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Home My WebLink About000179.tiff BlueCross BlueShield Northern Colorado Region 200 S. College Avenue HMOor and P.O. Box 1668 HMOO Colorado Fort Collins, Colorado 80522 An Independent licensee of the Blue Gloss and Blue Shield Association January 11, 1999 Masoud Shirazi Shirazi and Associates 1770 25i°Ave. Suite 302 P.O. Box 5315 Greeley, CO 80631 Dear Mr. Shirazi, This letter is to confirm the new benefit plan and premium rates for Weld County Government group number C07720 for the renewal year of January 1999. This letter is to become apart of the Addendum to be signed by all parties. The benefit plan description is a Modified Triple Option D,which is an HMO 15/1/15-25-40, HMO with a POS rider 15/1/15-25-40 P-250 and a Custom Plus 200 Deductible 80%coinsurance with a 15-25-40 prescription drug benefit. Further,the coverage includes riders for a Drug and Alcohol benefit,and a$15 copay for an eye exams every 24 months. Eye Health Network is the administrator of the eye benefit and has a network of doctors in the Greeley area. There are no out of network benefits for the eye care benefit. Retirees age 55 through age 64 will have an option to continue there health insurance until the date their age changes to 65. Provided they meet the following criteria and stipulations: a) Eligible employees must retire from county service with at least ten years of service,or be a county elected official for at least one full four-year term. b) Eligible employees must be enrolled in the county's health insurance plan at the time of retirement or leave of county office. c) Dependents' coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office. d) Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65,or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid or Medicare coverage before attaining the age of 65. Dependent coverage if still applicable will be offered under the same terms of COBRA offered employees' dependents. e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the time. The county will be responsible for paying the 40%surcharge of the premium,and the county contribution for the employee and dependents in the same manner as provided regular employees. f) After COBRA,dependents will have the same conversion rights as regular employees and dependents. Dependents may stay on the employees coverage as long as they are financially dependent on the subscribers,and until the end of the month they turn the age of 25. The agreed upon rates are split among the different options and are guaranteed for the renewal date of January 1, 1999 through December 31, 1999. The rates are structured in a two tier method as follows: USA C6 _ Metal l least,Plan Sponsor or the Tear app OS.Olympic Train 179 r BlueCross BlueShield Northern Colorado Region Arta 200 S. College Avenue VS of Colorado and P.O. Box 1668 • HMO Colorado Fort Collins, Colorado 80522 An Independent Licensee of the blue Cross and Blue Shield Association PLAN EMPLOYEE EMPLOYEE ONLY AND DEPENDENTS HMO 15/1/15-25-40 148.18 392.76 HMOPOS 15/1/15-25-40 155.88 413.08 P-250 CUSTOM PLUS $200 DEDUCTIBLE 80%COINSURANCE 15-25-40 Rx 196.32 520.26 Finally, Blue Cross Blue Shield will give the broker 90 day notification prior to the renewal of January 1 2000. The notification will include any benefit plan design change and any premium rate change. Signed Michael D Rankin Account Executive USA q9.9 Officialoolive Year Plan sponsor of the rear MX) US.Olympic Team 01/20/1995 13:23 3038312760 COLORADO SALES PAGE 01 BlueCross BlueShield 700 Broadway of Colorado Deliver,Colorado 80273-0002 (7G�" 303-831-2131 • • HMO Colorado www.bcbsro.com ledepeede•l Liae•teee of the Mut Cross and that SbIS Mwdedon November 10, 1998 Mr. Masoud Shirazi Shirazi and Associates 1770—25°Avenue, Suite 302 Greeley,CO 80631 VIA FACSIMILE (970)356-5154 Dear Masond: We have reviewed your letter of October 28, 1998 and agree with the terms as described. We are currently preparing the subscriber certificates and group agreement to reflect the new benefits for 1999. However,I can not release the information to you until we have received final approval on the new benefit plan from the Division of Insurance(DOI). We have requested expedited review from the DOT . We expect to complete the review process no later than November 30i°. Thank you for your efforts in this matter. We look forward to continuing our relationship with Weld County in 1999 and beyond. If you have any questions,please let me know. Sincerely, Kevin Magee Vice President Customer Development tee. Ina IWgM ea Mb thi cTa US Crowe ram r ,� Shirazi Associates, Inc. 1770 25th Avenue, Suite 302 • P.O. Box 5315 • Greeley, Colorado 80631 • (970) 356-5151 • FAX (970) 356-5154 October 28, 1998 Mr. Kevin Magee Vice President, Customer Development Blue Cross Blue Shield of Colorado 700 Broadway Denver, CO 80273 RE: WELD COUNTY GOVERNMENT ACCOUNT#8278 Dear Kevin: As we discussed on the phone yesterday, after numerous meetings and discussions with Weld County, reluctantly, Weld County Government has agreed to waive their rights to the original commitment made by Blue Cross Blue Shield regarding their 1999 calendar year renewal. Weld County Government has agreed to accept the BlueAdvantage Triple Option D plan design and rates that Blue Cross Blue Shield has proposed effective January 1, 1999. The new plan design and rates would be as follows: Employee Employee & Plan 'Only Rates Dependents Rates HMO - 15/ 1 /15-25-40 $148.16 $392.76 POS - 15/ 1 / 15-25-40 $155.88 $413.08 Custom Plus - $200 Deductible 80% Coinsurance 15-25-40 Rx $196.32 $520.26 As you indicated, these rates will be guaranteed by Blue Cross Blue Shield for the 12-month period starting January 1, 1999 through December 31, 1999. Blue Cross Blue Shield will notify the broker of record of any changes in the plan design or rates 90 days prior to the renewal January 1, 2000. Financial Planner • Benefit Consultant • Insurance Broker - Kevin Magee Weld County Government Page Two October 28, 1998 Kevin, as we discussed and as you have promised, the only changes in the present plan would be the rates, the office visit copay and the prescription drug copay, effective January 1, 1999. All other provisions, exceptions, benefits (i.e. COBRA administration, vision copayment, retiree provision), and broker compensation will remain unchanged. As I have clearly indicated, it was shocking and upsetting to both Shirazi & Associates and Weld County Government that Blue Cross Blue Shield decided not to honor their original commitment. However, I feel with your perseverance, we have come to a decision that hopefully will be economical and beneficial over the long term to all parties involved. Youhave indicated you wanted to have this request in writing in order to generate the contract. If you need any additional information, please let me know. I think we have covered all the bases and I am not expecting any more surprises. I am requesting that the contract be sent to me as soon as possible. Also, I think it is very crucial, and I would like to request that we begin the process of issuing prescription and identification cards to all the members, as soon as possible. Sincerely, asoud S. Shirazi Shirazi & Associates, Inc. • A Group Health Care Program Group Master Contract ooa n HMO . Colorado An Independent Licensee of the Blue Cross and Blue Shield Association • HMO COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract effective date 1 Anniversary date 1 Employee 1 Employer 1 Remittance 2 Benefit booklet 2 Group administrator 2 Assignment 2 Contract provision changes 2 Notices 2 Governing Laws 3 Attorneys' fees and expenses 3 Enforcement of the contract 3 Interpretation of the contract 3 Termination of the contract 3 Reinstatement of contract 3 SECTION III. PREMIUM: CHANGES, PAYMENT, TERMINATION FOR NON- PAYMENT, REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 4 Changes 4 Payment 4 Termination for non-payment 4 Refund of membership premium 4 Cashing of check not acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Notification of cessation of membership 5 Acceptance of contract 5 Group eligibility requirements 5 BLUH004M CON i • HMO COLORADO GROUP MASTER CONTRACT NO. 99-00772001 For Weld County Government Employer C07720 Group Number SECTION I. APPLICATION-ACCEPTANCE The application and addendum for group health coverage("application/addendum") executed by the employer has been accepted by HMO Colorado(sometimes referred to as "we," "us," and "our"). Such application/addendum and their contents are incorporated in this group master contract("contract"). In the event of any inconsistency between the terms of the application/addendum and the terms of the contract, the terms of the contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the employer's employees and their dependents. Such persons, when covered hereunder, are referred to as "members." 1. Contract effective date.The effective date of the contract shall be 12:01 A.M. on the first day of January 1, 1999, at Denver, Colorado; the contract shall continue to remain in effect on an annual basis from year to year thereafter unless terminated in accordance with the provisions of the contract. 2. Anniversary date. The anniversary date is the effective date for (i) coverage; (ii) changes to group enrollment and benefit eligibility implemented by the employer; and(iii) the date a group is due for appropriate renewal rating. 3. Employee.An employee as defined in the application/addendum as eligible for enrollment; the employee is the individual who is employed by the employer. 4. Employer. The employer or organization with whom HMO Colorado has contracted, and by reason of the contract the employees and their dependents become eligible for the coverage and benefits described in the contract. 5. Remittance. The employer shall pay to us monthly and prior to the first day in each month, the required premium on behalf of all enrolled employees and dependents who meet the eligibility requirements specified in the group application/addendum and benefit booklet that are incorporated in this contract. BLUHBMM.CON 1 • 12. Attorneys' fees and expenses. a. Should it become necessary for either party to this contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless HMO Colorado from its costs including losses, claims, settlements,judgments, or fees, including attorneys'fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder,the employer's obligation to indemnify us shall apply only to costs incurred after this contract has been cancelled or terminated. 13. Enforcement of the contract. Failure of HMO Colorado or the employer to enforce any of the provisions of this contract shall not constitute a waiver of rights for that or subsequent breaches. 14. Interpretation of the contract. This contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this contract and sound principles of contract interpretation. 15. Termination of the contract. a. The employer may terminate the contract at any time during its term upon giving 30 days advance written notice of termination to HMO Colorado. A group which voluntarily cancels coverage will not be considered for re-enrollment until a two-month period has elapsed from the date of cancellation. Such re-enrollment shall be subject to then current operating procedures and underwriting regulations of HMO Colorado. b. HMO Colorado may terminate the contract at any time during its term for (i) employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements, as provided in the application/addendum, (iv) misrepresentation of material facts or any other breach of the contract, or(v)for any reason, upon giving 30 days advance written notice of termination to the employer. 16. Reinstatement of contract.HMO Colorado,at its sole option,may reinstate this contract after it has been terminated. We may impose such conditions on the contract's reinstatement as we deem appropriate, including,without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of HMO Colorado. BLUH004M CON 3 b. If HMO Colorado terminates coverage of a member or terminates this contract for any reason, a refund of membership premium paid beyond the termination-date will only be granted if covered health services have not been provided and benefit payments have not been made for services rendered subsequent to the termination date. 5. Cashing of check not acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility.All employees,who have a regular work week as indicated on the application and/or addendum, paid for such employment by the employer, and listed as an employee on the employer's State unemployment insurance tax returns, and the dependents of the employees, are eligible to enroll for membership under the contract. We may inspect such records, public and private, as are necessary to verify employment. Applications of employees and dependents at open enrollment must be received prior to the anniversary date to be effective on the anniversary date. If applications are not received prior to the anniversary date, they will not be effective until the next anniversary date. 2. Notification of cessation of membership. The employer shall advise us when the employer has notice that a member is no longer employed by the employer or otherwise does not satisfy membership requirements. The employer shall so notify us, at the latest, by the first day of the month after a member ceases to be employed by employer or otherwise ceases to meet membership requirements. Such coverage shall terminate at the end of the month in which the member is no longer employed or does not satisfy membership requirements. The employer agrees that no person will be kept on the employer's payroll or otherwise be represented as an employee of the employer for the purpose of obtaining or maintaining coverage when no longer eligible for such coverage hereunder.The employer agrees to observe the terms thereof,and hold us harmless for all costs incurred, including attorneys' fees, in the defense of any claim or suit brought at any time by a person who is ineligible for coverage. 3. Acceptance of contract. The employer's signature on the group application/addendum constitutes acceptance of this contract. 4. Group eligibility requirements. If the employer does not comply with the group eligibility requirement, we reserve the right to cancel the contract upon 30 days advance written notice. BLUH004M.CON 5 A Group Health Care Program Group Master Contract .6° ® HMO Colorado An Independent Licensee of the Blue Cross and Blue Shield Association - HMO COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract effective date 1 Anniversary date 1 Employee 1 Employer 1 Remittance 2 Benefit booklet 2 Group administrator 2 Assignment 2 Contract provision changes 2 Notices 2 Governing Laws 3 Attorneys' fees and expenses 3 Enforcement of the contract 3 Interpretation of the contract 3 Termination of the contract 3 Reinstatement of contract 3 SECTION III. PREMIUM: CHANGES, PAYMENT, TERMINATION FOR NON- PAYMENT, REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 4 Changes 4 Payment 4 Termination for non-payment 4 Refund of membership premium 4 Cashing of check not acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility • 5 Notification of cessation of membership 5 Acceptance of contract 5 Group eligibility requirements 5 BLUH004M.CON i HMO COLORADO GROUP MASTER CONTRACT NO. 99-00772001 For Weld County Government Employer • C07720 Group Number SECTION I. APPLICATION ACCEPTANCE The application and addendum for group health coverage("application/addendum")executed by the employer has been accepted by HMO Colorado(sometimes referred to as "we," "us," and "our"). Such application/addendum and their contents are incorporated in this group master contract("contract"). In the event of any inconsistency between the terms of the application/addendum and the terms of the contract, the terms of the contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the employer's employees and their dependents. Such persons, when covered hereunder, are referred to as "members." 1. Contract effective date.The effective date of the contract shall be 12:01 A.M. on the first day of January 1, 1999, at Denver, Colorado; the contract shall continue to remain in effect on an annual basis from year to year thereafter unless terminated in accordance with the provisions of the contract. 2. Anniversary date. The anniversary date is the effective date for (i) coverage; (ii) changes to group enrollment and benefit eligibility implemented by the employer;and(iii) the date a group is due for appropriate renewal rating. 3. Employee.An employee as defined in the application/addendum as eligible for enrollment; the employee is the individual who is employed by the employer. 4. Employer. The employer or organization with whom HMO Colorado has contracted, and by reason of the contract the employees and their dependents become eligible for the coverage and benefits described in the contract. 