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Item 4C - MemoItem 4C ICITY OF SOUTHLAKE MEMORANDUM June 9, 2025 TO: Alison D. Ortowski, City Manager FROM: Stacey Black, Assistant City Manager / Senior Director of Human Resources SUBJECT: Approve a contract renewal with Cigna to provide employee health, dental, and vision insurance benefits for Plan Year October 1, 2025 through September 30, 2026. Action Requested: Approve a contract with Cigna to provide employee health, dental, and vision insurance benefits for the Plan Year October 1, 2025 to September 30, 2026. Background Information: The City offers a comprehensive benefits package to its full-time employees, which includes medical, dental, and vision insurance. Following a competitive selection process, Cigna has served as the City's insurance provider since October 1, 2021. Cigna currently offers employees three fully -insured medical plan options, two dental plan options, and one vision plan. Each year, Cigna provides proposed renewals for each plan. These renewals are reviewed to assess financial impact, claims experience, market competitiveness, and employee feedback. Health Insurance Renewal. Claims Experience and Renewal Context. The City's recent health insurance claims activity continues to reflect high utilization. Over the past 12 months, the City's loss ratio, the percentage of premiums used to pay employee medical and prescription claims, was 92%, indicating that nearly all premium dollars collected were spent on healthcare expenses. This trend has been consistent over the past several years, with loss ratios of 93% in FY 2022, 94% in FY 2023, and 100% in FY 2024, when claims costs fully matched premiums paid. This level of claims activity exceeds industry norms, where a sustainable loss ratio typically falls between 70% and 80%. High and sustained loss ratios signal elevated risk for the insurance provider and typically result in higher premium increases. In response to this trend, Cigna initially proposed a 9% rate increase for the upcoming Alison D. Ortowski, City Manager Item 4C June 9, 2025 Page 2 plan year. Negotiated Renewal Terms. Following extensive negotiations, the City successfully reduced the proposed rate increase from 9% to an average increase of 5%. It is important to note that the rate increase varies by plan option due to differences in usage. This outcome is favorable in light of the City's claims history and broader national trends in rising healthcare costs. The reduction demonstrates Cigna's willingness to work collaboratively with the City to maintain a cost-conscious yet sustainable benefits program. Plan Design Adjustments. The high -deductible health plan (HDHP) deductible will increase by $100, from $3,200 to $3,300. No other plan design changes are proposed. The City will continue to offer three medical plan options: • High -Deductible Health Plan (HDHP) with HSA • Narrow -Network Plan • Open -Access Buy -Up Plan In addition, the monthly administration fee for health savings accounts (HSAs) will be reduced from $3.30 to $2.79 per employee, generating approximately $565 in annual cost savings for the City. Employee Feedback and Plan Value. According to the 2025 Employee Benefits Survey, 91 % of employees feel that the current health insurance plan meets the needs of both themselves and their families. Improvements in Cigna's member service resolution rate were also noted. Employees emphasized the importance of affordability, provider access, and plan choice, factors that remain central to the proposed renewal. Financial Impact. The proposed 5% rate increase results in an estimated $177,000 increase in the City's annual contribution, bringing the projected total to approximately $5.9 million for FY 2026. These figures are based on current enrollment and will be included in the proposed FY 2026 budget. Given the City's ongoing high claims experience, the originally proposed 9% rate increase, and the successfully negotiated reduction to 5%, staff believes the renewal is favorable and fiscally responsible. The proposed plan maintains employee choice and coverage quality while minimizing financial impact. Alison D. Ortowski, City Manager June 9, 2025 Page 3 Dental Insurance. Item 4C Cigna's dental insurance renewal includes a 1.5% rate increase and a two-year rate guarantee, helping stabilize costs for the City and employees. In the last 12 months, Cigna reports the City has experienced an approximate 74% loss ratio for dental claims. Due to the increasing cost of dental procedures, Cigna's dental renewal proposes a 1.5% rate increase for the PPO dental plan and a 1.5% increase for the DMO dental plan. Both the City and employees share the cost of dental insurance. In direct response to employee feedback regarding dental coverage, the renewal proposes adding a third premium dental plan. This new plan will offer enhanced coverage and provider flexibility at no additional cost to the City, expanding choice and addressing concerns about coverage for major dental procedures. The new DPPO Premium Plan offers several enhancements designed to improve coverage and reduce out-of-pocket costs for employees. The plan features lower deductibles, $25 for individuals and $75 for families, and increases the annual maximum benefit to $2,500 per person. In addition, many commonly used restorative services, such as crown repairs, inlays, stainless steel and resin crowns, and denture adjustments, have been reclassified from Class 3 (major) to Class 2 (basic). This shift results in higher reimbursement rates and more affordable care for employees. Class 3 is now reserved for major services only, including bridges, dentures, and implants. The estimated annual cost of the premium increase for the City's contribution is $2,430 Vision Insurance. Cigna has proposed an 8% rate increase for vision insurance as part of this year's renewal. This adjustment coincides with the expiration of the City's current three-year rate guarantee, which has been in place since 2022. As part of the renewal, Cigna is offering a new three-year rate guarantee, providing price stability through 2028. In response to employee feedback and preferences expressed in the 2025 Employee Benefits Survey, the City will introduce a second vision plan option for the upcoming year. This new Vision Buy -Up Plan is intended to expand coverage choices and address concerns related to provider access and eyewear affordability. The enhanced plan increases the frame allowance from $130 to Alison D. Ortowski, City Manager June 9, 2025 Page 4 Financial Considerations: Item 4C $200 and raises the lens allowance from $110 to $180. These upgrades are aimed at reducing out-of-pocket costs and giving employees greater flexibility when selecting higher -quality frames and lenses, directly aligning with the needs and priorities shared by employees. Vision insurance is optional, and employees contribute 100% of the cost. Based on the City's ongoing claims experience and the continued rise in medical and prescription drug costs, staff believes the proposed health, dental, and vision insurance renewals represent a financially responsible and competitive option. Staff recommends that City Council approve the renewals as presented. COVERAGE RATE INCREASE ESTIMATED ANNUAL TOTAL CITY CONTRIBUTION ESTIMATED ANNUAL INCREASE Health Insurance 5.0% $5,916,056 $177,000 Dental Insurance 1.5% $177,383 $2,430 Vision Insurance 8.0% $0 $0 The cost estimates reflected above assume current employee enrollment and elections. The proposed insurance plan costs will be included in the proposed budget for FY 2026. Strategic Link: Performance Management and Service Delivery and L3: attracting, developing, and maintaining a talented and motivated workforce for lasting world -class performance. Citizen Input/ Board Review: N/A Legal Review: N/A Alternatives: Deny the contract with Cigna and seek alternative options. Supporting Documents: The following supporting documents are attached: 0 Cigna Health Insurance Renewal Alison D. Ortowski, City Manager Item 4C June 9, 2025 Page 5 Cigna Dental Insurance Renewal Cigna Vision Insurance Renewal Staff Recommendation: Approve a contract with Cigna to provide employee health insurance, dental insurance, and vision insurance benefits for the Plan Year October 1, 2025 through September 30, 2026. Cigna HealthCare Financial Proposal for City of Southlake Insurance Trust Fund 1400 Main St., Suite 210 Southlake, TX 76092-7645 SIC Code: 9111 Account Number: 3344509 Total Eligible Employees: 340 Participating Subscribers: 332 Waiting Period: Eligibility Definition: Active Employees working 30 hrs Effective Date: October 01, 2025 Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are subject to change in the event of changes in benefits selected or changes in the risk factors upon which the Quoted Rates are based. In addition, state law may require regulatory approval of rates. If required regulatory approval has not been obtained on the proposed effective date, the healthplan shall use rates that are consistent with its then currently approved rating methodology and the quoted rates shall be