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HomeMy WebLinkAbout25527AGREEMENT INFORMATION AGREEMENT NUMBER 25527 NAME/TYPE OF AGREEMENT CIGNA HEALTH & LIFE INSURANCE COMPANY DESCRIPTION 4TH AMENDMENT TO & ASSIGNMENT OF EMPLOYER/UNION GROUP PDP AGREEMENT/MEDICARE PART D PRESCRIPTION DRUG PLAN EFFECTIVE DATE January 1, 2025 ATTESTED BY TODD B. HANNON ATTESTED DATE 3/21/2025 DATE RECEIVED FROM ISSUING DEPT. 3/27/2025 NOTE DOCUSIGN AGREEMENT BY EMAIL CITY OF MIAMI DOCUMENT ROUTING FORM ORIGINATING DEPARTMENT: Risk Management DEPT. CONTACT PERSON: Ann -Marie Sharpe EXT. 1381 NAME OF CONTRACTUAL PARTY/ENTITY: IS THIS AGREEMENT TO BE EXPEDITED/RUSH TOTAL CONTRACT AMOUNT: $ TYPE OF AGREEMENT: ❑ MANAGEMENT AGREEMENT ® PROFESSIONAL SERVICES AGREEMENT ❑ GRANT AGREEMENT ❑ EXPERT CONSULTANT AGREEMENT ❑ LICENSE AGREEMENT OTHER: (PLEASE SPECIFY: ® YES ONO FUNDING INVOLVED? OYES ONO ❑ PUBLIC WORKS AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ INTER -LOCAL AGREEMENT ❑ LEASE AGREEMENT ❑ PURCHASE OR SALE AGREEMENT PURPOSE OF ITEM (DETAILED SUMMARY/ADD ADDITIONAL PAGES IF NECESSARY) Renewal of contract amendment required by CMS compliance for additional services being administered by Cigna. COMMISSION APPROVAL DATE: / / FILE ID: ENACTMENT NO: IF THIS DOES NOT REQUIRE COMMISSION APPROVAL, PLEASE EXPLAIN: Services are apart of an awarded contract. ROUTING INFORMATION Date PLEASE PRINT AND SIGN APPROVAL BY DEPARTMENTAL DIRECTOR March 17, 2025 PRINT: ANN-MARIE SHARPE 1 16:49:21 EDT �ooasa..a er: SIGNATURE: Q,,,,L,,_it, Sluup� SUBMITTED TO RISK MANAGEMENT March 17, 2025 PRINT: ANN-MARIE SHARPE 116:49:21og.STr_ „ SIGNATURE: Qt,.ti,-114.4 t, S vp� SUBMITTED TO CITY ATTORNEY March 19, 2025 �, Aa9 , essa49 PRINT: GEORGE K. WYSONG III 1 14:51:26 EDT SIGNATURE: Catty� `m9$64fri APPROVAL BY ASSISTANT CITY MANAGER March 20, 2025 PRINT: LARRY SPRING 1 12:43:26 EDT ,—ooc.S,s..de.: SIGNATURE (Atin SPyi4 APPROVAL BY DEPUTY CITY MANAGER PRINT: NATAS-PireQLEBROOK-WILLIAMS SIGNATURE: RECEIVED BY CITY MANAGER March 20, PRINT: ART NORIEGA, V 2025 1 18:59:01EDT SIGNATURE: CNb" SUBMITTED TO THE CITY CLERK March 21, 2 1 PRINT: TODD B. HANNON 25 1 08:49:50 EDT s ae SIGNATURE: r---,_ PLEASE ATTACH THIS ROUTING FORM TO ALL DOCUMENTS THAT REQUIRE EXECUTION BY THE CITY MANAGER �110 4, OW Cigna healthcare FOURTH AMENDMENT TO AND ASSIGNMENT OF EMPLOYER/UNION GROUP PDP AGREEMENT This is an Amendment to the Employer/Union Group Prescription Drug Plan ("PDP") Agreement (hereinafter "Agreement") between Cigna Health and Life Insurance Company ("CHLIC") and City of Miami ("Group"). This amendment is effective from January 1, 2025 through December 31, 2025. NOW THEREFORE, the parties hereby agree as follows: 1. Medco Containment Life Insurance Company ("Medco") is hereby identified as a CHLIC affiliate which has contracted with the Centers for Medicare and Medicaid Services ("CMS") to operate a Medicare Part D Prescription Drug Plan ("PDP") and offer employer/union only group PDP plans. 2. Group hereby consents to the assignment of the Agreement from CHLIC to Medco. 3. All references to "Cigna Health and Life Insurance Company" are hereby removed and replaced by "Medco Containment Life Insurance Company." 4. All references to "Cigna," "Cigna Healthcare," or "CHLIC" are hereby removed and replaced by "Medco." 5. Pursuant to Section 1, "Term." Medco and Group mutually agree to renew this Agreement. The Agreement is effective as of January 1, 2025 and shall continue in effect through December 31, 2025, unless sooner terminated in accordance with Section 2, Termination. 6. Other Prescription Drug Coverage/Other Health Insurance, Client acknowledges and agrees that to the extent that Client elects a plan benefit design that includes or incorporates other prescription drug coverage benefits, as that term is defined at 42 C.F.R. 423.464(f), such other prescription drug coverage benefits may be provided in certain states by an affiliated or unaffiliated insurer or health maintenance organization in conjunction with the Medicare Part D benefits that are offered by Medco in such states. 7 Exhibit A, 2024 Medicare Part D Prescription Drug Plan coverage description is hereby deleted in its entirety and replaced with the 2025 Exhibit A, attached hereto. 8. Exhibit B, Group Administrative Guidelines is hereby deleted in its entirety and replaced with the Exhibit B, attached hereto. Except as modified by this Amendment, all other terms and provisions of the Agreement shall continue in full force and effect. Please indicate your agreement to the amendment by signing below and returning the executed document to Medco. Alternatively, this amendment shall become effective on the effective date indicated unless Group notifies Medco either electronically or in writing within sixty (60) days of the date of receipt of this amendment that it does not accept all terms as herein modified, in which case Medco shall cooperate to negotiate mutually agreeable terms with Group. Once agreement with respect to the terms of this amendment is reached the amendment terms will apply retroactively to the effective date. The parties hereto have caused this Amendment to be executed in duplicate and signed by their respective officers duly authorized to do so. Medco Containment Life Insurance Company City of Miami r—DocuSigned by, By: �� By: [rflaw 461a 110/ Cigna healthcare Printed Name: Ryan Kocher Printed Name: Arthur Noriega Its: Medicare, Chief Growth Officer Its: City Manager Date: December 16, 2024 Date: March 20, 2025 I 18: 59:01 EDT ATTEST: rSigne by oa �s,a�ede.: B: Easo�seaoCF�asPrinted Name Hannon , Todd , oR. Its:_city Clerk n"+.March 21, 2025 1 08:49:50 EDT DS J�I • APPROVED AS TO LEGAL FORM AND CORRECTNESS: By: Ca.arT, (Uyw4 III nn„'aepd. tea_ George K Wysong III Printed Name: Its: City Attorney March 19, 2025 1 14:51:26 EDT Date: APPROVED AS TO INSURANCE REQUIREMENTS: By: [t,,n,-harit, SLIT, <eA<�,gnee�,y Printed Name: Ann -Marie Sharpe Its: Director, Risk Management Date: March 17, 2025 1 16:49:21 EDT _\$%i cigna healthcare Exhibit A Medicare Part D Prescription Drug Plan Coverage Description ar.. Cigna healthcare City of Miami- Cigna Healthcare Prescription Drug Plan SUMMARY OF BENEFITS Plan Type Effective Dates Cigna Healthcare Prescription Drug Plan January 1, 2025 - December 31, 2025 Pharmacy Premium Rate $262.42 Number of Medicare Beneficiaries 191 Funding Type Fully Insured Situs State FL Benefit Option Code RXPDP Rx Formulary Enhanced Pharmacy Network Medicare Broad Network Pharmacy Accumulation Period Benefit Description Deductible Phase Calendar Year What the Customer pays Individual Deductible $0 Individual Deductible Applies to Not Applicable Plan Out -of -Pocket Maximum Plan Out -of -Pocket Maximum $1,000 Initial Coverage Level Standard Retail Pharmacy (1-30 Day Supply) Tier 1 Tier 2 Tier 3 Tier 4 $15.00 $40.00 $60.00 $60.00 Standard Retail Pharmacy (31-60 Day Supply) Tier 1 Tier 2 Tier 3 Tier 4 $30.00 $80.00 $120.00 Not Available - Specialty drugs only available up to 30-day Standard Retail Pharmacy (61-90 Day Supply) Tier 1 Tier 2 Tier 3 Tier 4 $0.00 $80.00 $120.00 Not Available - Specialty drugs only available up to 30-day Long -Term Care (1-31 Day Supply) Tier 1 Tier 2 Tier 3 Tier 4 $15.00 $40.00 $60.00 $60.00 Standard Mail -Order Pharmacy (1-30 Day Supply) Tier 1 Tier 2 Tier 3 Tier 4 $15.00 $40.00 $60.00 $60.00 Standard Mail -Order Pharmacy(31-60 Day Supply) Tier 1 Tier 2 Tier 3 Tier4 $30.00 $80.00 $120.00 Not Available - Specialty drugs only available up to 30-day Standard Mail -Order Pharmacy (61-90 Day Supply) Tier 1 Tier 2 Tier 3 Tier 4 $0.00 $80.00 $120.00 Not Available - Specialty drugs only available up to 30-day Out -of -Network Coverage (1-30 Day Supply) Cost -sharing is the same as In -Network Standard Retail Pharmacy, and benefit is limited to a 30 Day Supply Catastrophic Coverage (Standard Part D Out -of -Pocket Maximum) $2,000 Generic Drugs Brand Drugs $0 $0 Clinical Management Step Therapy Prior Authorizations Quantity Limits Included Included Included Specialty Drugs Generic and Brand High Cost Specialty Drugs Limited to one month supply Opioids Opioids (all tiers)! Limited to one month supply Non -Part D Supplemental Coverage Fertility Drugs Prescription Vitamins Cold & Cough Preps Cold & Cough Preps including OTC Allergy Medicine Weight Loss/Weight Gain Erectile Dysfunction Courtesy & DESI Drugs Non -Sedating Antihistamines Cosmetic Drugs including Drugs for Hair Loss No Yes Yes No No Yes Yes No No 1 11/4/2024 Preventive Drugs at $0 Copay Adherence Package (Preventive Preferred Brand and Generic Drugs and Diabetic Drugs and Supplies) Preventive Generic Drugs Preventive Diabetic Drugs and Supplies PPACA Preventive Aspirin PPACA Preventive Breast Cancer Drugs PPACA Preventive Fluoride PPACA Preventive Folic Acid PPACA Preventive HIV Drugs PPACA Preventive Statins PPACA Smoking Cessation/Deterrent Medications Contraceptive Drugs and Supplies Yes No No No No No No No No No No State Mandated Benefits State Mandated Benefits Mail order equalization applies. Non -Standard Benefits