RETIREE INSURANCE ENROLLMENT SUMMARY
CITY OF EL PASO INSURANCE & BENEFITS DIVISION       PHONE #541-4208         3RD FLOOR CITY HALL Rates effective from September 1, 2008 – December 31, 2009
C  I  T  Y    H  E  A  L  T  H    P  L  A  N      ADMINISTRATOR – AETNA Inc.  (877) 800-8682  or www.AETNA.com             AETNA REPRESENTATIVE LOCATED AT CITY HALL, 3RD FLOOR: GABRIELA ZUÑIGA  541-4117
MEDICAL PLAN     BASIC PLAN     WITH MEDICARE     WITHOUT MEDICARE            BUY-UP PLAN   WITH MEDICARE     WITHOUT MEDICARE	RETIREE ONLY           $166.56       $333.14 MONTHLY         $202.24       $404.46   MONTHLY		RETIREE +1           $333.14       $666.29 MONTHLY         $404.46       $808.93   MONTHLY		RETIREE+2 OR MORE           $499.71           $999.42 MONTHLY                   $606.69       $1,213.39             MONTHLY		PREFERRED ANY DOCTOR OR HOSPITAL ON AETNA  LIST     $ 1000.00 DEDUCTIBLE  80% COVERAGE   $ 20.00 CO-PAY: GP, FAMILY,INTERNAL, & PEDIATRICS   $ 30.00 CO-PAY:  SPECIALIST       $ 300.00 DEDUCTIBLE  90% COVERAGE   $ 20.00 CO-PAY: GP, FAMILY,INTERNAL, & PEDIATRICS   $ 30.00 CO-PAY : SPECIALIST			NON-PREFERRED DOCTOR / HOSPITAL NOT ON AETNA LIST       $ 3000.00 DEDUCTIBLE   50%COVERAGE                 $ 1000.00 DEDUCTIBLE   50%COVERAGE
PRESCRIPTIONS THROUGH MEDCO: 30-DAY $15.00 GENERIC, $30.00 BRAND PREFERRED & $45.00 BRAND NON-PREFERRED MAIL ORDER THROUGH MEDCO: 90 – DAY $30.00 GENERIC, $60.00 BRAND PREFERRED & $90.00 BRAND NON-PREFERRED									QUEST LABORATORIES WILL BE THE ONLY IN- NETWORK (POS) PREFERRED LAB PAID AT 100%
D E N T A L  & V I S I O N   P L A N S   SAFEGUARD: 1-800-880-1800   UNITED CONCORDIA:1-800-332-0366 BLOCK VISION:  1-866-265-0517 CITY ACCOUNT REPRESENTATIVE:  JESSICA CONCHA  541-4692 OR MARC HERNANDEZ 542-3531
SAFEGUARD D-HMO PLAN DENTAL CARE		RETIREE ONLY    $8.35		RETIREE + 1   $15.45		RETIREE + 2 OR MORE   $19.62		DENTIST MUST BE SELECTED FROM DENTAL PLAN LIST
UNITED CONCORDIA DENTAL WITHOUT ORTHODONTICS		RETIREE ONLY     $19.43		RETIREE + 1     $40.00		RETIREE + 2 OR MORE     $64.81
UNITED CONCORDIA DENTAL  WITH ORTHODONTICS		RETIREE ONLY     $20.39		RETIREE + 1     $43.29		RETIREE + 2 OR MORE     $77.54
BLOCK VISION		RETIREE ONLY     $4.98		RETIREE + 1     $8.72		RETIREE + 2 OR MORE     $12.95		HAS A VISION PROVIDERS LIST.  CAN GO OUT-OF-NETWORK WITH DIFFERENT COVERAGE. CONTACT BLOCK FOR AN OUT OF NETWORK CLAIM FORM
RETIREES MAY ONLY ENROLL INTO THE MEDICAL, DENTAL OR VISION PLANS THEY ARE COVERED UNDER AT THE TIME OF THEIR RETIREMENT. RETIREES MAY COVER ONLY THOSE DEPENDENTS COVERED UNDER THEIR PLAN AT THE TIME OF RETIREMENT. ONCE A RETIREE CANCELS THEIR COVERAGE OR THE COVERAGE OF A DEPENDENT THAT COVERAGE CANNOT BE REINSTATED. NO NEW DEPENDENTS MAY BE ADDED AT ANY TIME.