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Anthem®, <br />M iodcpmdmt li~~ce oFtls Blue C,oa and Blue Shield Aa~odaatioa. <br />HAYFIELD VILLAGE <br />Renewal Effective: 3/1/97 <br />GID:S61305901 <br />Health Insurance otJered by Commuraty Lnsurance C.omparry <br />Community Preferred First Dollar <br />Benefit Plan Highlights <br />- Major Medical (Deductibles and Coinsurance may Apply) -Health Caze Management Program <br />- Inpatient%Outpatient Hospital Care -Emergency and Accident Care <br />- Physician Charges: $8 net./$15 non-net. Co-pay -Diagnostic Services <br />- Prescription Drugs: $5 Co-pay -Lifetime Maximum Benefit of $1,000,000 <br />-Maternity, Well Baby & Well Child Care -Psychiatric Care & Substance Abuse <br />- 12 Month Pre-existing Clause -Human Organ Transplant (Limitations Apply) <br />After the employee reaches their maximum, Community Insurance Company covers the the remaining eligible charges. <br />(Refer to your Community Insurance Company benefit booklet(s) for benefit details and limitations) <br />lbinnthly Premium Information <br />Current Monthly Health Premiums <br />Coverage Emps Health Drug Dental Vision TOTAL <br />Employee 10 $171.39 $21.78 * * $193.17 <br />Family 31 $535.80 $49.21 * *~ $585.01 <br />Monthly 41 $18,323.70 $1,743.31 * *; $20,067.01 <br />Renewal Monthly Health Premiums <br />Coverage Emps Health Drug Dental Vision TOTAL <br />Employee 10 $193.00 $24.53 * * $217.53 <br />Family 31 $603.36 $55.42 * * $658.78 <br />Monthly 41 $20,634.16 $1,963.32 * * $22,597.48 <br />* Coverage not selected <br />Premiums are increasing by 12.6% <br />The above premiums include 50.07 per month per employee attributable to a gtuuanty policy issued by Associated Insurance Companies, Inc. <br />Anthem. ~~ <br />® Registercd marks Blue Cmss and Blue Shield Association. um ue ross an ue a is e e name o ommunity Insurance Company. Pa e 1 <br />MindependentlicenseeoftheBlueCmssandBlueShieldAcsociation. MthemBlueCmssandBlueShieldisihetradenameofCommunirylnsuranceComparry. ®RegisteredmarksBlueCmssandBlueShieldAssociation, g <br />