effective immediately on the date for which they are approved for use. The Quoted Rates are guaranteed while the Group Service Agreement remains in effect until the next anniversary date, unless enrollment changes by 10% in which case Cigna HealthCare may change the Quoted Rate. Date: May 22, 2025 Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 Q1 P3 As -Is: +5% no -shop, $40k well. Cigna. Cigna PLAN OFFERED LocalPlus In -Network - LOCALPLUS Open Access Plus In- Network - NATIONAL OAP OAPIN Buy Up LCPIN Mid Plan Offering Triple Option Triple Option Plan Name OAPIN Buy Up (37256710) LCPIN Mid (37256713) Medical Management Model Complete Care Complete Care Health Advocacy Excluded Excluded Situs TX TX Funding Fully Insured Fully Insured M MEDICAL BENEFITS* Collective Deductible NO NO Collective OOP NO NO Combined Medical/Pharmacy Ded/OOP Combined OOP Only Combined OOP Only Variable Coinsurance Applies YES YES Plan Deductible Order of Applicability Benefit Copay, Plan Deductible, Coinsurance Benefit Copay, Plan Deductible, Coinsurance In -Network: Office Copay - PCP $30 $30 Office Copay - SPC $50 $50 Inpatient Deductible - Per Admit NA NA Inpatient Deductible - Per Day NA NA Outpatient Facility Copay None None Emergency Room Copay $500 $500 Urgent Care Copay $50 $50 Advanced Radiology Imaging Copay - Office None None Advanced Radiology Imaging Copay - Outpatient None None Deductible - Individual $2,000 $1,500 Deductible - Family $4,000 $3,000 Out -of -Pocket - Individual $5,500 $5,000 Out -of -Pocket - Family $11,000 $10,000 Out -of -Pocket - Family - Individual Amount $5,500 $5,000 Out -of -Pocket Max Deductibles Ded Accumulates Ded Accumulates Out -of -Pocket Max Copays All Copays Accumulate All Copays Accumulate Coinsurance Variable Variable PCP Office Visits 100% 100% Specialist Office Visits 100% 100% Inpatient Hospital Facility 80% 80% Outpatient Hospital Facility 80% 80% Inpatient Professional Services 80% 80% Outpatient Professional Services 80% 80% Emergency Room 80% 80% Urgent Care 100% 100% Laboratory Services at an Outpatient Facility 100% 100% Laboratory Services at an Independent Lab Facility 100% 100% Radiology Services at an Outpatient Facility 100% 100% Cigna Pathwell Specialty Drug Coinsurance 80% 80% Other Medical Pharmaceutical Drug Coinsurance 1 80% 1 80% Mental Health/Substance Use Disorder (Yes/No Vision Rider (Yes/No) *High level benefit summary. Please see your plan summary for a more detailed benefit description. If this proposal includes Cigna Care Network, the level of in -network benefits applicable may vary from what is shown above. Acct#:3344509/OP-5565553/Q1/3536283 Page 2 of 11 6/9/2025 4:37 PM Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 Q1 P3 As -Is: +5% no -shop. $40k well. Cigna. Cigna PLAN OFFERED Open Access Plus In- Network - NATIONAL OAP LocalPlus In -Network - LOCALPLUS OAPIN Buy Up LCPIN Mid Plan Offering Triple Option Triple Option Plan Name OAPIN Buy Up (37256710) LCPIN Mid (37256713) Medical Management Model Complete Care Complete Care Health Advocacy Excluded Excluded Situs TX TX Funding Fully Insured Fully Insured Pharmacy Benefits Pharmacy Network Cigna 90 Now CVS Cigna 90 Now CVS Formulary/Prescription Drug List Standard Standard Retail Generic Copay $10 $10 Retail Pref Brand Copay $35 $35 Retail Non Pref Brand Copay $70 $70 Retail Specialty Copay $150 $150 Retail Generic Copay (90 Days) $25 $25 Retail Pref Brand Copay (90 Days) $88 $88 Retail Non Pref Brand Copay (90 Days) $175 $175 Home Delivery Generic Copay $25 $25 Home Delivery Pref Brand Copay $88 $88 Home Delivery Non Pref Brand Copay $175 $175 Home Delivery Specialty Copay $375 $375 Pharmacy Deductible - Individual None ($0) None ($0) Pharmacy OOP Maximum - Individual Combined With Medical Combined With Medical Out -of -Pocket Adjuster Program Excluded Excluded 'High level benefit summary. Please see your plan summary for a more detailed benefit description. If this proposal includes Cigna Care Network, the level of in -network benefits applicable may vary from what is shown above. Page 3 of 11 6/9/2025 4:37 PM Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 1 Y3 As -is: +o /o no-snop, N4UK Well. ana PLAN OFFERED Plan Offering Plan Name Medical Management Model Health Advocacy 5rtus Funding Cigna MEDICAL BENEFITS* Collective Deductible Collective OOP Combined Medical / Pharmacy Ded / OOP Deductible/OOP Max Accumulator Variable Coinsurance Applies Plan Deductible Order of Applicability In -Network: Office Copay - PCP Office Copay - SPC Deductible - Individual Deductible - Family Individual - In a Family Amount Deductible Out -of -Pocket - Individual Out -of -Pocket - Family Out -of -Pocket - Family - Individual Amount Out -of -Pocket Max Deductible Out -of -Pocket Max Copays Coinsurance Cigna Pathwell Specialty Drug Coinsurance Other Medical Pharmaceutical Drug Coinsurance Adult Preventive Care Out of Network: Deductible - Individual Deductible - Family Individual - In a Family Amount Deductible Out -of -Pocket - Individual Out -of -Pocket - Family Out -of -Pocket - Family - Individual Amount Out -of -Pocket Max Deductibles Out -of -Pocket Max Copays Coinsurance Cigna Pathwell Specialty Drug Coinsurance Other Medical Pharmaceutical Drug Coinsurance MRC Fee Schedule Percentage (Professional) MRC Fee Schedule Percentage (Facility/Ancillary) Mental Health/Substance Use Disorder (Yes/No) Vision Rider (Yes/No) Employer Fund Contribution Fund Amount - Individual Fund Amount - Family Eligible Expense summarv. Please see vour plan summary for a more detailed benefit description. If this proposal includes Cigna Care Network, the level of in -network benefits applicable may vary from what is shown above. Cigna. CIGNA HealthCare - Choice Fund HSA Open Access Plus - NATIONAL OAP HSA OAP Base Triple Option HSA OAP Base (37256707) Complete Care Excluded TX Fully Insured NO NO Combined Ded & OOP No Cross Accumulation NO Plan Deductible, Benefit Copay, Coinsurance None None $3,300 $6,000 $3,300 $6,000 $12,000 $6,000 Ded Accumulates All Copays Accumulate 90% 90% 90% 100%, No Ded $6,000 $18,000 $6,000 $12,500 $37,500 $12,500 Ded Accumulates All Copays Accumulate 50% 50% 50% 110% 110% Yes No $0 $0 Included Acct#:3344509/OP-5565553/Q1/3536283 Page 4 of 11 6/9/2025 4:37 PM Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 Cigna PLAN OFFERED Plan Offering Plan Name Medical Management Model Health Advocacy Situs Funding Pharmacy Benefits Pharmacy Network Formulary/Prescription Drug List Retail Generic Copay Retail Pref Brand Copay Retail Non Pref Brand Copay Retail Specialty Copay Retail Generic Copay (90 Days) Retail Pref Brand Copay (90 Days) Retail Non Pref Brand Copay (90 Days) Home Delivery Generic Copay Home Delivery Pref Brand Copay Home Delivery Non Pref Brand Copay Home Delivery Specialty Copay Pharmacy Deductible - Individual Pharmacy OOP Maximum - Individual Out -of -Pocket Adjuster Program summary. mease see your plan summary Tor a more detailed benefit description. If this proposal includes Cigna Care Network, the level of in -network benefits applicable may vary from what is shown above. 0,111's Cigna. CIGNA HealthCare - Choice Fund HSA Open Access Plus - NATIONAL OAP Triple Option HSA OAP Base (37256707) Complete Care Excluded TX Fully Insured Cigna 90 Now CVS Standard $10 $35 $70 $150 $25 $88 $175 $25 $88 $175 $375 Combined With Medical Combined With Medical Excluded Page 5 of 11 6/9/2025 4:37 PM x;t . 4-c. Cigna. Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 Q1P3 As -Is: +5% no -shop, $40k well. Cigna PLAN OFFERED CIGNA HealthCare - Choice Fund HSA Open Access Plus - NATIONAL OAP HSA OAP Base Plan Offering Triple Option Plan Name HSA OAP Base Situs TX HSA OAP Base TXOAPD, TXOAPF, TXOAPN, TXOAPW, TXOAPX Subscribers Members Current Rate Renewal Rate Monthly Billed Change Amount Employee 50 $752.80 $831.49 $41,574.50 10.45% Emp +Spouse 7 $1,685.89 $1,862.11 $13,034.77 10.45% Emp + Child(ren) 17 $1,488.66 $1,644.26 $27,952.42 10.45% Emp + Family 19 $2,474.90 $2,733.59 $51,938.21 10.45% Monthly Billed Amount 93 192 $134,499.90 Cigna PLAN OFFERED Open Access Plus In- Network - NATIONAL OAP OAPIN Buy Up Plan Offering Triple Option Plan Name CAPIN Buy Up Situs TX OAPIN Buy U TXOAPD, TXOAPF, TXOAPN, TXOAPW, TXOAPX Subscribers Members Current Rate Renewal Rate Monthly Billed Change Amount Employee 71 $931.77 $962.33 $68,325.43 3.28% Emp + Spouse 10 $2,077.89 $2,146.03 $21,460.30 3.28% Emp + Child(ren) 31 $1,835.64 $1,895.84 $58,771.04 3.28% Emp + Family 26 $3,046.94 $3,146.86 $81,818.36 3.28% Monthly Billed Amount 138 293 $230,375.13 Cigna PLAN OFFERED LocalPlus In -Network - LOCALPLUS LCPIN Mid Plan Offering Triple Option Plan Name LCPIN Mid Situs TX LCPIN Mid TXLCPD, TXLCPF, TXLCPX Subscribers Members Current Rate Renewal Rate Monthly Billed Change Amount Employee 44 $905.04 $936.14 $41,190.16 3.44% Emp + Spouse 11 $2,018.22 $2,087.58 $22,963.38 3.44% Emp + Child(ren) 17 $1,782.91 $1,844.18 $31,351.06 3.44% Emp + Family 29 $2,959.45 $3,061.15 $88,773.35 3.44% Monthly Billed Amount 101 236 1 $184,277.95 Note: The fee associated with the administration of the HRA and/or HSA product and Incentive Program