Non -Standard Benefits! None City of Miami - Cigna Healthcare Prescription Drug Plan CAVEATS, EXCLUSIONS and DEFINITIONS The Employer Part D program does not integrate with medical plan deductibles, out-of-pocket maximums, or annual maximums. Only retirees and their dependents who are entitled to Medicare Part A and/or enrolled in Part B are included in this quote. If a retiree or dependent is not entitled to Medicare Part A and/or not enrolled in Part B, then they are not eligible to join this plan. Billing for this product is on a per member per month basis. Each enrollee will be set up on their own eligibility record and the employer group will be charged a single per Medicare member per month premium rate. Cigna Healthcare reserves the right to adjust the benefits and/or premiums in this proposal if such adjustments are necessary to comply with current Centers for Medicare & Medicaid Services (CMS) rules and regulations, and applicable pharmacy state mandates. Drug Exclusions: A Medicare Prescription Drug Plan can't cover a drug that would be covered under Medicare Part A or Part B. Also, while a Medicare Prescription Drug Plan can cover off -label uses (meaning for uses other than those indicated on a drug's label as approved by the Food and Drug Administration) of a prescription drug, we cover the off -label use only in cases where the use is supported by certain reference book citations. Congress specifically listed the reference books that list whether the off -label use would be permitted (these reference books are: (1) American Hospital Formulary Service Drug Information, (2) the DRUGDEX Information System). By law, certain types of drugs, or categories of drugs, are not covered by Medicare Prescription Drug Plans. These drugs are not considered Part D drugs and may be referred to as "exclusions" or "non -Part D drugs." These drugs include: • Non-prescription drugs (or over-the-counter drugs). • Drugs used for anorexia, weight loss, or weight gain. • Drugs when used to promote fertility. • Drugs when used for cosmetic purposes or hair growth. • Drugs when used for the symptomatic relief of cough and colds. • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. • Drugs, such as Viagra, Cialis, Levitra, and Caverject, when used for the treatment of sexual or erectile dysfunction. In addition, the following exclusions apply to any service that is a covered expense under this plan, but is not covered by Medicare: • Expenses for supplies, care, treatment, or surgery that are not medically necessary. • To the extent that payment is unlawful where the person resides when the expenses are incurred. • Charges which a customer is not obligated to pay or for which they are not billed or for which would not have been billed except that they were covered under this plan. 2 11/4/2024 Definitions Cigna Healthcare: For purposes of this agreement means Medco Containment Life Insurance Company. Day Supply Proration: Usually, the amount for a covered prescription drug is a one month supply. However, if the amount is less than a one month supply, then the amount paid is prorated based on the actual amount received. Proration may not apply in certain circumstances as outlined in CMS guidance. Typically proration applies to oral solid prescriptions. Retail example: Plan has a $10 copay for a 30 day supply. Actual day supply filled is 10 day supply. Copay is prorated as follows: $10 divided by 30 or $.3333 per day, rounded to $.33, times the day supply of 10, equals $3.30 copay owed by customer. Long -Term Care example: Plan has a $10 copay for a 31 day supply. Actual day supply filled is 10 day supply. Copay is prorated as follows: $10 divided by 31 or $.3226 per day, rounded to $.32, times the day supply of 10, equals $3.20 copay owed by customer. Employer Group Waiver Plans (EGWPs): EGWPs are a type of Medicare plan offered by employers to former employees and members of some companies, unions or government agencies. EGWPs are offered by insurers who contract with CMS to provide coverage for medical and/or prescription drug benefits. CMS grants certain program waivers and/or modifications for EGWP plans that do not apply to individual plans. Waivers enable EGWPs to provide customized benefits, tailored beneficiary educational materials, and more flexible enrollment procedures. Insulin Drug Products: Customers won't pay more than $35 for a one month supply of each insulin product covered by our plan no matter what cost -sharing tier it's on, even if they haven't paid the deductible. If the insulin is on a tier where cost -sharing is lower than $35, they will pay the lower cost Non -Part D Drugs: The following drug categories are excluded from CMS coverage. If a plan deductible applies, any non -Part D coverage added to the plan is not subject to the plan deductible. The cost share for these drugs is the same as the cost -shares in the initial coverage phase based on drug classification. • Cosmetic Drugs including Drugs for Hair Loss: drugs when used for cosmetic purposes or hair growth. • Courtesy Drugs: refers to drugs normally covered under commercial pharmacy plans but are excluded by CMS. • DESI (Drug Efficacy Study Implementation) Drugs: refers to drugs that were introduced between 1938-1962 and approved for safety but not effectiveness. DESI drugs are not "grandfathered" or generally recognized as safe and effective (GRAS/E). • Fertility Drugs - drugs used to promote fertility. • Prescription Vitamins - drugs used for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. • Cold & Cough Preps - drugs used for symptomatic relief of cough and colds. • Cold & Cough Preps including OTC Allergy Medicine - drugs used for symptomatic relief of cough and colds including OTC allergy medicine. • Non -Sedating Antihistamines - Antihistamine tablets designed to not make people drowsy. • Weight Loss/Weight Gain - drugs used for anorexia, weight loss, weight gain. • Erectile Dysfunction - drugs used for erectile dysfunction and female sexual dysfunction. Opioid Drugs: Customers who have received a recent fill of an opioid pain medication (not opioid naive) are limited to up to a month's supply of that medication at one time. Out -of -Network Coverage: Generally, we cover drugs filled at an out -of -network pharmacy only when the plan participant is not able to use a network pharmacy. Customers will most likely be required to pay the difference between what they pay for the drug at the out -of -network pharmacy and the cost that we would cover at an in -network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out -of -network pharmacy: • Customer travels outside the plan's service area and runs out of or loses covered Part D drugs, or becomes ill and needs a covered Part D drug and cannot access a network pharmacy. • Customers are unable to obtain a covered Part D drug in a timely manner within the service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24/7 service. • Customers are filling a prescription for a covered Part D drug and that particular drug is not regularly stocked at an accessible network Retail or Mail -Order pharmacy. • The Part D drugs are dispensed by an out -of -network institution -based pharmacy while in an emergency facility, provider -based clinic, outpatient surgery, or other outpatient setting. Part D Vaccines: Our plan covers most Part D vaccines at no cost, even when the deductible is not met Preferred Preventive Drugs at $0 Copay: Certain Generic and/or Brand Preventive Medications identified by Cigna Healthcare that are dispensed by a Retail or Mail -Order pharmacy are not subject to the deductible (if applicable), copay or coinsurance. Tier Labeling: Tier 1: Generic Drugs Tier 2: Preferred Brand Drugs Tier 3: Non -Preferred Drugs Tier4: Specialty Drugs All Medco products and services are provided exclusively by or through operating subsidiaries or affiliates of Medco, including Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York. The Medco name, logos, and marks are owned by Medco, or an affiliate of Medco. Medco contracts with Medicare to offer Part D Prescription Drug Plans (PDP) in select states. Enrollment in a Medco product depends on contract renewal. © 2024 Cigna Healthcare 3 11/4/2024 City of Miami - Cigna Healthcare Prescription Drug Plan Terms and Conditions A. General Terms of this Proposal Cigna Healthcare is pleased to present this Proposal for a Fully Insured group Cigna Rx Medicare (PDP) benefit plan. This proposal is valid for 90 days from its original date of release of 07/19/2024. Any revisions or updates made to this proposal will not renew this valid timeframe unless expressly communicated by Cigna Healthcare. The information contained in this Proposal by Cigna Healthcare is proprietary and highly confidential. It is being provided with the understanding that it will not be used by the employer, its representatives or consultants for any purpose other than the evaluation of the Proposal. Under no circumstances is any of information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used, disseminated, disclosed