5. Remittance. The employer shall pay to us monthly and prior to the first day in each month, the required premium on behalf of all enrolled employees and dependents who meet the eligibility requirements specified in the group application/addendum and benefit booklet that are incorporated in this contract. BLUN004M.CON 1 12. Attorneys' fees and expenses. a. Should it become necessary for either party to this contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless HMO Colorado from its costs including losses, claims, settlements,judgments, or fees,including attorneys'fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder,the employer's obligation to indemnify us shall apply only to costs incurred after this contract has been cancelled or terminated. 13. Enforcement of the contract. Failure of HMO Colorado or the employer to enforce any of the provisions of this contract shall not constitute a waiver of rights for that or subsequent breaches. 14. Interpretation of the contract. This contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this contract and sound principles of contract interpretation. 15. Termination of the contract. a. The employer may terminate the contract at any time during its term upon giving 30 days advance written notice of termination to HMO Colorado. A group which voluntarily cancels coverage will not be considered for re-enrollment until a two-month period has elapsed from the date of cancellation. Such re-enrollment shall be subject to then current operating procedures and underwriting regulations of HMO Colorado. b. HMO Colorado may terminate the contract at any time during its term for (i) employer's failure to make timely payment of amounts due hereunder, (ii)failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements, as provided in the application/addendum, (iv) misrepresentation of material facts or any other breach of the contract, or (v) for any reason, upon giving 30 days advance written notice of termination to the employer. 16. Reinstatement of contract.HMO Colorado,at its sole option,may reinstate this contract after it has been terminated. We may impose such conditions on the contract's reinstatement as we deem appropriate, including,without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of HMO Colorado. BLUHoo4M.CON 3 b. If HMO Colorado terminates coverage of a member or terminates this contract for any reason, a refund of membership premium paid beyond the termination date will only be granted if covered health services have not been provided and benefit payments have not been made for services rendered subsequent to the termination date. 5. Cashing of check not acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. • SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility.All employees,who have a regular work week as indicated on the application and/or addendum, paid for such employment by the employer, and listed as an employee on the employer's State unemployment insurance tax returns, and the dependents of the employees, are eligible to enroll for membership under the contract. We may inspect such records, public and private, as are necessary to verify employment. Applications of employees and dependents at open enrollment must be received prior to the anniversary date to be effective on the anniversary date. If applications are not received prior to the anniversary date, they will not be effective until the next anniversary date. 2. Notification of cessation of membership. The employer shall advise us when the employer has notice that a member is no longer employed by the employer or otherwise does not satisfy membership requirements. The employer shall so notify us, at the latest, by the first day of the month after a member ceases to be employed by employer or otherwise ceases to meet membership requirements. Such coverage shall terminate at the end of the month in which the member is no longer employed or does not satisfy membership requirements. The employer agrees that no person will be kept on the employer's payroll or otherwise be represented as an employee of the employer for the purpose of obtaining or maintaining coverage when no longer eligible for such coverage hereunder. The employer agrees to observe the terms thereof,and hold us harmless for all costs incurred, including attorneys' fees, in the defense of any claim or suit brought at any time by a person who is ineligible for coverage. 3. Acceptance of contract. The employer's signature on the group application/addendum constitutes acceptance of this contract. 4. Group eligibility requirements. If the employer does not comply with the group eligibility requirement, we reserve the right to cancel the contract upon 30 days advance written notice. BLUH004M.CON 5 A Group Health Care Program Group Master Contract _ Blue Cross r Q S Blue Shield An Independent Licensee of the Blue Cross and Blue Shield Association THE BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION ACCEPTANCE 2 SECTION II. GENERAL AGREEMENTS 2 Contract Effective Date 2 Anniversary Date 2 Annual Renewal Date 2 Employee 2 Employer 2 Remitting Agent 2 Remittance 2 Membership Certificate Terms 2 Group Administrator 2 Assignment 2 Contract Provision Changes 3 Reserve Funds 3 Notices 3 Governing Laws 3 Attorneys' Fees and Expenses ' 3 Warranties and Representations 4 Enforcement of the Contract 4 Interpretation of the Contract 4 BlueCard Program. 4 Termination of Contract 4 SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 5 Changes 5 Payment 5 Service Date 5 Termination for Non-Payment 5 Retroactive Refund of Membership Premium 5 Cashing of Check Not Acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Receipt of Applications 5 Notification of Cessation of Membership 5 BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT NO. 99-00772000 For Weld County Government Employer C07720 • Group Number SECTION I. APPLICATION-ACCEPTANCE The Application for Group Health Coverage ("Application") executed by the Employer has been accepted by Blue Cross and Blue Shield of Colorado (sometimes referred to as "we," "us," and "our"). Such Application and its contents are incorporated in this Group Master Contract ("Contract"). In the event of any inconsistency between the terms of the Application and the terms of the Contract, the terms of the Contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this Contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the Employer's Employees and their Dependents. Such persons, when covered hereunder, are referred to as "Members." 1. Contract Effective Date. The effective date of the Contract shall be 12:01 A.M. on the first day of January, 1999, at Denver, Colorado; the Contract shall continue to remain in effect on an annual basis from year to year thereafter unless terminated in accordance with the provisions of the Contract. 2. Anniversary Date. The Anniversary Date is the effective date for (i) enrollment or coverage changes to the Employee's Membership or (ii) to group enrollment and benefit eligibility implemented by the Employer. 3. Annual Renewal Date. The date a group is due for rate modification through application of the appropriate renewal rating formulas. 4. Employee.An Employee as defined in the Application as eligible for enrollment; the Employee is the Subscriber, and Identification Cards for the Employee and his or her covered Dependents are issued in the name of the Employee as the Subscriber. 5. Employer. The Employer or organization with whom Blue Cross and Blue Shield of Colorado has contracted, and by reason of the Contract the Employees and their Dependents become eligible for the coverage and benefits described in the Contract. 6. Remitting Agent. The Employer agrees to (i) act as remitting agent for the enrolled Members, (ii)make payroll deductions for that part of premium not otherwise provided for, and (iii)remit all premiums to us not later than the due date for each remitting period. 7. Remittance. The Employer shall pay to us monthly, in advance, required premiums on behalf of all enrolled Employees and Dependents who meet the eligibility requirements specified in the Application. 8. Membership Certificate Terms. The definitions and other terms of the Membership Certificate are incorporated herein by reference. 9. Group Administrator. The Employer will designate a person as the principal contact for all matters pertaining to Blue Cross and Blue Shield of Colorado group coverage. That person will OCBMZIC"a 1 15. Attorneys' Fees and Expenses. a. Should it become necessary for either party to this Contract to seek the.assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the Contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless Blue Cross and Blue Shield of Colorado from its costs including losses, claims, settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this Contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the Employer's obligation to indemnify us shall apply only to costs incurred after this Contract has been cancelled or terminated. 16. Warranties and Representations. The Employer acknowledges that no warranties or representations other than those contained in this Contract have been made or given by Blue Cross and Blue Shield of Colorado or its representatives or, if so given, have not been relied upon by the Employer. 17. Enforcement of the Contract. Failure of Blue Cross and Blue Shield of Colorado or the Employer to enforce any of the provisions of this Contract shall not constitute a waiver of rights for that or subsequent breaches. 18. Interpretation of the Contract. This Contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this Contract and sound principles of contract interpretation. 19. BlueCard Program. The calculation of subscriber liability for covered services for claims incurred outside the geographic area Blue Cross and Blue Shield of Colorado serves and processed through the BlueCard Program typically will be at the lower of the provider's billed charges or the negotiated rate Blue Cross and Blue Shield of Colorado pays the on-site Blue Cross and/or Blue Shield Plan. The negotiated rate paid by Blue Cross and Blue Shield of Colorado to the on-site Blue Cross and/or Blue Shield Plan for health care services provided through the BlueCard Program may represent either (i) the actual price paid on the claim, or (ii) an estimated price that reflects adjusted aggregate payments expected to result from settlements or other non-claims transactions with all of the on-site Plan's health care providers or one or more particular providers, or(iii)a discount from billed charges representing the on-site Plan's expected average savings for all of its providers or for a specified group of providers. Plans using either the estimated price or average savings factor methods may prospectively adjust the estimated or average price to correct for over-or underestimation of past prices. In addition, statutes require Blue Cross and/or Blue Shield Plans in a small number of states to use a basis for calculating member/subscriber liability for covered services that does not reflect the entire savings realized or expected to be realized on a particular claim. Thus, when your covered employees/subscribers receive covered services in these states, their subscriber liability for covered services will be calculated using these states' statutory methods. 20. Termination of Contract. a. The Employer may terminate the Contract at any time during its term upon giving one month advance written notice of termination to Blue Cross and Blue Shield of Colorado. A group which voluntarily cancels coverage will not be considered for re-enrollment until a two-month period has elapsed from the date of cancellation. Such re-enrollment shall be — subject to then current operating procedures and underwriting regulations of Blue Cross and Blue Shield of Colorado. eces.nc coo 3 termination shall be the date to which membership premium was last paid. All claims shall be refused when dates of service are beyond the last "paid-to-date" of coverage, according to the records of Blue Cross and Blue Shield of Colorado. 5. Retroactive Refund of Membership Premium. a. A retroactive refund of membership premium paid beyond the date of termination will be granted if written notification is received by Blue Cross and Blue Shield of Colorado at least one month before the termination date and benefit payments have not been made on behalf of a Member's claim for services rendered subsequent to the termination date. b. If notification is received less than one month before the termination date, no refund of membership premium will be made. Failure to comply with this provision shall negate any claim by, or on behalf of, the Employer or the Member for a retroactive refund of membership premium. 6. Cashing of Check Not Acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility. All Employees, who have a regular work week as indicted on the application and addendum, paid for such employment by the employer, and listed as an Employee on the Employer's State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to enroll for membership under the Contract. We may inspect such records, public and private, as are necessary to verify employment. 2. Receipt of Applications. Applications for Employees' coverage must be received by us within 30 days of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later. If the application is not received within this time period, the Employee is subject to current underwriting, state or federal law for provisions for late enrolles. 3. Notification of Cessation of Membership. Employer shall advise us when Employer has notice that a Member is no longer employed by Employer or otherwise does not satisfy membership requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member ceases to be employed by Employer or otherwise ceases to meet membership requirements. Employer agrees that no person will be kept on Employer's payroll or otherwise be represented as an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder. The Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred,including attorneys'fees,in the defense of any claim or suit brought at any time by a person ineligible for coverage. • a<BS, 5 A Group Health Care Program Group Master Contract 63 s aB e e Cross oov dam, An Independent Licensee of the Blue Cross and Blue Shield Association THE BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION ACCEPTANCE 2 SECTION II. GENERAL AGREEMENTS 2 Contract Effective Date 2 Anniversary Date 2 Annual Renewal Date 2 Employee 2 Employer 2 Remitting Agent 2 Remittance 2 Membership Certificate Terms 2 Group Administrator 2 Assignment 2 Contract Provision Changes 3 Reserve Funds 3 Notices 3 Governing Laws 3 Attorneys' Fees and Expenses 3 Warranties and Representations 4 Enforcement of the Contract 4 Interpretation of the Contract 4 BlueCard Program. 4 Termination of Contract 4 SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 5 Changes 5 Payment 5 Service Date 5 Termination for Non-Payment 5 Retroactive Refund of Membership Premium 5 Cashing of Check Not Acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Receipt of Applications 5 Notification of Cessation of Membership 5 0.. i BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT NO. 99-00772000 For Weld County Government Employer C07720 - Group Number SECTION L APPLICATION ACCEPTANCE The Application for Group Health Coverage ("Application") executed by the Employer has been accepted by Blue Cross and Blue Shield of Colorado(sometimes referred to as "we," "us," and "our"). Such Application and its contents are incorporated in this Group Master Contract ("Contract"). In the event of any inconsistency between the terms of the Application and the terms of the Contract, the terms of the Contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this Contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the Employer's Employees and their Dependents. Such persons, when covered hereunder, are referred to as "Members." 1. Contract Effective Date. The effective date of the Contract shall be 12:01 A.M. on the first day of January, 1999, at Denver, Colorado; the Contract shall continue to remain in effect on an annual basis from year to year thereafter unless terminated in accordance with the provisions of the Contract. 2. Anniversary Date. The Anniversary Date is the effective date for (i) enrollment or coverage changes to the Employee's Membership or (ii) to group enrollment and benefit eligibility implemented by the Employer. 3. Annual Renewal Date. The date a group is due for rate modification through application of the appropriate renewal rating formulas. 4. Employee. An Employee as defined in the Application as eligible for enrollment; the Employee is the Subscriber, and Identification Cards for the Employee and his or her covered Dependents are issued in the name of the Employee as the Subscriber. 