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HMA Client Intent & TPA Exhibit A – City of Everett 020188 Page 6 of 8 <br />020188 City of Everett 2025.01 Client Intent Exhibit A_Single Year 5.14.2024 Add Renewal Fee Product <br />☐ Healthcare Bluebook Care Connect (Client Funded) <br />Add to HCBB Quality + Go Green and Engagement Rewards for a concierge service for <br />joints, spine, and women’s surgical procedures health including finding the right provider, <br />scheduling appointments, and facilitating medical record transfer. Case rates range from <br />$700 to $5,500 with engagement rewards up to $1,500 for qualifying procedure. <br />Requires client to provide email addresses of all eligible employees. <br />Cannot be combined with Care Navigator Plus. <br />☐ $200 initial <br />consultation <br /> <br />$550 case rate <br />for Recovery <br />Phase (covers <br />12 months per <br />injury/issue) <br /> <br />Omada for Musculoskeletal <br /> <br />Billed as medical claims. <br />No cost for Prevention program. <br />Member cost share applies. Standard Plan Design is as follows: covered services shall be <br />covered at 100% DW for PPO Plan(s) and 100% after deductible for QHDHPs plan(s). If Plan <br />sponsor wants to have Omada services covered differently than indicated here, please use <br />the Summary of Communicated Changes box at the top of this document to indicate your <br />alternate plan design intent. <br />☐ $1.50 Wellness Hub PEPM <br />☐ $125 Incentive Administration per hour <br />After initial setup of 5 hours included. <br />☐ $3.50 Disease Management PEPM <br />☐ $350 Maternity per case <br />☐ $0.65 24 Hour Nurse Line PEPM <br />☐ $1.60 MDLIVE Mental Health, Psychiatry, Virtual Dermatology and Medical (Urgent Care) <br />PEPM <br /> <br />Please detail the group’s required cost share for any plans that apply: <br />☐ PPO plan member copay amount of $________ per virtual visit, deductible waived <br />☐ PPO plan member copay amount of $________ per virtual visit after deductible met <br />☐ HDHP plan member coinsurance amount of _________% <br />☐ $1.35 MDLIVE Mental Health, Psychiatry and Medical (Urgent Care) PEPM <br /> <br />Please detail the group’s required cost share for any plans that apply: <br />☐ PPO plan member copay amount of $________ per virtual visit, deductible waived <br />☐ PPO plan member copay amount of $________ per virtual visit after deductible met <br />☐ HDHP plan member coinsurance amount of _________% <br />☐ $1.30 MDLIVE Virtual Dermatology and Medical (Urgent Care) PEPM <br /> <br />Please detail the group’s required cost share for any plans that apply: <br />☐ PPO plan member copay amount of $________ per virtual visit, deductible waived <br />☐ PPO plan member copay amount of $________ per virtual visit after deductible met <br />☐ HDHP plan member coinsurance amount of _________% <br />Docusign Envelope ID: CC50B3B8-52FD-4DD0-8AA5-5843B00BE3B8