or otherwise the communicated to any person or entity other than the employer, its representatives and consultants, and their respective employees who are directly involved in the evaluation process. Proposal Caveats Cigna Healthcare may revise or withdraw this Proposal if: • there is a change to the effective date of the quote. • the policy period length is different than the quote. • the Plan benefits are different than shown in the RFP or benefit modifications are requested. • the policy will not be sitused in FL. • there is a change in law, regulation, tax rates, or the application of any of these that affects Cigna Healthcare's costs. • there are less than 50 retirees or less than 70% of total eligible individuals enroll in the Plan. • enrollment in the Plan at any time varies by 10% or more from the enrollment assumed by Cigna Healthcare in establishing the rates and/or fees set forth herein. • the employer changes its level of contribution toward the cost of the coverage. • the employer contributes toward the cost of purchasing individual coverage for an eligible individual. • Cigna Healthcare is not the exclusive provider of PDP benefits and the employer does not contribute the same percentage to the cost of each employer -sponsored plan unless expressly communicated by Cigna Healthcare. • the census data or experience data provided is deemed inaccurate. • there is a request to modify Commissions and/or benefit advisor fees • Cigna Healthcare is requested to interface with a third party vendor. • Cigna Healthcare is requested to provide optional services. • administration of the Plan will require more than the following: o Billing lines: 300 o Billing and Claim Branch Benefit Options: 60 4 11/4/2024 B. Scope and Application of this Proposal • Unless otherwise indicated, the coverage reflected in this proposal supersedes and renders null and void any prior Cigna Healthcare offer or proposal with respect to the Plan. • Although this proposal may include multiple plans/options for the employer sponsored plan, Cigna Healthcare reserves the right to limit the number of plans/options based on the offering environment and the total number of Medicare eligible individuals. Final plan selection requires approval by underwriting prior to implementation. • The information and materials provided for evaluation of this quote were assumed to be correct. If material errors or omissions are found after the quote is issued, Cigna Healthcare reserves the right to revise or rescind the quote. • Performance guarantees do not apply to this Medicare proposal. • This quote is on an incurred basis. Cigna Healthcare will be responsible for all eligible claims incurred on or after the effective date through the end of the contract period. • Group agrees to restrict enrollment in the Plan to those individuals eligible for Group's employment -based retiree group coverage who are eligible for Medicare. • This proposal assumes all eligible individuals are enrolled in Medicare Part A and/or Part B and the group provides the beneficiary Medicare plan number to complete enrollment. • Information provided here is pending CMS approval unless otherwise noted. Cigna Rx Medicare (PDP) • The rates are contingent upon the eligible individual residing in the service area of the quoted Medicare Part D plan. The enrollment will be based on the eligible individual's primary residence as defined by CMS. • The benefits presented in the Proposal are a high-level summary. Please consult the summary of benefits for a more detailed list of benefits proposed in this Cigna Healthcare plan. Due to annual changes in CMS mandated benefits, benefits may differ for certain service categories. • Due to regulatory requirements for the Medicare Part D product, services and timing may differ. Some areas of difference include, but are not limited to: reporting, web services, disease and wellness management, quality incentives, provider directories and networks, eligibility timing, communication pieces for pre -enrollment and members, billing, pharmacy and medical data integration, customer service, claims and appeals. • Cigna Healthcare requires a minimum of 20 enrolled members per standard product offering to renew an Employer Sponsored plan. All Medco products and services are provided exclusively by or through operating subsidiaries or affiliates of Medco, including Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York. The Medco name, logos, and marks are owned by Medco, or an affiliate of Medco. Medco contracts with Medicare to offer Part D Prescription Drug Plans (PDP) in select states. Enrollment in a Medco product depends on contract renewal. ©Cigna Healthcare 2024 5 11/4/2024 _\$%i cigna healthcare Exhibit B Group Administrative Guidelines Cigna Healthcare Medicare Prescription Drug Plans Group Administrative Guide cigna healthcare to Thank you for sharing our commitment to quality care. Contents We're pleased to work with you to improve the health, well-being and peace of mind of your retirees. Our goal is to provide you with resources you need for easier plan administration. Please take some time to review the plan administration topics and refer to this Cigna Healthcare Medicare Prescription Drug Plans' Group Administrative Guide as needed. Terms to know Employer Group Portal Eligibility and enrollment Fully insured premium billing and payment Employer/Union Group PDP Agreement Customer communications Customer resources Claims administration Additional resources 3 4 5 12 14 15 17 18 18 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Terms to know Group The term "Group" throughout this document refers to employers, unions and trusts. Customer The term "customer" throughout this document refers to retirees, covered dependents, beneficiaries and individuals. Centers for Medicare & Medicaid Services (CMS) CMS is the federal agency that runs the Medicare program and regulates all plans and provisions. Additional information can be found at www.Medicare.gov or by calling I-800-MEDICARE (1-800-633-4227). Employer Group Waiver Plan (EGWP) Group Medicare Prescription Drug Plans (PDPs) are also called Employer Group Waiver Plans (EGWPs), pronounced "egg -whips." EGWPs are a type of Medicare PDP offered to employees and retirees of some companies, unions or government agencies. Part D Low -Income Subsidy (LIS) People with limited income and resources may qualify for Extra Help for their prescription drug benefit. Extra Help is referred to as a Low -Income Subsidy (LIS). The amount of Extra Help an individual may receive depends on their income and resources. Some people automatically qualify for Extra Help and do not have to apply for it. If they answer "yes" to any of the questions below, they automatically qualify for Extra Help. This means they will receive a certain dollar amount that may go toward their premiums and their cost -shares for Part D prescription drugs: Do you have Medicare and full coverage from a state Medicaid program? Do you get Supplemental Security Income? Do you get help from your state Medicaid program paying your Medicare premiums? For example, do you belong to a Medicare Savings Program, such as the Qualified Medicare Beneficiary (QMB), Specified Low -Income Medicare Beneficiary (SLMB) or Qualified Individual (QI) program? Medicare will mail a gray Loss of Deemed Status Notice to individuals in September if Social Security determines that they no longer automatically qualify for Extra Help for the coming year. Our plan will also mail a notice to encourage people to apply to determine if they still qualify for Extra Help. Customers who no longer qualify for Extra Help will receive a notice in December. If your enrollees have questions about Extra Help with prescription drug costs or need assistance completing an application, they can contact the Social Security Administration (SSA) at 1-800-772-1213 or visit www.SocialSecurity.gov. 3 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Terms to know (continued) Medicare Advantage Plan (Part C) A type of Medicare plan offered by private health insurance carriers that contract with Medicare to provide Medicare Part A and Part B benefits. Cigna Healthcare is one such carrier. Medicare Prescription Drug Plan (Part D) A stand-alone drug plan offered by insurers and other private companies to people who get benefits through the Original Medicare Plan or through a Medicare Private Fee -for - Service Plan that doesn't offer prescription drug coverage. Medicare Advantage Plans may also offer prescription drug coverage that must follow the same rules as Medicare Prescription Drug Plans. Medicare prescription drug plans may be referred to as PDP plans. _..) Employer Group Portal Federal exemption The Medicare Modernization Act of 2003 has a very strong preemption provision. This means that in general, state laws don't apply to standard Part C and Part D benefits unless they pertain to state licensing or financial solvency of the insurer. Beginning in 2014, Part D coverage under an EGWP that provides