated annuity Contracts issued to an employee benefit plan protected under the federal Pension Benefit Guaranty Corporation; • Policies or Contracts issued by an insurer which was insolvent or unable to fulfill its contractual obligations as of July 1, 1991; • Policies or Contracts covering persons who are not citizens or permanent residents of the United States; • financial guarantees, funding agreements or guaranteed investment Contracts not containing mortality guarantees and not issued to or in connection with a specific employee benefit plan or governmental lottery; • any kind of insurance or annuity, the benefits of which are exclusively payable or determined by a separate account required by the terms of such insurance Policy or annuity maintained by the insurer or by a separate entity. LIMITS ON AMOUNT OF COVERAGE The act also limits the amount the Association is obligated to pay out. The Association cannot pay more than what the insurance company would owe under a Policy or Contract. Also, for any one insured life, the Association will pay a maximum of$300,000 -no matter how many Policies and Contracts there were with the same company, even if they provided different types of coverages. Within this overall $300,000 limit, the Association will not pay more than $100,000 in cash surrender values, $100,000 in health insurance benefits, $100,000 in present value of annuity benefits, or$300,000 in life insurance death benefits -again, no matter how many Policies and Contracts there were with the same company, and no matter how many different types of coverages. FORM:RA3441 • 5 • WYOMING GUARANTY ASSOCIATION ACT NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE WYOMING LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Residents of Wyoming who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Wyoming Life and Health Insurance Guaranty Association. The purpose of this association is to assure that Policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted below, this protection is not a substitute for consumers'care in selecting companies that are well-managed and financially stable. The Wyoming Life and Health Insurance Guaranty Association may not provide coverage for this Policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in Wyoming. You should not rely on coverage by the Wyoming Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance Policy. Coverage is NOT provided for your Policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable Contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the guaranty association to induce • you to purchase any kind of insurance Policy. The Wyoming Life and Health Insurance Guaranty Association PO BOX 480164 Denver, Colorado 80248 State of Wyoming Department of Insurance Herschler Building 122 West 25th Street Cheyenne,Wyoming 82002-0440 The state law that provides for this safety-net coverage is called the Wyoming Life and Health Insurance Guaranty Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law, nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the guaranty association. COVERAGE Generally, individuals will be protected by the Wyoming Life and Health Insurance Guaranty Association if they live in this state and hold a life or health insurance Contract, or an annuity, or if they are insured under a group insurance Contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. . EXCLUSIONS FROM COVERAGE However, persons holding such Policies are not protected by this Association if: • they are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); • the insurer was not authorized to do business in this state; 6 • their Policy was issued by a fraternal benefit society, a mandatory state pooling plan, a stipulated premium • insurance company, local mutual burial association, a mutual assessment company, or similar plan in which the Policyholder is subject to future assessments, or by an insurance exchange. The Association also does not provide coverage for: • any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable Contract sold by prospectus; • any Policy of reinsurance(unless an assumption certificate was issued); • interest rate yields that exceed an average rate; • dividends; • credits given in connection with the administration of a Policy by a group Contractholder; • annuity Contracts issued by a nonprofit insurance company exclusively for the benefit of nonprofit educational institutions; • unallocated annuity Contracts (which given rights to group Contractholders, not individuals). • any plan or program of an employer or association that provides life, health or annuity benefits to its employees or members to the extent the plan is self-funded or uninsured. LIMITS ON AMOUNT OF COVERAGE The act also limits the amount the Association is obligated to pay out: the Association cannot pay more than what the insurance company would owe under a Policy or Contract. Also,for any one insured life, the Association will pay a maximum of$300,000- no matter how many Policies and Contracts there were with the same company, even if they provided different types of coverages. Within this overall$300,000 limit,the Association will not pay more than $100,000 in cash surrender values, $100,000 in health insurance benefits, $100,000 in present value of annuities, or$300,000 in life insurance death benefits -again, no matter how many Policies and Contracts there were with the same company, and no matter how many different types of coverages. • • 7 MEDICAL OUTREACH PROGRAM APPENDIX To be attached to and made a part of the Administrative Services Contract Effective: January 1, 2006 By and between Weld County Government and GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY Disease Management 1) The Company, through its own employees, Affiliates and/or employees of Contracted third-party vendor(s), may provide Disease Management(the"Program")which delivers services and/or supplies to Members and consists of, but is not limited to, disease and pain management. 2) The Company, through its own employees, Affiliates and/or employees of Contracted third-party vendor(s), will perform an initial identification of Members who meet predetermined medical criteria indicating their potential to be service and/or supply recipients. This identification process will be based on information legally obtained through claims, Members' self-referral or other valid sources. 3) A Member who is accepted into the Program ("Participant")will receive services and/or supplies that may consist of assessment and/or education for targeted diseases or chronic conditions (including, but not limited • to, pain, diabetes, asthma, and renal failure). The services and/or supplies are designed to enable the Participant to gain the knowledge and skills necessary to prevent severe chronic medical conditions, to manage his or her life-long condition and/or to improve the quality of his or her life. The Program neither warrants nor guarantees the well-being or improvement of the Participant's chronic medical condition or disease. 4) The Company shall cover the Program's costs by treating program services and/or supplies similarly to a claim and billing the Contractholder similarly to the billing and claim process for Plan's covered benefits. Features of the Program may be added, expanded or deleted at any time by the Company without the prior consent of the Contractholder. Nothing herein shall negate the Company's rights pursuant to Section 15 hereof. 5) The Contractholder agrees to provide 100% benefit reimbursement under its Plan, without application of the deductible or copayment, for all Program services and/or supplies received. The benefit reimbursement amount shall apply to the Member's lifetime maximum. Maternity Support Program This program monitors the health and well-being of pregnant Members. The program neither warrants nor guarantees a normal or safe pregnancy or delivery. Nor does it guarantee the health or well-being of pregnant mothers or their newborn child(ren). The Client agrees to provide 100% benefit reimbursement under its Plan, without application of the deductible or copayment, for all Program services and/or supplies received. The benefit reimbursement amount shall apply to the Member's lifetime maximum. Nurseline Program This program provides a telephone-based nurse triage service designed to respond to a Members' medical • needs quickly. The goal of this program is for experienced registered nurses to appropriately address the callers' symptoms by determining the severity of the problem and suggesting the appropriate level of care. The ultimate treatment decision rests with caller. The program neither warrants nor guarantees the well-being of the Covered Person. GSVCS Version 6.2002/2001.1 1 Policy Eff Date January 1,2005 Hello