are excluded from the Rates. Above rates do not reflect employer liability for fund contributions Included in the proposed Monthly Billed Amount is the Benefit Advisor Fee which is not part of the monthly premium. Acct#:3344509/OP-5565553/Q1/3536283 Page 6 of 11 6/9/2025 4:37 PM Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 Program Administrative Fees 4% Cigna, Fee Type Enrollment PEPM Fee CIGNA HealthCare - Choice Fund HSA Open Access Plus - HSA Administrative Fee 88 $2.79 CIGNA HealthCare - Choice Fund HSA Open Access Plus - Incentive Program 88 $0.00 Open Access Plus In- Network - NATIONAL OAP Incentive Program 135 $0.00 LocalPlus In -Network - LOCALPLUS Incentive Program 108 $0.00 Total Program Administrative Monthly Fees $259.47 For Cigna Healthcare HSA products, the Fees above include the Cigna Healthcare Administrative Fee plus any Additional Options selected. For Cigna Healthcare products, the Fees above include the Incentive Program Fees. Acct#:3344509/OP-5565553/Q1/3536283 Page 7 of 11 6/9/2025 4:37 PM Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 PROPOSAL TERMS AND CONDITIONS for Proposal: Q1 P3 As -Is: +5% no -shop, $40k well. A. General Terms of this Proposal eWn i!r . Cigna. Cigna HealthCare is pleased to present this Proposal for a Fully Insured Non -Participating group medical and pharmacy benefit plan (the "Plan") sponsored by City of Southlake Insurance Trust Fund. This proposal is valid for 60 days from its original date of release,05/22/2025. Any revisions or updates to this proposal will not renew this valid timeframe unless expressly communicated by Cigna HealthCare. Proposal Caveats Cigna HealthCare may revise or withdraw this Proposal if: 1 there is a change to the effective date and/or duration of the period covered by the quote. 2 the policy period length is different than 12 months. 3 the policy will not be sitused in TX. 4 there is a change in any law, regulation, or required assessment or tax that changes Cigna HealthCare's costs in offering the plan. 5 enrollment increases or decreases by 10% or more, by product or for the total account, from the enrollment assumptions used in establishing the rates, fees, funds and/or fee credits set forth herein. 6 the final enrollment deviates from the quoted enrollment such that it results in a needed change in premium rates. Rates are based on final enrollment factors, including total number of enrollees, their age, sex, demographics, location and the distribution of enrollees by product or by customer tier. 7 enrollment in the Cigna HealthCare administered plan is less than 50% of the total eligible population identified as 340. 8 requires you to notify us within 30 days if any of the information upon which these rates or benefits were based (including Medical History Information) changes or is inaccurate. 9 it is not the exclusive provider of Medical / Pharmacy or like products for all of City of Southlake Insurance Trust Fund's employees in all worksites. 10 the employer contributes less than 50% toward the total cost of the coverage elected by each enrolled employee. 11 the current waiting period is different than . 12 By way of illustration, such legislation or executive actions which impose controls or requirements that affect: our ability to determine rates; covered medical expenses or service benefits; providers' delivery of care or the fees they charge; or our contracts with providers, may be deemed to so affect our contractual obligations. Should this happen, Cigna HealthCare will make a good faith effort to work to reach a new agreement that equitably reflects the circumstances as altered by government action. 13 there is any reimbursement arrangement ("gap" cards, etc.) that subsidizes or reduces the out-of-pocket obligation of covered persons under the policy. 14 benefit advisor fees/commissions are requested to be different than 4.20%. 15 Client confirmation of employee counts reveal the group to be a Small Employer,as defined under the Patient Protection and Affordable Care Act,and accordingly Cigna HealthCare is not able to offer a PPACA compliant plan. B. Scope and Application of this Proposal Unless otherwise indicated, the coverage reflected in this Proposal: 1 supersedes and renders null and void any prior Cigna HealthCare offer or proposal with respect to the Plan. 2 Assumes incentive design follows the standard guidelines offered by Cigna Healthcare. Incentive rewards will be funded by the client and certain reward types will be direct billed or withdrawn from the bank account (as applicable). 3 or policy may be canceled as of any Premium Due Date if the number of insured Employees fails to meet the minimum required per group participation rules; or for failure to comply with any other material plan provision relating to Employer contributions or group participation rules. 4 includes fixed charges for behavioral care services arranged by Evernorth Behavioral Health, Inc. or Evernorth Care Solutions, Inc. The fixed fee varies depending on location and plan design and may not apply in certain states. 5 includes capitated charges for the provision of Hi -Tech Radiology services by eviCore. Reimbursement methodology varies by state. 6 includes charges made by either a specialty vendor or an affiliate, such as eviCore for care management programs to contain the cost of specific health services/items and/or improve adherence to evidence -based guidelines to promote patient safety and efficient care (i.e., charges for management of diagnostic cardiology, radiation therapy, musculoskeletal procedures, medical oncology, gastroenterology, sleep management and home health/DME/HIT and appropriate setting of care/service) when applicable, and medical necessity review (i.e chiropractic services). 7 includes Cigna Pathwell Specialty, a network solution for medical specialty drugs. 8 includes Cigna's One Guide digital and customer guidance solution. 9 requires a separate benefit option due to state regulations, if you have purchased any product with Cigna Total Behavioral Health and you have customers residing in CA or VI. 10 does not apply to part-time or seasonal employees for any plan. 11 Medicare eligible retirees are not included in this plan unless mandated by situs state legislation. 12 includes Cigna's Network Savings Program (NSP) and other Bill Negotiation Services (BNS) programs designed to contain costs with respect to charges for out -of -network health care services/supplies that are covered by the Plan and reduce the member's balance billing exposure. For administering these programs, Cigna retains a portion of the savings generated. 13 excludes charges for converting a qualified customer of a group plan to an individual plan. 14 includes a maximum reimbursable charge (MRC) for out -of -network coverage equal to 110% of a fee schedule developed by Cigna HealthCare based upon a methodology similar to that used by Medicare to determine the allowable fee for similar services in the geographic market OR, where that fee schedule does not provide a value, Cigna may determine the MRC based on a rate for the same or similar service or supply by applying a Medicare -based methodology that Cigna deems appropriate. 15 assumes all employees are located in the network area, and that all employees are only eligible for the Cigna HealthCare or any other affiliated company product offerings specified. 16 may require regulatory approval of rates. If, as of their proposed effective date, regulatory approval is not obtained, the healthplan shall use rates consistent with its then currently approved rates and the foregoing rates shall be effective automatically. If a product is new and has never had approved rates, the effective date of coverage will be postponed until regulatory approval is received. 17 allows caveats and conditions set forth in this document to survive execution of any final contract and/or issuance by Cigna HealthCare of any policy and/or Group Service Agreement. Acct#:3344509/OP-5565553/Q1/3536283 Page 8 of 11 6/9/2025 4:37 PM 18 assumes that Cigna HealthCare's standard insurance policy form approved for use in the applicable state by the state insurance regulator will be issued. Because the insurance policy and certificate terms require regulatory approval, there is very little flexibility to change the provisions. The provisions of the insurance policy and certificate will control in the event of a conflict with the terms of the request for proposal and the Proposal. Cigna. r 19 is a high-level summary of the proposed coverage. It does not identify all the categories of health care expenses that are covered or excluded. 20 may include state required continuation rates which will match the rates for the underlying plan. For Nebraska and New York Over Age Dependents the rates will match the employee rate for the underlying plan. 21 includes fixed charges for Embarc Benefit ProtectionsM, a network solution for certain high -cost gene therapy drugs arranged by eviCore. 