5. Employer. The Employer or organization with whom Blue Cross and Blue Shield of Colorado has contracted, and by reason of the Contract the Employees and their Dependents become eligible for the coverage and benefits described in the Contract. 6. Remitting Agent. The Employer agrees to (i) act as remitting agent for the enrolled Members, (ii)make payroll deductions for that part of premium not otherwise provided for, and (iii) remit all premiums to us not later than the due date for each remitting period. 7. Remittance. The Employer shall pay to us monthly, in advance, required premiums on behalf of all enrolled Employees and Dependents who meet the eligibility requirements specified in the Application. 8. Membership Certificate Terms. The definitions and other terms of the Membership Certificate are incorporated herein by reference. 9. 'Croup Administrator. The Employer will designate a person as the principal contact for all matters pertaining to Blue Cross and Blue Shield of Colorado group coverage. That person will . tea" a 1 • 15. Attorneys' Fees and Expenses. a. Should it become necessary for either party to this Contract to seek the,assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the Contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless Blue Cross and Blue Shield of Colorado from its costs including losses, claims, settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this Contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the Employer's obligation to indemnify us shall apply only to costs incurred after this Contract has been cancelled or terminated. 16. Warranties and Representations. The Employer acknowledges that no warranties or representations other than those contained in this Contract have been made or given by Blue Cross and Blue Shield of Colorado or its representatives or, if so given, have not been relied upon by the Employer. 17. Enforcement of the Contract. Failure of Blue Cross and Blue Shield of Colorado or the Employer to enforce any of the provisions of this Contract shall not constitute a waiver of rights for that or subsequent breaches. 18. Interpretation of the Contract. This Contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this Contract and sound principles of contract interpretation. 19. BlueCard Program. The calculation of subscriber liability for covered services for claims incurred outside the geographic area Blue Cross and Blue Shield of Colorado serves and processed through the BlueCard Program typically will be at the lower of the provider's billed charges or the negotiated rate Blue Cross and Blue Shield of Colorado pays the on-site Blue Cross and/or Blue Shield Plan. The negotiated rate paid by Blue Cross and Blue Shield of Colorado to the on-site Blue Cross and/or Blue Shield Plan for health care services provided through the BlueCard Program may represent either (i) the actual price paid on the claim, or (ii) an estimated price that reflects adjusted aggregate payments expected to result from settlements or other non-claims transactions with all of the on-site Plan's health care providers or one or more particular providers,or(iii)a discount from billed charges representing the on-site Plan's expected average savings for all of its providers or for a specified group of providers. Plans using either the estimated price or average savings factor methods may prospectively adjust the estimated or average price to correct for over-or underestimation of past prices. In addition, statutes require Blue Cross and/or Blue Shield Plans in a small number of states to use a basis for calculating member/subscriber liability for covered services that does not reflect the entire savings realized or expected to be realized on a particular claim. Thus, when your covered employees/subscribers receive covered services in these states, their subscriber liability for covered services will be calculated using these states' statutory methods. 20. Termination of Contract. a. The Employer may terminate the Contract at any time during its term upon giving one month advance written notice of termination to Blue Cross and Blue Shield of Colorado. A group which voluntarily cancels coverage will not be considered for re-enrollment until a two-month period has elapsed from the date of cancellation. Such re-enrollment shall be subject to then current operating procedures and underwriting regulations of Blue Cross and Blue Shield of Colorado. BCBS922C C« 3 termination shall be the date to which membership premium was last paid. All claims shall be refused when dates of service are beyond the last "paid-to-date" of coverage.according to the records of Blue Cross and Blue Shield of Colorado. 5. Retroactive Refund of Membership Premium. a. A retroactive refund of membership premium paid beyond the date of termination will be granted if written notification is received by Blue Cross and Blue Shield of Colorado at least one month before the termination date and benefit payments have not been made on behalf of a Member's claim for services rendered subsequent to the termination date. b. If notification is received less than one month before the termination date, no refund of membership premium will be made. - Failure to comply with this provision shall negate any claim by, or on behalf of, the Employer or the Member for a retroactive refund of membership premium. 6. Cashing of Check Not Acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility. All Employees, who have a regular work week as indicted on the application and addendum, paid for such employment by the employer, and listed as an Employee on the Employer's State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to enroll for membership under the Contract. We may inspect such records, public and private, as are necessary to verify employment. 2. Receipt of Applications. Applications for Employees' coverage must be received by us within 30 days of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later. If the application is not received within this time period, the Employee is subject to current underwriting, state or federal law for provisions for late enrolles. 3. Notification of Cessation of Membership. Employer shall advise us when Employer has notice that a Member is no longer employed by Employer or otherwise does not satisfy membership requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member ceases to be employed by Employer or otherwise ceases to meet membership requirements. Employer agrees that no person will be kept on Employer's payroll or otherwise be represented as an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder. The Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred,including attorneys'fees,in the defense of any claim or suit brought at any time by a person ineligible for coverage. BCBSP220 CCC 5 689 P02iO2 DEC 03 '98 14:26 IIIIAmendment to BlueAdvantage HMO Plan Benefit Booklet This amendment is effective January 1, 1997, or your effective date of membership, whichever is later. In Section 3: Covered Services, under Preventive, Routine, and Family Planning Services, the following benefit is added as a covered service: • Routine eye refraction once every 24 months. The refraction may be performed without a referral by an ophthalmologist or optometrist who participates with HMO Colorado or Cole Vision. Routine eye refractions are not covered under the BlueAdvantage Point- of-Service Rider, they must be provided as indicated above. This amendment is part of and to be read in conjunction with your BlueAdvantage HMO Plan Benefit Booklet. deetbt Bev Sloan President HMO Colorado cfr c3(29) \)\N\\\ SG G - cis BLUP062aAMC • 3037595280 EYE HEALTH NETWORK 774 P02 NOV 24 '98 11:05 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Nelson i 1 OD icg 12431 Main Alunaa 81101 3-719589.9600 Patrick__ Terry OD cy .12708 W 64th Ave. Arvada 80004 `7034242991._. _. { - 18 e Bashford Gordon IOD C *5801 WdswoM Blvd Arvada 80003 903422-7817,. Cross John tOD :Cg 51301 Widmann Blvd .-_, Arvada 80003 ., !303422.3817_ ._. Gunderson Glen OD log 5801 WadrwoM Blvd !Arvada 80003 303-422-3817, Bui Thong OD cg 7913 Allison Way Ste 102 _. �Arvade 80005 7074245282 Crawford Daniel C. OD eg 7911 Nikon Way Ste 102. Arvada.!Arvada._._......__._ !0005 .. _..._303-424.5212 Caddy._..._—._ Donald 0D eg 7913 Allison Way Ste 102 ._... Arvada 80035 3034244212 McGuire Dennis 01) cg 7913 Allison Way Ste 102 Arvada 80O05 3034245282 Duvall John MD cg 7950 Kipling,#203 Arvada 80005 303422-2305 , Tarkanian Malcolm MD cg 7950 Kipling,#203 ..._ Arvada 80005 303-422-2305 Ashline John MD eg 8850 Ralston Road _. ..__ Arvada 80003 303467-0500 Boulder Nancy MD eg 8850 Ralston Road _._ _.. Arvada 800O3 303-467-0500 O'Rourke Melinda MD eg 8850 Ralston Road ... Arvada 80003 303467-0500 Self William MD eg 8850 Ralston Road —Arvada 130003 303467-0500 Pincher Randolph OD eg 1399 5.Havana Street.#101 Aurora 80012 303-750-7621 Galosh Edward OD eg 1399 S.Havana,#101 Aurora 80012 303-750-7621 Eiaebaum Allan MD PBD c 1400 S Potomac#130 _ Aurora 80012 303-3694881 Straub Howard DO c 1421 SPomnnac#250 _ Aurora ,80012 303-337.2431 Alcock Ronald 01) eg 14321 B Alameda Ave.SI Aurora 80012 303-366.1235 Pond L.Page 013 eg 1460 Clambers Road Aurora 80011 303-360-8878 BaDnad Paul MD cg 14991 E Hampden #110 Aurora 180014 303693-9(561 Bryant John 01) cg 14991E Hampden #110 Aurora 80014 303-693-9561 Carroll Charmion OD cg 14991 6 Hampden #110 Aurora 80014 303493-9561 Conner Doadd 013 cg 14991 B Hampden #110 Aurora 80014 303-693-9561 Keyser Robert MD cg 14991 H Hampden #110 Amon 80014 303-6934561 Walters .Loci 013 a 14991 H Hampden #110 Aurora 80014 303493.9561 Brock Rebecca MD 14991 H Hampden.#110 _ Aurora 80014 303-693-9561 Yarwood Roger OD a 15101 E Riff Ave..#100 Aurora 80014 303-750-0990 Johnson Gene 01) eg 15101 B.Oifr,1100 Aaron 80014 303.750-0990 Gertock Rhoda 01) eg 1550 S Potomac#155 Aurora 80012 303369-1020 Hardy Ronald MD cg 1550 S Potomac#155 Aurora 80012 303-369-1020 Jaehning Mark OD eg 1550 S Potomac#155 Aurora 10012 303-369-1020 Ridder Kenneth 01) cg 1550 S Potomac#155 Aurora 80012 303-369-1020 Roberson Rex OD cg 1530 S Potomac#157 Ant 80012 303-369-1020 Rood Donald 01) cg 1550 S Potomac,#155 - Aurora 80012 303-369-1020 Kassel an Stephen MD 1550 S Potomac.#240 Aurora 80012 303.751-1272 Taylor Roger OD cg 1550 S.Potomac#155 Aurora 80012 303-369-1020 Durfee Lynn OD cy 2203 8.Peoria Street Aurora 80314 303-369-2020 Maybury Mark 01) 4239 S.Buckley Road -_ - Aurora 80013 307-093.1859 Baifu0 Paul MD eg 730 Potomac,#324 Aurora 80011 303.364-2866 Burchano James MD c 750 Potomac.#223 Aurora 80011 303-3404600 Nafsinger Kent MD 750 Potomac.#223 --_ Aurora 80011 303-340-4600 DeSarttis Diana MD PHD 1280 Village Road.Third Floor Beaver Creek 81620 (800)4734874 Smith Jeffrey OD eg 1050 Walnut Street 1202 Boulder 80302 303-939.8021 Gwin Larry OD cg 1050 Walnut Street.#202 Boulder 80302 303-939-8021 Dow Is Roger OD _ cg 1645 28th Street _- _- --_Boulder _ 80301 3034434545 Wharton Karen OD cy 166630th Sweet ___.._..—.._ Boulder 80301 303-449-0857 White Dennis OD cg 2400 Broadway ,Boulder — 80304 303-442-0590 Page 1 '-'' N0V 2 4 1998 :Li BCBSCO - NCRO 3037595280 EYE HEALTH NETWORK 774 P03 NOV 24 '98 11:05 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Boulder !~302 703.440.7049 White SuWry OD 1r{- 2400Broedway ... ..._._ - ._ Kellum so3o4 303442-0590 _. Donald -..•MD :cg 2750 Broadway - `Boulder ... - hy 1BD302 13W�404019 I MD t ,2750 Broadway Boulder ._....A__...._.. hungMcCo ark Dodd _ Te... Boulder . . 180304 303-4424260 hung Edwin I OD is 2600 Folsom,IC Tripp Warren MD lc 2800 Folsom.4'C 'Bouldtt .._. -.._ 80304 b340 -6260 Britt -- Berton _ .. OD 1ccgg 350 Broadway 120 _Y ...{Bouldu 80303 303-494.4449 Dougherty Marlyn MD _ cg 365 Broadway ..... . .. 1Boulde ... . 80303-.._ 303-4494770 Roberts William MD cg 315 Broadway ,^__ I 80307 303+49.3710 Cross Richard OD cg 5365 Spine Road,Sae —......__._.... I Boulder 80301 30-530.2020 _..___.____.__—.T--.----••• BTU= Richard OD - c-7-1045 Our4ark Drive,6250 Boulder 80301 303-530-1973 Fair _ Rodney OD q 105 Bridge Sweet __ B^6Mon _ 80601 303659.3036 Fair Ron OD cg 105 Bridge Street Brighton 80601 303-659.3036 Kauvar Ketnerh MD _ c 2700 B Bridge Brighton 80601 303459-3700 Stennis Kellie OD eg 657E Bridge Street 1Brighton 80601 303454-7933 Brill Lla OD q 80 Garden Center 014 --- Broomfield 80020 303-469-1941 Davis Steven OD eg 80 Garden Center 014 Broomfield 80020 303-469.1941 Faulkner Ronald OD _ cg $0 Garden Center#14 Broomfield 80020 303469.1941 May Jack OD q 80 Garden Center#14 Brocenheld 80220 303-469-1941 Meat Willard OD teg 80 Garden Center.#14 Brocenfdd 80020 303.469.1941 Campbell Douglas DO cg 115 Tabor St.Box 1109 _.., Buena Visa 61211 719.3956356 Herb Bdrmod OD ,q 115 Tabor St.Box 1109 Buena Vista 81211 719-3956756 Faeroes ,Robert MD 498 15th Street Burlington 80807 303-346.415 William Larry OD q 498 15*Street Burlington 80807 719.36.8415 Murphy John OD eg 113 Lady Lane 0A Canon City 81212 7193697933 Coatney Michael DO 1145 Ohio Canon City 81212 719257.7481 Greenlee Lynn MD eg 1145 Ohio Canon City 81212 719-275.7481 Martinez Marvin OD a 1115 Ohio Avenue Canon City 81212 719.275-7481 Carlin Sean OD cg 212 North 19th 8ueet _ Canon City 81212 719-276.1660 Buckley Brit MD 700 B Main Street Canon City 60121 719-275-1523 Bosse James OD q 700 Main Street Canon City 81212 719.275-1523 Tyler Keny OD eg 409 S Wilcox,Sic A Castle Rock 60104 303688-4044 Comnan Jame MD eg 409 S.Wilcox,Sze.A Castle Rock 80104 3036864044 Clausen David OD teg 834-B S Brbwc Street Castle Rock 80104 303661-0290 Anctil Pierre OD eg 1625 B Plate Avenue Colorado Spring ,60909 719-632-3561 Pedersen Richard OD q 1635 B Plane Avenue Colorado Springs 80909 719-614-nn Murphy David OD 1715 N.Weber St.#360 Colorado Springs 80907 719471- 000 Reese Timothy OD 1715 N.Weber,,1360 Colorado Springs 80907 7194714000 Archdale Ted OD q 1791 S.8th Stan,Ste H Colorado Springs 80906 719.577.4400 _ Plotkin Ronald OD cg 1833 N.Circle Drive Colorado Springs 80909 719.6344480 Mills, Michael OD q 1639 Bnargare Blvd Colorado Springs 80920 719-593-2333 Gardner Horace B. MD 2020 W.Colorado Ave Colorado Spring 80904 /19-6354898 Dewey Steven MI) 209 S Nevada _Colorado springs 80907 719-475-7700 _—.1 Sutton Thomas OD cg 2131 N Tejon.U-1 Colorado Springs 80907 719632-5192 Solomon Ronald OD cg 2145 Academy Circle Colorado Springs 80909 719-597-7101 Frank H.Randolph MI) 2910 Austin Bluth Parkway Colorado Springs 80918 719.594-9800 Schunk Peter_ MD cg_2910 Austin Bluffs Pkwy Colorado Springs 80918 719599-9720 Baron 1.Gregory MD _ 2920 N Cascade Arc. Colorado Springs 80907 719636-3937 Gelder Bram OD c 2920 N.Cascade 3rd Floor Colorado Springs 80907 719-634-2001 Wright John DO 2920 N.Cascade 3rd Floor Color %,j .,-_, WS', r.. --'(19634-2001 D Page2 -1� N0V 241998 J BCBSCO - NCRO - • 30.3' 95280 EYE HEALTH NETWORK 774 PO4 NOU 24 '98 11:06 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado r •RobFoerster e Robe �MD '2920 N Cascade Ave. IColorado Springs 1110907 T19-636-3937 Thatcher D.B. MD t '2920 N.Cascade Ave. ,Colorado Springs 80907 .719436-3937 Bode i 'Colorado ri '80907_ 719-630-3937 Bode Don MD ;g :7155 N Upton Blvd. Springs.. . ,._ .. __-. ---- Buckley Britt ND lag 13155 N Union Blvd. !Colorado Sprigs 180907 T719-630.3937 Tltuutc !Thomas_ W. OD I 720 Jrorttarsero Supt 103 SCoI°rado SSprirtgs }60907 _ ,719 635-1686 Hoyle.lfl C. 1--Mb c 3237 W Carefree Circle 'Colored°Springs 719-5968850— _ - — •— - Roark Stcpheo R. OD Icg 3510E Galley*101 -Colorado Springs 180904.. 719-597423 Freeman Roger _OD cg 38 Southgate — -Colorado Spring 80906 719-630-8146 C aitridcr Niece MD FED cg_3910 3 Carefree Circle - Colorado Springs — 80907 — _ 719-574-1654 Omitz _.._— Donnas — MD PEI) Cg 3910 S Carefree Circle Catnrado Springs -- 80907 —119-574-1654 •- .. - -- Anderson W.Dale_ �,MD - } 3910 S Carefree Circle Suite A Colorado Springs 190917 1719-637-1416 Keyser L.&ny OD — cg 4 9 22 Security Blvd. Colorado Springs 80911 719-390-490 Meyer Marcus 013 eg 14331 Cenleniel Blvd. Colorado Springs 80906 719-528-1919 Byers Mark OD cg 4331 Centennial Blvd. Colorado Springs $0906 719-528-1919 DRyin Alan MD 455 E Pikes Peak Av#309 Colorado Springs _ 80903 719473-9595 Harrison Bret 013 cg 4740 Fiintridge,1105 tColo ado Springs -- 80918 719-598-1010 ^ Sutton Thomas OD cg 4740 Fliusridge.#105 Colorado Springs 80918 719-599-7111 Gardner Robert MD cg 525 N.Tejon Colorado Springs 80903 719-471-2020 lJg toe C. Neal MD cg 525 N.Tejon Colorado Springs 80903 /719-471-2020 Van Camp James 013 cg 5525 N Union Blvd (Colorado Springs 80918 719-5984000 Christiansen John MD Cl: 555 E.Pikes Peak Avenue.#101 ,^Colorado Springs 80903 719.632-0164 t Werrig Carl MD cg 616 S Tejon Saeet Colorado Springs 80903 719432.1547 Wetzig Richard MI) cg 616 S Tejon Street Colorado Springs 80903 719-632-3547 Palmer James OD cg 6665 Ddm:mica Drive.