customers with supplemental benefits beyond the parameters of the defined standard Part D benefit are treated as non -Medicare Other Health Insurance (OHI) that wraps around Part D. Employers/unions offering EGWPs must ensure any supplemental benefits comply with any applicable requirements for issuance under state insurance laws and/or the Employee Retirement Income Security Act (ERISA) rules. This is similar to commercial health care products that are subject to both state laws and federal laws. Certain state exemptions may apply. Go online to save time The Cigna HealthcaresM Medicare Employer Group Portal helps you manage your plan. From requesting replacement identification (ID) cards to having access to various reporting and plan documents, you have immediate access to information to help simplify plan administration. The Employer Group Portal will provide employers the ability to: • View Group Enrollment Reports. • Submit address change requests. • View Group Billing Reports (invoices). • View customer eligibility details, including • View when a customer's ID card was last information for access to care (enrolled, ordered/mailed. future and disenrolled in the last 12 months). • Submit ID card replacement requests. ▪ View/print plan documents and forms. Getting started To request Employer Group Portal access, provide your name and email address to your designated Medicare Client Account Manager. Soon after, you will receive an email invitation to register and access the portal at Employer.HSConnectOnline.com/Home/Login. Your Medicare Client Account Manager can provide training and/or a user guide to get you started. 4 Eligibility and enrollment Plan eligibility Only customers who are entitled to Medicare Part A and/or enrolled in Part B are eligible to enroll in a Cigna Healthcare Medicare Part D EGWP plan. If not, CMS will reject the application and the customer will not have coverage under the Cigna Healthcare EGWP Medicare plan. To avoid these situations, the Group must validate the customer's Medicare status by requesting their Medicare ID card. Prior to sending pre -enrollment packages, Cigna Healthcare can verify Medicare Part A and B enrollment to confirm eligibility for potential enrollees. In order to perform the verification, the following demographic information is required: Medicare Beneficiary Identifier (MBI), name, date of birth (DOB) and gender. If the Group has customers who don't meet the eligibility requirements to enroll in the Cigna Healthcare Medicare EGWP, the Group should contact their Cigna Healthcare Sales Representative to discuss possible alternative plans. There are specific sign-up periods when a customer can enroll in Medicare Part A and/or B. If the customer does not enroll during their Initial Enrollment Period or a Special Enrollment Period, they will need to enroll during the General Enrollment Period, between January I and March 31 each year. Coverage will start the first day of the month after they sign up. The customer may have to pay a higher Part A and/or Part B premium for late enrollment. A customer may not be enrolled in more than one Medicare plan at any given time. However, CMS has granted a waiver for all employer and union groups to simultaneously enroll their members in an "800 Series" Local MA -only Coordinated Care Plan (HMO, HMOPOS, PPO) and an "800 series" stand-alone PDP. CMS requires the separate medical and prescription drug carriers to work closely together with the employer sponsor to provide coordinated care and disease management services between the medical and pharmacy portions of the benefit. This coordination is similar to the kind that would be offered if the employer purchased the medical coverage and the drug coverage from a single carrier under one Medicare Advantage plan with Part D. A customer is eligible to enroll in the Cigna Healthcare Medicare EGWP as long as the enrollee permanently resides in the Cigna Healthcare Medicare service area, which includes all 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands. For purposes of enrollment in the Cigna Healthcare Medicare EGWP, incarcerated customers are to be considered as residing out of the plan service area, regardless of the location of the correctional facility. Customers must be U.S. citizens or lawfully present in the United States. CMS will notify Cigna Healthcare if the customer is not eligible to enroll on this basis at the time of enrollment. Cigna Healthcare will notify the Group via the Group Enrollment Report. Please reference Chapter 3 of the Medicare Prescription Drug Benefit manual found on www.CMS.gov for complete enrollment and disenrollment information. 5 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Eligibility and enrollment (continued) Medicare eligibility Medicare is usually available for people age 65 or older, younger people with disabilities, and people with permanent kidney failure requiring dialysis or transplant, also known as end -stage renal disease (ESRD). Customers must be in a non -working status (i.e., retiree or disabled) or entitled to benefits due to a retirement status (i.e., spouse of retiree), and Medicare must be primary. Age Customers are typically eligible for Medicare at age 65. To be eligible for our plan, the customer must also meet eligibility requirements outlined in the Plan eligibility. For employer groups with 20 or more employees, Medicare will pay secondary if the customer has other coverage through their employer or spouse based on their current employment status. For employer groups with under 20 employees, Medicare will pay primary. Disability Customers can become Medicare eligible due to disability. To be eligible for our plan, the customer must also meet eligibility requirements outlined in the Plan eligibility section. For employer groups with 100 or more employees, Medicare will pay secondary if the customer has other coverage through their employer or spouse based on their current employment status. For employer groups with under 100 employees, Medicare will pay primary. ESRD Customers can become Medicare eligible due to an ESRD diagnosis. If Medicare already pays primary for the customer due to age or disability and subsequently they are diagnosed with ESRD, Medicare will continue to pay primary. If the customer becomes eligible for Medicare because of ESRD only, Medicare coverage will start the fourth month of dialysis treatments, unless certain criteria are met. Medicare will pay secondary for the first 30 months. At the end of the 30-month coordination period, the customer becomes eligible to enroll in the Employer Group Medicare Advantage plan) If the customer turns age 65 during the 30-month coordination period, Medicare remains secondary until the end of the coordination period. CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Eligibility and enrollment (continued) Medicare Beneficiary Identifier (MBI) CMS requires that the customer MBI be included with each enrollment application. The MBI can be found on the customer's Medicare ID card. The Group is responsible for providing the customer's MBI to Cigna Healthcare with their enrollment application. Eligibility received without the MBI will be considered an incomplete enrollment application (see Incomplete enrollment information). The customer will not have access to care due to incomplete enrollment. As a reminder, Cigna Healthcare can verify Medicare Part A and B enrollment along with MBI for potential enrollees. See Plan eligibility for more details. Enrollment information required by CMS and Cigna Healthcare for Medicare customers The Group must provide all the information required by CMS and Cigna Healthcare in order to successfully enroll the customer into the elected plan. Required information Customer name Customer DOB Customer gender Permanent residence address: If a P.O. Box is used for the mailing address, then the Group must also provide the customer's physical address. Enrollment applications received without the permanent residence address will be considered an incomplete application (see Incomplete enrollment information). If the permanent residence address cannot be provided due to security concerns, a Permanent Residence Attestation can be provided by the client or the customer. Mailing address (if different than permanent residence) • Customer MBI • Account number • Branch code Benefit option code Coverage start date Coverage cancel date (required for all disenrollments, excluding those initiated by CMS) Other insurance information (--- Recommended information • Phone number • Email address Newly enrolled customers with phone numbers and email addresses will receive a Welcome Call and Welcome Emails to answer any questions they may have and review key benefits, features and resources to help them make the most of their new plan. At other points during the year, phone numbers and email addresses may be used for clinical care outreaches or to share plan information and updates. 