22 Cigna HealthCare assumes that the group health plan or health insurance coverage to which this proposal applies will not be a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the "Act") and that it will be subject to all requirements of the Act applicable to a group health plan or health insurance coverage unless otherwise specified in writing. 23 includes applicable Patient Protection and Affordable Care Act fees and assessments imposed upon health insurers including the Comparative Effectiveness Research Fee. 24 Assumes a non -Cigna HealthCare Pharmacy Benefit Manager administers oral or other self-administered anti -cancer prescription medication claims at a copayment/coinsurance level that is no less favorable than that for intravenous or injected anti -cancer medication prescribed for the same purpose and covered under employer's Cigna HealthCare plan. This assumption is applicable only if: (a) employer has contracted with a PBM (not Cigna HealthCare); (b) employer's plan is either insured, or, if self -funded, not subject to ERISA (i.e., is a church, government or association plan); and (c) employer's Cigna HealthCare plan is sitused in IA, HI, NM, OR, NJ, NE, VA, MA, NV, FL, ME, GA or a state with similar chemotherapy coverage law, or covers one or more individuals residing in CO, OK, VT, WA, TX, LA, MO or OH or in a state with similar extraterritorial chemotherapy coverage mandate. 25 establishes a Wellness/Health Improvement Fund (the "Fund") in the amount of $40000.00 for clinical/wellness/behavioral programs offered by Cigna HealthCare. These funds shall be used to defray the cost of Cigna HealthCare designated and arranged health and wellness improvement programs for employees (e.g., biometric screenings, flu shots, etc.) and to reward participation in these programs. The Fund may be accessed during the period from 10/01/2025 - 09/30/2026. The Fund may not be accessed following notice of termination of the Cigna HealthCare agreement. Unused funds cannot be rolled over and Cigna HealthCare must pre -approve use of the Fund. 26 Important Notice Regarding Benefit Advisor Compensation - The premium for this guaranteed cost (i.e., non -Shared Returns) policy may not include compensation payable to your benefit advisor. Check with your Cigna Sales representative to confirm whether this is the case. When that is the case, the proposed billed amount includes both premium and benefit advisor fees, which are not part of the monthly premium and Cigna will include any benefit advisor fees agreed to by the client and benefit advisor on client invoices and forward payments received to the benefit advisor if both the client and the benefit advisor authorize Cigna to do so by signing Cigna's Client and Benefit Advisor Acknowledgement Form. When required, this form must be signed before the date when the new rates take effect. If the form is not signed, the benefit advisor will be responsible for billing the client directly for any benefit advisor fees. 27 This proposal made by Cigna HealthCare is contingent upon: Cigna HealthCare's receipt of the following information: -Completed medical history questionnaire prior to the policy effective date. 28 assumes that any non -voluntary vision benefit that is included in the medical plan and not provided through a separate policy is subject to ACA requirements. 29 does not apply to individuals unless employed by the policyholder or an entity that participates in an association or trust that is the policyholder. o ADDITIONAL GENERAL TERMS OF THIS PROPOSAL: 30 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 the information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used, disseminated, disclosed or otherwise 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. C. Additional Representations & Disclosures 1 Each plan presented in this proposal has an actuarial value, determined by Cigna HealthCare, of 60% or greater. This determination was made using Cigna HealthCare's manual rating application which may produce an actuarial value slightly different than the official HHS calculator. Although we would expect any deviation to be small, you will have to consult with your actuarial consultant for a more precise determination of the plan's actuarial value. Cigna HealthCare does not provide actuarial certifications. 2 In order to implement the requested benefit design, different funding arrangements (i.e., insured, self -insured and/or HMO) involving affiliated Cigna companies may be required with respect to plan participants residing in certain states. 3 Cigna HealthCare may have an agreement with your benefit advisor, under which the benefit advisor may be paid for providing marketplace intelligence or for the performance of administrative services. The qualification for and amount of this payment may be based upon overall business growth and/or retention levels. Any such payment is funded through Cigna HealthCare's general overhead. 4 The benefit advisor may qualify for incentive payment (monetary or non -monetary) from Cigna HealthCare. For example, the benefit advisor may receive payment based upon new sales, new customer growth or retention. This incentive payment is funded from Cigna HealthCare's general overhead. 5 Cigna HealthCare sponsors programs to inform benefit advisors about Cigna HealthCare's plan coverage and services (including producer advisory councils). The cost of these events is funded through Cigna HealthCare's general overhead. 6 Cigna HealthCare reserves the right to change the Quoted Rates and/or Quoted Benefits or to decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed Effective Date indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of this summary information form. If any of the information identified above changes either prior to the proposed Effective Date or while coverage is in effect, you agree to notify us promptly of such change. 7 The Underwriting Contingencies set forth above shall survive execution of any insurance policy, application, etc., issued by Cigna HealthCare or any affiliated company, and shall further survive the effective date of any such policies. 8 The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the rates. Please review the Benefit Summary and its attachments for information about the benefits available in your sites. 9 "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. Acct#:3344509/OP-5565553/Q1/3536283 Page 9 of 11 6/9/2025 4:37 PM 41Vh 'r Cigna. Gap Fund Acknowledgement Are your employees reimbursed for their co -payments, co-insurance cost, deductibles or out of pocket expenses? If so, please let us know the details below. If not, please still confirm and sign below. We assume NO subsidization or reimbursement for any portion of the employees' cost -sharing responsibilities. And that's how we set the premium rates/charges for all benefit plans insured and/or administered for you by Cigna HealthCare companies ("Cigna HealthCare, we, us"). Subsidization/reimbursement is also known as "Gap Funding". That is because employees receive money to fund the gap between their cost -share responsibility and Cigna HealthCare's payments. Do you offer any of these plans? ❑ YES ❑ NO - Health Savings Account (HSA) - Health Reimbursement Account (HRA) - Other means to reimburse employees for health plan expenses If YES, please confirm the following: - How much is the employer funding amount? - What is the reimbursement order? Does the HSA and/or HRA fund pay first, or something else? - Is there an annual rollover provision for the fund? ❑ YES ❑ No - Any changes in employer funding in the past year or future year? - If YES, please provide details: ❑ YES ❑ NO Please notify Cigna HealthCare prior to implementing any "Gap Funding" program. Cigna HealthCare will determine if we need to change the premium rates/charges both now and in the future based on the information you provide. Please affirm that the above information is true and complete. Thanks! City of Southlake Insurance Trust Fund Date: Title: Underwriting Contingencies For City of Southlake Insurance Trust Fund Cigna HealthCare reserves the right to change the Quoted Rates and/or Quoted Benefits or to decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed Effective Date indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of this summary information form. If any of the information identified above changes either prior to the proposed Effective Date or while coverage is in effect, you agree to notify us promptly of such change. The "Underwriting Contingencies" set forth above shall survive execution of any insurance policy, application, etc., issued by Cigna HealthCare or any affiliated company, and shall further survive the effective date of any such policies. The benefits displayed in this summary are, for the most part, modular benefit packages used to develop the rates. Please review the Benefit Summary and its attachments for information about the benefits available in your sites. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. I UNDERSTAND AND AGREE ON BEHALF OF CONTRACTHOLDER THAT CIGNA HEALTHCARE MAY, NOTWITHSTANDING THE TERMS OF THE INSURANCE POLICY OR SERVICE AGREEMENT, REVISE ANY PREMIUM RATES OR PREPAYMENTS FEES AT ANY TIME IF THE ENROLLMENT OR EMPLOYER CONTRIBUTION LEVEL IS DIFFERENT THAN ASSUMED BY CIGNA HEALTHCARE IN UNDERWRITING THE CONTRACT OR IF CIGNA HEALTHCARE IS (i) REQUIRED TO PAY ANY ASSESSMENT, OR (ii) INCUR ADDITIONAL COSTS IN ADMINISTERING THE CONTRACT AS A RESULT OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT AND THE REGULATIONS PROMULGATED THEREUNDER. Client Signature Client Name Date Title Cigna I cigna healthcare 1 urn your dental nla: �0 ci na healthcare Cigna Dental is Your New Growth Plan. Dental care is not just a cost of doing business. It's an investment in your future success. And dental benefits aren't "just dental." When provided by Cigna, your dental program can help ensure financial health, engage individual employees, nurture a healthy work culture, and prepare for the future. Cigna unlocks the full potential of your dental program to deliver more value. We help predict and manage financial risk for your company while optimizing cash flow and improving profitability. We also help your employees manage and control their health -related finances. myCigna.com gives employees 24171365 access to value -based network search tools and information that can help them find a dentist who meets their specific, unique needs. It puts them in the driver's seat and when employees utilize myCigna, they save an average of $117.10 PMPY more than those who don't, and have 6.9% more in -network claims.' Cigna Dental Oral Health Integration Program® provides proactive, personalized support for customers with one of 14 medical conditions that can be impacted by oral health risks like gum disease and cavities. Preventive care for these employees can drive average savings of 12.2% over five years 2 Our industry -leading Brighter Score technology brings customers greater transparency and guides employees to high -value in -network dentists using myCigna. Engage Individual Employees is Cigna Dental is an industry leader in engaging customers to use their preventive dental care benefits. And when customers get preventive care, the risk of developing periodontal disease, experiencing potential medical complications or needing care in the emergency room or urgent care center is reduced.' Engaging customers to get important preventive dental care through proactive, automated outreach results in a 67% increase in visits' and 31% lower future dental costs'. We connect your employees to the preventive care they need --regardless of the challenges they face. This results in 30%+ more medical cost savings for employees impacted by a high social index.' Poor oral health directly impacts employers. Every year, $800M in productivity is lost due to health -related problems, and 320.8M hours of work/school are lost for dental cares 92.4M of those hours are lost for unplanned or emergency dental care.5 The Cigna Dental program can help reduce lost productivity by making it easy and affordable for employees to access dental care, when, how and where employees need it most. Making it easy and affordable to access care by bringing network dentists right to the workplace through Cigna Onsite Dentalsm Moving the center of care to support better oral health routines with Cigna @Home Dental can help to reduce plaque by 77%.7 Reducing the risk of opioid addiction through our proprietary opioid dashboard and safe prescribing program has resulted in a 23% reduction in the number of prescriptions written for children under 18, and a 9% reduction overall e Prepare for the Future At the heart of our dental solution is the relentless pursuit of innovation. Cigna continuously innovates for the future to address the health challenges of today and tomorrow. From the beginning of each customer's journey with us, we are by their side. Enrollment support, oral health assessments, network search -ability, treatment cost estimators, 24171365 access to dentists through Cigna Dental Virtual Care - our proactive and innovative solutions make getting dental care affordable and easy. The Cigna Dental Innovation Studio delivers forward -thinking, customer -centric solutions to help improve outcomes. It's part of our dedication to staying ahead of challenges and bringing the latest solutions to you and your employees to promote whole person health. Cigna Dental Payment Solutions is an innovative program designed to help customers turn out-of-pocket dental expenses into a more affordable payment plan with no additional fees or interest charges. 1. Internal reporting as of November 2021 for DPPO customers who use myCigna and customers who do not use myCigna. 2. "Preventive Dental Treatment Associated with Lower Medical Utilization and Costs.' Cigna national study, December 2020. Individual results may vary. 3. Internal reporting as of November 2021 for DPPO customers who received email for overdue preventive rare and outof-network claims. 4. "Preventive Dental Treatment Associated with Lower Medical Utilization and Costs." Cigna national study, December 2020. Individual results may vary. 5. Kelekar, Uma, and Shillpa Naavaal.'Hours Lost to Planned and Unplanned Dental Visits Among US Adults." Preventing chronic disease vol. 15 E04. 11 Jan. 2018, doi:10.5888/pcd15.170225. Accessed November 2021. 6. Cigna provides access to virtual care through national teledental care providers via myCigna.com as pad of your plan. Providers are solely responsible for any treatment provided to their patients. Video chat may not be available in all areas or with all providers and is a requirement for this service. See your plan materials for the details of your speck Dental plan. This service is separate from coverage for virtual dental care obtained by your Dental plan's network and may not be available in all areas. A referral is not required for this service 7. Kay, E., Shou, L. A randomised controlled trial of a smadphone application for improving oral hygiene. Br Dent J 226, 508511 (2019). 8. Internal report published in 2019, based on review and analysis of 2015-2018 Cigna pharmacy claims and Cigna dental membership data. Results may vary. Oppty #: OP-5064163 6/9/2025 4:33 PM Cigna Healthcare Financial Exhibit for: -60 � Zotrcig City of Southlake Insurance Trust Fund GY GC Dentacom healthcare Effective Date: October 01, 2025 This is a summary of benefits for your dental plan. All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network. Your DPPO"" plan allows you to see any licensed dentist, but using an in -network dentist may minimize your out-of-pocket expenses. Plan Design Total Network— Out -of -Network Calendar Year Maximum (Class I, II, III, IX Expenses) $1750, Class I Applies $1750, Class I Applies Calendar Year Deductible Per Individual $50 $50 Per Family $150 $150 Class I Expenses - Preventive & Diagnostic Care Oral Exams 100%, No Deductible 100%, No Deductible Cleanings Routine X-rays Fluoride Application Sealants Space Maintainers (limited to non -orthodontic treatment) Non -Routine X-rays Emergency care to relieve pain (administrated at In Network coinsurance) Class II Expenses - Basic Restorative Care Fillings 80%, After Deductible 80%, After Deductible Oral Surgery - Simple Extractions Oral Surgery - All Except Simple Extraction Surgical Extraction of Impacted Teeth Anesthetics Minor Periodontics Major Periodontics Root Canal Therapy / Endodontics Brush Biopsy Class III Expenses - Major Restorative Care Relines, Rebases, and Adjustments 50%, After Deductible 50%, After Deductible Repairs - Bridges, Crowns, and Inlays Repairs - Dentures Crowns/Inlays/O nlays Stainless Steel/Resin Crowns Dentures Bridges Class IV Expenses - Orthodontia Coverage for Eligible Children and Adults 50%, No Ortho Deductible 50%, No Ortho Deductible Lifetime Maximum $1500 $1500 Class IX Expenses - Implants 50%, After Deductible 50%, After Deductible Plan Calendar Year Max $1750 $1750 Dental Plan Reimbursement Levels I Based on Contracted Fees I 90th Percentile of Allowed Charges — Additional Member Responsibility in excess of Yes, the difference between the None member's dentist's billed charges and Coinsurance ,k_ a,.. -I 1_;_,,,._,.___+ I_­_I­ Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund GC Dentacom Effective Date: October 01, 2025 Cigna Dental Choice / Indemnity Exclusions and Limitations: Procedure Exclusions & Limitations Exams Two per calendar year Prophylaxis (cleanings) Two per calendar year Fluoride 1 per calendar year for people under 19 X-Rays (routine) Bitewings: 2 per calendar year X-Rays (non -routine) Full mouth: 1 every 3 calendar years. Panorex: 1 every 3 calendar years Cone Beams Not covered Model Payable only when in conjunction with Ortho workup Minor Perio (non -surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Prosthesis over Implants 1 per 5 years if unserviceable and cannot be repaired. Benefits are based on the amount payable for non -precious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non -Orthodontic treatment. No frequency limit for participants under ape 19. Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. cigna Missing Tooth Provision The amount payable is 50 % of the amount otherwise payable until insured for a specified time period; thereafter, considered a Class III expense Late Entrant Limit**** 50 % coverage on Class III, IV (if applicable), and IX for 12 months Pre -Treatment Review Available on a voluntary basis when extensive work in excess of $200 is proposed Benefit Exclusions: ' Services performed primarily for cosmetic reasons * Replacement of a lost or stolen appliance ' Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards ' Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion ' Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars * Bite registrations; precision or semi -precision attachments; splinting ' Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards ' Services that are deemed to be medical services * Services and supplies received from a hospital ' Charges which the person is not legally required to pay * Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service * Experimental or investigational procedures and treatments ' Any injury resulting from, or in the course of, any employment for wage or profit * Any sickness covered under any workers' compensation or similar law ' Charges in excess of the reasonable and customary allowances * To the extent that payment is unlawful where the person resides when the expenses are incurred; ' Procedures performed by a Dentist who is a member of the covered person's family (covered person's family is limited to a spouse, siblings, parents, children, grandparents, and the spouse's siblings and parents); ' For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; * To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; * To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a "no-fault" insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. ' In addition, these benefits will be reduced so that the total payment will not be more than 100 % of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer. *' In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. ***Charges are based upon an independent third party organization that is the industry standard. Percentile data is based upon the third party organization's aggregated industry -wide claims data ****Late Entrant coverage limitation does not apply to New Mexico Residents for Insured Dental Products. This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Cigna HealthCare. Did you know that most of Cigna's dental plans include the Cigna Dental Oral Health Integration Program? This program was designed to address research that supports the association of oral health to overall health and provides reimbursement of copays or coinsurance for customers with qualifying medical conditions for program eligible procedures. Additionally, registered program members can access articles on behavioral conditions that impact oral health. Cigna is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Prepared by Underwriting. Cigna Total Network (P0010) 05/28/2025 11:00 AM Cigna Healthcare Financial Exhibit for: _% 0 City of Southlake Insurance Trust Fund cigna GC Dentacom healthcare Effective Date: October 01, 2025 This is a summary of benefits for your dental plan. All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network. Your DPPO"" plan allows you to see any licensed dentist, but using an in -network dentist may minimize your out-of-pocket expenses. Plan Design Total Network— Out -of -Network Calendar Year Maximum (Class I, II, III, IX Expenses) $2500, Class I Applies $2500, Class I Applies Calendar Year Deductible Per Individual $25 $25 Per Family $75 $75 Class I Expenses - Preventive & Diagnostic Care Oral Exams 100%, No Deductible 100%, No Deductible Cleanings Routine X-rays Fluoride Application Sealants Space Maintainers (limited to non -orthodontic treatment) Non -Routine X-rays Emergency care to relieve pain (administrated at In Network coinsurance) Class II Expenses - Basic Restorative Care Fillings 80%, After Deductible 80%, After Deductible Oral Surgery - Simple Extractions Oral Surgery - All Except Simple Extraction Surgical Extraction of Impacted Teeth Anesthetics Minor Periodontics Major Periodontics Root Canal Therapy / Endodontics Relines, Rebases, and Adjustments Repairs - Bridges, Crowns, and Inlays Stainless Steel/Resin Crowns Brush Biopsy Class III Expenses - Major Restorative Care Repairs - Dentures 60%, After Deductible 60%, After Deductible Crowns/Inlays/O nlays Dentures Bridges Class IV Expenses - Orthodontia Coverage for Eligible Children and Adults 50%, No Ortho Deductible 50%, No Ortho Deductible Lifetime Maximum $1500 $1500 Class IX Expenses - Implants 50%, After Deductible 50%, After Deductible Plan Calendar Year Max $1750 $1750 Dental Plan Reimbursement Levels I Based on Contracted Fees I 90th Percentile of Allowed Charges — Additional Member Responsibility in excess of Yes, the difference between the None member's dentist's billed charges and Coinsurance ,k_ a,.. -I 1_;_,,,._,.___+ I_­_I­ Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund GC Dentacom Effective Date: October 01, 2025 Cigna Dental Choice / Indemnity Exclusions and Limitations: Procedure Exclusions & Limitations Exams Two per calendar year Prophylaxis (cleanings) Two per calendar year Fluoride 1 per calendar year for people under 19 X-Rays (routine) Bitewings: 2 per calendar year X-Rays (non -routine) Full mouth: 1 every 3 calendar years. Panorex: 1 every 3 calendar years Cone Beams Not covered Model Payable only when in conjunction with Ortho workup Minor Perio (non -surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Prosthesis over Implants 1 per 5 years if unserviceable and cannot be repaired. Benefits are based on the amount payable for non -precious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non -Orthodontic treatment. No frequency limit for participants under ape 19. Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. Cigna Missing Tooth Provision The amount payable is 50 % of the amount otherwise payable until insured for a specified time period; thereafter, considered a Class III expense Late Entrant Limit**** 50 % coverage on Class III, IV (if applicable), and IX for 12 months Pre -Treatment Review Available on a voluntary basis when extensive work in excess of $200 is proposed Benefit Exclusions: ' Services performed primarily for cosmetic reasons * Replacement of a lost or stolen appliance ' Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards ' Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion ' Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars * Bite registrations; precision or semi -precision attachments; splinting ' Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards ' Services that are deemed to be medical services * Services and supplies received from a hospital ' Charges which the person is not legally required to pay * Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service * Experimental or investigational procedures and treatments ' Any injury resulting from, or in the course of, any employment for wage or profit * Any sickness covered under any workers' compensation or similar law ' Charges in excess of the reasonable and customary allowances * To the extent that payment is unlawful where the person resides when the expenses are incurred; ' Procedures performed by a Dentist who is a member of the covered person's family (covered person's family is limited to a spouse, siblings, parents, children, grandparents, and the spouse's siblings and parents); ' For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; * To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; * To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a "no-fault" insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. ' In addition, these benefits will be reduced so that the total payment will not be more than 100 % of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer. *' In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. ***Charges are based upon an independent third party organization that is the industry standard. Percentile data is based upon the third party organization's aggregated industry -wide claims data ****Late Entrant coverage limitation does not apply to New Mexico Residents for Insured Dental Products. This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Cigna HealthCare. Did you know that most of Cigna's dental plans include the Cigna Dental Oral Health Integration Program? This program was designed to address research that supports the association of oral health to overall health and provides reimbursement of copays or coinsurance for customers with qualifying medical conditions for program eligible procedures. Additionally, registered program members can access articles on behavioral conditions that impact oral health. Cigna is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Prepared by Underwriting. Cigna Total Network (P0010) 05/28/2025 11:05 AM Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 Plan Cost Summary - Rates Total Enrollment Current Renewal Cigna Rates Choice Employee 70 $44.12 $44.78 GC Dentacom Emp + Spouse 16 $88.24 $89.56 Emp + Child(ren) 23 $98.15 $99.62 Emp + Family 37 $149.46 $151.70 Choice Employee 70 $44.12 $52.50 GC Dentacom Emp + Spouse 16 $88.24 $105.01 Emp + Child(ren) 23 $98.15 $116.80 Emp + Family 37 $149.46 $177.86 Monthly Total $24,575.42 $27,094.40 RenewalChangel 10.25% This quote assumes the proposed DPPO benefits will be administered on Dentacom. The above DPPO renewal rates are guaranteed for 2 years, valid for 10/01/2025 and 10/01/2026 effective dates Total Enrollment Current Renewal Cigna Rates Dental Care Access Plus Employee 27 $13.57 $13.78 K1-V9 Emp + Spouse 3 $25.78 $26.17 Employer Emp + Child(ren) 3 $27.16 $27.57 Emp + Family 14 $42.05 $42.69 Monthly Total $1,113.91 $1,130.94 RenewalChangel 1.53% This quote assumes the proposed DHMO benefits will be administered on WEBSTER The above DHMO renewal rates are guaranteed for 2 years, valid for 10/01/2025 and 10/01/2026 effective dates CIgIlCY neaim�a.e Account #: 3344509 6/9/2025 4:33 PM cigna healthcare Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 PROPOSAL TERMS AND CONDITIONS for Dental A. General Terms of this Proposal Cigna HealthCare is pleased to present this Proposal for a Fully Insured Non -Participating group Dental benefit plan (the "Plan") sponsored by City of Southlake Insurance Trust Fund. This proposal is valid for 60 days from its original date of release, 05/28/2025. Any revisions or updates 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 the information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used, disseminated, disclosed or otherwise 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: 1 there is a change to the effective date of the quote. 2 the Plan benefits are different than shown or benefit modifications are requested. 3 participation is below 99%. This will be based on the total eligible employees, identified as 374. 4 enrollment increases or decreases by 10% or more, by product or for the total account, from the enrollment assumptions used in establishing the rates and/or fees set forth herein. 5 it is not the exclusive provider of Dental for all of City of Southlake Insurance Trust Fund's employees in all worksites. 6 there is a change in law, regulation, tax rates, or the application of any of these that affects Cigna's costs 7 a multi -year rate/fee guarantee/cap is offered as part of the proposal and/or resulting contract, and City of Southlake Insurance Trust Fund attempts to seek a request for proposal or goes out to bid prior to the end of or does not remain with Cigna for the full term of the multi -year term period noted in this proposal and/or resulting contract. B. Scope and Application of this Proposal Unless otherwise indicated, this Proposal: 1 assumes the quoted Dental rates are valid only when Dental is packaged and sold alongside Cigna Medical. 2 assumes employer contributions match the previous year's sold quote. 3 assumes the premium rates proposed by Cigna Healthcare are subject to final Underwriting approval and may be changed due to differences ii selection of benefits, changes in census data, or any other changes in risk determined by Cigna Healthcare. 4 includes rates which are subject to regulatory approval. If, as of their proposed effective date, regulatory approval is not obtained, Cigna shall use rates consistent with its then currently approved rates and the foregoing rates shall be effective automatically upon approval. 5 assumes that Cigna HealthCare's standard insurance policy form approved for use in the applicable state by the state insurance regulator will be issued. Because the insurance policy and certificate terms require regulatory approval, there is very little flexibility to change the provisions. The provisions of the insurance policy and certificate will supersede the Proposal in the event of a conflict. 6 includes Dental rates which are guaranteed for a period of 24 months while the contract remains inforce. The guarantee is valid only if medical renews with dental in subsequent period. 7 assumes the rates contain sufficient commission load for Dental of 10%. 8 assumes only a passive DPPO plan may be offered to TX or MS employees due to regulatory requirements. 9 assumes the plan will be implemented using Cigna's standard policy provisions, limitations, and contract language as reflected in Cigna's summary plan description unless specific modifications have been approved and rated appropriately. These standards are summarized in the Underwriting benefit summary. Any benefit modifications must be communicated in writing from Underwriting. 10 Cigna's Dental and/or Vision products are "excepted benefits" and not subject to Essential Health Benefit requirements. 11 Cigna HealthCare may have an agreement with your benefit advisor, under which the benefit advisor may be paid for providing marketplace intelligence or for the performance of administrative services. The qualification for and amount of this payment may be based upon overall business growth and/or retention levels. Any such payment is funded through Cigna HealthCare's general overhead. 12 The benefit advisor may qualify for incentive payment (monetary or non -monetary) from Cigna HealthCare. For example, the benefit advisor may receive payment based upon new sales, new customer growth or retention. This incentive payment is funded from Cigna HealthCare's general overhead. 13 Cigna HealthCare sponsors programs to inform benefit advisors about Cigna HealthCare's plan coverage and services (including producer advisory councils). The cost of these events is funded through Cigna HealthCare's general overhead. Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund Effective Date: October 01, 2025 PROPOSAL TERMS AND CONDITIONS for Cigna Dental Care Rates contain sufficient load for a 10% flat commission. Rates are guaranteed for 24 months. This renewal information is being communicated in order to meet contractual requirements of changes to the rates/benefit schedules at least 60 days in advance of the change. This Cigna Dental Care ("DHMO") proposal assumes covered services will be provided by the Cigna Dental Care Access Plus network of contracted general and specialty dentists The term DHMO is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. The Cigna DHMO is not available in the following states: AK, ME, MT, NH, NM, ND, PR, SD, VI, VT, and WY. The dental insurance coverage shall be provided under a standalone group insurance policy and is an "excepted benefit" as defined in Public Health Service Act Section 2721(c) and (d). Cigna HealthCare sponsors programs to inform benefit advisors about Cigna HealthCare's plan coverage and services (including producer advisory councils). The cost of these events is funded through Cigna HealthCare's general overhead. Cigna HealthCare may have an agreement with your benefit advisor, under which the benefit advisor may be paid for providing marketplace intelligence or for the performance of administrative services. The qualification for and amount of this payment may be based upon overall business growth and/or retention levels. Any such payment is funded through Cigna HealthCare's general overhead. The benefit advisor may qualify for incentive payment (monetary or non -monetary) from Cigna HealthCare. For example, the benefit advisor may receive payment based upon new sales, new customer growth or retention. This incentive payment is funded from Cigna HealthCare's general overhead. This quote assumes that Cigna HealthCare's standard insurance policy form approved for use in the applicable state by the state insurance regulator will be issued. Because the insurance policy and certificate terms require regulatory approval, there is very little flexibility to change the provisions. The provisions of the insurance policy and certificate will supersede the Proposal in the event of a conflict. 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 the information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used, disseminated, disclosed or otherwise 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. Account #: 3344509 6/9/2025 4:33 PM CI na Cigna Vision Solution for City of Southlake Insurance Trust Fund Plan co g healthcare Effective Date : 10/01/2025 Renewal quote completed by Cigna Dental & Vision Underwriting on May 22, 2025 Voluntary FI Quote (Per Employee Per Month) Enrolled EE's 10/01/2025 10/01/2026 10/01/2027 Employee Only 134 $6.73 $6.73 $6.73 Employee + Spouse 32 $13.46 $13.46 $13.46 Employee + Child(ren) 35 $13.59 $13.59 $13.59 Employee + Family 63 $21.70 $21.70 $21.70 Total EE's 264 *Broker commissions of 10.00% are included in this quote. *Voluntary., Medical and/or dental subscribers can elect to not enroll in vision. Does not refer to contribution levels. *Quote is valid for 90 days and includes claim processing, network access, customer service, policy and certificate, and standard vision reporting. The fee also includes two vision specific ID cards, mailed directly to the member's home address (unless other arrangements are made in advance). *Our Cigna Vision proposal is contingent upon selecting Cigna for your dental and/or medical coverage. *This quote assumes the Cigna Vision will be administered on Cigna East *Rates are guaranteed for 3 years. *Cigna Healthcare's vision products are "excepted benefits"and not