#A Colorado Spring _ 80919 719-599-9393 Archdale Ted OD ca 709 N.Union Blvd Colorado Springs 80909 719-6344483 Clyde Tom OD cg 710 N Circle Drive Colorado Springs 80909 719-632-1587 Darby Jeanne OD cg 710 N Circle Drive Colorado Springs 80909 719432-1587 ,Hampton Lstvrentce 01) cg 710 N Circle Drive Colorado Springs 80909 _719432-1587 McKim Lisa lOD cg 7606 N Union Bl#0 Colorado Springs 80920 `719-599-SDd3 Wilson Thomas OD cg 7606 N Union Suite G Colorado Springs 80920 7194993083 Guhl David OD ,cg 7606 N Union.#0 Colorado Springs 80920 719-599-3083 Hendrick Joanne 013 cg 7606 N Union,80 Colorado Springs 80920 719-599-5083 , Puckett Prank OD cg 7606 N Union,PG Colorado Springs 80920 •719-599-5083 Mamba Glenn 01) eg 6402 B.72nd Place Commerce City 80012 3033-288-•4515 Mamba Robert OD cg 6402 E.72nd Place Commerce City 80022 303-288-IS1S Yano-Matoba E.Naomi OD eg 6402 H.72nd Place Commerce City 80022 X303-288-451S Kirol Michael OD cg 10791 Kitty Drive Conifer 80433 303-674-2115 Danner Ronald OD cg 1111 W Victory Way#110 Craig 81625 970-824-1488 F.claoth Craig OD cg 1111 w Victory Way#110 Craig 81625 97024.3488 —X Schott Kirk OD cg 1111 W.Viciory Way.#110 Craig 8162.5 970-424.5648 Helm Mark MD 785 Russell Street Craig —V 81625 970424-8411 Cohen Juana _ MD PED c 1010 E 196 Ave#406 - Denver 80218 303-797-3390 Sargent Robert MD PED 1010 5 19th Ave 1406 Denver 80218 303-797-3390 Bateman 1.Bronwya MD 1056E 19th Avenue Denver 80218 303-329-3066 — 1 i Fowler Patrick 013 cg 12075 B 45th Avenue,#210 Deriver _ 80239 303-373-5990 Orleans Elizabeth OD cg 12075 13 45th.1210 Denver_ 80239 303-373-5990 Y Valcrmuela - Valerie -` OD cg 12075 E 45th,#210 Denver _ 80239 303-373-5990 Williams Edward OD cg 123 Madison St#100 Denver _ 80206 303-355-6111 Printer Kent MD cg 1245E Colfax#100 Denver 80218 303-832-5168 Pale 3 N0V 2 4 1998 I J BCBSCO - NCRO , • 3037595280 EYE HEALTH NETWORK 774 P05 NOV 24 '98 11:07 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Keats !William 'MD .cg 11325 S Colorado BI 0408 Denver 80222 . 6303-75L0933 line __. . . b. ----f._.. r. .....+ penver .180720 1303433-9898 linen !hnice .OD cg...�13361rydeo. ..- Mamba _._._ —_.. _Mamba __ !Glom 'OD cg.. 1355 Suva Fe Drive.Unit E .. .__.!Denver _._._ �_�__ _ ..;303 534-1941.. Mamba _Robert - IOD icg 1355 Santa Fe Drive.Unit E 'Denver_ _-... 20 r180 303-53419661 YavMmba E.15 E' OD lc! 11355 Santa Fe Drive.Unit 6 .._ 'Denver _._. ...1!0204 .._._. 30}334.1961 AWerae 'Rani -._ IOD leg 1555 Welton Street__ Denver 80202 - 1303-825-2500 Hanson MD lc 1601 H 19th Ave 13450 Denver 80218. _,303.8611231--, Kauvsr Kenneth MD c 1633 Fillmore 0404 10206 - 303-399-0130 _y. Smith William MD cg 1701 S Federal Blvd _Demrcr 80219 ]039345835 -- Winograd Lawrence MD egg 1701 5 Federal Blvd Denver �---"' 80219-_- 303-934583.5 Wagner Robert OD J cg 1701 South Federal Blvd Denver 80219 303-934-5835 Drucker David MD eg 1860 Larimer 0145 Denver 80202 303-293-9311 Bamberg Neil MD c 1919 S University Denver 80210 303-744-2705 Lynch 13.eat 01) eg 1945 S.Sheridan Denver 80227 303.985-5350 Canal= Janet MD e8 2005 Franklin,0400 Denver 80205 303-830-6901 Witten Jan OD cg 12465 5 Downing 0109 Denver 80210 303722-9858 Hanson Stanley OD eg 2465 S Downing.0109 Denver 80210 303-777-85.51 Cushing Stanley OD c 24805 Downing 00-30 and 0100 Denver 80210 303-777-3277 Larkin Thomas MD q 2480 5 Downing,#100 Denver 80210 303-777-5455 Hines William MD es 2480 S Downing.06.30 Denver 80230 303-777-3277 Greens® Sty OD eg 26 S Broadway Denver 80209 303-777-7990 Criss (David OD eg 2741 S Colorado Blvd Denver 80222 303-757-3311 riGrupe Ivan OD q 2741 5.Colorado Blvd. Denver 80222 303-753-9090 Hamilton Alvin MD c 3005 E. 16th Avenue.0230 Denver 80206 303-393-0750 Simons Ruben MD cg 3545 S Tamarac 0170 Denier 80231 301770-7100 Patterson James MD eg 3600 5 Alameda.0120 Denver 80209 303-320-1777 Lubeck Marvin MD q 3600E Alameda,0120 Denver _80209 303-320-1777 Keyser Robin MD eg 3600 B.Alameda Deemer 80209 303-320.1717 Conn Donald OD eg 3600 E.Alameda Ave.0120 Denver 80209 Armors Timothy MD 4 3600 E.Alameda,0120 Denier 80209 303-320-1777 Arnold Charles MD c 3865 Cherry Creek N Dr 0140 Denver 80209 303-388-4393 Spivack Lawrence MD c 3865 Cherry Creek N Dr 1140 Denver 80209 303-388-4393 Levinson 1Richard MD cg 454559th Avenue 1270 Denver 180220 303-393- 047 Goldstein Sod MD es 4999E Kmucky Ave 0201 Denver 80246 303-691-0505 Kamer Karen MD cg 4999 E Kentucky Ave./800 Denver 80246 303-758-1611 Brock Rebecca MD 4999 H ICranucky Ave.,1102 Denver 80222 303691-0777 Frankel Stuart MD a 4999E Kentucky Ave.,/102 Drava 80222 303-691-0777 Vlckan at Sherwyn OD 4999 H.Kentucky 1203 Denver 80222 303-758-5477 Barn= Hirsh MD q 4999 E.Kentucky Ave.,1203 Denver 80222 303-759-5477 Pardos George MD 55 Madison,0355 Denver 80206 303-377-2020 Prouty Ruben OD 55 Madison,#355 Denver 80206 303-377-2020 Fowler Patrick OD q 5560 W 44th Avenue Denver 80212 303-421-2424 • Orleans Elizabeth 013 q 5560 W.44th Avenue Denver 80212 303-421.2424 Vale Wader Valerie OD cg 5560 W.44th Avenue Denver 80212 303-421-2424 Meler Craig OD q 5645 Broadway _ Denver _ 80209 303-777-1403 Cannavo Laura MD cg 850 E.Harvard.0245 Denver — 80210 _ 303.698-9161 Welts Delbert _ MD _ c 9101 6th Street 0630 Denver 80202 303423.5416 Whalen - William MD 950 E Harvard 0680 Denver 80210 3017773342 Ammons Timothy MD cg 950E Harvard,0320 Denver _ 303777-7683 D - IE L) b IE' Page4 NOV�l 241998 1 " BCBSCO - NCRO, 3037595280 EYE HEALTH NETWORK 774 0-06 NOV 24 '98 11:07 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Gentry lane' IMD -cg '950 E Harvard.76320 Denver ._ ..__'80310 • 1303-777-7683.. Maxwell lanes TMD .;` 1950E Harvard.4380 ... 'Denver 80210 1303-744-1086 Gleason IKevin IOD !cg _I9797 W Colfax .Denver_-. _ 1_80215 _ 303-237-3314 Stickler Kemetn OD leg,,_99918th Suter 0146 -I Denver 30202 301291.80]0-. Garlock Rhea OD or 999 18th Sues 0146 ....1°enver ..________ scars_....__.x'293-9410 Glick Steven OD cg 999 18th Street 0146 Denver 80202 303.2984410 Swanson OD _ �,- , CasaOpt.Ci 2736 Wean/6'20D Denver 80205 303'295-2402 Fidler - OD leg Colo Optaneuic Ctr 2736 WehonDenver 90205 303.295-2402 Patel Alper OD Colo Optometric,Cu 2736 Wince n.Den.ver 80205 303-293-2402 Lerwick Dale 013 eg 120 E.Buffalo.P.O.Boa 1477 Dillon 80435 9704686591 __ Reddin Diane OD cg P.O.Bons 1477 Dillon _ 80435 970x68-6591 Engehere Howard OD ril 1010 Main Strut Durango 81301 970.247-1613 Palmer Mark OD _ MI 1165 S Camino Del Rio 0100 Dunogo 81301 970-247-1762 Et Donald OD ill 215 Elm Ave. Eaton 80615 970434-3387 Heather OD ©215 Elm Ave. Eaton 80615 970454-3387 OD 34061 Forest Park Dr. Elizabeth80107 30 .646-9144 Eillira MD ell1100 E Hampden 0131 Englewood 80110 303-777-9674 Koleeki Marek 013 To 3191 S Broadway Englewood 80110 303-781-281 Whalen William MD .3535 S Lafayette,0204 ,Englewood 80110 303-761-2020 M01er Leaf OD Ell 3555 S Clarkson 030 _ Englewood 80110 303-789.2221 Reinserts= Richard MD II 3601 S Clarkson 0120 Englewood 80110 303-781.408 Mmell Guy A. MD .3601 S Clarkson St 0120 Eogiewoad 80110 303-781.4008 Gibbs Barbara OD III 601 E Hampden 0255 Englewood 90110 303-788-8848 Repine Karen MD 601 E Hampden 0255 --_ Englewood 80110 ,303-7882848 Padgorski Steven MD .601 E.Hampden.0490 Englewood 80110 303.7614944 Hellenrein Lynn OD .7180 E.Orchard Rd.,Ste 103 Eaglewood 80111 303850-9499 Finches Randolph OD 74476 E.Arapahoe Road Baglewood 80122 303-770-8081 Golesh Edward OD 7447-6 E.Arapahoe Road Englewood 80122 303-770-8081 Arnold Charles MD ell 820E Belleviiew B Tower 0200 Englewood 80111 303-740-9310 Conkliog Paul OD ra 240 E Bdleview E Tower 0200 Englewood 80111 301-740-9310 Spivack Lawrence MD eg 8200 E Beileview B Twr 0200 Englewood 80111 303-740-9310 King Robert MD PED 1200 B.Belleview Ave..0 295 Englewood 80111 303488-0000 Dreads Dian MD PED 820 E.BeOeview HTower,0295 Halewood 80111 300488-0000 Lanus Joseph OD eg 600 S St.Vrain Suite 4 Estes Park 80517 970-386-4418 Peeheue Douglas MD 28000 Meadow Drive.01 Evergreen 80439 1303674-7477 Norris Andrew MD cg 1025 Garfield Street Fort Collins 80524 970-224-2020 Alexander Daiwa OD eg 1304 S Shields Fort Collins 80521 970-2214811 Smith Pear OD cg 1304 3 Shields Fort Collis 80521 970.221-1811 vogel Brad OD ri 1304 S Shields Fort Collins 80521 970.221-4811 DeGeorge Mark OD ern 162 5 College Av Pont Collins 80525 970-2264500 Baddke Russell MD 1725 E.Prospect Fort Collins 80525 9704844722 Foster Guy J. MD_ 1725 H.Prospect For Collins 80525 970484.5322 Olsen Gerald MD. e _1725 E.Prospect Fort Collins 80525 9704844322 Robinson Matthew MD c 1725 E.Prospect ---.— Port_-- Collins 80525 970-484-5322 -- Stevens William MD cg 1725 E.Prospect - Fort Collins 80525 970-484-5322 Shulman William MD 1725 E.Prospect --_ Fort Collins 80525 970-484-5322 Tergenon Michael S. OD cg 120 S College Ave. -_- For Collins 10525 910-493-6360 Larson Robert OD_ eg 2001 S Shields,IB-3 -.--_�T For Collins _ 80526 _ 970-221-1931 VeyEereig Greg 0D s{ 210 W.Drake Rd..06----� For Collis 80526 970.221300 r icig, 0\v - , -[ Page 5 N0V 2 4 1998 .i L BCBSCO - NCRO 3037595280 EYE HEALTH NETWORK 774 Fa07 NOV 24 '98 11:08 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Metard ,Jay .�OD ,eg 1215 E Foothills Pkwy .Fort Collins 180525 970-223-3000 . _ {..__ Robertson !Rodger 'OD e{ 215E Foothills Pk vry .Fort Collins ;80525 970223-3000 Andanon 'Kevin IOD •cg 2601 S.Lemay 015 Fort Colii'u I80S25 970.22}0592 Bateman Ikon OD eg 373 W.Drake Rood 03 _Port Collins II 80526 970.223-7150 Johnson Tamara 013 cg 412 Remington (Fort Colitis 80524 970-4824700 'Oiling David OD eg 4631 S Mason B5 .--..,.'Port Collins 80525 970-226-0959 __ -- Haa{en Scott _.. 013 eg 645 Whitcomb ....__-.-..... ._.__ !Fat Collins . .. .._.__._ 80521 970.2214808 Breen William OD cg 7014th Street IFon Lupton 80621 303-8514550 Ellin Jobe E. ....MD 102 W.9th Ave ._...Fort QQorgan 80701 970.522.1833._ T_. Save__ Thomas OD eg 1100 Mom Fort Mogan 80701 970-867-3016_ Finch Craig 01) cg 221 B Kiowa Fo_n Morgan 80701 970867-3937 Coot Paul _ 015 cg 620 B.Male Sty Box 2700 _'Frisco._...... 80443 970-668-3736 Hauac __.... Hirsh MD Summit Medical Cu.PO Box 545 }Frisco 80435 970-262-3233 Hines William MD eg 1904 Parkin Ave. ,Glenwood Splints 81601 301777-3277 Snubs — Eva OD cg 1208 Washington Avenue Golden 80401 '305.279-3713 Caton Viekl MD eg 13772 Denver West Pkwy#100 Golden 80401 3034794600 Kreider Larry MD eg 13772 Denver West Pkwy 0100 ---- Golden 80401 303-279-6600 Storac Robert MD eg 13772 Denver West Pkwy 0100 _Golden 80401 13032794603 — Zapf Delvin MD cg _13772 Denver West Pkwy 0100 Golden 80401 303-2794600 Stahl Jan MD eg 13772 Denver Wen Pkwy 0110 Golden 80401 303-279-6600 Mamba _ Olean OD cg 14799 W 6th Av UN B-1 Golden 80101 303-273-4754 Mamba Robert 073 eg 14799 W 6th Av UN B-1 Golden 80401 303-278-4754 Ysno-Matoba E.Naomi 013 cg 14799 W 6th A.UN B-I Golden 80401 303-278-4754 Baton ,Sam 013 cg 2301 Ford Street Golden 80401 '303-278-2020 Bush Jetty MD 1000 Wellington Ave Grand Junction 81501 970-243-9000 — Cam$dll Dennis MD 1000 wellington Ave _ Grand Junction 81501 970.243-9000 Dunn Lester MD 1000 Wellington Ave Grand Junction 81501 970-243-9000 Lupine Carl MD g 1120 Wellington . Grand Junction 81501 970-242-8811 Ronan Randy MD g 1120 Wellington Grand Junction 81501 ,970-2424723 Delano Ronald 015 q 1150 N 12th Street Grand Junction 81501 970-2424222 Klaich Michael 013 eg 1306 E Sherwoal Dr Grand Ismailia 81501 9704454678 718,Jr. George OD eg 2232 N 7th 010 Grand lunation 81501 ,970-242-4909 Brownsan Robert OD cg 2356 North 7th Sate Grand Junction 81501 970443-9681 Call Parka OD eg 2356 North 70 Street Grand Junedm 81501 970443-9681 Sankey-Hicks Melinda OD cg 2356 North 7th Street Grand Junction 81501 970143-9681 Hanna Robert MD c 425 Patterson 0405 Grand Junction 81501 970.2564100 Freitag Mary 015 q 2001-46th A. - Greeley 80631 970-330-7070 Saimaa Zany OD cg 2001-46th Av _ Greeley 80634 970-352.2020 I Harvey.Pr Denim OD cg 2001 46th Av Greeley 80631 9703307070 Lee George JE OD q 2525 W 16rh Street G'S 80631 1970-356-4020 , Stutter Marcia OD eg 2525 W. 16th Street.NB —_... Ores ey ... 80631 970-3524200 I Bowen ___ !aqua 0D cg 300023rd Avenue 01 —_ Greeley 80631 970-352-3358 Milmla Monique 013 3506 West 10th Grimly 80634 970-356.9741 Jacobs Lawrence OD cg 2000 E County Line Rd Ste B _. .Highlands R-anch 80126 303-794-2020 Fowler _— _•- Patrick OD q 1800 Colorado Blvd.Box 725 — Idaho Springs 80452 303-567-4838 Orleans.___ _.._ Elisabeth OD cg 1800 Colorado Blvd..Box 725 _.—.__._.Idaho Springs... 80452 303-567-6838 Valeazuela Valerie OD cg_1800 Colorado Blvd..Box 725 Idaho Springs 804,52 303-567-4838 Jews--.. _- Edwin_ OD _ q 109 E 2nd _ Julesbag _ 80737 970474-3499 Tripp —. . Warren MD cg 900 Cedar Julesberg 80737 970474-3499 Pages r N0V 241998 D _J BCBSCO - NCRO 3037595280 EYE HEALTH NETWORK 774 P08 Nov 24 '98 11:08 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Murphy 'Benton IM-- log 11102Fe .... __..._—___. +'aims ;COM 719-384-8719 Bro !Reed .0D _ cg.__+102 Santa Fe Ammo La Junta .81050 719-384-8719 __.. . . Byers 'Mark iOD :cg 1716 ColondO Ave. _JV Junta 81050 719384-2M0 Fran_ Frank_ _ 1H.LtardolDhlD JAR Valley Rag.Md.Ctr. 1100 Gaon Ilk Junta 81050 — 719384.5412 Swam Donald ,IOD„ cg "Lincoln Professional Bldg./102 lit Juno ._ 181050 719384-1982_ --- — r Himcl David lOD q +1280 Centaur Village Dr.,#2 ILafayeue 180262 303404-1060 _— Amato" Cleve l0D c8 801 S..Publlc Rood "Lafayette 180026 308665-3200 • Nelms - Patrick ton cg 12792 W Alameda Pkwy.IF 'Lakewood 180228 303.986-5565 • Gebel Denise Z. OD eg 12792 W.Alameda Pkwy.Su F Lakewood 80228 303-986-5565 Crockett David OD cg 1343 Wadsworth Blvd Lakewood 80215 303-238-9900 Bryan Wendell OD ,cg 25255 Wadsworth#101 Lakewood 80227 3034865983 Hlavac Jill OD cg 23255 Wadsworth/101 Lakewood 80227 303-986-5983 Ammon _ TunotM MD _ leg 235 Union Blvd..8270 Lakewood .....---..._._ 80228 303-9894023 Hock Daniel OD cg 255 Union Blvd..#270 Lakewood.__..— 80228 303409-2023 Keyser Robert MD eg 255 Union Blvd.,#270 Lakewood 80228 ,303-989-2023 Patterson James MD tcg 2.55 Union Blvd.,#270 Lakewood 80228 303-989-2023 Seifert David OD cg 3190 S Wadsworth Blvd.,/320 Lakewood 80227 303.988-5858 Mamalk George 013 cg 390 Union Blvd#240 Lakewood 80228 303.9850004 Zweifach Esc.___. MD 550 S.Wadsworth►201 Lakewood_ 80226 1303-935-2020 Wagner Robert OD cg 550 S.Wadsworth Blvd.#201 Lakewood __ 80226 +303-935-2020 Farnsworth Craig 013 'eg 550 S.Wadsworth Blvd.,#201 Lakewood 80226 303-935-2020 T !Udder Kenneth OD cg 5505.Wadworth Blvd.#208 Lakewtxd 80226 3034362020 Whalen William_ MD 16565 W Jewell Av#2 Lakewood _ — 80232 303-9343681 Pegg Robert MD c 6565 W Jewell,#2 Lakewood 80232 307-9343681 Bergpcn Ronald OD cg 6565 W.Jewell,#7 Lakewood 80232 303-936-1671 Reddin Diane 01) cg 7575 W 20th Avenue Lakewood 80215 1303-233-7575 l ervick Dale 0D cg 7575 W 20th Avenue Lakewood 80215 303-233-7575 IBuortherg _ Nciel MD c 8015 W Alameda#230 Lakewood 80226 303-2384484 Wood Brian 01) cg 8600W 14th Avenue Lakewood 80215 303-238-4357 Bro Reed OD cg 316 S Main SL Lamar 81052 7194363201 TWswell Jeff OD eg 403 Kendall Drive,/1300 Lamar 81052 719-336-4922 Bleb Edmund OD cg 825 W 6th Leadviie 80461 ;7194862305 Paentar Robert MD 269 E Avenue Limon 80828 7197753831 Rebern John OD cg 10143 W Chatfield Ave Littleton 80127 303473.1948 L naya Harrison MD cg 19l E Orchard Road Littleton 80121 x303.794.1111 Poderson _ Jerry OD eg 2275E Arapahoe Rod,#105 Lialaon 80122 303-7984533 Voight,Jr. Earl OD teg 5590 S W0ldamere Laretou — ,80120 303-798-1277_ 1Taykx Warren OD cg 5911 S Middlefield Rd/200 LittletonLittleton80123 303-798-5911 Roberts Alfred _ MD cg 6169 Balsam Way#270 Littleton 80123 303-9483020 Meager Donald OD cg 6610 S Broadway LiWemn 80121 303-797-2015 Baumgardner David _ OD cg 6638 W.Ottawa Avenue,#235 Link-ion 80123 303-979.6767 Yount Kent _OD cg 6901 5 Pierce St.,#235 Lifemn 80123 303-979-4505 Knrchat Mark OD es 6901 S Pierce Street#235 Littleton 80123 303-973-8653 Loomis Steven OD cg 6901 S Pierce Street#235 Liman 80123 303-9794505 ..._ __ Strum __.. Mark OD cg 6905 S Broadway#51 Littleton,__.__.. _.._ 80122 303-798-7520 Clausen David OD eg 7562 S Univenity Blvd Littleton 80122 303-773-2020 - Cohen Justin MD PHD a 7720 S Broadway#200 LiWemn 80122 303-797-3390 Roe Chester MD PED c 7720 S Broadway 1200 linietnn 80122 303.797-3390 Sargent Robert MD PED c 77203 Broadway#280 liukmn._...... 80122 301797-3390 Er Page 7 N0V 2 4 1998 J 1 BCBSCO - NCRO 3037595280 EYE HEALTH NETWORK 774 P09 NIOl1 24 '98 11:09 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Berg ...