7 Eligibility and enrollment (continued) Eligibility format and processing The following methods are acceptable for submitting enrollments to Cigna Healthcare: Automated eligibility file CMS -compliant spreadsheet Enrollment requests via phone call or email are never allowed, even in an emergency situation. CMS requires a seven calendar -day processing time from the date completed Medicare eligibility is received by Cigna Healthcare. We will send all enrollment information to CMS. In the event an enrollment is rejected, a letter will be sent to the customer indicating the reason for the rejection. The Group will receive a Group Enrollment Report that identifies the customers who have not been accepted by CMS. Group Enrollment Report This report is generated weekly upon receipt of the CMS response file and includes all accepted enrollments into, disenrollments from and address changes related to the plan. The report will indicate when action is required by the Group. Critical Error Report This report contains errors encountered when the eligibility file is processed. Incomplete enrollment information Enrollment information that is incomplete is not legally valid for enrollment into the Cigna Healthcare Medicare EGWP. In addition, an enrollment is not legally valid if it is later determined that the customer did not meet all of the CMS eligibility requirements. If there is missing or incorrect information, including a missing permanent residence address when a P.O. Box is provided, the customer will receive a letter instructing them to contact the Cigna Healthcare Dedicated Medicare Customer Service Team (see Customer resources); they can immediately update the missing information in order to expedite processing the initial enrollment. Cigna Healthcare will notify the Group of the missing information on the Group Enrollment and Critical Error Reports for the Group to update their records. The customer has 21 days to respond to the request for missing information. If a valid MBI or permanent residence address cannot be obtained within 21 days, Cigna Healthcare will send the customer a Denial of Enrollment letter and they will notify the Group that the customer must be terminated from the Cigna Healthcare Medicare EGWP on the Group Enrollment Report. The Group may choose to move the customer to a non-EGWP, provide the necessary information to complete enrollment and resubmit the customer (effective date must be within the CMS allowable time frame), or they may choose to remove the customer from Cigna Healthcare coverage on future files. If the information is provided after the 21 days, the customer's effective date will be postponed until the following month, when the customer's completed information is received and validated by CMS. 8 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Eligibility and enrollment (continued) Effective dates CMS has sole authority to verify effective dates; however, a proposed effective date may be communicated to the customer. Effective dates will always be the first day of the month. The effective date may not be earlier than the first of the month following the month in which the customer enrollment request was made. The effective date may not be earlier than the first day of the customer's entitlement to Medicare. If a customer's enrollment is submitted with a date prior to their entitlement date, Cigna Healthcare will process the enrollment using the Medicare entitlement date. Enrollments cannot be processed earlier than three months prior to the effective date. Terminations Terminations will always be the last day of the month, including terminations resulting from the death of the customer. The disenrollment is effective the last day of the month in which the customer (or his/ her legal representative) provides notice to disenroll to the Group and the Group sends the disenrollment to Cigna Healthcare. The disenrollment date may not be earlier than the end of the month in which the customer disenrollment request was made or the customer no longer qualifies for the plan. Retroactivity Retroactive enrollments and disenrollments are not allowed, except in extraordinary circumstances (subject to audit by CMS) when the Group knew of the customer's enrollment or disenrollment intent prior to the requested effective date. The effective date may be retroactive up to, but not exceeding, three months from the date Cigna Healthcare received the request from the Group. The ability to submit limited retroactive enrollment transactions is to be used only for the purpose of submitting a retroactive enrollment made necessary due to the Group's delay in forwarding the completed enrollment request to Cigna Healthcare. Repeated retroactive requests by a Group may indicate an ongoing problem to CMS and lead to a request from CMS to review the Group's documentation of their records. CMS requires a special review process when requesting enrollment/disenrollment effective dates that are older than three months. If the Group submits a request older than three months, Cigna Healthcare will request a completed form, including the required CMS documentation: The customer's enrollment/disenrollment intent (election form, call notes, opt -out form, etc., dated prior to the requested effective date). The premium impact to the customer if the request is approved. Hardship created for the customer if the request is not approved. The reason for the Group's delay in submission to Cigna Healthcare and preventive actions to avoid future occurrences. Once received, we will review the documentation to determine if it meets CMS requirements. If it doesn't, we will work with you for alternative options. If the documentation supports the requested enrollment/ disenrollment effective date, we will submit the request to CMS for review. This review can take CMS up to 60 days. In the event that CMS denies the retroactive request, we will work with you to determine an alternative solution within CMS guidelines that minimizes customer impact. 9 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Eligibility and enrollment (continued) (--- Disenrollment/Cancellation A customer may disenroll from a Medicare Part D plan only during one of the CMS -approved election periods. If the customer is enrolled in an EGWP-sponsored plan, the EGWP Special Election Period is available, which allows the customer to disenroll at any time during the plan year. The customer must elect another Part D plan or other creditable prescription drug coverage that is at least as good as the standard Medicare prescription drug coverage or they may be subject to a late enrollment penalty. When the customer elects another Medicare Part D plan, CMS will generate an automatic disenrollment from the current Medicare Part D plan. CMS will notify Cigna Healthcare, and Cigna Healthcare will send the customer a letter and notify the Group through the Group Enrollment Report. The Group must terminate the customer from their plan upon notification from Cigna Healthcare using the date provided by CMS. This individual may not remain enrolled in the Cigna Healthcare Medicare EGWP. Cancellations may be necessary in cases of mistaken enrollment or disenrollment made by a customer. Requests for cancellations can only be accepted prior to the effective date of the enrollment or disenrollment request. If a cancellation occurs after the effective date, retroactive disenrollment and reinstatement actions may be necessary. This is only available on a very limited exception basis per CMS guidelines. See Retroactivity. CMS -initiated disenrollments CMS will automatically disenroll a customer: • Upon notification of his/her death. Disenrollments due to date of death can only be initiated by CMS. • Upon enrollment in another MA/MAPD or individual PDP (MA plans). • Upon enrollment in another MA/MAPD. • Who is no longer entitled to either Medicare Part A and/or B benefits.2 • For failure to pay their Part D income -related monthly adjustment amount (IRMAA) to the government. • Upon notification of a change in residence that results in the customer being outside of the service area (including incarceration). If it is determined he or she is unlawfully present in the United States. CMS -initiated reinstatements CMS will automatically reinstate a customer in the following situations: Customer was disenrolled due to enrollment in another plan and the new plan was cancelled. • CMS disenrolled customer due to erroneous report of death and CMS has corrected the retiree's information. • CMS disenrolled customer for failure to pay IRMAA and the customer has been approved for reinstatement due to good cause and customer fulfills requirements. Customers who have been automatically reinstated will appear on the Enrolled Members tab of the Group Enrollment Report. If the Group does not agree to the reinstatement, Cigna Healthcare will submit a disenrollment transaction to CMS. If the Group agrees to reinstate the customer, the customer will remain enrolled in the plan. For failure to pay IRMAA, if CMS notifies Cigna Healthcare prior to reinstating the customer, we will verify if the Group agrees to the reinstatement