Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 9/23/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Human Resources
5) Department Contact: Rebecca Gilliam
6) Description: Aetna Retiree Medicare Plan for 2025
7) PEID No: 723578
8) Req No:
9) Orgkey: 6123 155023
10) Object Code: 5491738
11) Vendor: Aetna Health Management LLC
12) Vendor Contract No: E00067101612
Expenditure Budget/Revenue Projections
13) Fund Name: Med Ins Prem-Retiree 65&Older
14) Fund #: 5491738
15) Current Year Budgeted: $1,896,824.00
16) Current Year Projected: $1,896,824.00
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals: $1,896,824.00
To Be Completed by Purchasing Department
22) Contract Start Date: 1/1/2025
23) Auto Renewal Contract: Yes
24) Bid No: NA
25) Contract End Date: 12/31/2025
26) Contract # Issued by Purchasing Department: CM21287A
NOTES: HB1295 Not Required