[Allan MD kg 17720 S Broadway/120 jLiWeton 180122 }303.7944184 Bidder. ..'Kenneth 140D cg 7720 S BraWway,#220 ,4r0ewn 80122 X 1303494-2433 Roberson !Aex 'OD Jcg..y77205 Broadway#220 LiWeton 4 !80122 301794.2473 Margolis _ Aar IMD leg 77503 Broadway#0-50 Littleton 180122 303497.1150 Taylor Roger _.. . fOD leg 8120S Holly,0102 _._ . ._ Littletot .80122 - —1301771.1830- 3aehning -- Mark }IO-D cg 8120 S.Holly,0102 Littleton _ [0122 I303-771-1830 (Cook Paul IOD 9046 W Bowles Ave#6 Littleton [80113 303.979-1518 Creatable... _.. _..ley ...._—.1OD icg 9350 W Cross Dr#200 Littleton 80123 3034724717 Meet lobo OD cg 1250 S Hova Sweet'D' latpnont 180501 103.772-2755 Johnson Dale MD eg 1319 Vivian Suit Longman 80501 303-772-3611 Robinson Terry _ MD _ cg 1319 Vivian Street Longmont 80501 303-772-3611 Powers Douglas MD 1319 Vivian Street Longmont 80501 303-772-3611 Olljnyk Irene MD cg 1446 Hover Road Lanyoonl____ 80501 303-772-3300 Meyer Joel BID - cg 1446 Hover Road Longmont 80501 303-772-3300 Schaefer Lowell _ OD cg 2080 N Main loogmom 80501 303-651-2020 Blackwood Clark OD cg 2080 N Main St l.aegmmnt 80501 303-651-20x0 Eland William _ OD _ cg 2080 N Main St fonpnon -- 80501 303-6514020 Forren Larry OD eg 2080 N Main St Longman 80501 303651-2020 Baker Phillip _ OD cg 412 Main St. la gmora 80501 303451-6700 Pukai Michael OD q 1371 Meet Way Louisville 80027 303666.7226 Tripp Warren _ MD eg 335$Boulder Rd.#2 Louisville 80027 303-665-7797 Kell Hale OD cg 335 5 Boulder Road Louisville 80027 303665-7797 Jong Edwin_ OD q 400 S.McCastin Blvd.,See.101 Louisville 80027 303-666-0104 Colvin John OD_ _cg 166 E.29th Street Lovelard 80538 970-667-3664 Lee George I OD cg 2004 W 15th Street.#2 ,Loveland 80538 970-669-2040 Straub William OD q 2017 W Eisenhower Blvd Loveland 80537 970667-4366 Danner Rooaid OD q 335 6th Street.Box 736 Meeker 81841 970-878-3515 Betroth Craig OD eg 335 6th Street,Box 736 Meager 81841 970-878-3515 Haersink Paul OD eg 110 Rupert Street Monte Visa 81144 719152.3412 Young Charles OD cg 140 S UnartWabgre.P.O.Box 546 Montrose 81402 970-1494020 Cooper Weeley OD cg 400 S Nevada Street Montrose 81401 970.1493914 Guhl David OD eg 1860 Woodmoor Drive,#103 Moament 80132 71948/4042 Puckett Frank OD cg 1860 Woodmoor Drive,#103 Monument 80132 7194867042 Wilson Thomas OD q 1860 Woodmoor Drive.#103 Monument 80132 719488-2042 Bui Thong OD cg 10360 Melody Drive Northglean 80221 303-452-5672 Cnwfoed Daniel C. OD cg 10360 Melody Drive Nonbgktm 80221 303-4524672 Gootdy Donald OD q 10360 Melody Drive Nonhglem 80221 3034526672 McGuire Dennis OD cg 10360 Melody Drive Nonhgleno 80221 303-4525672 Ballad Paul MD _ q 10371 Partglen Way See 190 Parka 80134 30}840.6168 Le4}ak Thomas OD eg 4 10521 S Parker Road Parts 80134 303-841-8143 Spirom Louis OD eg 19750 B Parker Sq Dr,Box 628 Parker 80134 303-841-3937 Sehlamer Donald _ MD 1315 S Pueblo BI Pueblo 81001 Greenlee Lynn MD 1315 5 Pueblo Blvd Pueblo 81001 Wainwright Neil MD 1315 S Pueblo Blvd Pueblo 81001 _ 719-545-1530 >— Cmtnay Michael _DO_—__-tg 1315 S.Pueblo Blvd. Pueblo 81001 719361.2244 Eickelnun lames OD eg 1315 South Pueblo Blvd. Pueblo 81005 719.361-3795 ` Fowls James MD Cl 1501 Coon Pueblo 81003 719446-3937 - Rasa-ell; Paul----MD 1501 Court Street Pueblo .4_181003 719446-3937 Nelson — Thomas _OD 1753 S Pueblo Blvd -__ Prwhrn -. IMAM 719-561-0412 . Pages , N0V 2 4 1998 J BCBSCO - NCRO 3037595280 EYE HEALTH NETWORK 774 P10 NOU 24 '9B 11: 10 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado House Allison OD lcg 1821 W.Fortino Blvd. Pueblo 181008 . '719-583-0344 ! __. Meyer Marcus `OD Leg '2001 Highway 50 West ( Pueblo 181008 •719 542-1222.. Gea es grs Jam _ _.SOD Icg 122 Club Manor Drive �>'ueblo 81008 '719.5427325 Coauey-__,_ Michael DO leg 127 hfontebello Road Pueblo 181001 719.545-1530 Gree lee Lynn MD cg ,_.427 Montebello flood Pueblo 719 81001 .545.1530 Royer L.R. MD cg 27 Mmucbello Rad�_.. 'Pueblo 81001 719-545.1530 Muter Marvin__......._ �...._ eg ...27 Montebello Road ....._.Pueblo___...__.._.. 81001 719-545.1530 Murphy Benton MD cg 27 Montebello Road Pueblo 81001 719-545.1530 Schlosser Donald MD cg 27 Montebello Road Pueblo 81001 719-545-1530 rune Jay MD cg 27 Montebello Road Pueblo 81001 719-545-1530 Wainwright Neil MD cg 27 Montebello Road Pueblo 61001 719-545-1530 Conan Michael OD eg 3116 North Elizabeth Pueblo 81008 719.542.3555 Snyder Charles MD cg 3715 Thatcher Avenue_ Pueblo 81005 719-5614480 Meyer Maras OD cg 900 W.Northern Pueblo 81004 719-542.2222 Auberr Allen OD cg 305 S.Main Rocky Ford 81067 719-254-7404 Bode Don MD 203 G Sweet Salida 81201 719-539-2519 Lund Larry OD 205 0 Street Salida 81201 719-539-2519 Weber Mark MD 515 B Ian Street Salida 61201 719-539-3581 Miguel Guy OD 9th&Oak.P.O.Box 73007 Steamboat Springs 80477 970-679-4266 Pctroth Craig OD P.O.Box 774445 Sambas Springs 80477 970-879.2020 William MD 1410 3 7th Ave _ Sterling 80751 970-522-1833 EMIT John B. MD 1410 5 7dt Ave.Box 951 Staling 80751 970.522.1833 Wolrley Todd OD cg 419 W Main Sweet Smiti"g 80751 970-522.4396 Still Lisa OD cg 10001 N Washington Thornton 80229 3034514075_ Davis Steven OD cg l0001 N Washington Thornton 80029 303451.8075 Faulkner Ronald OD 10001 N Washington Thornton 80029 303451.8075 May Jack on 10001 N Washington Thornton 60229 303451-8075 Santoro John MD 10001 N Washington_ Thornton 80129 303.252.9981 Willard OD g 10001 N Washington Thornton 80029 303451.8075 Smiley OD 3953A E.120dt Avenue Thornton 80233 303-452-2020 Straub Howard DO -9141 Gram St..Ste 239 Thornton 80229 303-450-7363 gillJohn MD 9141 Orem Street 01110 Thornton 80229 303451-5454 Nancy MD 91410ram Sueet#110 Thornton 802'19 303-451-5454 George OD 1114 E.Main 014 Trinidad 81062 719.646-7342 Berman Hirsh MD .181 W Meadow Dr.0203 Vail 61657 741476-5695 Goldstein Joel MD 181 W Meadow Dr.1200 Vail 61657 970-476-5695 Page Dennis MD eg 2109 N Fronntge Rd 0B wail 81657 970-476-3670 Royer L.R. MD cg 100 W.401 Walseoburg 81089 719-738-3155 Martina Marvin OD eg 100 W.4th _ Wabanbnrg 81089 719-738-3155 Rae Marry . 013 cg 7290 Samuel Drive 0106 Westminster 80221 303-428-7231 Baroele John MD .8400 Moon.0109 Wearnimtor 80030 303426.9696 Aahline John MD cg 8403 Bryant Street Wesnnimer 80030 303.426-4810 Moulder Nancy MD cg 8403 Bryant Street--_—_ Westminster 80030 303-426-4810 O'Rourke Melinda MD cg 8403 Bryant Street Wesmimter 80030 303426-1810 Self William MD cg 8403 Bryant Sneer Westminster 80030 303-426-4810 Underwood Larry MD cg 3655 Lutheran Pkwy 1204 --- Wheat Ridge 80033 3034243206 Thomas John OD cg 3994 Youngfield Bldg A,Ste B Wheat Ridge 80033 3034250700 King Robert MD PED 4045 Wadsworth Blvd 0111 Wheat Ridge 80033 303.446+&46 _ __.. DeSands Diana MD PED 4045 Wadsworth Blvd.0111 W e" dge 880033 303-456-9456 Liu IDi iyi-EPa9e9 N0V 241998 1 BCBSCO - NCRO 3037595260 EYE HEALTH NETWORK 774 P11 ICU 24 X96 11:10 The Eye Health Network Directory of Eye Care Providers for Blue Cross Blue Shield of Colorado Brookes `Thomas !OD leg 4685 Wadsworth 'Who Ridge 180033'--- 1303422-7068 PJsembud Erie MD 4 .7760 W 38th Ava.c 1100 What Ridge .._ 180033 303413454.5 Cohen tJusdn IMD FED c -t$23 W 38th Me .. .Wheat Ridge :80033 303-797-3390 Dngmo Blain = MD es 7823 W 38th Ave .L Rage-_ ... —_. 180033 3034204424 Roe ...._.. Chester MD RED c 7823 W 3ltb Avenue .. . . . ... IWbnt.Ridge... ---. 18033 303-797.3390 —_ —...._. .. _.__ _—� ...... ----...._ Sargea Rabin MD PHD c 7827 W 38th AMOK— -- Wheat Ridge — 80037 703-797-3390 ; ^ Colvin .._.. John............._ OD o8 2095th 3tnct 1Wiodsor 80550 170446.1030 . S Pederun Richard OD e8 757 Gold Hill Sq.S..Boa 797 ....—_!Woodland Park ' 80866 719-687.2931 Cummings Thomas OD eg 781 Gold Hill Place Woodland Perk 80663 719-667.3937 Avail _ Pierre OD cg 781 Gold Hill Sq.Place,Box 797'... Woodland Park 80666 719-687.2931 Hanky Randy OD cg 107 Main Yuan 80759 970-46-5345.... # Nov 24 1998 gli. Page 10 BCBSCO _ I NCRO I - ' Qa BlueAdvantage Application For BlueAdvantage vav ti From HMO Colorado" • INTERNAL USE ONLY ) An Independent Licensee of the Blue Cross GROUP NUMBER ANNIVERSARY MONTH CONTRACT EFFECTIVE DATE ® and Blue Shield Association PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART Application for BlueAdvantage(Application)group coverage is hereby made for eligible Employees of the Employer. If this Application is approved by HMO Colorado and Blue Cross and Blue Shield of Colorado(if applicable),this coverage will be issued to: Weld County Government ("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) 915 10th Street Greeley.CO 80631 (PHYSICAL ADDRESS-STREET, CITY,STATE,ZIP CODE) (MAILING ADDRESS—IF DIFFERENT) NOTE: "We,""Us,"and"Our"refer to HMO Colorado.For group sizes of 51 or more Employees,BlueAdvantage is federally qualified in Adams,Arapahoe,Boulder,Clear Creek,Crowley,Denver,Douglas,El Paso,Fremont,Gilpin,Huerfano,Jefferson,Lorimer,Otero,Pueblo, Teller and Weld counties.For groups with 51 or more employees,counties not listed are not federally qualified.For group sizes of 50 or fewer Employees,BlueAdvantage is a not a federally qualified HMO product.When the product is not federally qualified,BlueAdvantage coverage can differ from those required by federal HMO laws and regulations."We,""Us,"and"Our"also refers to Blue Cross and Blue Shield of Colorado if coverage is provided far BlueAdvantage Custom Plus coverage. IN CONSIDERATION of the submission of this Application by the Employer,approval thereof by us,and of the payment of premiums in accordance with the Group Master Contract(Contract), we agree to provide group coverage as described in the Contract, the Benefit Booklet,and this Application and the Addendum to the Application for BlueAdvantage(Addendum),for any eligible enrolled Employees and eligible enrolled dependents,and the Employer agrees to abide by the terms,conditions,and limitations contained in such documents. GENERAL AGREEMENT 1. NATURE OF BUSINESS(please be specific):County Government Type of organization: 0 Proprietorship 0 Corporation 0 Partnership 2. Do you have current coverage in force? 0 Yes 0 No,if"Yes"do you intend to cancel that coverage? 0 Yes 0 No. If you are applying for or retaining other group health coverage in addition to this coverage on some or all Employees specify coverage(s),Carrier,amounts, and give details: 3. Do you intend to enroll retirees under this group health Plan?(Retirees may enroll for coverage if there are 51 or more Employees enrolled under this coverage.) 0 Yes 0 No If"Yes,"give details: 4. CONTRIBUTION —The Employer will be required to contribute a minimum of 50%toward the Employee's single or 50%of the Employees portion of the family-cost of membership premiums. 5. PREMIUMS-It is understood that the premiums quoted may change based on the actual enrollment of the group.Premiums will be billed by us monthly,and will be reviewed in accordance with the Contract and State or Federal requirements. 6. CLASSIFICATION OF EMPLOYEES ELIGIBLE—All eligible Employees of the Employer who have a regular work week as stated on the Addendum,shall be eligible to enroll.If the Employer reduces the working hours of such Employees to leas hours per week than stated on the Addendum,coverage will be continued for such Employees and their dependents under the same conditions and for the same premium,if the following conditions are met and the Employer so certifies: (a) The covered Employee has been continuously employed as an Employee of the Employer and has been insured under the group Contract, or under any group Contract providing similar benefits which said group Contract replaces, for at least six months immediately prior to such reduction in working hours; (b) The Employer has imposed such reduction in working hours due to economic conditions;and (c) The Employer intends to restore the Employee to a full work week schedule as soon as economic conditions improve. 7. ENROLLMENT PERCENTAGE REQUIREMENTS— For all size groups to apply for and retain group coverage and rates if we are the sole carrier,the Employer agrees to maintain the following enrollment percentage requirements,based on TOTAL ELIGIBLE EMPLOYEES: • Group size 50 or fewer Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES • Group size 51 or more Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES,with no less than 50%of TOTAL ELIGIBLE EMPLOYEES. To arrive at NET ELIGIBLE EMPLOYEES,Employees covered elsewhere with the following types of group insurance maybe excluded, nless such coverage is offered through THE EMPLOYER: A Blue Cross and Blue Shield Plan; A Health Maintenance Organization; The Federal Employees Program; Indian Health Services; Federal Peace Corps; Colorado Uninsurable Health Insurance Plan,or Through a commercial carrier. 44. BLU22sM WPD FORM NO.96064(REV.1197) an c BlueAdvantage S From HMO Colorado Addendum To Application For BlueAdvantage An Independent Licensee of the Blue Cross and Blue Shield Association GROUP NLUM5Ea ANNIVEFi$AR1 MONTH ADDENDUM EFFECTJ,VE DATE (( ]] pp PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO/ NOT TEAR FORM APART Complete all information on this Addendum to Application for BlueAdvantage(Addendum)if you are completing the Application for BlueAdvantage. If you have previously submitted an Addendum,complete only information that is relevant to the change.If a change is not indicated,the previous Addendum will remain in effect. CHANGE-Indicate one or more Classification of Eligible to Dependent Age .a Probationary Period - 0 Coverage Applied For 0 Optional G;oup Benefit O COBRA Billing:Ndtification 0 New ownership This Addendum is issued to:Weld County Government ("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) This Addendum amends provisions of the Application.If we approve this Addendum,we will return the approved Addendum with the effective date completed. The Addendum will become a part of the Contract.If we do not approve this Addendum, it will be returned. Other than specifically amended herein,the terms and provisions of the Application and Contract shall remain in full force and effect. CLASSIFICATION OF EMPLOYEES ELIGIBLE—The Employer requires that all eligible Employees have a regular work week of at least 20 hours per week(minimum of 24 hours per week).Eligible Employees do not include those on a temporary or substitute basis. If other Eligibility,please explain The Employer hereby certifies the following number of Employees in each category below: _Total Employees employed by the employer working at least 24 hours per week(include those not yet eligible) _Enrolling for coverage _Total Eligible Employees who have met probationary period Enrolled elsewhere COBRA or Colorado State law continuation of coverage enrollees No other coverage Other,please explain: DEPENDENTS—Unmarried dependent children are covered until the end of the month in which they become age 19,or 25 if financially dependent upon the parent. PROBATIONARY PERIOD 1't of the month following first full pay period worked,employer assigns effective date. GROUP HEALTH COVERAGE APPLIED FOR(select only one): BlueAdvantage HMO Plan Plan No. 15-1-15/25/40#of Employees enrolling BlueAdvantage Point of Service Plan No. 15-1-15/25/40$250 deductible#of Employees enrolling BlueAdvantage Custom Plus Deductible $200 single$400 family Coinsurance 80%to$5,000/$10,000 #of Employees enrolling Eighteen months pre-existing clause for late entrants with no prior coverage for the Custom Plus. OPTIONAL GROUP BENEFIT INFORMATION C Optional Chemical Dependency Rehabilitation Program ❑ Other Eye Health Network eye exam once every 24 months REMARKS Retirees age 55 through 64 will have an option to continue health insurance coverage until the date their age changes to 65,provided they meet the following criteria and stipulations: a) Eligible employees must retire from county service with at least ten years of service,or be a county elected official for at least one full four-year term. b) Eligible employees must be enrolled in the county's health insurance plan at the time of retirement or leave of county office. c) Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office. d) Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65, or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid ro Medicare coverage before attaining the age of 65.Dependent coverage if still applicable will be offered under the same terms of COBRA offered employee's dependents. e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the same time. The county will be responsible for paying the 40%surcharge of the premium,and the county contribution for the employee and dependents in the same manner as provided regular employees. f) After COBRA,dependents will have the same conversion rights as regular employees and dependents. The Employe erstands 'f e ap ye t is Addendum,the employer agrees to be bound by the terms of the Contract and this Addendum. Dated at 'Ape( U I Uthis it'-'41day of rte' h /L(/�Yt-i2 19 61 By ( / Air.) 13A j�J� i d /G CkMr11iss1UY1E A UR HORIZED PERSON TITLE Approved and accepted by HMO Co ado nd Blue Cr ss and Blue Shield of Colorado By Date !,ie # r DE O 114 By Date CHIEF EXECUTIVE OFFICER r E CRO SHIELD OF COLORADO Weld County Govt s r NOTE: In the event the group does not meet the minimum enrollment requirements,we reserve the right to accept this Application with prior underwriting approval. In all cases the Employer must meet the minimum enrollment and eligibility requirements according to HMO Colorado underwriting regulations and policies and Colorado State law. If we are a dual carrier,to apply for and retain group coverage and rates,a minimum of three Employees must be enrolled at all times. When we are a dual carrier,the enrollment percentage requirements do not apply If the number of eligible Employees enrolled does not comply with the required percentage,we reserve the right to cancel the Contract upon thirty day advance written notice. Employers with 50 or fewer Employees may also be,sole proprietor's,a single full time Employee of a subchapter S or C corporation, limited liability company,or a partnership that has carried on significant business activity for a period of at least one year prior to application for coverage. The Employer agrees and warrants that no person who is not an eligible member under this provision will be listed, named, or otherwise represented by it in any way to be an eligible member,and that the Employer will not remit membership premiums for any such person or participant or assist in obtaining or maintaining a Benefit Booklet for such ineligible person. The Employer agrees to maintain complete records and to furnish to us,upon request,such information as may be requested by us for our underwriting review. The Employer further agrees to permit a payroll audit by us or by a representative appointed by us.This may include a request for business tax records. 