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. . . . MAI'FIELD NqLLAGF, <br />. " , 2003 Renewal <br /> . Health Benefu aftd Premium-C <br />a <br /> ompar ir <br />n . <br />Com an <br />g?an Authe? CurreotPEaa Aotheuz U' <br /> <br />. <br />. <br />Blue Access on <br />Bfue AccESS Anthe?rt O <br />? tiun <br />DeducEi6le: <br />?ing3e N??a? Nm N?ork <br />$0 N??k <br />Nan Nenyork Blue Access Blae Access <br />Nerivo <br />k <br />? <br /> <br />Ramil $3Q0 <br />$0 <br />?100 $ZOp r <br />Non I?i <br />ehvor <br />$260 k Nefwork <br />Nau Network <br />Coinsarance: Sing!e 10010 o . . $600 <br />o $240 C400 $44p <br />' $404 $2(10 $460 <br /> <br />? <br />g OOP . - <br />o <br />' $800 <br />98%/10°0 <br />70%!30% <br />$900 $809 <br />? o <br />80 / <br />120?/ <br /> <br />• <br />??? <br />$500 $ f,000 <br />$506 0 <br />, 60 /o/44%a <br /> <br />In aiienf _FarniE - $1000 $2,000 <br />CoveredIrz Full T1,000 <br />$10(}0 S2 400 $1,040 $2,000 <br />62 000 $I,000 <br /> <br />$?OQO <br />O <br />rev aff eafive eut Ded/Coin <br />Covexed Irt Fu1I DecUCoin DadlCoin Ded/C <br /> <br />oin <br />De <br />?f?i <br />' <br />Ded/Coin $4Ded/Cfl000 im $2 00 $4,000 <br />Ded/Coin <br /> <br />Uffice Visits • $5 Co - <br />Ded/Coin <br />$5 C n <br />Decl/Coin <br />$1 D Co a DedfCoi D'ed/Coin <br />?Coin Ded/Coin <br />Ded/Coin Dedl?in <br />Eaier ea a. Ded/Coin <br />$50 Co n <br />$?O Co DedlCoin $lO a DedlCoin <br />$10 ?' 010 Co $ DedfCfli.u <br />r e??t Care <br />Preserlptioas: <br /> <br />' $SU C <br />?S?Co fi ' DedfCoi? $50 Cu $50 C$• <br />$35 Co Ded/Coin <br />$75 Ca a $75 Co a $10 Cfl Desi/?in <br /> <br />$75 Co <br /> <br />•Retai? <br />. <br />S?Generie/S15Erartd <br />(Famwlery) a <br />D <br />edlCoiti <br />SqCencrnJSISBrand(gomiu?a <br />,) <br />$35 U?pay Ded/C om ?75 Co $ <br />$35 C <br />Ded/Coli! <br /> Mail Order $25 (Non Foanulary) <br />' <br />$16 GeneriaWOBrand Farmaf ?y <br />S2S (?oa parmuEary) $80ene <br />?$15Braad ?ormul <br />m) <br />$25 (Non Formula <br />S8Ganeric4IS Brand (Formolary) <br /> <br />R?? ary . <br />S50 on Formu $16 3prettc/W0 Hwtd Formal <br />?Y ry) . <br />$16 C3enerieJ$J$3?0 Brand Fopm,l <br />, s? $23 (rlonFoimuFeEp) <br />$ <br /> <br /> <br />??$I? <br /> <br />• <br /> <br />urr • Renewcl SSO on <br />Po y <br /> <br />$30 onFarmoi 16 GrmnwirMU Brand Farmufary <br /> <br /> <br />$50 <br />REf.Spn?se 10 <br /> <br />12 $284.10 <br />$30 8 .B3 <br />S305AD oaFaimul <br />EE+Chitd Z . $680.53 $738.19 <br />$? <br />62 $729,03 - ?94.? . $287.84 <br />,P?1?, <br />26 . <br />$566.90 <br />$955.77 $1 <br />036 <br />75 ' <br />. <br />$559.87 $703.27 <br /> <br /> <br />$540.69 <br /> <br /> <br />688.02 <br /> , <br />. <br />. $1,023_90 <br />71 <br />$9987 $528.37 <br />YiunWI Preinium <br />$36 <br />9?3 O . 5966.29 <br />?anua?Premiam - , <br />40 035 <br />$442,831 $480;431 <br />. <br />' $38 142 <br />. . ?474 474 ?S? ?0$ $37,315 <br />. . . $447 T79 <br /> Changes appearin bvld„ . <br />3112/03 • <br />Caporate F1Q?t,s, Ina