prior to providing CMS approval for the reinstatement. If the Group agrees to reinstate the customer, notification must be received within five calendar days. 10 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Eligibility and enrollment (continued) Termination due to nonpayment of premiums If the Group's policy is to disenroll enrollees for failure to pay their monthly premium, the Group must apply the policy consistently across its enrollees. The Group must give an enrollee a minimum grace period and provide them with written notice prior to disenrollment. The grace period must be at least two calendar months, and it begins on the first day of the month for which the premium is unpaid. If an enrollee fails to pay his or her premium within the grace period, the enrollee can be disenrolled on the first day after the end of the grace period. The Group can attempt to collect the premium but cannot retroactively terminate the enrollee. Income -related monthly adjustment amount (IRMAA) Medicare -eligible customers with Part D coverage could be assessed a higher Part D premium based on their annual income. Customers with a single annual income over $103,000 or joint income of over $206,000 will be charged additional premiums by the SSA.3 NOTE: These amounts are subject to change annually. • They may either have premiums deducted from their monthly Social Security payment or, if they are not receiving Social Security yet, Medicare will bill them directly. • Customers who fail to pay the additional premium will be involuntarily terminated from the plan. • IRMAA is administered by Medicare and the SSA. Cigna Healthcare is not provided any information regarding which persons are affected by IRMAA. Any questions about IRMAA should be directed to the SSA at 1-800-772-1213. Income -related monthly adjustment amount (IRMAA) terminations When a customer does not pay their IRMAA to the SSA, CMS will notify Cigna Healthcare that the customer must be terminated. Cigna Healthcare will then notify the Group via the Group Enrollment Report that the customer must be terminated per CMS. CMS provides an opportunity for reinstatement of customers into their Medicare Part D Plan for good cause situations. If the customer advises the Group they have a good reason for failure to pay Part D IRMAA premiums, the Group should tell the customer to contact I-800-MEDICARE (1-800-633-4227) within 60 calendar days of the disenrollment effective date. CMS will then determine whether the customer qualifies for good cause reinstatement. If so, the customer works with CMS to make payment arrangements in order to get reinstated into the plan. CMS will notify Cigna Healthcare if the customer qualifies for reinstatement for good cause. Cigna Healthcare will reach out to the Group to confirm if the customer can be added back into the plan based on the Group's eligibility rules. Once the customer makes all the required payments, CMS will reinstate the customer and Cigna Healthcare will notify the Group via the Group Enrollment Report. Record retention CMS requires that Cigna Healthcare has a record of all enrollment requests. CMS guidelines require customer enrollment elections to be retained for 10 years. Additionally, the Group will maintain all records and documentation relating to enrollment for a period of 10 years from the final date of group coverage. 11 Fully insured premium billing and payment Billing invoice A separate invoice will be generated for your Cigna Healthcare Medicare plans. If there are multiple account numbers, each account number will generate a separate invoice. The invoice will include a monthly summary and a detailed roster. For Administrative Services Only (ASO) clients, please see separate ASO Companion Guide for all billing information. Payment due date Premium is due by the end of the month. Any premium not received after the last day of the month is considered past due. Cigna Healthcare will provide notice of the unpaid premiums on the next month's invoice and may provide a separate notice of late payment if unpaid premiums are more than one month past due. Cigna Healthcare may terminate the agreement one month after it provides the Group with a notice of late payment if the Group has not paid the premiums due. Payment remittance method Eligibility -based billing, or Pay as Billed (PAB), is the Cigna Healthcare remittance method. The Group will need to remit payment for Cigna Healthcare Medicare plan coverage separately from other Cigna Healthcare plans. A separate W-9 is not required for Cigna Healthcare Medicare clients with a Cigna Healthcare commercial relationship. A W-9 is required for clients with Cigna Healthcare Medicare plans only. r Wire and Automated Clearing House (ACH) details Bank: Bank of America, N.A. ACH ABA routing/transit number: 011900571 Bank account number: 385015921381 Bank account name: Cigna Health and Life Insurance Company Bank ACH address: 101 S Tryon Street Charlotte, NC 28255 Wire transfer ABA number: 026009593 Swift: BOFAUS3N Bank: Bank of America Bank address: 101 West 33rd Street New York, NY 10001 12 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Fully insured premium billing and payment (continued) Part D low-income premium subsidy (LIPS) adjustment Medicare provides a premium subsidy for those who qualify for Extra Help to assist with payment of their plan premiums. CMS will notify Cigna Healthcare of any customers eligible for LIS premium adjustments and will pass the LIPS adjustment amount to Cigna Healthcare for each eligible retiree. If the retiree Part D monthly premium contribution is more than the LIPS amount, the Group should advise the retiree that they can opt out of current coverage to enroll in a plan with a monthly premium equal to or below the LIPS amount. The Group should communicate the potential financial impact and implications of opting out of their Group coverage. CMS requires the LIPS adjustment amount be passed to eligible retirees within 45 days of the date Cigna Healthcare receives the LIPS adjustment. The Group or Cigna Healthcare would pass the LIPS adjustment to eligible retirees. Late enrollment penalty (LEP) Customers may have to pay an LEP in addition to their monthly plan premium if there is a continuous period of 63 days or more at any time after the end of their Part D initial enrollment period during which they were eligible to enroll but were not enrolled in a Medicare Part D plan and were not covered under any creditable prescription drug coverage. Creditable prescription drug coverage is coverage that is at least as good as the standard Medicare prescription drug coverage. The customer may have to pay this LEP for as long as they have Medicare prescription drug coverage. The penalty amount may change each year based on the national base beneficiary premium amount. Although you can estimate, only CMS is authorized to calculate the actual amount of the penalty. CMS will inform Cigna Healthcare of the LEP amount that the customer would be responsible for paying. Cigna Healthcare will pass the penalty on to the Group via the employer monthly billing invoice. The detailed billing roster will provide the names of the applicable customers and the amount of the LEP. The Group is responsible for paying the penalty on behalf of the customer(s) and may choose to collect the LEP amount from them. If a customer has been assessed an LEP under a non -Cigna Healthcare plan and disagrees with the penalty, the customer must initiate the appeal process by contacting Medicare at I-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048. The customer will need to fill out a reconsideration request form and provide proof that they had previous creditable coverage 4 Cigna Healthcare is unable to assist in the appeal process when the customer did not have coverage through Cigna Healthcare. 