8. DEPENDENT—Dependent children are covered until they attain the age as stated on the Addendum. 9. PROBATIONARY PERIOD—Probationary period selection is as stated on the Addendum.There will be one open enrollment on the group's Anniversary Date for the BlueAdvantage HMO Plan and/or BlueAdvantage Point-of-Service Plan.For BlueAdvantage Custom Plus,late entrants with prior coverage can be added at the group's anniversary date.In addition, if BlueAdvantage Triple Option coverage is selected by the Employer,members will be allowed to choose between the HMO Plan,Point-of-Service,and Custom Plus coverage(for Employers with 50 or fewer employees only out-of-state employees can enroll in the Custom Plus). 10. GROUP HEALTH COVERAGE APPLIED FOR—Coverage selection is as stated on the Addendum. COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES,INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN,UPON THE REQUEST OF A SMALL EMPLOYER TO THE ENTIRE SMALL GROUP,REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN THE GROUP.BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT PLAN. 11. Employer represents,agrees,and warrants that the Employer is in compliance with all applicable local,state,and federal laws,rules and regulations,including but not limited to COBRA,the Family Medical Leave Act,TEFRA,DEFRA,and OBRA.To the extent any part of this application is inconsistent with such laws, rules, and regulations, such provision shall not be deemed a part of this application. However,the application shall be otherwise enforceable.If the Employer has agreed to have us perform specific billing and notification duties related to COBRA, such information will be stated on the Addendum. Masoud Shirazi-Shirazi&Assoc 970-356-5151 BROKER TELEPHONE NUMBER 1770 25th Avenue#302 Greeley, CO 80631 STREET,CITY, STATE,ZIP CODE The Employer represents, agrees, and warrants that the information contained in this Application is true and correct and forms an essential basis for our issuance of the Contract. EVEN THOUGH THIS APPLICATION IS SUBMITTED WITH PROPOSED PREMIUMS OR OTHER FUNDS,THERE WILL BE NO COVERAGE UNTIL THIS APPLICATION IS APPROVED BY US. If we approve this Application,we will send you a Contract of which this Application will become a part.Your prior coverage should not be cancelled until you have been notified that your Application has been accepted.No agent can bind coverage,set an effective date,or waive or alter any provision of this Application.The Contract will specify the effective date of group coverage. If we do not approve this Application,the submitted funds will be returned to the Employer. The Employer understands that if we approve this Application,the Employer agrees to be bound by the terms of the Contract 1- Datedit, ),--/ I0 this �U day of /��, IZGG�� 19 /7'7 By 4 a A - C6 i ?d � 'PId ['O ( iyiM/; ,Une �`G'� " SIGNA RE F AUTHORIZED PERSON JA TITLE t� Approved and accepted by HMO rado and Blue ss and Blue Shield of Colorado JAN 2 6 1999 By Date P S T-H�GIp C O By i• f^'i.'�- / y f" Date JAs 2 61999 CHIEF EXECUTIVE OFFIC R-BLUE DROSS AND LUE SHIELD OF COLORADO BLU226M.WP➢ FORM NO.96064(REV.11/97) A Group Health Care Program Group Master Contract voa c HMO . Colorado An Independent Licensee or the Blue Cross and Blue Shield Association 4 ' HMO COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION-ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract effective date 1 Anniversary date 1 Employee 1 Employer 1 Remittance 1 Benefit booklet 2 Group administrator 2 Assignment 2 Contract provision changes 2 Notices 2 Governing Laws 2 Attorneys' fees and expenses 3 Enforcement of the contract 3 Interpretation of the contract 3 Termination of the contract 3 Reinstatement of contract 3 SECTION III. PREMIUM CHANGES, PAYMENT, TERMINATION FOR NON-PAYMENT, REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 4 Changes 4 Payment 4 Termination for non-payment 4 Refund of membership premium 4 Cashing of check not acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Notification of cessation of membership 5 Acceptance of contract 5 Group eligibility requirements 5 BLUH119GCOC i HMO COLORADO GROUP MASTER CONTRACT NO. 99-00772001 For Weld County Government Employer C07720 Group Number SECTION I. APPLICATION-ACCEPTANCE The application and addendum for group health coverage("application/addendum")executed by the employer has been accepted by HMO Colorado(sometimes referred to as "we," "us," and "our"). Such application/addendum and their contents are incorporated in this group master contract("contract"). In the event of any inconsistency between the terms of the application/addendum and the terms of the contract, the terms of the contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the employer's employees and their dependents. Such persons, when covered hereunder, are referred to as "members." 1. Contract effective date.The effective date of the contract shall be 12:01 A.M. on the first day of January, 1999, at Denver, Colorado; the contract shall continue to remain in effect through December 31, 1999. 2. Anniversary date. The anniversary date is the effective date for (i) coverage; (ii) changes to group enrollment and benefit eligibility implemented by the employer; and(iii) the date a group is due for appropriate renewal rating. 3. Employee.An employee as defined in the application/addendum as eligible for enrollment; the employee is the individual who is employed by the employer. 4. Employer. The employer or organization with whom HMO Colorado has contracted; and by reason of the contract the employees and their dependents become eligible for the coverage and benefits described in the contract. 5. Remittance. The employer shall pay to us monthly and prior to the first day in each month, the required premium on behalf of all enrolled employees and dependents who meet the eligibility requirements specified in the group application/addendum and benefit booklet that are incorporated in this contract. BLUR 119G.COC 1 6. Benefit booklet.The definitions and other terms of the benefit booklet are incorporated herein by reference. 7. Group administrator. The employer will designate a person as the principal contact for all matters pertaining to HMO Colorado group coverage. That person will assist employees in the administration and payment of claims. It is understood that HMO Colorado is not the "administrator" within the meaning of the Employee Retirement Income Security Act (ERISA). 8. Assignment. None of the rights, benefits, duties, or obligations of the employer shall be assigned without the prior written consent of a duly authorized officer of HMO Colorado. Any attempted assignment will be void. 9. Contract provision changes. a. This contract, the benefit booklet and any amendments thereto, and the group application/addendum constitute the entire agreement between the parties hereto and supersede all other contracts, either oral or in writing, between the parties with respect to the subject matter hereof. No course of action, usage or custom or internal policy of HMO Colorado may amend or become a part of this contract. Except as provided in paragraphs b. and c. immediately below, no change or modification to this contract shall be valid unless the same is in writing and signed by the parties hereto. b. During the initial annual term or any renewal annual term of the contract, the provisions of this contract may be amended at any time by an endorsement signed only by a duly authorized officer of HMO Colorado. When the endorsement has been so signed, the endorsement shall be deemed a part of the contract, effective as of the date specified by the endorsement. c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by the Commissioner of Insurance of the State of Colorado may be made at any time by endorsement to the contract signed only by a duly authorized officer of HMO Colorado and shall become effective as of the effective date of such law, regulation, ruling, or approval. 10. Notices. All notices to HMO Colorado shall be sent by United States mail or personal delivery to HMO Colorado, 700 Broadway, Denver, CO 80203-3441. All notices to employees or the employer shall be sent by United States mail to the last address appearing in the records of HMO Colorado or by personal delivery to the office of the employer. The employer shall notify members in the event that this contract is terminated within ten (10) days of the date that the employer has notice that this contract is to be or has been terminated, whichever occurs first. If the employer has engaged the services of a broker/consultant, then delivery of all notices to the named broker/consultant meets the requirements of this contract. Notice shall be effective upon mailing. Notice mailed to the employer or broker/consultant shall be deemed effective notice to each employee. However, the employer agrees to post each notice promptly in a place reasonably calculated to facilitate the employees' reading of the notice. The employer agrees to hold us harmless for its failure to provide notice to the employees of any contract provision changes or termination. 11. Governing Laws. This contract is made and delivered in the State of Colorado, and will be interpreted and enforced so as to remain in compliance with Colorado statutes and regulations. Nothing contained herein shall be interpreted to mean that HMO Colorado is doing business in any other state of jurisdiction. Any legal action against us must be brought in the City and County of Denver, Colorado. 2 - BLUH119G.COC SECTION lll. PREMIUM: CHANGES, PAYMENT, TERMINATION FOR NON-PAYMENT, REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 1. Changes. From January 1, 1999 thorough December 31, 1999 premium are guaranteed. HMO Colorado reserves the right to review monthly premium whenever a group, section, or classification of employees is added to or deleted from enrollment under the contract. The employer shall notify HMO Colorado no later than 30 days prior to the effective date of such addition or deletion, and any change in monthly premium which may be required as the result of an increased or decreased total group enrollment will become effective on the same date as such addition to or deletion from total enrollment under the contract. This provision shall apply regardless of the employer's normal rate review date or any other advance rate notification agreement which may be in effect between HMO Colorado and the employer. 2. Payment. Initial premium shall become payable on or before the effective date of the contract. Subsequent premium shall be payable on or before the first of each month thereafter. Eligibility of members, claims processing, and payment will be suspended if premium is not timely paid. In no event shall coverage under the contract become effective until we accept the application/addendum and payment of the initial premium is received by HMO Colorado. 3. Termination for non-payment. The contract shall terminate by its own terms if premium is not paid on or before 30 days after the first day of the month, and no notice of cancellation other than this provision shall be required. However,we may by sending notice thereof terminate this contract before 30 days after the first day of the month if premium is not paid on or before the first day of the month. When the contract is terminated or cancelled, the effective date of such cancellation or termination shall be the date to which membership premium was last paid. Members shall no longer be eligible to receive covered health services and all claims shall be refused when dates of service are beyond the last day of the month for which payment has been received. Claims that we deny because the employer fails to submit premium payments in a timely manner should be submitted for payment to, and may be the responsibility of, the employer. 4. Refund of membership premium. a. If the employer terminates the coverage of a member or terminates this contract for any reason, a refund of membership premium paid beyond the first of the month following the termination date will be granted only if written notification of termination is received by HMO Colorado at least 30 days before the termination date, covered health services have not been provided and benefit payments have not been made for services rendered subsequent to the termination date. If notification of termination is received less than 30 days before the termination date, no refund of membership premium will be made and coverage shall cease on the first of the month following the termination date. 4 BLUH119G.coc • 12. Attorneys' fees and expenses. a. Should it become necessary for either party to this contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless HMO Colorado from its costs including losses, claims,settlements,judgments,or fees,including attorneys'fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the employer's obligation to indemnify us shall apply only to costs incurred after this contract has been cancelled or terminated. 13. Enforcement of the contract. Failure of HMO Colorado or the employer to enforce any of the provisions of this contract shall not constitute a waiver of rights for that or subsequent breaches. 14. Interpretation of the contract. This contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this contract and sound principles of contract interpretation. 15. Termination of the contract. HMO Colorado may terminate the contract at any time during its term for(i)employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements, as provided in the application/addendum, or (iv) misrepresentation of material facts or any other breach of the contract. 16. Reinstatement of contract.HMO Colorado,at its sole option,may reinstate this contract after it has been terminated. We may impose such conditions on the contract's reinstatement as we deem appropriate,including,without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of HMO Colorado. BLUH 1190 COC 3 • negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility. All Employees, who have a regular work week as indicted on the application and addendum, paid for such employment by the employer, and listed as an Employee on the Employer's State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to enroll for membership under the Contract. We may inspect such records, public and private, as are necessary to verify employment. 2. Receipt of Applications. Applications for Employees' coverage must be received by us within 30 days of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later. If the application is not received within this time period, the Employee is subject to current underwriting, state or federal law for provisions for late enrolles. 