13-Exhibit 3. Fort Bend ISD Stop Loss Policy Amendment.pdf
PDF 82 KB Posted
- Attached to
- Stop Loss Insurance
- Solicitation number
- RFP 26-023KB
- Issued by
- Fort Bend County, Texas
About this file
This document is an insurance policy amendment from United HealthCare Insurance Company for Fort Bend Independent School District, specifically a Schedule of Benefits for Excess Loss Insurance. The policy is effective from January 1, 2025, through December 31, 2025, with coverage for medical and stand-alone prescription drug programs. The specific excess loss insurance includes a specific deductible of $450,000 per covered person, with 100% reimbursement and an unlimited maximum specific benefit per covered person.
The policy has a composite rate of $40.17 and covers expenses incurred from January 1, 2019, through December 31, 2025, with payment period from January 1, 2025, through December 31, 2025. The administrator includes United HealthCare Services, Inc., Bind Benefits, Inc. (d/b/a Surest), and CVS/Caremark. There is no aggregate excess loss insurance included, and no special conditions are noted. The document represents an amendment to the original group policy number UHIC-600820, replacing the previous Schedule of Benefits with this updated version.
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Text version
UHIC AMEND (07/06)
United HealthCare Insurance Company 185 Asylum Street Hartford, CT 06103-3408
AMENDMENT NO:
Amendment to be attached to and made a part of Group Policy No. UHIC-600820, issued by United HealthCare Insurance Company (herein called Company) to Fort Bend Independent School District (herein called Policyholder).
It is agreed by and between the Company and the Policyholder that
1. The page entitled "Schedule Of Benefits" as contained in the Policy is hereby replaced with the attached page entitled "Schedule Of Benefits".
2. This Amendment will hereby be effective as of January 1, 2025.
UHIELP-TX (07/06) SCHED
United HealthCare Insurance Company A Stock Company
185 Asylum Street Hartford, CT 06103-3408 Phone: 1-800-357-1371
SCHEDULE OF BENEFITS
This Schedule of Benefits is only applicable to Excess Loss Insurance provided by the Company during the Policy Period shown below.
Policyholder: Fort Bend Independent School District Policy Number: UHIC-600820 Effective Date: 01/01/2025 Administrator: United HealthCare Services, Inc., Bind Benefits, Inc., d/b/a Surest and any entity to which it delegates administrative services., CVS/Caremark Coverage specified herein is applicable only during the Policy Period from 01/01/2025 through 12/31/2025, and is further subject to all terms and conditions of this Policy.
SPECIFIC EXCESS LOSS INSURANCE: X YES NO
Benefit Period: Covered Expenses Incurred from 01/01/2019 through 12/31/2025 and Paid from 01/01/2025 through 12/31/2025.
Specific Deductible per Covered Person: $450,000 Specific Percentage Reimbursable: 100% Maximum Specific Benefit per Covered Person: Unlimited
Specific Excess Loss Insurance includes:
X Medical X Stand Alone Prescription Drug Program
Description Rates Composite $40.17
AGGREGATE EXCESS LOSS INSURANCE: YES X NO
SPECIAL CONDITIONS:
n/a
File details come from the government source that posted it. Updated .