subject to Essential Health Benefit requirements. *The above quoted rates include Health Insurance Assessment fees (PPACA) for 2020 months, but not for 2021 and beyond. Cigna reserves the right to modify quoted rates, as necessary, should there be any changes in future regulation or costs. Cigna Vision Network serviced by EyeMed offers one of the largest national routine vision networks, with optometrists and ophthalmologists at full service locations nationwide, including private practice and national and regional retail locations. Please be aware that the Cigna Vision Network serviced by EyeMed is different from the Cigna medical networks. Out -of -Network Vision Services and Frequency In -Network Plan Coverage** In -Network Member Cost— Reimbursement Exam and Professional Services: Frequency*: once per 12 month Eye Exam 100% after Copay $10 Copay Up to $45 Allowance Retinal Screening Not Covered Up to $39 Not Covered Standard Contact Lens Fit & Follow-up $0 Up to $40' Not Covered' Premium Contact Lens Fit & Follow-up $0 90% of Retail' Not Covered' Standard Eyeglass Lenses Allowances: Frequency*: one pair per 12 month Lenses: Single Vision 100% after Copay $25 Copay Up to $32 Allowance Lined Bifocal 100% after Copay $25 Copay Up to $55 Allowance Lined Trifocal 100% after Copay $25 Copay Up to $65 Allowance Lenticular 100% after Copay $25 Copay Up to $80 Allowance Lens Enhancements I Options Oversize lenses 100% $0 Not Covered Rose #1 and #2 Solid Tints 100% $0 Not Covered Polycarbonate Lenses <19 years of age 100% $0 Not Covered Polycarbonate Lenses $0 $40 Not Covered Standard Progressives' $0 $652 Not Covered Premium Progressives' $0 Tier 1: $852 Not Covered Tier 2: $952 Tier 3: $1102 Tier 4: $65 plus 20% off retail Less $120 allowance Plastic Dye Tints $0 $15 Not Covered Photochromic — Glass or Plastic $0 $75 Not Covered Standard Scratch Coating $0 $15 Not Covered Standard Ultraviolet (UV) $0 $15 Not Covered Standard Anti -Reflective (AR) Coating' $0 $45 Not Covered Premium Anti -Reflective Coating' $0 Tier 1: $57 Not Covered Tier 2: $68 Tier 3: 20% off Retail Hi -Index Lenses $0 20% off retail Not Covered All other lens options $0 20% off retail Not Covered Contact Lenses Retail Allowance: Frequency*: one pair or single purchase per 12 month Elective — Conventional 100% up to $110 Retail Allowance; Additional Balance over $110 Allowance Up to $98 Allowance 15% off balance over allowance Elective — Disposable 100% up to $110 Retail Allowance Therapeutic 100% $0 Up to $210 Allowance Frame Allowance Frequency*: one per 12 month Retail 100% up to $130 Allowance 20% off balance over Allowance Up to $71 Allowance Costco 100% up to $80 Allowance Balance over Allowance * Your Frequency Period begins on January 1 (Calendar year basis) 'Changes to the products in each tier and member out-of-pocket amounts are subject to change; All providers are not required to carry all brands at all levels. Check with your in -network provider for details. 'May be applied to Contact Lens Allowance. 2Member out-of-pocket includes Lined Bifocal copay. Out -of -network reimbursement based on Lined Bifocal allowance. **Coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information. ***Provider participation is 100% voluntary and subject to applicable law, please check with your Eye Care Professional for any offered discounts; stated Customer Cost, up to maximums, are subject to change without notice. Benefits are underwritten or administered by Cigna. Read your plan carefully- this rate sheet provides a very brief description of the important features of your plans. This is not the insurance contract. Your full rights and benefits are expressed in the actual plan documents that are available to you upon request. Network providers are independent contractors solely responsible for your routine vision examination and products. 05/22/2025 16:33 18 Opportunity Number: OP-5565553 Delancy McKinley (Austin - 329) Account Number: 3344509 CIgrip=_" a,� na Cigna Vision Solution for City of Southlake Insurance Trust Fund Effective Date : 10/01/2025 Renewal quote completed by Cigna Dental & Vision Underwriting on May 28, 2025 Voluntary FI Quote (Per Employee Per Month) - Premium Plan Enrolled EE's Employee Only 134 Employee + Spouse 32 Employee + Child(ren) 35 Employee + Family 63 Total EE's 264 10/01/2025 10/01/2026 10/01/2027 $8.07 $8.07 $8.07 $16.14 $16.14 $16.14 $16.29 $16.29 $16.29 $26.02 $26.02 $26.02 *Broker commissions of 10.00% are included in this quote. *Voluntary., Medical and/or dental subscribers can elect to not enroll in vision. Does not refer to contribution levels. *Quote is valid for 90 days and includes claim processing, network access, customer service, policy and certificate, and standard vision reporting. The fee also includes two vision specific ID cards, mailed directly to the member's home address (unless other arrangements are made in advance). *Our Cigna Vision proposal is contingent upon selecting Cigna for your dental and/or medical coverage. *This quote assumes the Cigna Vision will be administered on Cigna East *Rates are guaranteed for 3 years. *Cigna Healthcare's vision products are "excepted benefits" and not subject to Essential Health Benefit requirements. *The above quoted rates include Health Insurance Assessment fees (PPACA) for 2020 months, but not for 2021 and beyond. Cigna reserves the right to modify quoted rates, as necessary, should there be any changes in future regulation or costs. Plan Co Cigna Vision Network serviced by EyeMed offers one of the largest national routine vision networks, with optometrists and ophthalmologists at full service locations nationwide, including private practice and national and regional retail locations. Please be aware that the Cigna Vision Network serviced by EyeMed is different from the Cigna medical networks. Vision Services and Frequency In -Network Plan Coverage— In -Network Member Cost" Out -of -Network Reimbursement Exam and Professional Services: Frequency': once per 12 month Eye Exam 100% after Copay $10 Copay Up to $45 Allowance Retinal Screening Not Covered Up to $39 Not Covered Standard Contact Lens Fit & Follow-up $0 Up to $40' Not Covered' Premium Contact Lens Fit & Follow-up $0 90% of Retail' Not Covered' Standard Eyeglass Lenses Allowances: Frequency': one pair per 12 month Lenses: Single Vision 100% after Copay $25 Copay Up to $32 Allowance Lined Bifocal 100% after Copay $25 Copay Up to $55 Allowance Lined Trifocal 100% after Copay $25 Copay Up to $65 Allowance Lenticular 100% after Copay $25 Copay Up to $80 Allowance Lens Enhancements / Options Oversize lenses 100% $0 Not Covered Rose #1 and #2 Solid Tints 100% $0 Not Covered Polycarbonate Lenses <19 years of age 100% $0 Not Covered Polycarbonate Lenses $0 $40 Not Covered Standard Progressives' $0 $652 Not Covered Premium Progressives` $0 Tier 1: $W Not Covered Tier 2: $W Tier 3: $1102 Tier 4: $65 plus 20% off retail Less $120 allowance Plastic Dye Tints $0 $15 Not Covered Photochromic - Glass or Plastic $0 $75 Not Covered Standard Scratch Coating $0 $15 Not Covered Standard Ultraviolet (UV) $0 $15 Not Covered Standard Anti -Reflective (AR) Coating` $0 $45 Not Covered Premium Anti -Reflective Coating' $0 Tier 1: $57 Not Covered Tier 2: $68 Tier 3: 20% off Retail Hi -Index Lenses $0 20% off retail Not Covered All other lens options $0 20% off retail Not Covered Contact Lenses Retail Allowance: Frequency': one pair or single purchase per 12 month Elective - Conventional 100% up to $180 Retail Allowance; Additional Balance over $180 Allowance Up to $144 Allowance 15% off balance over allowance Elective - Disposable 100% up to $180 Retail Allowance Therapeutic 100% $0 Up to $210 Allowance Frame Allowance Frequency': one per 12 month Retail 100% up to $200 Allowance 20% off balance over Allowance Up to $110 Allowance Costco 100% up to $140 Allowance Balance over Allowance " Your Frequency Period begins on January 1 (Calendar year basis) `Changes to the products in each tier and member out-of-pocket amounts are subject to change; All providers are not required to carry all brands at all levels. Check with your in -network provider for details. 'May be applied to Contact Lens Allowance. Member out-of-pocket includes Lined Bifocal Copay. Out -of -network reimbursement based on Lined Bifocal allowance. "Coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information. —Provider participation is 100% voluntary and subject to applicable law, please check with your Eye Care Professional for any offered discounts; stated Customer Cost, up to maximums, are subject to change without notice. Benefits are underwritten or administered by Cigna. Read your plan carefully - this rate sheet provides a very brief description of the important features of your plans. This is not the insurance contract. Your full rights and benefits are expressed in the actual plan documents that are available to you upon request. Network providers are independent contractors solely responsible for your routine vision examination and products. 05/28/2025 11:24 18 Opportunity Number: OP-5565553 Delancy McKinley (Austin - 329) Account Number: 3344509