3. Notification of Cessation of Membership. Employer shall advise us when Employer has notice that a Member is no longer employed by Employer or otherwise does not satisfy membership requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member ceases to be employed by Employer or otherwise ceases to meet membership requirements. Employer agrees that no person will be kept on Employer's payroll or otherwise be represented as an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder. The Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred,including attorneys'fees,in the defense of any claim or suit brought at any time by a person ineligible for coverage. Weld County Goverment BLUE CROSS AND BLUE SHIELD (Group Name) OF COLORADO By By C. David Kikumoto Printed or Typed Name Printed or Typed Name (Title) (Title) Chief Executive Officer (Date) (Date) January 25, 1999 acassac.coc 5 ENDORSEMENT NO.: 1 TO GROUP MASTER CONTRACT NO.: 99-00772001 The Contract identified above is hereby amended by this endorsement which is issued to form part of the Contract with the Employer. Effective January 1, 1999, this Contract is amended to incorporate benefit booklet no. 97000 (Rev. 6-97) for BlueAduantage HMO Plan, and any amendment(s) listed below: Amendment No. Title 96679 (11-97) Amendment for BlueAdvantage HMO Plan Benefit Booklet BLUPCS.AMC Amendment for BlueAdvantage HMO Plan Benefit Booklet for Prescription Drugs BLU122G.AMC Amendment to BlueAdvantage HMO Plan Benefit Booklet for routine eye exam HMO COLORADO By 417 >1'62(4 (Title) President Date January 26, 1999 BLO003M.ENC ENDORSEMENT NO.: 2 TO GROUP MASTER CONTRACT NO.: 99-00772001 The Contract identified above is hereby amended by this endorsement which is issued to form part of the Contract with the Employer. Effective January 1, 1999, this Contract is amended to incorporate benefit booklet no. 97000 (Rev. 6-97) for the BlueAdvantage HMO Plan, the BlueAdvantage Point-of-Service Rider no. 96055 (Rev. 6-97), and any amendment(s) listed below: Amendment No. Title 96679 (11-97) Amendment for BlueAdvantage HMO Plan Benefit Booklet 96680 (11-97) Amendment for BlueAdvantage Point-of-Service Rider BLUPCS.AMC Amendment for BlueAdvantage HMO Plan Benefit Booklet for Prescription Drugs BLU122G.AMC Amendment to BlueAdvantage HMO Plan Benefit Booklet for routine eye exam HMO COLORADO By 41/- at6ia (Title) President Date January 26, 1999 BLUP006M.ENC A Group Health Care Program Group Master Contract Blue Cross pQ0 S Blue SlieId eceeree An Independent Licensee of the Blue Cross and Blue Shield Association THE BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract Effective Date 1 Anniversary Date 1 Annual Renewal Date 1 Employee 1 Employer 1 Remitting Agent 1 Remittance 1 Membership Certificate Terms 1 Group Administrator 2 Assignment 2 Contract Provision Changes 2 Reserve Funds 2 Notices 2 Governing Laws 2 Attorneys' Fees and Expenses 3 Warranties and Representations 3 Enforcement of the Contract 3 Interpretation of the Contract 3 BlueCard Program. 3 Termination of Contract 3 SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 4 Changes 4 Payment 4 Service Date 4 Termination for Non-Payment 4 Retroactive Refund of Membership Premium 4 Cashing of Check Not Acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Receipt of Applications 5 Notification of Cessation of Membership 5 BCBnGCa i BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT NO. 99-00772000 For Weld County Government Employer C07720 Group Number SECTION I. APPLICATION-ACCEPTANCE The Application for Group Health Coverage ("Application") executed by the Employer has been accepted by Blue Cross and Blue Shield of Colorado (sometimes referred to as "we," "us," and "our"). Such Application and its contents are incorporated in this Group Master Contract ("Contract"). In the event of any inconsistency between the terms of the Application and the terms of the Contract, the terms of the Contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this Contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the Employer's Employees and their Dependents. Such persons, when covered hereunder, are referred to as "Members." 1. Contract Effective Date. The effective date of the Contract shall be 12:01 A.M. on the first day of January, 1999, at Denver, Colorado; the Contract shall continue to remain in effect through December 31, 1999. 2. Anniversary Date. The Anniversary Date is the effective date for (i) enrollment or coverage changes to the Employee's Membership or (ii) to group enrollment and benefit eligibility implemented by the Employer. 3. Annual Renewal Date. The date a group is due for rate modification through application of the appropriate renewal rating formulas. 4. Employee.An Employee as defined in the Application as eligible for enrollment; the Employee is the Subscriber, and Identification Cards for the Employee and his or her covered Dependents are issued in the name of the Employee as the Subscriber. 5. Employer. The Employer or organization with whom Blue Cross and Blue Shield of Colorado has contracted, and by reason of the Contract the Employees and their Dependents become eligible for the coverage and benefits described in the Contract. 6. Remitting Agent. The Employer agrees to (i) act as remitting agent for the enrolled Members, (ii)make payroll deductions for that part of premium not otherwise provided for, and (iii)remit all premiums to us not later than the due date for each remitting period. 7. Remittance. The Employer shall pay to us monthly, in advance, required premiums on behalf of all enrolled Employees and Dependents who meet the eligibility requirements specified in the Application. S. Membership Certificate Terms. The definitions and other terms of the Membership Certificate are incorporated herein by reference. a" "« 1 9. Group Administrator. The Employer will designate a person as the principal contact for all matters pertaining to Blue Cross and Blue Shield of Colorado group coverage. That person will assist Employees in the administration and payment of claims. It is understood that Blue Cross and Blue Shield of Colorado is not the "administrator" within the meaning of the Employee Retirement Income Security Act (ERISA). 10. Assignment. None of the rights, benefits, duties, or obligations of the Employer may be assigned without the prior written consent of a duly authorized officer of Blue Cross and Blue Shield of Colorado. Any attempted assignment will be void. 11. Contract Provision Changes. a. This Contract constitutes the entire agreement between the parties hereto and supersedes all other contracts, either oral or in writing, between the parties with respect to the subject matter hereof. No course of action, usage or custom or internal policy of Blue Cross and Blue Shield of Colorado may amend or become a part of this Contract. Except as provided in paragraphs b. and c. immediately below, no change or modification to this Contract shall be valid unless the same is in writing and signed by the parties hereto. b. During the initial annual term or any renewal annual term of the Contract, the provisions of this Contract may be amended at any time by an endorsement signed only by a duly authorized officer of Blue Cross and Blue Shield of Colorado. When the endorsement has been so signed, the endorsement shall be deemed a part of the Contract, effective as of the date specified by the endorsement. c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by the Commissioner of Insurance of the State of Colorado may be made at any time by endorsement to the Contract signed only by a duly authorized officer of Blue Cross and Blue Shield of Colorado and shall become effective as of the effective date of such law, regulation, ruling, or approval. 12. Reserve Funds. Neither any Member nor the Employer shall be entitled to share in any reserve or other funds that may be accumulated or otherwise owned by Blue Cross and Blue Shield of Colorado, unless and until a right to share in such funds is granted in writing by the Board of Directors of Blue Cross and Blue Shield of Colorado. 13. Notices. All notices to Blue Cross and Blue Shield of Colorado shall be sent by United States mail or personal delivery to Blue Cross and Blue Shield of Colorado, 700 Broadway, Denver, CO 80273. All notices to Employees or the Employer shall be sent by United States mail to the last address appearing in the records of Blue Cross and Blue Shield of Colorado or by personal delivery to the office of the Employer. The Employer shall notify Members in the event that this Contract is terminated within ten (10) days of the date that the Employer has notice that this Contract is to be or has been terminated, whichever occurs first. If the Employer has engaged the services of a broker/consultant, then delivery of all notices to the named broker/consultant meets the requirements of this Contract. Notice shall be effective upon mailing. Notice mailed to the Employer or broker/consultant shall be deemed effective notice to each Employee. However, the Employer agrees to post each notice promptly in a place reasonably calculated to facilitate the Employees' reading of the notice. 14. Governing Laws. This Contract is made and delivered in the State of Colorado, and will be interpreted and enforced so as to remain in compliance with Colorado statutes and regulations. Nothing contained herein shall be interpreted to mean that Blue Cross and Blue Shield of Colorado is doing business in any other state or jurisdiction. Any legal action against us must be brought in the City and County of Denver, Colorado. Should any provision of this Contract in any way contravene the laws of Colorado or the United States of America, such provision shall not be deemed a part of the Contract. However, the Contract shall be otherwise enforceable. BC593122000C 2 • 15. Attorneys' Fees and Expenses. a. Should it become necessary for either party to this Contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the Contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless Blue Cross and Blue Shield of Colorado from its costs including losses, claims, settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this Contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the Employer's obligation to indemnify us shall apply only to costs incurred after this Contract has been cancelled or terminated. 16. Warranties and Representations. The Employer acknowledges that no warranties or representations other than those contained in this Contract have been made or given by Blue Cross and Blue Shield of Colorado or its representatives or, if so given, have not been relied upon by the Employer. 17. Enforcement of the Contract. Failure of Blue Cross and Blue Shield of Colorado or the Employer to enforce any of the provisions of this Contract shall not constitute a waiver of rights for that or subsequent breaches. 18. Interpretation of the Contract. This Contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this Contract and sound principles of contract interpretation. 19. BlueCard Program. The calculation of subscriber liability for covered services for claims incurred outside the geographic area Blue Cross and Blue Shield of Colorado serves and processed through the BlueCard Program typically will be at the lower of the provider's billed • charges or the negotiated rate Blue Cross and Blue Shield of Colorado pays the on-site Blue Cross and/or Blue Shield Plan. The negotiated rate paid by Blue Cross and Blue Shield of Colorado to the on-site Blue Cross and/or Blue Shield Plan for health care services provided through the BlueCard Program may represent either (i) the actual price paid on the claim, or (ii) an estimated price that reflects adjusted aggregate payments expected to result from settlements or other non-claims transactions with all of the on-site Plan's health care providers or one or more particular providers, or(iii)a discount from billed charges representing the on-site Plan's expected average savings for all of its providers or for a specified group of providers. Plans using either the estimated price or average savings factor methods may prospectively adjust the estimated or average price to correct for over-or underestimation of past prices. In addition, statutes require Blue Cross and/or Blue Shield Plans in a small number of states to use a basis for calculating member/subscriber liability for covered services that does not reflect the entire savings realized or expected to be realized on a particular claim. Thus, when your covered employees/subscribers receive covered services in these states, their subscriber liability for covered services will be calculated using these states' statutory methods. 20. Termination of Contract. a. Blue Cross and Blue Shield of Colorado may terminate the Contract at any time during its term for (i) Employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements, as provided in the Application, or (iv) — misrepresentation of material facts or any other breach of the Contract. eaamac coc 3 b. Blue Cross and Blue Shield of Colorado, at its sole option, may reinstate this Contract after it has been terminated. We may impose such conditions on the Contract's reinstatement as we deem appropriate, including, without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of Blue Cross and Blue Shield of Colorado. SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 1. Changes. From January 1, 1999 through December 31, 1999, premiums are guaranteed. Blue Cross and Blue Shield of Colorado reserves the right to review monthly premium whenever a group, section, or classification of Employees is added to or deleted from enrollment under the Contract. The Employer shall notify Blue Cross and Blue Shield of Colorado no later than 30 days prior to the effective date of such addition or deletion, and any change in monthly premium which may be required as the result of an increased or decreased total group enrollment will become effective on the same date as such addition to or deletion from total enrollment under the Contract. This provision shall apply regardless of the Employer's normal rate review date or any other advance rate notification agreement which may be in effect between Blue Cross and Blue Shield of Colorado and the Employer. 2. Payment. Initial premium shall become payable on or before the effective date of the Contract. Subsequent premiums shall be payable on or before the established Service Date of each month thereafter. Claims processing and payment will be suspended if premium is not timely paid. In no event shall coverage under the Contract become effective until we accept the Application and payment of the initial premium is received by Blue Cross and Blue Shield of Colorado. 3. Service Date. The Service Date is the 1st or 16th day of the month as established for the group for billing purposes (the "due date"). 4. Termination for Non-Payment. The Contract shall terminate by its own terms if premium is not paid on or before 30 days after the Service Date, and no notice of cancellation other than this provision shall be required. However, we may by sending notice thereof terminate this Contract before 30 days after the Service Date if premium is not paid on or before the Service Date. When the Contract is terminated or cancelled, the effective date of such cancellation or termination shall be the date to which membership premium was last paid. All claims shall be refused when dates of service are beyond the last "paid-to-date" of coverage according to the records of Blue Cross and Blue Shield of Colorado. 5. Retroactive Refund of Membership Premium. a. A retroactive refund of membership premium paid beyond the date of termination will be granted if written notification is received by Blue Cross and Blue Shield of Colorado at least one month before the termination date and benefit payments have not been made on behalf of a Member's claim for services rendered subsequent to the termination date. b. If notification is received less than one month before the termination date, no refund of membership premium will be made. Failure to comply with this provision shall negate any claim by, or on behalf of, the Employer or the Member for a retroactive refund of membership premium. 6. Cashing of Check Not Acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such BCBS922CCa 4 negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility. All Employees, who have a regular work week as indicted on the application and addendum, paid for such employment by the employer, and listed as an Employee on the Employer's State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to enroll for membership under the Contract. We may inspect such records, public and private, as are necessary to verify employment. 2. Receipt of Applications. Applications for Employees' coverage must be received by us within 30 days of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later. If the application is not received within this time period, the Employee is subject to current underwriting, state or federal law for provisions for late enrolles. 