Benefit Administrative/HR/175,000/Plan Administrator Benefit Administrative Systems
2014 Fixed Costs SCHEDULE B
Administrative & Ancillary Service Fees:
Contract Year 01/01/14- I2/31/14-City of Carmel
COVERAGE: [;' PREMIUM
Specific S/L, $175,000*
Single Standard Security $41.11 per single, per month
Family Standard Security $110.84 per family, per month
(12.50% commission payable to Detrude;2.50% to BAS)
Aggregate Premium Standard Security $9.50 per employee, per month
Specific Advance Fee BAS $1.00 per employee, per month
Aggregate Factors:
Single Standard Security $890.61 per single, per month
Family Standard Security $2,326.29 per family, per month
Administrative Fees:
Medical BAS $22.00 per employee, per month
Dental BAS $2.25 per employee, per month
Vision VSP $7.34 per employee, per month
Vision VSP $11.20 per employee+ 1, per month
Vision VSP $20.80 per family, per month
PPO Fee CIGNA $16.50 per employee, per month
U.R. Fee CIGNA Included Above
Flex BAS $5.50 per employee, per month
Debit Card BAS $2.00 per employee, per month
Debit Card Set-Up Fee BAS $500.00 Annual
Administrative Fee BAS $3,000.00 Annual
Compliance Fee BAS $500.00 Annual
Benefit Informatics Platinum BAS $2.75 per employee, per month
Banking Fee BAS $100.00 per month
Subrogation Fee BAS 10% of Recovery
*Specific deductible of$200,000.00 for claimant 0320936-ee
Signature Page Attached
Plan Sponsor: Date: _
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
/
/dames Brainard, Presiding Date ��
4 gris,12.. /) - 9-13
Mary7Burke, Board Member Date
/a/ di3
Lori Wagon, oard Member Date
ATTEST:
0/4/ 3—
Nina Cordray, IA- C, Clerk-Treasurer Date