Okaloosa County BOCC — August 19, 2014 — Florida Blue Medicare Supplement Amendment 1

CONTRACT & LEASE INTERNAL COORDINATION SHEET Contract/Lease Number: Tracking Number: fo 4S - 1} _ . Grant Funded: YES NO >< Contractor/Lessee Name: Elude. Bllene _ purpose PY\Odedase See gop lomo taf Date/Term: || |e = FYaohs | 1. LJ Greater THAN $50,000 Amount:_ {29 sut}enes mlexh A 2. L] Greater THAN $25,000 Department:___ (CN 3. L] $25,000 or Less Dept. Monitor Name: i ON Document has been reviewed and includes any attachments or exhibits. Purchasing Review Procurement requirements et: S<KOLAA Date: 7-30-I PurcHasing Diyector or Désignee Joanne Kublik Risk Management Review Approved as written: ay brad Lor Date. ~/- SI~-iY Risk Manager or designee Kany Cadiosn | Q County Attorney Review Approved as written: << Date: + [20 Ayu County Aferney Gregony-F-Stewart ij | Lymm tHosniHARA Following Okaloosa County approval: Contracts & Grants Document has been received: Date: Contracts & Grants Manager AMENDMENT NUMBER ONE TO AGREEMENT TO PROVIDE SUPPLEMENTAL INSURANCE TO INDIVIDUALS ELIGIBLE FOR MEDICARE IN OKALOOSA COUNTY CONTRACT # C14-2126-RM AMENDMENT Number One to the agreement entered into by and between Okaloosa County, a political subdivision of the State of Florida, herein after referred to as “County,” and Florida Blue, hereinafter referred to as the “Service Provider,” signed June 25, 2014, is hereby amended as outlined in Exhibit A. Amendment Number One shall begin on October 1, 2014, and shall end on September 30, 2015, and may be renewed annually upon agreement of both parties. All other terms and conditions of the contract remain in effect. IN WITNESS WHEREOF, the parties have executed Amendment Number One as of the Amendment Effective Date by their duly authorized representative. Okaloosa County Board of County Commissioners Florida Blue Charles K. Windes, Jr., Chairman Signature — ss zDebbie Rittengur Date Name - VP Goveramers Mov ket Title O&-05-2014 Date ATTEST: Bornes \nsuvance om ~ \C2. DON HOWARD r\ noncias Sericés Clerk of the Court Der 5 Barnes / President Told Exhibit A OKALOOSA COUNTY BOARD OF Co. COMMISSIONERS Medicare Carve Out Rates For Florida Blue (BCBSFL) 2014-2015 These are the carve-out rates for retired employees who are either on disability or have met the requirements of retirement age of 65 or older. Plan 03769 Plan 03559 Plan 3361 Retiree Only (Over age 65 w/Medicare) $428.33 $457.60 $390.87 Retiree + 1 (Over age 65, Both w/Medicare) $856.70 $915.24 $781.78 Retiree/Family (7 Over age 65 w/Medicare) $963.81 $1,029.68 $879.52 If over 65 and have part A & B can sign up for BlueMedicare BlueMedicare Group PPO Plan 2 w/Rx Opt 2 $346.60 OR BlueMedicare Standalone Rx Opt2 ~ ($165.29 If the spouse/dependent is not over 65, can offer a split contract. One would go on Blue Medicare the other stay on current plan. | Plan 03769 Plan03559 Plan 3361 Dependent/Split Contract $535.49 $572.07 $488.65 Florida Blue Barnes Insurance and Financial Services David E. San Oe Executive Dennis a Signature LE ti LEP Signature¢ - _ Cee Date: 8/8/2014 Date: 8/8/2014 Medicare Carve-Out 2014-2015 Rev 6/4/2014