3. Notification of Cessation of Membership. Employer shall advise us when Employer has notice that a Member is no longer employed by Employer or otherwise does not satisfy membership requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member ceases to be employed by Employer or otherwise ceases to meet membership requirements. Employer agrees that no person will be kept on Employer's payroll or otherwise be represented as an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder. The Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred,including attorneys'fees, in the defense of any claim or suit brow time by a person ineligible for coverage. Weld County Goverment BLUE CROSS AND BLUE SHI (Group Name) OF COLORADO By By C. David Kikumoto Printed or Typed Name Printed or Typed Name (Title) (Title) Chief Executive Officer (Date) (Date) January 25, 1999 BCBnG C« 5 ENDORSEMENT NO.: 1 TO GROUP MASTER CONTRACT NO.: 99-00772000 The Contract identified above is hereby amended by this endorsement which is issued to form part of the Contract with the Employer. Effective January 1, 1999, this Contract is amended to incorporate Membership Certificate No. 95297 (Rev. 6-97) for Custom Plus coverage, and any amendment(s) as listed below: Amendment No. Title 96674 (11-97) Amendment for Custom Plus Coverage WEDLDEV.AMC Dependent to age 25 PCS3TIER.AMC Prescription Drug Program BLUE CROSS AND BLUE SHIELD OF COLORADO By \/u d_f_ (Title) Chief Executive Officer Date January 26, 1999 FORM NO. 94987 BCBS44M.END A Group Health Care Program Group Master Contract • S s Cross 631 OQ � atoaraeo ® e An Independent Licensee of the Blue Cross and Blue Shield Association THE BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract Effective Date 1 Anniversary Date 1 Annual Renewal Date 1 Employee 1 Employer 1 Remitting Agent 1 Remittance 1 Membership Certificate Terms 1 Group Administrator 2 Assignment 2 Contract Provision Changes 2 Reserve Funds 2 Notices 2 Governing Laws 2 Attorneys' Fees and Expenses 3 Warranties and Representations 3 Enforcement of the Contract 3 Interpretation of the Contract 3 BlueCard Program. 3 Termination of Contract 3 SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 4 Changes 4 Payment 4 Service Date 4 Termination for Non-Payment 4 Retroactive Refund of Membership Premium 4 Cashing of Check Not Acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Receipt of Applications 5 Notification of Cessation of Membership 5 BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT NO. 99-00772000 For Weld County Government Employer C07720 Group Number SECTION I. APPLICATION ACCEPTANCE The Application for Group Health Coverage ("Application") executed by the Employer has been accepted by Blue Cross and Blue Shield of Colorado (sometimes referred to as "we," "us," and "our"). Such Application and its contents are incorporated in this Group Master Contract ("Contract"). In the event of any inconsistency between the terms of the Application and the terms of the Contract, the terms of the Contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this Contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the Employer's Employees and their Dependents. Such persons, when covered hereunder, are referred to as "Members." 1. Contract Effective Date. The effective date of the Contract shall be 12:01 A.M. on the first day of January, 1999, at Denver, Colorado; the Contract shall continue to remain in effect through December 31, 1999. 2. Anniversary Date. The Anniversary Date is the effective date for (i) enrollment or coverage changes to the Employee's Membership or (ii) to group enrollment and benefit eligibility implemented by the Employer. 3. Annual Renewal Date. The date a group is due for rate modification through application of the appropriate renewal rating formulas. 4. Employee.An Employee as defined in the Application as eligible for enrollment; the Employee is the Subscriber, and Identification Cards for the Employee and his or her covered Dependents are issued in the name of the Employee as the Subscriber. 5. Employer. The Employer or organization with whom Blue Cross and Blue Shield of Colorado has contracted, and by reason of the Contract the Employees and their Dependents become eligible for the coverage and benefits described in the Contract. 6. Remitting Agent. The Employer agrees to (i) act as remitting agent for the enrolled Members, (ii)make payroll deductions for that part of premium not otherwise provided for, and (iii) remit all premiums to us not later than the due date for each remitting period. 7. Remittance. The Employer shall pay to us monthly, in advance, required premiums on behalf of all enrolled Employees and Dependents who meet the eligibility requirements specified in the Application. 8. Membership Certificate Terms. The definitions and other terms of the Membership Certificate are incorporated herein by reference. 8C0S29C"« 1 9. Group Administrator. The Employer will designate a person as the principal contact for all matters pertaining to Blue Cross and Blue Shield of Colorado group coverage. That person will assist Employees in the administration and payment of claims. It is understood that Blue Cross and Blue Shield of Colorado is not the "administrator" within the meaning of the Employee Retirement Income Security Act (ERISA). 10. Assignment. None of the rights, benefits, duties, or obligations of the Employer may be assigned without the prior written consent of a duly authorized officer of Blue Cross and Blue Shield of Colorado. Any attempted assignment will be void. 11. Contract Provision Changes. a. This Contract constitutes the entire agreement between the parties hereto and supersedes all other contracts, either oral or in writing, between the parties with respect to the subject matter hereof. No course of action, usage or custom or internal policy of Blue Cross and Blue Shield of Colorado may amend or become a part of this Contract. Except as provided in paragraphs b. and c. immediately below, no change or modification to this Contract shall be valid unless the same is in writing and signed by the parties hereto. b. During the initial annual term or any renewal annual term of the Contract, the provisions of this Contract may be amended at any time by an endorsement signed only by a duly authorized officer of Blue Cross and Blue Shield of Colorado. When the endorsement has been so signed, the endorsement shall be deemed a part of the Contract, effective as of the date specified by the endorsement. c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by the Commissioner of Insurance of the State of Colorado may be made at any time by endorsement to the Contract signed only by a duly authorized officer of Blue Cross and Blue Shield of Colorado and shall become effective as of the effective date of such law, regulation, ruling, or approval. 12. Reserve Funds. Neither any Member nor the Employer shall be entitled to share in any reserve or other funds that may be accumulated or otherwise owned by Blue Cross and Blue Shield of Colorado, unless and until a right to share in such funds is granted in writing by the Board of Directors of Blue Cross and Blue Shield of Colorado. 13. Notices. All notices to Blue Cross and Blue Shield of Colorado shall be sent by United States mail or personal delivery to Blue Cross and Blue Shield of Colorado, 700 Broadway, Denver, CO 80273. All notices to Employees or the Employer shall be sent by United States mail to the last address appearing in the records of Blue Cross and Blue Shield of Colorado or by personal delivery to the office of the Employer. The Employer shall notify Members in the event that this Contract is terminated within ten (10) days of the date that the Employer has notice that this Contract is to be or has been terminated, whichever occurs first. If the Employer has engaged the services of a broker/consultant, then delivery of all notices to the named broker/consultant meets the requirements of this Contract. Notice shall be effective upon mailing. Notice mailed to the Employer or broker/consultant shall be deemed effective notice to each Employee. However, the Employer agrees to post each notice promptly in a place reasonably calculated to facilitate the Employees' reading of the notice. 14. Governing Laws. This Contract is made and delivered in the State of Colorado, and will be interpreted and enforced so as to remain in compliance with Colorado statutes and regulations. Nothing contained herein shall be interpreted to mean that Blue Cross and Blue Shield of Colorado is doing business in any other state or jurisdiction. Any legal action against us must be brought in the City and County of Denver, Colorado. Should any provision of this Contract in any way contravene the laws of Colorado or the United States of America, such provision shall not be deemed a part of the Contract. However, the Contract shall be otherwise enforceable. ,,.�"« 2 15. Attorneys' Fees and Expenses. a. Should it become necessary for either party to this Contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the Contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless Blue Cross and Blue Shield of Colorado from its costs including losses, claims, settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this Contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the Employer's obligation to indemnify us shall apply only to costs incurred after this Contract has been cancelled or terminated. 16. Warranties and Representations. The Employer acknowledges that no warranties or representations other than those contained in this Contract have been made or given by Blue Cross and Blue Shield of Colorado or its representatives or, if so given, have not been relied upon by the Employer. 17. Enforcement of the Contract. Failure of Blue Cross and Blue Shield of Colorado or the Employer to enforce any of the provisions of this Contract shall not constitute a waiver of rights for that or subsequent breaches. 18. Interpretation of the Contract. This Contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this Contract and sound principles of contract interpretation. 19. BlueCard Program. The calculation of subscriber liability for covered services for claims incurred outside the geographic area Blue Cross and Blue Shield of Colorado serves and processed through the BlueCard Program typically will be at the lower of the provider's billed charges or the negotiated rate Blue Cross and Blue Shield of Colorado pays the on-site Blue Cross and/or Blue Shield Plan. The negotiated rate paid by Blue Cross and Blue Shield of Colorado to the on-site Blue Cross and/or Blue Shield Plan for health care services provided through the BlueCard Program may represent either (i) the actual price paid on the claim, or (ii) an estimated price that reflects adjusted aggregate payments expected to result from settlements or other non-claims transactions with all of the on-site Plan's health care providers or one or more particular providers, or(iii) a discount from billed charges representing the on-site Plan's expected average savings for all of its providers or for a specified group of providers. Plans using either the estimated price or average savings factor methods may prospectively adjust the estimated or average price to correct for over-or underestimation of past prices. In addition, statutes require Blue Cross and/or Blue Shield Plans in a small number of states to use a basis for calculating member/subscriber liability for covered services that does not reflect the entire savings realized or expected to be realized on a particular claim. Thus, when your covered employees/subscribers receive covered services in these states, their subscriber liability for covered services will be calculated using these states' statutory methods. 20. Termination of Contract. a. Blue Cross and Blue Shield of Colorado may terminate the Contract at any time during its term for (i) Employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements, as provided in the Application, or (iv) misrepresentation of material facts or any other breach of the Contract. ecsSIt2GCOC 3 b. Blue Cross and Blue Shield of Colorado, at its sole option, may reinstate this Contract after it has been terminated. We may impose such conditions on the Contract's reinstatement as we deem appropriate, including, without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of Blue Cross and Blue Shield of Colorado. SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 1. Changes. From January 1, 1999 through December 31, 1999, premiums are guaranteed. Blue Cross and Blue Shield of Colorado reserves the right to review monthly premium whenever a group, section, or classification of Employees is added to or deleted from enrollment under the Contract. The Employer shall notify Blue Cross and Blue Shield of Colorado no later than 30 days prior to the effective date of such addition or deletion, and any change in monthly premium which may be required as the result of an increased or decreased total group enrollment will become effective on the same date as such addition to or deletion from total enrollment under the Contract. This provision shall apply regardless of the Employer's normal rate review date or any other advance rate notification agreement which may be in effect between Blue Cross and Blue Shield of Colorado and the Employer. 2. Payment. Initial premium shall become payable on or before the effective date of the Contract. Subsequent premiums shall be payable on or before the established Service Date of each month thereafter. Claims processing and payment will be suspended if premium is not timely paid. In no event shall coverage under the Contract become effective until we accept the Application and payment of the initial premium is received by Blue Cross and Blue Shield of Colorado. 3. Service Date.The Service Date is the 1st or 16th day of the month as established for the group for billing purposes (the "due date"). 4. Termination for Non-Payment. The Contract shall terminate by its own terms if premium is not paid on or before 30 days after the Service Date, and no notice of cancellation other than this provision shall be required. However, we may by sending notice thereof terminate this Contract before 30 days after the Service Date if premium is not paid on or before the Service Date. When the Contract is terminated or cancelled, the effective date of such cancellation or termination shall be the date to which membership premium was last paid. All claims shall be refused when dates of service are beyond the last "paid-to-date" of coverage according to the records of Blue Cross and Blue Shield of Colorado. 5. Retroactive Refund of Membership Premium. a. A retroactive refund of membership premium paid beyond the date of termination will be granted if written notification is received by Blue Cross and Blue Shield of Colorado at least one month before the termination date and benefit payments have not been made on behalf of a Member's claim for services rendered subsequent to the termination date. b. If notification is received less than one month before the termination date, no refund of membership premium will be made. Failure to comply with this provision shall negate any claim by, or on behalf of, the Employer or the Member for a retroactive refund of membership premium. 6. Cashing of Check Not Acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such . asa 4 negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility. All Employees, who have a regular work week as indicted on the application and addendum, paid for such employment by the employer, and listed as an Employee on the Employer's State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to enroll for membership under the Contract. We may inspect such records, public and private, as are necessary to verify employment. 2. Receipt of Applications. Applications for Employees' coverage must be received by us within 30 days of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later. If the application is not received within this time period, the Employee is subject to current underwriting, state or federal law for provisions for late enrolles. 3. Notification of Cessation of Membership. Employer shall advise us when Employer has notice that a Member is no longer employed by Employer or otherwise does not satisfy membership requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member ceases to be employed by Employer or otherwise ceases to meet membership requirements. Employer agrees that no person will be kept on Employer's payroll or otherwise be represented as an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder. The Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred,including attorneys'fees,in the defense of any claim or suit brow time by a person ineligible for coverage. Weld County Goverment BLUE CROSS AND BLUE SHI (Group Name) OF COLORADO By By rfr— C. David Kikumoto Printed or Typed Name Printed or Typed Name (Title) (Title) Chief Executive Officer (Date) (Date) January 25, 1999 B0159720 COC 5 ENDORSEMENT NO.: 1 TO GROUP MASTER CONTRACT NO.: 99-00772000 The Contract identified above is hereby amended by this endorsement which is issued to form part of the Contract with the Employer. Effective January 1, 1999, this Contract is amended to incorporate Membership Certificate No. 95297 (Rev. 6-97) for Custom Plus coverage, and any amendment(s) as listed below: Amendment No. Title 96674 (11-97) Amendment for Custom Plus Coverage WEDLDEV.AMC Dependent to age 25 PCS3TIER.AMC Prescription Drug Program BLUE CROSS AND BLUE SHIELD OF COLORADO By a4P �2L& (Title) Chief Executive Officer Date January 26, 1999 FORM NO. 94987 BCBS44M.END Hello