13 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Fully insured premium billing and payment (continued) Attestation Cigna Healthcare will accept an attestation from the Group that all customers submitted on the eligibility file for initial enrollment into the Cigna Healthcare Medicare EGWP were previously enrolled in a plan that provided creditable pharmacy coverage and did not have a gap in creditable coverage for 63 days or longer. If the retirees were enrolled in a Retiree Drug Subsidy filed plan, Cigna Healthcare will also accept an attestation that the customers have been notified of the opportunity to enroll and the process for opting out of coverage in the Cigna Healthcare Medicare EGWP. These attestations apply to valid and complete enrollment applications/records processed prior to the initial effective date of the plan. Enrollment requests processed after the initial effective date will receive communications regarding creditable coverage and/or Retiree Drug Subsidy as required by CMS. Employer/Union Group PDP Agreement The CMS contract addendum with Cigna Healthcare (Employer/Union-Only Group Addendum) requires that Cigna Healthcare obtain written agreements from each employer or union with which it contracts for employer/union-only group PDP plans and that such agreements contain certain terms and provisions. This agreement will be provided to you by your account team and will need to be fully executed prior to the effective date. A full agreement is provided with the initial plan year, and an amendment is provided for each renewing year. ...) Employer/Union Group PDP policy and certificate Cigna Healthcare will provide electronic copies of policy and certificate documents to fully insured plans that offer prescription drug coverage as part of your plan. The policy and certificate comprise our contract with you. The policy and certificate will be provided to you by your account team along with the Employer/Union Group PDP Agreement or Amendment. CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Customer communications Required group communications to customers Pre -enrollment kits Group pre -enrollment kits are required to go out to all eligible customers and must be received no later than 21 days before the effective date for passive enrollment or 21 days before the Open Enrollment Period for active enrollment. Further, pre -enrollment kits are required to be sent to retirees as they reach the age of Medicare eligibility and meet the Group's enrollment rules. Cigna Healthcare will provide the client with a bulk shipment of pre -enrollment (or age -in) kits prior to the start of the calendar year. The client will send a kit to each retiree 60 days prior to their Medicare eligibility. Both the pre -enrollment and age -in kits will include: Pre-enrollment/Age-in letter Summary of Benefits Online resource insert (Directory and Drug List) Information Guide Multi -language insert Formulary Addendum Additional general plan information is available at CignaMedicare.com/group/PDPresources. See page 17 for more details. Renewal kits Group renewal kits are required to go out to all enrolled customers and must be received 15 days before the beginning of the Group's health plan Open Enrollment Period. If the Group does not have an Open Enrollment Period, then the materials are required to be received or available to review online by customers no later than 15 days before the beginning of the plan year. • Renewal cover letter • Annual Notice of Change (ANOC) • Evidence of Coverage (EOC) Snapshot • Formulary Addendum for PDP Online resource insert (Directory and Drug List) • Notice of Privacy Practices • Multi -language insert Post -enrollment communications Upon completion of the customer's enrollment into the Cigna Healthcare Medicare EGWP, the following will be mailed to the customer within 10 calendar days from receipt of CMS confirmation of enrollment or by the last day of the month prior to the effective date, whichever is later: • Welcome letter • Evidence of Coverage (EOC) Snapshot • Online resource insert (Directory and Drug List) • Customer Handbook • Notice of Privacy Practices • ID card (mailed separately) Medicare Prescription Payment Plan Information and Enrollment Form (MAPD only) Multi -language interpreter services Acknowledgment/Confirmation of Enrollment Acceptance Notices (mailed separately) 15 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Customer communications (continued) Required plan communications to customers Cigna Healthcare will provide a copy of the following items and other communications to the Group and/or broker, if requested. Acknowledgment/Confirmation of Enrollment Acceptance Notices The notices are mailed to the customer within 7 to 10 calendar days of the CMS confirmation of enrollment. The notices can be used by the customer as proof of coverage prior to receiving the ID card. Identification (ID) Card ID cards are mailed to the customer within 10 days from receipt of CMS confirmation of enrollment (approval) or by the last day of the month prior to the effective date. Under most circumstances, ID cards are mailed within 10 days to the mailing address on file. Replacement Cigna Healthcare Medicare ID cards can be ordered by calling the dedicated customer service team (see Customer resources). Replacement ID cards can also be requested on behalf of the customer via the Group Employer Portal. Cigna Healthcare customers will receive a new customer identifier when moving from commercial coverage to the Cigna Healthcare Medicare EGWP. Cigna Healthcare Medicare Plans are member -based products, which require all customers to be loaded as individual subscribers. • Low -Income Subsidy (LIS) Rider (if applicable) The rider is mailed to the customer within 30 calendar days of notification from CMS that the customer qualifies for an LIS. • Medicare Prescription Payment Plan Likely to Benefit Letter This letter is mailed to customers who have high drug costs and may benefit from having those costs spread evenly over a year's time. Late Enrollment Penalty (LEP) Attestation Notice This notice is mailed to the customer within 10 calendar days of receipt of application when there is a potential gap in coverage of 63 days or more, and it must be returned within 30 calendar days of the date on the form. Acknowledgment of Disenrollment Notice The notice is mailed to the customer within 10 calendar days of Cigna Healthcare receiving the disenrollment election. Confirmation of Disenrollment Notice This notice is mailed within 7 to 10 calendar days of the CMS confirmation of disenrollment. Explanations of Benefits (EOBs) EOBs will be produced for claim activity and will be mailed to the customer's mailing address in accordance with CMS guidelines. Research Potential Out -of -Area Status Notice This notice is mailed to the customer when we receive notice (undeliverable mail with no forwarding address, CMS notification, etc.) that they may have moved out of the service area. The customer must confirm that they still live in the service area within six months or they will be disenrolled from the plan. Notice of Disenrollment Due to Out -of -Area Status (upon new address verification from customer) This notice is mailed within 10 calendar days of Cigna Healthcare verifying that the customer has permanently moved out of the service area. Termination Letter CMS allows a Group to disenroll its customers from a Medicare plan using the group disenrollment process. The process requires a letter of notification of disenrollment be sent to each customer 21 days prior to the effective date of their disenrollment from the Group - sponsored Medicare plan. This is not a complete list of all communications that may be sent throughout the plan year. There are system -generated letters that are sent to request information in order to process claims, update customer records, etc. Electronic samples of these system -generated letters can be provided upon request. Customer resources Medicare PDP dedicated customer service team Phone number: I-800-558-9562 (TTY/TDD users should call 711) Hours of operation: October I - March 31, 7 days a week, 8 a.m. to 8 p.m. local time. April I - September 30, Monday - Friday, 8 a.m. to 8 p.m. local time. Our automated phone system may answer your call during weekends or holidays and after hours. Home delivery with Express Scripts Pharmacy' To set up an account, retirees should have their Cigna Healthcare Medicare ID card and medication list nearby and call Express Scripts° Pharmacy at 1-877-860-0982 (TTY 711), 24 hours a day, 365 days a year. Customer web access Customers can sign in to myCigna.com®, which is a personalized website where they can: • View Medicare Part D benefits • Manage prescriptions • Manage profiles and preferences • Price a medication • View plan coverage documents • Access Healthy Rewards° discount programs6 • Find a network pharmacy • View and print ID cards Review claim history and EOB details The CignaMedicare.com/group/PDPresources public website provides customers with access to general plan information that does not list client -specific benefits. EOC shell (the legal language of the plan) Quantity limit criteria The ability to find a pharmacy Step therapy criteria Chain pharmacy listings Prior authorization criteria Information on how to transition to Vaccinations flyer a new plan policy B vs. D flyer • Drug lists Medicare Prescription Payment Plan • Claim forms Personal medication list • Medication therapy management 17 CIGNA HEALTHCARE PDP GROUP ADMINISTRATIVE GUIDE Claims administration Claims When a manual claim is necessary (majority of providers will submit electronically), customers will need to complete a claim form to request payment. Copies of the form can be downloaded from CignaMedicare.com/ group/PDPresources, or customers can contact customer service to request a form be mailed to them. Claims should be mailed to the following address: Pharmacy Cigna Healthcare Attn: Medicare Part D P.O. Box 14718 Lexington, KY 40512-4718 Claims payment Cigna Healthcare will administer claims in accordance with the EOC document. From time to time, Cigna Healthcare Medicare will reprocess or adjust claims that have been processed under the plan for several potential reasons including, but not limited to, obtaining additional information from the customer, the customer's provider or CMS and upon identifying errors. If Cigna Healthcare reprocesses or adjusts a processed claim and this results in a change to the amount due from the customer, Cigna Healthcare shall notify the customer of the change and, as applicable, refund the difference to the customer or request payment of the difference. In the case of an ASO plan, Cigna Healthcare will offset the amount of the group overpayment/underpayment in future group reconciliation reports. Additional resources Medicare website: www.Medicare.gov Cigna Healthcare website: Cigna.com Employer Group customer resources: CignaMedicare.com/Group/PDPresources Group Medicare Online Pharmacy Directory: CignaMedicare.com/Group/PDPresources Group Employer Portal: Employer.HSConnectOnline.com/home/login 18 cigna healthcare 1. Effective January 1, 2021, Medicare allows individuals with an ESRD diagnosis to enroll in Medicare Advantage plans at the end of the 30-month coordination period. 