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RATE PROPOSAL
Company Name: City of Nashua Effective Date: 07/01/2016 - 06/30/2017
Group Number: 027219 Plan ID : MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option
Rate Proposal terms and conditions
lf applicable, please review the detailed caveats page(s) released by the Stop-loss Carrier.
Preferred Drug List Rebates - Harvard Pilgrim Health Care will retain 30% of any net preferred
drug list rebate recovery attributable to prescription drug products utilized by participants.
3. The customer will retain 70% of that rebate recovery amount.
These figures are approximate based upon 315 subscribers.
5. You may request a fully insured quote, which could provide greater savings (e.g., reduced
HIPAA compliance, avoidance of stop loss volatility and enhanced discounts reflected in fully
insured rates).
Noo
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Tam authorizing Harvard Pilgrim Health Care (including its affiliates) to proceed with the account setup of the benefit package and fees in this rate proposal,
which is subject to the execution of Harvard Pilgrim's Administrative Service Agreement (ASA) or an applicable amendment to the ASA.
Signature of Company Official/Broker/Consultant Title Date
Form No.1207 Printed Date: 03/29/16
