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MVP 2rIrlt ~M~e mvphuithcare..{om Attestation of Creditable Coverage Prescription Drug Coverage for Part D EmployerlUnion Retiree Group Plans "Creditable prescription drug coverage" generally means prescription drug coverage that is expected to pay at least as much as Medicare's standard prescription drug coverage. Creditable prescription drug coverage includes, but is not limited to: some employer- based prescription drug coverage, including the Federal Employees Health Benefits program; qualified State Pharmaceutical Assistance Programs (e.g., EPIC); military- related coverage (e.g., V A, TRICARE); and certain Medicare supplemental (Medigap) policies. For detailed information on Creditable Coverage, please visit: http://www .cms. gOV /Cred i tab I eCoverage/ Employers and unions who enroll groups of beneficiaries into Medicare prescription drug coverage may attest to their members' creditable coverage history by completing the following question: Are your prescription drug plans Creditable? D All of our employees are covered by a prescription drug plan that is Creditable. D Some or None of our employees are covered by a prescription drug plan that is creditable. Time period Creditable Coverage was not in force: From date: to date: NOTE: If the first box is checked, MVP will not send out any Creditable Coverage questionnaires to your retirees or eligible spouses on your group health plan. If the second box is checked, MVP will send out Creditable Coverage questionnaires to your retirees or eligible spouses on your group health plan. TolP~ Or-- WAPP;~6fi(l.. Group Name: ~/Oq74- Group Number: IIJI.?/~ if- Authorized Repres Date 6v- r bCH~. A. ~ vi I- 2/ ~ r 7 c;rurx ~TJ (2y,r1 ).~ Authorized Representative Name and Title (Please Print) MVP Health Plan, Inc. Preferred GOLD HMO 2013 Group Customer Quote , ~ tt1'XAe Customer Name: TOWN OF WAPPINGER Customer Number: 210974 0002 Contract Period: 1/1/2013 thru 12/31/2013 Region: Mid-Hudson Product Description and Rates: MVP PRODUCT HG130028/ RHG0067X BASE PLAN MC029GR PCP Office Visits $10 Specialist Office Visits $15 Hospital Inpatient Copay $0 Emergency Room $65 Skilled Nursing Facility Copay $0 days 1-20; $135/day days 21-100 Eyewear $100 Annual Allowance Hearing Aids $600 Allowance /3 years Dental Not Covered Attached Riders: MRX055A1MRX055B RX $5/$15/$30/$30/$0-EGWP Plus Plan-Copays Thru Gap Copay Change Rider MR019B - Copay BUY UP Rider - (from Bid FFS to BUY UP Plan) - MID-HUDSON Eyewear MR002 Eyewear $100 Allowance Hearing Aids MR003 Hearing Aids $600 allowance/3years Dental Rider Not Covered Contingencies: Group Retiree members must be enrolled in Medicare Part A and Part B to be eligible to join MVP Medicare Advantage Plans. Employer must contribute a minimum of 80% of the member premium. Minimum reauirement of 3 enrolled contracts. Rates per Subscriber per Month $329.80 These rates are approved and guaranteed through 12/31/2013 Rates must be accepted no later than November 302012 Name of Group Representative ,~ c? ~ .,Group Ropres.n"'ivo Date /U/ij/ ~ /':2-- aej201 0_1 005Update Gold HMO-PaS_Town of Wappinger _1-1-13.xls, CustomerQuoteC MVP Health Plan, Inc. Article 44 HMO NEW YORK GROUP RATE QUOTE TOWN OF WAPPINGER 210974_0001 Contract Period: 1/01/2013 - 12/31/2013 Q1 - 2013 Approved Guaranteed 10-5-12 Package A Benefits COC-20+L PCP/Specialist Copay $20/$20 Inpatient Hospital Copay $0 Per admission Outpatient Surgery $20 Facility Fee, $20 Phys (in office) Emergency Room $50 Ambulance $0 Attached Riders: External Prosthetic Devices, Ostomy Supplies & Durable Medical MED513L Equipment 80% FRNY-1G Grandfathered UNQ012NY Federal Womens Health Mandate UNQ013NY NY Autism Mandate DP500L Domestic Partner Benefits (B/12/12) RX-RX504L $10 Generic Copay/$30 Brand Copay/$50 Non-Formulary Copay MVP reserves the right to adjust rates due to changes in Federal or State benefit mandates or tax policies. Quoted Rate: SINGLE $ 697.63 DOUBLE $ 1,395.26 PARENT CHILD $ - FAMILY $ 1,813.83 Log# 30423 Package Sold I Marketing Representative: Date: Group RepresentatjVe/Broker:~a_~ Date: /f/INI.;H'/~ I I 10/16/2012 10/5/2012 ApprovedGuaranteed 30423_JSB_TOWN OF WAPPINGER_Guaranteed_HMO_101212.xls