2. A customer can ask Cigna Healthcare to reinstate coverage if they feel that CMS disenrolled them in error. If the Group agrees, Cigna Healthcare will reinstate coverage for the customer for a period of 60 days. If CMS systems are updated within 60 days, the reinstatement will be submitted to CMS and the customer will receive the Acknowledgment of Reinstatement letter. If CMS systems are not updated after 60 days, Cigna Healthcare will disenroll the customer back to the original disenrollment date and the customer will receive a letter to close the reinstatement request. 3. For the most up-to-date income ranges, visit hops://www.Medicare.gov/Drug-Coverage-Part-D/Costs-For-Medicare-Drug-Coverage/Monthly-Premium-For-Drug-Plans. 4. CMS. Understanding Medicare Advantage & Medicare Drug Plan Enrollment Periods. CMS Product No. 11219. Page last accessed August 18, 2024. https://www.medicare.gov/publications/11219-Understanding-Medicare-Advantage-Medicare-Drug-Plan-. 5. Express Scripts Pharmacy is a trademark of Express Scripts Strategic Development, Inc. Other pharmacies are available in our network. 6. Some discount programs are not available in all states, and programs may be discontinued at anytime. A discount program is NOT insurance, and customers must pay the entire discounted charge. All goods, services and discounts offered through discount programs are provided by third parties that are solely responsible for their products, services and discounts. All Medco products and services are provided exclusively by or through operating subsidiaries or affiliates of Medco, including Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York. The Medco name, logos, and marks are owned by Medco or an affiliate of Medco. Medco contracts with Medicare to offer Part D Prescription Drug Plans (PDPs) in select states. Enrollment in a Medco product depends on contract renewal. 983494 09/24 © 2024 Cigna Healthcare. Cigna Healthcare 4 Medicare Prescription Payment Plan Group Administrative Guidelines Addendum Group Administrative Guidelines Addendum M3P Program Effective January I, 2025, all Part D plan sponsors must offer their Medicare Part D plan Members the option of enrolling in the Medicare Prescription Payment Plan ("M3P Program") as established by the Inflation Reduction Act. The M3P Program allows Medicare Part D Customers the option to pay out-of-pocket prescription drug costs in the form of monthly payments over the course of the plan year, instead of paying in full at the pharmacy. Definitions "M3P Monthly Amount" means the monthly amount to be invoiced to the Participant to participate in the M3P Program that spreads the Participant's drug cost shares across the months of the year that remain after the Participant's election to participate in the M3P Program. The M3P Monthly Amount is separate from the Customer Premium. Terms and Conditions Cigna Healthcare holds the right to modify the program and pricing if additional changes are required by CMS guidance. • Group will provide Cigna Healthcare all information that is necessary for Cigna Healthcare to perform the M3P Program as required by CMS. • Cigna Healthcare may engage third -party vendors as determined by Cigna Healthcare. Cigna Healthcare will require any third party - vendor to be subject to appropriate business associate agreement and to appropriately protect any Customer specific information, including protected health information, needed to administer the M3P Program. Cigna Healthcare or its vendor may contact Customers (including via electronic means) to discuss the M3P Program and educate and assist Customers on enrollment into the related digital communication initiatives. • Group delegates to Cigna Healthcare the administration and offering of the M3P Program, including all required Customer communications. • Participants who fail to pay their M3P Monthly Amounts will not be disenrolled from Group's Plan but may be disenrolled from the M3P Program in accordance with CMS regulations and guidance. Prior to being disenrolled from the M3P Program, Participants will receive the CMS required grace period for payment of their M3P Monthly Amount. "Participant" means a Customer who has a timeline of participation in the M3P Program during the applicable month, or a Customer who carries a balance after being terminated and continues to be invoiced. "PPPM" means per Participant per month. Cigna Healthcare may share Customer contact information (including electronic addresses) with necessary vendors, allowing such vendor to contact Group's Customers for election support in M3P Programs and to otherwise communicate regarding the M3P Program's services. Cigna Healthcare may obtain additional information to enable and operate M3P including, but not limited to, data associated with Customer contact data and payment information, eligibility, election/termination, Platform interaction, and information obtained or other criteria that is needed of Group. Cigna Healthcare may use information or data collected for participation in M3P including information collected from third parties, to administer the program, to contact Participants in the program to support their participation, for the purpose of performing outcomes and/or opportunity analyses, pharmacy benefit plan administration, administration of other programs that Group may enroll in. Participant Invoicing Cigna Healthcare will calculate the appropriate Participant's monthly payment in accordance with CMS requirements and invoice the Participant accordingly. M3P Program Service(s) Cigna Healthcare will provide the following services in accordance with final guidance set forth by CMS to support aspects of the M3P Program, including: PBM Services M3P Transaction Adjudication • Process data Feeds of M3P Transactions Reporting required by CMS in relation to the M3P Program Population of M3P related information on the PDE Inclusion of CMS required messaging on the Explanation of Benefit (EOB) Participant Invoicing Services Participant invoicing Participant payment processing Process data feeds of Participant payment information Elections/Terminations Services Participant election and termination/ opt -out support Process data feeds of Elections/ Termination information Participant Communication Services Included: • Removal for failure to pay • Invoice/billing notices • Notice of failure to make payments • Likely to Benefit messaging at point of sale (starting I/1/25) provided through network pharmacies • Prior to plan year Likely to Benefit Letters • Election approval notice • Request for additional information • Denial letter • Notification of voluntary removal Ad -hoc communications as required to support the services Returned mail support for M3P Communications M3P Designated Call Center -Included Services Invoicing, payment, and election related calls cigna healthcare All Medco products and services are provided exclusively by or through operating subsidiaries or affiliates of Medco, including Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York. The Medco name, logos, and marks are owned by Medco, or an affiliate of Medco. Medco contracts with Medicare to offer Part D Prescription Drug Plans (PDP) in select states. Enrollment in a Medco product depends on contract renewal. 986484 11/24 © 2024 Cigna Healthcare. Olivera, Rosemary From: Aviles, Yesenia Sent: Thursday, March 27, 2025 2:09 PM To: Olivera, Rosemary; Ewan, Nicole; Hannon, Todd Subject: 2025 Cigna Healthcare EGWP PDP FI_Agreement Amendment_City of Miami Attachments: 2025 _Cigna_Healthcare_EGWP_PDP_FI_Agreement_Amendment_City_of_Miami_RK_signed_( 004).pdf Good afternoon, Please find attached a fully executed copy of an agreement from DocuSign that is to be considered an original agreement for your records. Thank you Regards, Yesenia Aviles Assistant to the Director, Risk Management Ph: (305) 416-1723 I Fax: (305) 416-1760 I YAviles©miami.gov One Flagler Building 14 NE 1st Ave, 2nd Floor Miami, FL 33132 Website: Risk Management - Miami 1