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?:..xij IBIT FOQ OR1, I? <br />q la - Oq <br />MAY]FIELD VMLAGE <br />GID: 561305901 <br />Renewal Effective: March 1, 1996 - February 28, 1997 <br />First Dollar Community Preferred Health Plan <br />Benefit Plan Highlights <br />- Major Medical - Deductibles and Coinsurance may apply - Health Care Management Program <br />- InpatiendOutpatient Hospital Care - Emergency and Accident Care <br />- Office Visits subject to $8 net./$15 non-net. copay - Diagnostic Services <br />- Prescription drugs -$5 copay - Psychiatric Care & Substance Abuse <br />- Matemity, Well Baby & Well Child Care - Human Organ Transplant (Limitations Apply) <br />- 12 Month Pre-Existing Clause - Lifetime Maximum Benefit of $1,000,000 <br />the employee reaches the maximum, Community lnsurance Company covers rhe remarning eligible charges <br /> Rate Adjustment Information <br /> ? CURRENT RATES <br />Coverage : <br />; Cantracts Health Drug Dental <br />: Vision Premium <br />......_..._ .............._.. <br />_._. <br />Single; ..................... _........... <br />9 ...... .... _.. ................ _..... _. <br />$159.28 ................................. ........... .... <br />._,... <br />............. ............................................... <br />$20.24 N/A ........ ........ <br />. ....... <br />N/A ..... ...... . . . ...... <br />...,... ._ .............._ <br />$1,615.68 <br />Family; 31 $497.96 $45.73 N/A N/A $16,854.39 <br />Medicare 1 <br />.... ......... ............_... ...... 0 <br />........................ ...... _. <br />.....a..__. N/A <br />...._..............._.. N/A N/A <br />............ ............................................... s.... _............................ _...........a........ N/A <br />.......................... <br />. <br />.. N/A <br />... <br />_a....... <br />.... <br />. <br />. <br />... <br />...... <br />. <br />..... <br /> <br />ToTnr, <br />......................... _..... . <br />. ... <br />. <br />.......... <br />... <br />. <br />. <br />.. <br />. <br />. <br />sis,a7o.o7 <br />............................................... <br /> RENEWAL RATES <br />....Coverage ; <br />.._..._......_.._ <br />............ Contracts <br />..._......._......._._.._.._ ? <br />_...._... Health <br />_.........._ ............. ' ................D?$.............._.e..._........._Dental......_....._..._... <br />.. ....... .. .......Vision. Premium <br />. <br /> <br />Single'•. <br />9 <br />$171.39 <br />$21.78 N/A ....... <br />N/A ..............._ <br />... <br />............ <br />51,738.53 _ <br />Family; 31 $535.80 $49.21 N/A N/A $18,135.31 <br />Medicare€ 0 <br />_ N/A N/A N/A <br />a <br />_ <br />: N/A N/A <br />...._....._....__._...._.;...... <br /> <br /> <br />TOTAL : <br />........... ..................: _.._..._..........._......_... ..... <br />..._.. .._.._... _.. ...... . ............ <br />..................__.......__.............. <br />........... _.._............ <br />............_.._ <br />........ <br />......................_....... <br />........ . _ ...................... <br />.... <br />... <br />$19,873.84 <br />:............................................... <br /> Premium is increasing by 7.6% <br />i ne aoove premium incwaes su.ui per montn per empioyee attnoucatiie to a guaranry poucy issuea oy v,ssociatea insurance companies, inc. <br />AuShL?f?ss`l"te Qield <br />An irdepardent lieeneee ol the Blue Gone end Blue Shield Aeeoeie,im <br />0 , <br />M independent licensee of the Blue Cross and Blue Shield Association. Mthem Blue Cross and BlaaS"i?thaVadcl:Qa¢"6aqimuniry Insurance Company. O Registe2d marks Blue Cross and Blue Shield Association. Page I of 1 <br />L-90 (REV. 70/95)